Cluster Randomized Controlled Trial of Intervention to Increase Participant Retention and Completed Home Visits in the Nurse-Family Partnership.

We conducted a cluster-based randomized controlled trial of an intervention designed to improve participant retention in community replication sites of the Nurse-Family Partnership (NFP). We registered 26 sites and randomized them into three groups: retention intervention (RI, N = 9), delayed RI (DRI, N = 6), or control (C, NFP as usual, N = 11). The RI consisted of training nurses to give more explicit control over the frequency of visits and content of the program to the parent participants. Two of the sites assigned to the RI, two assigned to the DRI, and two out of four nurses in one other site assigned to the DRI chose not to participate in the intervention. Primary analyses (intention to treat) contrasted changes in participant retention and completed visits (the primary outcomes) in the two intervention groups (RI and DRI) compared to control sites, focusing on differences in performance among baseline cohorts compared to cohorts enrolled during the first year during which the retention intervention was implemented. Compared to baseline, retention declined in the control sites over time but stayed the same in the RI and DRI sites (p value for interaction = 0.099). Compared to baseline, the number of completed home visits declined over time in the control sites but did not in the RI and DRI sites, producing a significant treatment difference in change in mean completed home visits over time (2.71 visits, SE = 1.164, p = 0.020). The intervention offset a decline over time in retention and completed home visits found in the control group during the time covered by this trial. Quantitative and qualitative evaluation of the intervention indicated that improvements are needed to promote its uptake.

Effects of home visits by paraprofessionals and by nurses on children: follow-up of a randomized trial at ages 6 and 9 years.

IMPORTANCE: The Nurse-Family Partnership delivered by nurses has been found to produce long-term effects on maternal and child health in replicated randomized trials. A persistent question is whether paraprofessional home visitors might produce comparable effects. OBJECTIVE: To examine the impact of prenatal and infancy/toddler home visits by paraprofessionals and by nurses on child development at child ages 6 and 9 years. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial in public and private care settings in Denver, Colorado, of 735 low-income women and their first-born children (85% of the mothers were unmarried; 47% were Hispanic, 35% were non-Hispanic white, 15% were African American, and 3% were American Indian/Asian). INTERVENTIONS: Home visits provided from pregnancy through child age 2 years delivered in one group by paraprofessionals and in the other by nurses. MAIN OUTCOMES AND MEASURES: Reports of children's internalizing, externalizing, and total emotional/behavioral problems, and tests of children's language, intelligence, attention, attention dysfunction, visual attention/task switching, working memory, and academic achievement. We hypothesized that program effects on cognitive-related outcomes would be more pronounced among children born to mothers with low psychological resources. We report paraprofessional-control and nurse-control differences with P < .10 given similar effects in a previous trial, earlier effects in this trial, and limited statistical power. RESULTS: There were no significant paraprofessional effects on emotional/behavioral problems, but paraprofessional-visited children born to mothers with low psychological resources compared with control group counterparts exhibited fewer errors in visual attention/task switching at age 9 years (effect size = -0.30, P = .08). There were no statistically significant paraprofessional effects on other primary outcomes. Nurse-visited children were less likely to be classified as having total emotional/behavioral problems at age 6 years (relative risk [RR] = 0.45, P = .08), internalizing problems at age 9 years (RR = 0.44, P = .08), and dysfunctional attention at age 9 years (RR = 0.34, P = .07). Nurse-visited children born to low-resource mothers compared with control-group counterparts had better receptive language averaged over ages 2, 4, and 6 years (effect size = 0.30, P = .01) and sustained attention averaged over ages 4, 6, and 9 years (effect size = 0.36, P = .006). There were no significant nurse effects on externalizing problems, intellectual functioning, and academic achievement. CONCLUSIONS AND RELEVANCE: Children born to low-resource mothers visited by paraprofessionals exhibited improvement in visual attention/task switching. Nurse-visited children showed improved behavioral functioning, and those born to low-resource mothers benefited in language and attention but did not improve in intellectual functioning and academic achievement. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00438282 and NCT00438594.

