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Maternal and Child Health Leadership Conference Translating Research into MCH Public Health Practice

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Maternal and Child Health Leadership Conference ... University of Colorado. Health Sciences Center. David Olds, PhD. May 17, 2004. Baltimore, 1970 ... – PowerPoint PPT presentation

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Title: Maternal and Child Health Leadership Conference Translating Research into MCH Public Health Practice


1
Maternal and Child Health Leadership
Conference Translating Research into MCH Public
Health Practice The Role of Evaluation Plenary
II Home Visitation May 17, 2004
Making Change Happen Translating Research into
MCH Public Health Practice The Role of Evaluation
2
David Olds, PhD
  • Professor of Pediatrics, Psychiatry, and
    Preventive Medicine
  • University of Colorado
  • Health Sciences Center

May 17, 2004
3
Baltimore, 1970
4
NURSE FAMILY PARTNERSHIP
  • Program with power
  • Make sense to parents
  • Solid clinical underpinnings
  • Nurse home visits from pregnancy through child
    age two
  • Rigorously tested

5
FAMILIES SERVED
  • Low income pregnant women
  • Usually teens
  • Usually unmarried
  • First-time parents

6
THREE GOALS
  • Improve pregnancy outcomes
  • Improve child health and development
  • Improve parents economic self-sufficiency

7
Prenatal Health-Related Behaviors
Child Neurodevelopmental Impairment
Child/Adolescent Functioning
Dysfunctional Caregiving
Program
Emotional/Behavior Dysregulation
Antisocial Behavior Substance Abuse
Cognitive Impairment
Maternal Life Course
Closely Spaced Unplanned Pregnancy
Negative Peers
Welfare Dependence
Substance Abuse
8
TRIALS OF PROGRAM
Elmira, NY
Memphis, TN
Denver, CO
N 400
N 1,138
N 735
  • Low-income whites
  • Semi-rural
  • Low-income
  • blacks
  • Urban
  • Large portion of Hispanics
  • Nurse versus paraprofessional visitors

9
CONSISTENT RESULTS ACROSS TRIALS
  • Improvements in womens prenatal health
  • Reductions in childrens injuries
  • Fewer subsequent pregnancies
  • Greater intervals between births
  • Increases in fathers involvement
  • Increases in employment
  • Reductions in welfare and food stamps
  • Improvements in school readiness

10
Elmira Maltreatment Injuries (0 - 2 Years)
  • 80 Reduction in Child Maltreatment
  • (Poor, Unmarried Teens)
  • 56 Reduction in Emergency Room Visits (12-24
    Months)

11
100
60
Simultaneous Region of Treatment Differences (p lt
.10)
50
Abuse / Neglect
40
30
20
Comparison
10
Nurse
0
9
10
11
12
13
14
Maternal Sense of Control
12
(No Transcript)
13
ELMIRA SUSTAINABLE RESULTS Mothers

LOW-INCOME, UNMARRIED 15-YEAR FOLLOW-UP
14
ELMIRA SUSTAINABLE RESULTS Adolescents

15-YEAR OLDS BORN TO UNMARRIED, LOW-INCOME MOTHERS
15
Cumulative Cost Savings Elmira High-Risk
Families
Cumulative savings
Cumulative dollars per child
Cumulative Costs
Age of child (years)
16
Memphis Design
  • Urban Setting
  • Sample (N 1139 for prenatal and N 743 for
    postnatal)
  • 92 African American
  • 98 Unmarried
  • 85 lt Federal Poverty Index
  • 64 lt 19 years at intake
  • Randomized Trial

17
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

18
Diagnosis for Hospitalization in which Injuries
and Ingestions Were Detected Nurse-Visited (n204)
  • 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

Kitzman, H., Olds, D.L., Henderson, Jr., C.R., et
al. JAMA 1997 278 644-652.
19
Diagnosis for Hospitalization in which Injuries
and Ingestions Were Detected - Comparison (n453)
  • 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 Hemotoma 4.9 19
  • Fractured Skull 5.2 5
  • Bilateral Subdural Hemotoma (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

20
1.5
Comparison
1.0
Simultaneous Region of Treatment Differences (p lt
.05)
No. Health Care Encounters with
Injuries/Ingestions
0.5
Nurse
0.0
60
70
80
90
100
110
120
130
Mothers Psychological Resources
21
3.5
3.0
2.5
No. Days Hospitalized with Injuries/Ingestions
2.0
Comparison
1.5
Simultaneous Region of Treatment Differences (p lt
0.05)
1.0
0.5
Nurse
0.0
60
110
120
130
80
90
100
70
Mothers Psychological Resources
22
Enduring Effects on Maternal Life-Course in
Memphis
  • 31 Fewer Closely Spaced (lt6 months) Subsequent
    Pregnancies
  • 50 Fewer Subsequent Therapeutic Abortions
  • 30 Fewer Subsequent Admissions to Neonatal
    Intensive Care
  • 3.64 Fewer Months of Welfare Use
  • 32 Increase in Father Presence in Household
  • 50 Increase in Marriage

