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Program Profile: Nurse–Family Partnership

Evidence Rating: Effective - More than one study Effective - More than one study

Date: This profile was posted on June 15, 2011

Program Summary

A home visitation program for low-income, first-time mothers to improve family functioning. The program is rated Effective. Program children had less substance use, reported fewer internalizing problems, and had higher child academic achievement. At the 15-year follow-up, less child abuse and neglect involving the mother as the perpetrator or involving the study child for families receiving home visitations during pregnancy and infancy.

This program’s rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Description

Program Goals
Nurse–Family Partnership (NFP) provides low-income, first-time mothers of any age with home-visitation services from public health nurses. The program addresses substance abuse and other behaviors that contribute to family poverty, subsequent pregnancies, poor maternal and infant outcomes, suboptimal childcare, and limited opportunities for the children.

Program Theory
NFP is based on the integration of three theories. First is the theory of human ecology that emphasizes the impact of the social context on human development. This context includes relationships with other family members, friends, neighborhoods, communities and cultures. The second is the self-efficacy theory, which posits that people are more likely to engage in a desirable behavior if they believe the behavior will produce a desired outcome. The program helps parents set realistic goals and bolsters parents’ confidence in their ability to reach those goals. The third, attachment theory, holds that children who receive sensitive and responsive parenting are more likely to embody these qualities themselves.

Program Components
The nurses work intensively with the mothers to improve maternal, prenatal, and early childhood health and well-being, with the expectation that this intervention will help achieve long-term improvements in the lives of at-risk families.

The intervention process concentrates on developing therapeutic relationships with the family and is designed to improve five broad domains of family functioning:

  • Parental roles · Family and friend support
  • Physical and mental health
  • Home and neighborhood environment
  • Major life events (e.g., pregnancy planning, education, employment)
Home visits by nurses are conducted during the woman’s pregnancy and continue until the child reaches 24 months of age. Maternal and child health nurses meet with each first-time mother in 64 planned home visits over 2 ½ years. Prenatally, they focus on preventive health and prenatal practices for the mother–helping her find appropriate prenatal care, improve her diet, and reduce her use of tobacco, alcohol, and illegal substances. Additionally, maternal and child health nurses help the mother prepare emotionally for the arrival of the baby. Post-birth, they focus on health and development education, focusing on child development milestones and behaviors and teaching parents to use praise and other nonviolent techniques. They also focus on coaching the mothers and their families in planning for their future, staying in school, finding employment, and planning future pregnancies.

Target Population
Although the primary client is the first-time mother, ultimately her baby and all the members of her support system (e.g., friends, parents, and the child’s father) become involved in the program.

Evaluation Outcomes

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Study 1
Overall, the Olds and colleagues (2004) study found contradictory results. There were greater effects on paraprofessional-visited mothers than on nurse-visited mothers, but for children the effects were greater in the nurse-visited families than in the paraprofessional-visited families.

Maternal Life Course
For the treatment group that received visits from paraprofessionals, results showed that 2 years after the end of the program, women who received visits from paraprofessionals were more likely to work between the child’s second and fourth birthday. They also had significantly higher scores that indicated a greater sense of mastery, and better mental health scores compared to control subjects. However, women visited by paraprofessionals were less likely than control subjects to be married and to live with the child’s biological father. There were no statistically significant paraprofessional effects on women’s educational achievement, use of welfare, use of marijuana or alcohol, behavior problems attributable to substance use, or experience of domestic violence.

When compared to control subjects, nurse-visited women had greater lapses between their first and second births, when a second birth occurred. Nurse-visited women also reported significantly less domestic violence from patterns during the 6-month time period before the 4-year interview. Nurse-visited mothers also reported enrolling their children significantly less frequently in preschool, Head Start, or licensed day care. However, there were no significant nurse effects on women’s educational achievement, employment, use of welfare, mental health, mastery, use of marijuana or alcohol, behavior problems attributable to substance use, marriage, or living with a partner or father of the child.

Home Environments, Mother–Child Interaction, and Child Development
Paraprofessional-visited mothers displayed significantly more sensitive and responsive interactions with their children during free-play sessions than the control group mothers. Low-resource paraprofessional-visited mothers (those who had low psychological resources at registration of the original study) had home environments that were significantly more supportive of early learning than their control group counterparts. There were no significant paraprofessional effects on children’s language, executive functioning, emotional regulation, behavioral adaptation, or on mothers’ reports of externalizing behavior problems.

Nurse-visited mothers who had low psychological resources at study registration also had home environments significantly more conducive to early learning, better language development, superior executive functioning, and better behavioral adaptation during testing when compared to the control group. There were no statistically significant nurse effects on sensitive–responsive mother–child interaction, children’s emotional regulation, or externalizing behavior problems.