Quasi-experimental pilot study of intervention to increase participant retention and completed home visits in the nurse-family partnership.

We evaluated an intervention to increase participant retention and engagement in community practice settings of the Nurse-Family Partnership (NFP), an evidence-based program of nurse home visiting for low-income, first-time parents. Using a quasi-experimental design (6 intervention and 11 control sites that delivered the NFP), we compared intervention and control sites on retention and number of completed home visits during a 10-month period after the intervention was initiated. Nurses at the five intervention sites were guided in tailoring the frequency, duration, and content of the visits to participants' needs. NFP nurses at the control sites delivered the program as usual. At the intervention sites, participant retention and completed home visits increased from the pre-intervention to intervention periods, while at the control sites, these outcomes decreased from the pre-intervention to intervention periods, leading to a significant intervention-control difference in change in participant retention (hazard ratio, 0.42; p = 0.015) and a 1.4 visit difference in change in completed home visits (p < 0.001, ES = 0.36). We conclude that training nurse home visitors to promote adaptation of program dosage and content to meet families' needs shows promise as a way to improve participant retention and completed home visits.

Mixed methods analysis of participant attrition in the nurse-family partnership.

Participant attrition is a major influence on the effectiveness of evidence-based interventions. Assessing predictors of participant attrition and nurse and site characteristics associated with it could lay a foundation for increasing retention and engagement. We examined this issue in the national expansion of the Nurse-Family Partnership, an evidence-based program of prenatal and infancy home visiting for low-income, first-time mothers, their children, and families. Using a mixed methods approach, we examined participant, nurse, and site predictors of participant attrition and completed home visits. We used mixed multivariate regression models to identify participant, nurse, program, and site predictors of addressable attrition and completed home visits during pregnancy and the first year of the child's life for 10,367 participants at 66 implementation sites. We then conducted semi-structured interviews with nurse home visitors and supervisors at selected sites with the highest (N = 5 sites) and lowest (N = 6 sites) rates of participant addressable attrition and employed qualitative methods to synthesize themes that emerged in nurses' descriptions of the strategies they used to retain participants. Mothers who were younger, unmarried, African American, and visited by nurses who ceased employment had higher rates of attrition and fewer home visits. Hispanic mothers, those living with partners, and those employed at registration had lower rates of attrition. Those who were living with partners and employed had more home visits. Nurses in high retention sites adapted the program to their clients' needs, were less directive, and more collaborative with them. Increasing nurses' flexibility in adapting this structured, evidence-based program to families' needs may increase participant retention and completed home visits.

Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: follow-up of a randomized trial among children at age 12 years.

OBJECTIVE: To test, among an urban primarily African American sample, the effects of prenatal and infancy home visiting by nurses on mothers' fertility, partner relationships, and economic self-sufficiency and on government spending through age 12 years of their firstborn child. DESIGN: Randomized controlled trial. SETTING: Public system of obstetric and pediatric care in Memphis, Tennessee. PARTICIPANTS: A total of 594 urban primarily African American economically disadvantaged mothers (among 743 who registered during pregnancy). Intervention Prenatal and infancy home visiting by nurses. MAIN OUTCOME MEASURES: Mothers' cohabitation with and marriage to the child's biological father, intimate partner violence, duration (stability) of partner relationships, role impairment due to alcohol and other drug use, use and cost of welfare benefits, arrests, mastery, child foster care placements, and cumulative subsequent births. RESULTS: By the time the firstborn child was 12 years old, nurse-visited mothers compared with control subjects reported less role impairment owing to alcohol and other drug use (0.0% vs 2.5%, P = .04), longer partner relationships (59.58 vs 52.67 months, P = .02), and greater sense of mastery (101.04 vs 99.60, P = .005). During this 12-year period, 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 ($8772 vs $9797, P = .02); this represents $12 300 in discounted savings compared with a program cost of $11 511, both expressed in 2006 US dollars. No statistically significant program effects were noted on mothers' marriage, partnership with the child's biological father, intimate partner violence, alcohol and other drug use, arrests, incarceration, psychological distress, or reports of child foster care placements. CONCLUSION: The program improved maternal life course and reduced government spending among children through age 12 years.