Kitzman, Olds, Sidora, et al. Journal of the
American Medical Association, April 19, 2000
1983-1989.
23
Growing Effects on Child Development Memphis
6-Year
  • Higher IQs
  • Better language development
  • Fewer mental health problems

24
Denver Maternal Characteristics
Married 13 Mexican American 46 African
American 17 European American (Non-Hispanic)
35 Monolingual Spanish Speakers
4 Cigarette Smokers 25
25
Denver Design
735 Families
Nurses N236
Controls N255
Paraprofessionals N244
26
Pattern of Denver Program Effects
Maternal and Child Functioning
Comparison
Para
Nurse
27
Change in Cotinine From Intake to End of Pregnancy
100
Change In Cotinine
0
Control -36.6
Para -73.8
-100
-200
Nurse -235.6
-300
-400
P lt .05
28
(No Transcript)
29
Preschool Language Scale 21 months (Born to
Low-Resource Mothers)
PC-N .04
30
Child Executive Functioning Index
4-Years (Born to Low-Resource Mothers)
Pc-p .06, ES .29 Pc-n .000, ES .47
31
Child Activity Level - 4-Years (Born to
Low-Resource Mothers)
Pc-n .02 ES .39
32
NATIONAL REPLICATION
Now operating in over 250 counties in 23 states,
serving over 12,000 families per year.
33
FROM SCIENCE TO PRACTICE
  • Nurturing Community, Organizational, and State
    Development
  • Training and Technical Assistance
  • Program Guidelines
  • Clinical Information System
  • Assessing Program Performance
  • Continuous Improvement

34
Communities Served as of January 2004
5
6
3
2
2
3
1
23
30
1
1
4
1
1
46
11
3
2
1
1
77
8
13
Numbers indicate number of counties in which
the program serves clients
35
Typical Sources of Funding
  • Medicaid
  • TANF
  • Child Welfare
  • Maternal and Child Health
  • Juvenile Justice

36
(No Transcript)
37
  • Use of Para-Professionals in Home Visitation
    Interventions Results from the San Diego
    Randomized Trial and Reflections on Related
    Studies
  • John Landsverk, Ph.D.
  • Professor of Social Work
  • San Diego State University
  • May 17, 2004 UIC MCH Conference

38
Healthy Families San Diego
  • Combined funding from state agency and two
    foundations CA DSS-OCAP, CA Wellness Fd.,
    Stuart Fd., with supplemental funding from the
    federal AHCPR
  • Purpose - to test the Hawaii model within a State
    of California context.
  • Direct replication of Hawaii Johns Hopkins study
    (Duggan)
  • screening and assessment procedures
  • randomized design - yearly outcomes measures to
    3rd birthday
  • data collection independent of program with same
    measures

39
Overall Study Objective
  • Determine whether in-home family support services
    by paraprofessionals result in
  • improved child health and development outcomes
  • improved parental life course outcomes
  • reduced risk for child abuse and neglect
  • reduced incidence of child abuse and neglect
  • families being more effectively tied into other
    needed services in the community.

40
Intervention
  • Weekly home visits for up to 36 months
  • Limited caseloads - no more than 25 per home
    visitor
  • Enhancements of Hawaii program
  • Team case management
  • Child development specialist role
  • Structured groups
  • Pre-service and wrap around training
  • Focus on
  • Parent child relationship
  • Preventative health care
  • Child development

41
Healthy Families - San Diego Team
Team Leader LCSW
Child Development Specialist Available to entire
team
Home Visitor
Home Visitor
Home Visitor
Home Visitor
Home Visitor
42
Study Performance
  • Successful Randomization
  • No significant differences between groups at
    baseline or follow-up years on demographics and
    clinical risk factors
  • Substantial Cohort Retention
  • (N247) (N241)
  • Year One 89 Intervention 89.5, Control
    88.8
  • Year Two 83 Intervention 79.0,
    Control 86.0
  • Year Three 85 Intervention 83.0, Control
    86.0

43
Service Delivery Statistics (Intent to treat)
  • Total Home Visits for 247 Families Over 36 Months
  • Year One 3,807
  • Year Two 3,538
  • Year Three 2,563
  • Year Four 491
  • Total 10,489
  • Home Visits for 247 Families
  • Mean Median Range
  • Year One 20 20 0 - 55
  • Year Two 13 10 0 - 55
  • Year Three 10 6 0 47
  • 36 Months 43 40 0-144

44
Percent of Eligible Families Receiving Services
by Program Month
Percent of Eligible Families
Month
45
Repeat Pregnancy
Percent
46
Pregnancy Within 36 Months of Index Birth
By Group within Ethnicity
p .005
46
45
44
45


