professor of pediatrics, nursing, and public health university of colorado nurse family partnership...
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Professor of Pediatrics, Nursing, and Public
Health
University of ColoradoUniversity of Colorado
NurseFamily Partnership
David Olds, PhD
November 13, 2014
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Baltimore, 1970
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NURSE FAMILY PARTNERSHIP
• Prenatal and infancy home visiting by nurses
• Focused on low-income mothers with no previous live births
• Clarity in goals, objectives, and methods
• Activates and supports parents’ instincts to protect their children
• Strengths-based
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NURSE FAMILY PARTNERSHIP’STHREE GOALS
1. Improve pregnancy outcomes
2. Improve child health and development
3. Improve parents’ health and economic self-sufficiency
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TRIALS OF PROGRAM
• Low-income whites
• Semi-rural
• Low-income blacks
• Urban
• Large portion of Latino families
• Nurse versus paraprofessional visitors
Elmira, NY1977
N = 400
Memphis, TN1987
N = 1,138 and N=743
Denver, CO1994
N = 735
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CONSISTENT RESULTS ACROSS TRIALS
Prenatal health
Children’s injuries Children’s language and school readiness
(low resource mothers)
Children’s behavioral problems
Children’s depression/anxiety
Children’s substance use Maternal Impairment due to substance use
Short inter-birth intervals
Maternal employment
Welfare & food stamp use
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Indicated Cases of Child Abuse and Neglect0 to 15 Years - Elmira
*P= .03 JAMA, 1997;278:637-643
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Number of Life-Time ArrestsElmira Youth - Age 19
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Comparison Nurse
P=.02, IR = 0.49 Arch Pediatr Adolesc Med 164(1) 9-15
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Memphis DesignMemphis Design
Urban Setting Sample (N = 1138 for prenatal and N = 743 for
postnatal)
92% African American 98% Unmarried 85% < Federal Poverty Index 64% < 19 years at intake 2.4 SD above mean neighborhood adversity
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Services Treatment 1N=166
Treatment 2N=514
Treatment 3N=230
Treatment 4N=228
Transportation for prenatal care
X
X
X
X
Screening and referral for children
X
X
Prenatal/neonatal home visiting
X
X
Infant and toddler home visiting
X
Services Provided in Each Treatment ConditionMemphis
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Memphis Program Effects on Childhood Injuries (0 - 2 Years)
23% Reduction in Health-Care Encounters for Injuries & Ingestions
80% Reduction in Days Hospitalized for Injuries & Ingestions
JAMA 1997; 278: 644-652.
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Nurse
Simultaneous Region of TreatmentDifferences (p < 0.05)
Comparison
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
60 110 120 13080 90 10070
Mothers’ Psychological Resources
No
. Day
s H
osp
ital
i ze d
wi t
h In
juri
e s/ In
ge s
tio
ns
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Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected
Nurse-Visited (n=204)
Age Length(in months) of Stay
Burns (10 & 20 to face) 12.0 2 Coin Ingestion 12.1 1 Ingestion of Iron Medication 20.4 4
JAMA 1997; 278: 644-652.
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Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected - Comparison (n=453)
Age Length (in months) of Stay
Head Trauma 2.4 1 Fractured Fibula/Congenital Syphilis 2.4 12 Strangulated Hemia with Delay in Seeking Care/ Burns (10 to lips) 3.5 15 Bilateral Subdural Hematoma 4.9 19 Fractured Skull 5.2 5 Bilateral Subdural Hematoma (Unresolved)/ Aseptic Meningitis - 2nd hospitalization 5.3 4 Fractured Skull 7.8 3 Coin Ingestion 10.9 2 Child Abuse Neglect Suspected 14.6 2 Fractured Tibia 14.8 2 Burns (20 face/neck) 15.1 5 Burns (20 & 30 bilateral leg) 19.6 4 Gastroenteritis/Head Trauma 20.0 3 Burns (splinting/grafting) - 2nd hospitalization 20.1 6 Finger Injury/Osteomyelitis 23.0 6
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Reading & Math Achievement – Age 12Reading & Math Achievement – Age 12(Born to Low-Resource Mothers)(Born to Low-Resource Mothers)
p=.009, Effect Size = 0.25 Arch Pediatr Adoles Med, 164(5) 412-418
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Percent of Children Who Used Tobacco, Alcohol, or Marijuana (Last 30 Days)
Memphis – Child Age 12
P = .04 OR = 0.31 Arch Pediatr Adoles Med, 164(5) 412-418
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Percent of Children with Depression- Anxiety – Child Age 12
P = .04 OR = 0.63 Arch Pediatr Adoles Med, 164(5) 412-418
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Copyright restrictions may apply.