Enduring effects of prenatal and infancy home visiting by nurses on children: follow-up of a randomized trial among children at age 12 years.

OBJECTIVE: To test the effect of prenatal and infancy home visits by nurses on 12-year-old, firstborn children's use of substances, behavioral adjustment, and academic achievement. DESIGN: Randomized controlled trial. SETTING: Public system of obstetric and pediatric care in Memphis, Tennessee. PARTICIPANTS: We studied 12-year-old, firstborn children (n = 613) of primarily African American, economically disadvantaged women (743 randomized during pregnancy). INTERVENTION: Program of prenatal and infancy home visits by nurses. OUTCOME MEASURES: Use of cigarettes, alcohol, and marijuana; internalizing, externalizing, and total behavioral problems; and academic achievement. RESULTS: By the time the firstborn child was 12 years of age, those visited by nurses, compared with those in the control group, reported fewer days of having used cigarettes, alcohol, and marijuana during the 30-day period before the 12-year interview (0.03 vs 0.18, P = .02) and were less likely to report having internalizing disorders that met the borderline or clinical threshold (22.1% vs 30.9%, P = .04). Nurse-visited children born to mothers with low psychological resources, compared with their control group counterparts, scored higher on the Peabody Individual Achievement Tests in reading and math (88.78 vs 85.70, P = .009) and, during their first 6 years of education, scored higher on group-administered standardized tests of math and reading achievement (40.52 vs 34.85, P = .02). No statistically significant program effects were found on children's externalizing or total behavioral problems. CONCLUSIONS: Through age 12, the program reduced children's use of substances and internalizing mental health problems and improved the academic achievement of children born to mothers with low psychological resources.

Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial.

OBJECTIVE: To examine the effect of prenatal and infancy nurse home visitation on the life course development of 19-year-old youths whose mothers participated in the program. DESIGN: Randomized trial. SETTING: Semirural community in New York. PARTICIPANTS: Three hundred ten youths from the 400 families enrolled in the Elmira Nurse-Family Partnership program. Intervention Families received a mean of 9 home visits (range, 0-16) during pregnancy and 23 (range, 0-59) from birth through the child's second birthday. MAIN OUTCOME MEASURES: Youth self-reports of educational achievement, reproductive behaviors, welfare use, and criminal involvement. RESULTS: Relative to the comparison group, girls in the pregnancy and infancy nurse-visited group were less likely to have been arrested (10% vs 30%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.13-0.82) and convicted (4% vs 20%; 0.20; 0.05-0.85) and had fewer lifetime arrests (mean: 0.10 vs 0.54; incidence RR [IRR], 0.18; 95% CI, 0.06-0.54) and convictions (0.04 vs 0.37; 0.11; 0.02-0.51). Nurse-visited girls born to unmarried and low-income mothers had fewer children (11% vs 30%; RR, 0.35; 95% CI, 0.12-1.02) and less Medicaid use (18% vs 45%; 0.40; 0.18-0.87) than their comparison group counterparts. CONCLUSIONS: Prenatal and infancy home visitation reduced the proportion of girls entering the criminal justice system. For girls born to high-risk mothers, there were additional positive program effects consistent with results from earlier phases of this trial. There were few program effects for boys.

Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial.

OBJECTIVE: Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2. METHODS: We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women <29 weeks' gestation, with previous live births and at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed), were randomly assigned to receive nurse home visits or comparison services. Primary outcomes consisted of intervals between births of first and second children and number of children born per year; mothers' stability of relationships with partners and relationships with the biological father of the child; mothers' use of welfare, food stamps, and Medicaid; mothers' use of substances; mothers' arrests and incarcerations; and children's academic achievement, school conduct, and mental disorders. Secondary outcomes were the sequelae of subsequent pregnancies, women's employment, experience of domestic violence, and children's mortality. RESULTS: Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes. CONCLUSIONS: By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.

Effects of nurse home-visiting on maternal life course and child development: age 6 follow-up results of a randomized trial.

