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Making Change Happen Translating Research into MCH Public Health Practice: The Role of Evaluation

Making Change Happen Translating Research into MCH Public Health Practice: The Role of Evaluation. Maternal and Child Health Leadership Conference Translating Research into MCH Public Health Practice: The Role of Evaluation Plenary II: Home Visitation May 17, 2004. David Olds, PhD.

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Making Change Happen Translating Research into MCH Public Health Practice: The Role of Evaluation

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  1. Making Change Happen Translating Research into MCH Public Health Practice: The Role of Evaluation Maternal and Child Health Leadership ConferenceTranslating Research into MCH Public Health Practice: The Role of EvaluationPlenary II: Home VisitationMay 17, 2004

  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 women’s prenatal health • Reductions in children’s 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 < .10) 50 % Abuse / Neglect 40 30 20 Comparison 10 Nurse 0 9 10 11 12 13 14 Maternal Sense of Control

  12. Verified reports of child abuse and neglect 79% Behavioral problems due to drug or alcohol use 44% Arrests 69% ELMIRA SUSTAINABLE RESULTS: Mothers LOW-INCOME, UNMARRIED 15-YEAR FOLLOW-UP

  13. Arrests 54% Convictions 69% Sexual Partners 58% Cigarettes Smoked 28% Number of days consuming alcohol 51% ELMIRA SUSTAINABLE RESULTS: Adolescents 15-YEAR OLDS BORN TO UNMARRIED, LOW-INCOME MOTHERS

  14. Cumulative Cost Savings: Elmira High-Risk Families Cumulative savings Cumulative dollars per child Cumulative Costs Age of child (years)

  15. Memphis Design • Urban Setting • Sample (N = 1139 for prenatal and N = 743 for postnatal) • 92% African American • 98% Unmarried • 85% < Federal Poverty Index • 64% < 19 years at intake • Randomized Trial

  16. 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

  17. 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 Kitzman, H., Olds, D.L., Henderson, Jr., C.R., et al. JAMA 1997; 278: 644-652.

  18. 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 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

  19. 1.5 Comparison 1.0 Simultaneous Region of Treatment Differences (p < .05) No. Health Care Encounters with Injuries/Ingestions 0.5 Nurse 0.0 60 70 80 90 100 110 120 130 Mothers’ Psychological Resources

  20. 3.5 3.0 2.5 No. Days Hospitalized with Injuries/Ingestions 2.0 Comparison 1.5 Simultaneous Region of Treatment Differences (p < 0.05) 1.0 0.5 Nurse 0.0 60 70 80 90 100 110 120 130 Mothers’ Psychological Resources

  21. Enduring Effects on Maternal Life-Course in Memphis • 31% Fewer Closely Spaced (<6 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.

  22. Growing Effects on Child Development Memphis 6-Year • Higher IQ’s • Better language development • Fewer mental health problems

  23. Denver Maternal Characteristics Married 13% Mexican American 46% African American 17% European American (Non-Hispanic) 35% Monolingual Spanish Speakers 4% Cigarette Smokers 25%

  24. Denver Design 735 Families Nurses N=236 Paraprofessionals N=244 Controls N=255

  25. Pattern of Denver Program Effects Maternal and Child Functioning Comparison Para Nurse

  26. 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 < .05

  27. Preschool Language Scale 21 months (Born to Low-Resource Mothers) PC-N = .04

  28. Child Executive Functioning Index 4-Years (Born to Low-Resource Mothers) Pc-p = .06, ES = .29; Pc-n = .000, ES = .47

  29. Child Activity Level - 4-Years (Born to Low-Resource Mothers) Pc-n = .02 ES = .39

  30. NATIONAL REPLICATION Now operating in over 250 counties in 23 states, serving over 12,000 families per year.

  31. FROM SCIENCE TO PRACTICE • Nurturing Community, Organizational, and State Development • Training and Technical Assistance • Program Guidelines • Clinical Information System • Assessing Program Performance • Continuous Improvement

  32. Communities Served as of January 2004 5 6 3 2 2 3 23 1 30 1 1 4 1 1 46 11 2 3 1 1 77 8 13 * Numbers indicate number of counties in which the program serves clients

  33. Typical Sources of Funding • Medicaid • TANF • Child Welfare • Maternal and Child Health • Juvenile Justice

  34. 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

  35. 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

  36. 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.

  37. 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

  38. 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

  39. Study Performance • Successful Randomization • No significant differences between groups at baseline or follow-up years on demographics and clinical risk factors • Substantial Cohort Retention (N=247) (N=241) • 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%

  40. 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

  41. Percent of Eligible Families Receiving Services by Program Month Percent of Eligible Families Month

  42. Repeat Pregnancy Percent

  43. Pregnancy Within 36 Months of Index Birth By Group within Ethnicity p = .005 46 45 44 45 Percent 59 52 56 55 49 28

  44. Any Live Births Percent

  45. Maternal Depressive Symptoms (CES-D) Group x Time p = .10 Mean CES-D Score

  46. Any Neglect By Group (CTS-PC) Percent

  47. Use of Corporal Punishment By Group (CTS-PC) p = .07 Percent

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