Study 2
Child Substance Use

The study by Kitzman and colleagues (2010) found that in the 30 days preceding the 12-year interview, Nurse-Family Partnership (NFP) program children were significantly less likely to have used cigarettes, alcohol, or marijuana; to have used less of these substances; and to have used these substances for fewer days.

Child Mental Health
Nurse-visited children reported fewer internalizing problems than control group children. However, there were no significant differences in children’s sustained attention, externalizing problems, and total behavior problems.

Child Academic Achievement
Nurse-visited children born to low-resource mothers had significantly higher Peabody Individual Achievement Test scores in reading and math at age 12, and significantly higher grade-point averages and group-based reading and math achievement test scores in grades 1 through 6 when compared to their control group counterparts. There was no statistical difference in conduct grades.

Study 3
Child Abuse and Neglect

Eckenrode and colleagues (2000) found at the 15-year follow-up that there were significantly fewer child maltreatment reports involving the mother as the perpetrator or involving the study child for families receiving home visitations during pregnancy and infancy compared with families not receiving home visitations. For families receiving home visitations only during pregnancy, the number of maltreatment reports for the group fell between the other two groups but was not significantly different compared with the control group.

Domestic Violence
Home visitation made no impact on the incidence of domestic violence. Specifically, for mothers who received visits through the child’s second birthday, the treatment effect decreased as the level of domestic violence increased. Almost half (48 percent) of the mothers in the entire study sample report some form of domestic violence since birth of the study child. The average number of incidents over the 15 years was 22.2. For those women reporting any domestic violence, the average number of incidents was 43.1. Overall, the presence of domestic violence may limit the effectiveness of the NFP intervention to reduce incidence of child abuse and neglect.
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Evaluation Methodology

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Study 1
In this study, Olds and colleagues (2004) used a randomized controlled trial design with three groups to study the long-term effects of the Nurse-Family Partnership (NFP). The participants were 735 low-income, pregnant women with no prior live births, who were recruited from 1994 through 1995 from public- and private-care settings in Denver, Colorado. Participants were randomized to control (n= 255), paraprofessional (n= 245), or nurse condition (n= 245) groups. Study participants were 85 percent unmarried and 47 percent Mexican American, 35 percent white non-Mexican American, 15 percent black, and 3 percent American Indian/Asian.

The control group participants were provided developmental screening and referral services for their children. Treatment groups received developmental screening and referral services, plus home visits by nurses (nurse condition) or paraprofessionals (paraprofessional condition). Treatment goals for the home-visitation program consisted of improved maternal and fetal health during pregnancy, improved maternal care-giving, and improved maternal personal development by promoting planning of future pregnancies and helping women continue their education and find work. Home visits were provided from pregnancy until the child was 2 years old.

Two years after the intervention ended, when the children were approximately 4 years old, data was collected through interviews with the mothers, home observations, and child assessments conducted in the home. Outcomes were collected on approximately 85 percent of the original randomized sample (control n= 220, paraprofessional n= 211, and nurse condition n= 204). The outcomes of interest included maternal reports of subsequent pregnancies, participation in education and work, use of welfare, marriage, cohabitation, experience of domestic violence, mental health, substance use, sense of mastery, and mother-child interaction. For children, the outcomes of interest were children’s language and executive functioning and externalizing behavior problems. Aside from self-reports from the mothers, several different instruments were used to collect information on the outcome measurements. The Shipley Intelligence Scale Adult measured intelligence, the Mental Health Inventory measured adult mental health, the Mastery Scale measured mastery, the Child Behavior Checklist measured externalizing behavior, the Preschool Language Scale measured children’s language skills, and the Conflict Tactics Scale measured domestic violence.

Continuous variables were analyzed with the general linear model and dichotomous variables were analyzed with the logistic–linear model. For dichotomous correlated outcomes, generalized estimating equations, with a logit link function and assumption of an exchangeable (compound symmetry) correlation structure, were used.

Study 2
This 2010 study by Kitzman and colleagues is a follow-up study of the effects of the NFP on children through age 12. The original sample consisted of 1,139 young, low-income, and primarily African American women who were less than 29 weeks pregnant and were recruited from an obstetric clinic in Memphis, Tennessee, from 1990 through 1991. Women were randomly assigned to receive nurse home visits (n= 228) or comparison (control group) services (n= 515).

At the 12-year follow-up assessment, the control group included 422 study participants and the nurse–home visitation group included 191 participants. The control group was mostly African American (5.7 percent of the control group were another race) and the vast majority were unmarried (1.4 percent were married). The nurse visitation group was almost entirely African American (8.4 percent of the group were another race) and unmarried (1.0 percent were married). The two groups were not significantly different, except that at the original intake the nurse-visited women lived in households with less discretionary income, higher person-per-room density, and higher scores on the household poverty index.