control groups over timeTotal Discounted Government Spending (2006 US dollars) after Birth of First Child for Food Stamps, Medicaid, & AFDC/TANF
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All mothers assigned to treatments 1- 4 All children assigned to treatments 2 & 4
National Death Index Review
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Survival plots for intervention and control mothers – all causes of
death
(T1+T2 vs. T3 p=.007; T1+T2 vs. T4 p=.19; T1+T2 vs. T3+T4 p=.008) JAMAPEDIATRICS.2014.472.pages E1-E7.July 7, 2014
Control (T1 and T2)
Nurse-Visited Prenatal/Postpartum (T3)
Nurse-Visited Prenatal/Infancy/Toddler (T4)
Surv
ival
90%
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
Follow-up time since randomization (years)
0 2 4 6 8 10 12 14 16 18 20 22
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* Sudden Infant Death Syndrome, injury, homicide (T2 vs. T4 p=.02) JAMAPEDIATRICS.2014.472.pages E1-E7.July 7, 2014
Survival plots for intervention and control children - preventable causes
of death*
Control (T2)
Nurse-Visited Prenatal/Infancy/Toddler (T4)
Sur
viva
l - P
reve
ntab
le C
ause
s
90%
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
Follow-up time since birth (years)
0 2 4 6 8 10 12 14 16 18 20 22
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Tip of the Iceberg Health Disparities
• Cardiovascular disease
• Type-2 Diabetes
• Depression
• Cognitive decline
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Pattern of Denver Program Effects
Maternaland
ChildFunctioning
Comparison Para Nurse
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Washington State Institute for Public Policy Economic Analysis (2011)
Nurse Family Partnership produced
large return on investment:
– Implementation costs $9,421– Benefits $30,325 – Return on investment $20,904
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Coalition for Evidence-Based Policy
• Committed to reducing waste by identifying interventions that meet high evidentiary standards
• “Top Tier” interventions– Well designed and conducted randomized controlled trials– Replicated findings – Community settings– Sizable and sustained effects– Outcomes of clear public health, educational or social
significance
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Support Organizational and Community Capacity
Education and Consultation
Program Guidelines
Information System
Assessing Program Performance
Continuous Improvement
FROM SCIENCE TO PRACTICE
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27
Nurse-Family Partnership is a growing, national program
43 States that NFP serves
Number of counties NFP is serving
Where we work
551
Tribal agencies are denoted by Band
Map does not include program in U.S. Virgin Islands
© Copyright 2014 Nurse-Family Partnership. All rights reserved.
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Research Focused on Improving Program Model and Implementation
• Participant retention and completed home visits
• Intimate partner violence
• New method to observe & promote caregiver-child interaction
• Maternal depression and anxiety
• Development of STAR (Strength and Risk) framework to guide program implementation
Pediatrics 2013; 132; S110
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International Replication• No presumptions
• Adaptation
• Pre-test and small-scale trial
• Larger trial
• Faithful replication of adapted program
• International work:– UK – England, Scotland, Northern Ireland– Australia – aboriginal families– Netherlands– Canada – ON and BC– American Indians & Alaskan Natives
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Model Development
Original Trials
Trial 1
Trial 2
Trial 3
Articulate Essential Model Elements
Develop/Test Model Innovations
Studies of Implementation
Process
International Replication
Adapt and Test Original Model
US Community Replication
Community Preparation
Ed/Coachingof Nurses
Performance Monitoring
Continuous Quality Improvement
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