Percent
59
52
56
55
49
28
47
Any Live Births
Percent
48
Maternal Depressive Symptoms (CES-D)
Group x Time p .10
Mean CES-D Score
49
Any Neglect By Group (CTS-PC)
Percent
50
Use of Corporal Punishment By Group (CTS-PC)
p .07
Percent
51
Physical Assault By Group (CTS-PC)
p .87
p .14
Percent
p .11
52
Any Psychological Aggression (CTS-PC)
p .04
p .10
p .47
Percent
53
Frequency in Psychological Aggression - Users
p .17
p .03
p .01
Mean CTSPC Score
54
Frequency in Corporal Punishment - Users
p .44
p .77
p .005
Mean CTSPC Score
55
Bayley MDI Scale Scores
p .02
p .03
56
Number of Well Child Visits
p 0.05
p 0.01
57
Outcomes With No Significant Differences Between
Groups
  • Physical aggression by parent with child (CTS)
  • Neglect of child by parent (CTS)
  • Mother-Child interaction as observed on the NCAST
  • Home learning environment (measured by the HOME)
  • Maternal mental health /substance use by
    self-report
  • Intimate partner violence as reported by mother
    (CTS)
  • Maternal life course (degree completion,
    employment, receipt of welfare)
  • Use of social, mental health, and substance abuse
    services
  • Child behavior problems and adaptive functioning
    per mothers report at years 2 3 (CBCL and
    Vineland)
  • Mental functioning at year 3 (Stanford Benet)
  • Use of safety measures in the home

58
Reflections - Three Randomized Studies
  • San Diego stand-alone randomized trial
    comparing para-professional home visitation with
    control condition and yearly outcomes to third
    birthday of index child replication of design
    and measures from Hawaii study
  • Hawaii embedded service system randomized trial
    comparing para-professional home visitation with
    control condition and yearly outcomes to third
    birthday of index children
  • Denver stand-alone randomized trial of home
    visitation comparing nurses, community based
    para-professionals, and control condition with
    yearly outcomes from pre-natal period to second
    birthday of index child

59
San Diego Hawaii Studies
  • No Significant Differences Observed
  • Maternal Life Course (degree completion,
    employment, receipt of welfare)
  • Parenting Behavior and Attitudes (home learning
    environment and mother-child interactions
  • Child Abuse and Neglect (incidence of neglect,
    corporal punishment, and
  • physical assault)
  • Child Preventive Health Care (immunizations)
  • Home Environment (social support, confidence in
    relations, maternal substance use)
  • Cognitive development, problem behaviors,
    subsequent births or spacing of subsequent births

60
San Diego Hawaii Studies
  • Positive Outcomes in San Diego
  • Not Observed in Hawaii
  • Number of well child visits Years 1, 2, 3
  • Mothers school attendance - Year 3
  • Bayley Mental Development Index Years 1 2
  • Frequency in Use of Mother to Child Psychological
    Aggression or Corporal Punishment Years 2 3
    (users)
  • Mothers depression scores at Year 2

61
Denver Home Visitation Trial
  • Paraprofessional Home Visitor Outcomes
  • More responsive Mother-child interactions
    (mothers with low psychological resources) than
    control group counterparts,
  • Trend (p .10)
  • to reduce subsequent pregnancies and births,
  • to delay subsequent pregnancies.

62
Denver Home Visitation Trial
  • Nurse Home Visitor Outcomes compared to control
    group counterparts
  • Maternal Outcomes
  • Greater reduction in cotinine levels from intake
    to end of pregnancy (tobacco use),
  • Reduction in subsequent pregnancies and birth -
    24 months,
  • Longer intervals until next conception - 24
    months,
  • Employed longer during second year after childs
    birth.

63
Denver Home Visitation Trial
  • Nurse Home Visitor Outcomes compared to control
    group counterparts
  • Caregiving Child Outcomes
  • More responsive mother-child interactions,
  • Infants at 6 months of age less likely to
    exhibit emotional vulnerability in response to
    fear stimuli,
  • Infants born to mothers with low psychological
    resources less likely to display low emotional
    vitality in response to joy and anger stimuli,
  • Children less likely to exhibit language delays
    at 21 months,
  • Children born to mothers with low psychological
    resources had superior average language and
    mental health development,

64
Summary Questions and Results
  • (1) Will greater dosage result in better
    outcomes?
  • San Diego Denver and gt Hawaii with comparable
    results
  • (2) Will greater structure to the program model
    result in better outcomes? Denver gt Hawaii and
    San Diego with comparable results
  • (3) Will longer program duration result in
    better outcomes? Denver (2.5 years) lt Hawaii and
    San Diego (3 years) with comparable results
  • (4) Will different models, contexts and research
    teams lead to different results? Program models,
    contexts, and research teams all differed with
    comparable results.
  • (5) Overall, differences between
    para-professionals and control condition were few
    in number and small when observed.
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