Women in the control group were provided free transportation for scheduled prenatal care plus developmental screening and referral for the child at 6, 12, and 24 months of age. Women in the nurse-visited treatment group were provided the same services, plus prenatal, infancy, and child home visits through the child’s second birthday.

The primary child outcomes were derived from tests of children’s academic achievement, interviews with children and parents, reviews of children’s school records, and teachers’ ratings of children. Standardized tests and end-of-year grade-point average were used for assessing reading and math achievement. The tests included the Peabody Individual Achievement Test and the Tennessee Comprehensive Assessment Program for grades 1 through 6. Information on children's use of cigarettes, alcohol, and marijuana was obtained from the child interview. Information on externalizing and internalizing problems and total behavior problems was obtained from teachers’, parents’, and children’s reports using forms from the Achenbach System of Empirically Based Assessment. Arrests by age 12 came from the parent and child reports.

The study also assessed four secondary outcomes: 1) special education placement, 2) grade retention, and 3) grade retention and conduct grades obtained from school records, and 4) sustained attention obtained from the Letter R Sustained Attention Test.

Data was analyzed using an intent-to-treat analysis. Continuous dependent variables were analyzed in the general linear model and dichotomous variables in the logistic linear model. For low-frequency count outcomes, the data was analyzed in generalized linear models with negative binomial error assumptions.

Study 3
There have been several reports that examined the outcome results of a randomized trial conducted in Elmira, New York, looking at the effects of the NFP intervention on a study sample of 400 socially disadvantaged pregnant women with no previous births. Eckenrode and colleagues (2000) conducted a long-term follow-up of the women and their children from the original sample who received home visitation between April 1978 and September 1980. The original study sample was randomly assigned to receive one of three intervention conditions: 1) routine perinatal care (the control group), 2) routine care plus nurse home visit during pregnancy only (first intervention), or 3) routine care plus nurse home visits during pregnancy and through the child’s second birthday (second intervention). The original sample included 47 percent of mothers who were under age 19, 62 percent who were unmarried, and 61 percent who came from households classified as low socioeconomic status. There were no significant differences in the age, education, or marital status of the women in the study. The 15-year follow-up included 324 mothers and their children (81 percent of mothers who were originally randomized). The control group included 184 participants, the group that received home visitations during pregnancy only included 100 participants, and the group that received home visitations during pregnancy through the child’s second birthday included 116 participants.

At the 15-year follow-up, mothers were interviewed using a life-history calendar designed to help them recall major life events, such as births of subsequent children, marriages/partnerships, education, employment, moves, and housing arrangements. Mothers also reported their exposure to domestic violence using the violence subscale of the Conflict Tactics Scale. The measure used for analysis consisted of the total number of times the mother reported having experienced any form of partner-perpetrated violence since the birthday of the study child. Variables were also constructed reflecting frequency of major and minor violence. Minor violence included throwing items, pushing, and slapping. Major violence included kicking, biting, hitting with a hand or an object, beating, choking, threatening with a knife or gun, or using a knife or gun. New York State Child Protective Services (CPS) records were also reviewed. Reports involving either the mother as the perpetrator or the study child as the subject were coded. Substantiated reports were abstracted to ascertain key features of the maltreatment incident.

The primary outcome measure of interest for the analysis was the number of substantiated reports over the 15-year follow-up period involving the study child, regardless of the identity of the perpetrator, or involving the mother as the perpetrator, regardless of the identity of the child. Maltreatment type was distinguished between neglect only and abuse only. The analyses included a 3x2x2 factorial structure: treatment (control group versus the first intervention group versus the second intervention group), maternal marital status (married versus unmarried at study registration) and social class (Hollingshead levels III or IV versus I or II at registration). The abuse and neglect outcome results were reported as incidence and log incidence. The distribution of outcomes used a Poisson log-linear model.
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A study by Olds and colleagues (2010) found that during the 12-year follow-up period, the Government spent less per year on food stamps, Medicaid, and Aid to Families with Dependent Children and Temporary Assistance for Needy Families for nurse-visited than control families ($8,772 versus $9,797); this represents $12,300 in discounted savings compared with a program cost of $11,511, both expressed in 2006 US dollars.
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Implementation Information

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Information about implementing the Nurse-Family Partnership (NFP) program can be found on the NFP Web site.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Olds, David L., JoAnn Robinson, Lisa M. Pettitt, Dennis W. Luckey, John R. Holmberg, Rosanna K. Ng, Kathy Isacks, Karen L. Sheff, and Charles R. Henderson Jr. 2004. “Effects of Home Visits by Paraprofessionals and by Nurses: Age 4 Follow-Up Results of a Randomized Trial.” Pediatrics 114(6):1560–68.