OBJECTIVE: To test, with an urban, primarily black sample, the effects of prenatal and infancy home visits by nurses on mothers' fertility and economic self-sufficiency and the academic and behavioral adjustment of their children as the children finished kindergarten, near their sixth birthday. METHODS: We conducted a randomized, controlled trial of a program of prenatal and infancy home-visiting in a public system of obstetric and pediatric care in Memphis, Tennessee. A total of 743 primarily black women at <29 weeks of gestation, with no previous live births and with > or =2 sociodemographic risk characteristics (unmarried, <12 years of education, or unemployed), were randomly assigned to receive nurse home visits or comparison services. Outcomes consisted of women's number and timing of subsequent pregnancies, months of employment, use of welfare, food stamps, and Medicaid, educational achievement, behavioral problems attributable to the use of substances, rates of marriage and cohabitation, and duration of relationships with partners and their children's behavior problems, responses to story stems, intellectual functioning, receptive language, and academic achievement. RESULTS: In contrast to counterparts assigned to the comparison group, women visited by nurses had fewer subsequent pregnancies and births (1.16 vs 1.38 pregnancies and 1.08 vs 1.28 births, respectively), longer intervals between births of the first and second children (34.28 vs 30.23 months), longer relationships with current partners (54.36 vs 45.00 months), and, since the previous follow-up evaluation at 4.5 years, fewer months of using welfare (7.21 vs 8.96 months) and food stamps (9.67 vs 11.50 months). Nurse-visited children were more likely to have been enrolled in formal out-of-home care between 2 and 4.5 years of age (82.0% vs 74.9%). Children visited by nurses demonstrated higher intellectual functioning and receptive vocabulary scores (scores of 92.34 vs 90.24 and 84.32 vs 82.13, respectively) and fewer behavior problems in the borderline or clinical range (1.8% vs 5.4%). Nurse-visited children born to mothers with low levels of psychologic resources had higher arithmetic achievement test scores (score of 88.61 vs 85.42) and expressed less aggression (score of 98.58 vs 101.10) and incoherence (score of 20.90 vs 29.84) in response to story stems. There were no statistically significant program effects on women's education, duration of employment, rates of marriage, being in a partnered relationship, living with the father of the child, or domestic violence, current partner's educational level, or behavioral problems attributable to the use of alcohol or drugs. CONCLUSION: This program of prenatal and infancy home-visiting by nurses continued to improve the lives of women and children at child age 6 years, 4 years after the program ended.

Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial.

OBJECTIVE: To examine the effects of prenatal and infancy home visiting by paraprofessionals and by nurses from child age 2 through age 4 years. METHODS: We conducted, in public and private care settings in Denver, Colorado, a randomized, controlled trial with 3 arms, ie, control, paraprofessional visits, and nurse visits. Home visits were provided from pregnancy through child age 2 years. We invited 1178 consecutive, low-income, pregnant women with no previous live births to participate, and we randomized 735; 85% were unmarried, 47% Mexican American, 35% white non-Mexican American, 15% black, and 3% American Indian/Asian. Outcomes consisted of maternal reports of subsequent pregnancies, participation in education and work, use of welfare, marriage, cohabitation, experience of domestic violence, mental health, substance use, and sense of mastery; observations of mother-child interaction and the home environment; tests of children's language and executive functioning; and mothers' reports of children's externalizing behavior problems. RESULTS: Two years after the program ended, women who were visited by paraprofessionals, compared with control subjects, were less likely to be married (32.2% vs 44.0%) and to live with the biological father of the child (32.7% vs 43.1%) but worked more (15.13 months vs 13.38 months) and reported a greater sense of mastery and better mental health (standardized scores [mean = 100, SD = 10] of 101.25 vs 99.31 and 101.21 vs 99.16, respectively). Paraprofessional-visited women had fewer subsequent miscarriages (6.6% vs 12.3%) and low birth weight newborns (2.8% vs 7.7%). Mothers and children who were visited by paraprofessionals, compared with control subjects, displayed greater sensitivity and responsiveness toward one another (standardized score [mean = 100, SD = 10] of 100.92 vs 98.66) and, in cases in which the mothers had low levels of psychologic resources at registration, had home environments that were more supportive of children's early learning (score of 24.63 vs 23.35). Nurse-visited women reported greater intervals between the births of their first and second children (24.51 months vs 20.39 months) and less domestic violence (6.9% vs 13.6%) and enrolled their children less frequently in preschool, Head Start, or licensed day care than did control subjects. Nurse-visited children whose mothers had low levels of psychologic resources at registration, compared with control group counterparts, demonstrated home environments that were more supportive of children's early learning (score of 24.61 vs 23.35), more advanced language (score of 91.39 vs 86.73), superior executive functioning (score of 100.16 vs 95.48), and better behavioral adaptation during testing (score of 100.41 vs 96.66). There were no statistically significant effects of either nurse or paraprofessional visits on the number of subsequent pregnancies, women's educational achievement, use of substances, use of welfare, or children's externalizing behavior problems. CONCLUSIONS: Paraprofessional-visited mothers began to experience benefits from the program 2 years after the program ended at child age 2 years, but their first-born children were not statistically distinguishable from their control group counterparts. Nurse-visited mothers and children continued to benefit from the program 2 years after it ended. The impact of the nurse-delivered program on children was concentrated on children born to mothers with low levels of psychologic resources.

Home visiting by paraprofessionals and by nurses: a randomized, controlled trial.

OBJECTIVE: To examine the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health when both types of visitors are trained in a program model that has demonstrated effectiveness when delivered by nurses. METHODS: A randomized, controlled trial was conducted in public- and private-care settings in Denver, Colorado. One thousand one hundred seventy-eight consecutive pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were invited to participate. Seven hundred thirty-five women were randomized to control, paraprofessional, or nurse conditions. Nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the children's second birthdays. Paraprofessionals completed an average of 6.3 home visits during pregnancy and 16 visits from birth to the children's second birthdays. The main outcomes consisted of changes in women's urine cotinine over the course of pregnancy; women's use of ancillary services during pregnancy; subsequent pregnancies and births, educational achievement, workforce participation, and use of welfare; mother-infant responsive interaction; families' home environments; infants' emotional vulnerability in response to fear stimuli and low emotional vitality in response to joy and anger stimuli; and children's language and mental development, temperament, and behavioral problems. RESULTS: Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control-group counterparts (99.45 vs 97.54 standard score points). There were no other statistically significant paraprofessional effects. In contrast to their control-group counterparts, nurse-visited smokers had greater reductions in cotinine levels from intake to the end of pregnancy (259.0 vs 12.32 ng/mL); by the study child's second birthday, women visited by nurses had fewer subsequent pregnancies (29% vs 41%) and births (12% vs 19%); they delayed subsequent pregnancies for longer intervals; and during the second year after the birth of their first child, they worked more than women in the control group (6.83 vs 5.65 months). Nurse-visited mother-child pairs interacted with one another more responsively than those in the control group (100.31 vs 98.99 standard score points). At 6 months of age, nurse-visited infants, in contrast to their control-group counterparts, were less likely to exhibit emotional vulnerability in response to fear stimuli (16% vs 25%) and nurse-visited infants born to women with low psychological resources were less likely to exhibit low emotional vitality in response to joy and anger stimuli (24% vs 40% and 13% vs 33%). At 21 months, nurse-visited children born to women with low psychological resources were less likely to exhibit language delays (7% vs 18%); and at 24 months, they exhibited superior mental development (90.18 vs 86.20 Mental Development Index scores) than their control-group counterparts. There were no statistically significant program effects for the nurses on women's use of ancillary prenatal services, educational achievement, use of welfare, or their children's temperament or behavior problems. For most outcomes on which either visitor produced significant effects, the paraprofessionals typically had effects that were about half the size of those produced by nurses. CONCLUSIONS: When trained in a model program of prenatal and infancy home visiting, paraprofessionals produced small effects that rarely achieved statistical or clinical significance; the absence of statistical significance for some outcomes is probably attributable to limited statistical power to detect small effects. Nurses produced significant effects on a wide range of maternal and child outcomes.