Study 2
Kitzman, Harriet J., David L. Olds, Robert E. Cole, Carole A. Hanks, Elizabeth A. Anson, Kimberly J. Sidora–Arcoleo, Dennis W. Luckey, Michael D. Knudtson, Charles R. Henderson, and John R. Holmberg. 2010. “Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Children.” Archives of Pediatrics & Adolescent Medicine 164(5):412–18.

Study 3
Eckenrode, John, Mary Campa, Dennis W. Luckey, Charles R. Henderson Jr., Robert E. Cole, Harriet J. Kitzman, Elizabeth A. Anson, Kimberly J. Sidora–Arcoleo, Jane Powers, and David L. Olds. 2000. “Long-Term Effects of Prenatal and Infancy Nurse Home Visitation on the Life Course of Youths, 19-Year Follow-Up of a Randomized Trial.” Archives of Pediatrics & Adolescent Medicine 164(1):9–15.
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Additional References

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These sources were used in the development of the program profile:

Nurse-Family Partnership. 2011. “Home.” Accessed June 7, 2011.

Olds, David L. 2007. “Preventing Crime With Prenatal and Infancy Support of Parents: The Nurse–Family Partnership.” Victims & Offenders 2(2):205–25.

———. 2008. “Preventing Child Maltreatment and Crime With Prenatal and Infancy Support of Parents: The Nurse–Family Partnership.” Journal of Scandinavian Studies in Criminology and Crime Prevention 9:2–24.

Olds, David L., Charles R. Henderson Jr., Harriet J. Kitzman, John Eckenrode, Robert E. Cole, and Robert C. Tatelbaum. 1998. “The Promise of Home Visitation: Results of Two Randomized Trials.” Journal of Community Psychology 26(1):5–21.

Olds, David L., Harriet J. Kitzman, Robert E. Cole, Carole A. Hanks, Kimberly J. Sidora–Arcoleo, Elizabeth A. Anson, Dennis W. Luckey, Michael D. Knudtson, Charles R. Henderson Jr., Jessica Bondy, and Amanda J. Stevenson. 2010. “Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Maternal Life Course and Government Spending.” Archives of Pediatrics & Adolescent Medicine 164(5):419–24.

Olds, David L., Harriet J. Kitzman, Robert E. Cole, and JoAnn Robinson. 1997. “Theoretical Foundations of a Program of Home Visitation for Pregnant Women and Parents of Young Children.” Journal of Community Psychology 25(1):9–26.

Olds, David L., JoAnn Robinson, Ruth O’Brien, Dennis W. Luckey, Lisa M. Pettitt, Charles R. Henderson Jr., Rosanna K. Ng, Karen L. Sheff, Jon Korfmacher, Susan Hiatt, and Ayelet Talmi. 2002. “Home Visiting by Paraprofessionals and by Nurses: A Randomized, Controlled Trial.” Pediatrics 110(3):486–96.

Sidora–Arcoleo, Kimberly H., Elizabeth A. Anson, Michael Lorber, Robert E. Cole, David L. Olds, and Harriet J. Kitzman. 2010. “Differential Effects of a Nurse Home-Visiting Intervention on Physically Aggressive Behavior in Children.” Journal of Pediatric Nursing 25:35–45.
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Program Snapshot

Age: 0 - 4, 14 - 24

Gender: Both

Race/Ethnicity: Black, American Indians/Alaska Native, Hispanic, White

Geography: Rural, Suburban, Urban

Setting (Delivery): Home

Program Type: Conflict Resolution/Interpersonal Skills, Family Therapy, Parent Training, Children Exposed to Violence

Targeted Population: Children Exposed to Violence, Families

Current Program Status: Active

Listed by Other Directories: Child Exposure to Violence Evidence Based Guide, Campbell Collaboration, Model Programs Guide, National Registry of Evidence-based Programs and Practices, Blueprints for Healthy Youth Development (formerly Blueprints for Violence Prevention), Top Tier Evidence Initiative

Program Developer:
Nurse–Family Partnership National Service Office
1900 Grant Street, Suite 400
Denver CO 80203
Phone: 866.864.5226
Fax: 303.327.4260

Program Developer:
David Olds
Professor of Pediatrics and Director
Prevention Research Center for Family and Child Health, University of Colorado Denver
13121 East 17th Avenue, Room 5317, M.S. 8410, P.O. Box 6511
Aurora CO 80045
Phone: 303.724.2892
Fax: 303.724.2901