Objective: The translation of complex, well-tested experimental nursing interventions into clinical practice can be problematic unless the dissemination process is carefully planned and monitored. The National Center for Children, Families and Communities is an interdisciplinary Center of the Schools of Nursing and Medicine at the University of Colorado Health Sciences Center that is devoted to research, development and replication of effective programs that improve the lives of children and families in the context of the communities in which they live. The first major initiative undertaken by the Center is the replication of the Nurse-Family Partnership (NFP), a home visitation program serving low-income, first-time mothers from pregnancy through the child’s second birthday. The objectives of this study were to: (a) identify the degree to which the replication sites conducted the program in accordance with the model tested in randomized trials, and (b) compare the health and social functioning of women, children, and families enrolled in the replication sites to benchmark outcomes attained in the randomized trials.
Design: The study employed a descriptive design with data from the replication sites compared to benchmarks for program implementation and outcomes drawn from the randomized clinical trials.
Setting and Sample: The sample included 21,198 first-time mothers and their infants enrolled in NFP programs from 7/1/96 through 6/30/01 in 23 states. At program entry, participants ranged in age from 10 to 42 years, were predominantly unmarried (77%), and reported a median household income of $10,500. With respect to race and ethnicity, 52% of the women identified themselves as White, non-Hispanic, 19% as African-American, 17% as Hispanic, 7% as Native American, 1% as Asian, and 4% as bi-racial.
Variables: Measures of program fidelity included the frequency, length and content of home visits. The impact of the intervention on maternal and child functioning examined the reduction in women’s substance use during pregnancy, percent of premature and low birth weight infants, and rates of subsequent pregnancies.
Methods: Home visitors at replication sites completed a set of standardized record keeping forms based on measures used in the randomized trials.
Findings: The number of completed visits (Mean=8.1), the completed to expected visit ratio (Mean=0.7), length of visits (Mean=81 minutes), and the proportion of time spent on various content areas by nurses in the replication sites during the pregnancy phase of the intervention were relatively comparable to that observed for the randomized trials. Following the birth of the infant, the number of completed visits (Mean=17.0) and the completed to expected visit ratio (Mean=0.4) were lower in the replication sites than in the trials (Means=21.4 and 0.5, respectively). We also found a lower emphasis by nurses on time allocated to maternal role content in the replication sites during the infancy (Mean=34.5%) and toddler stages (Mean=35.3) than by nurses in the clinical trials (Means=48.8 and 42.0, respectively). With respect to change in participants’ health related behaviors during pregnancy, the proportion of cigarette smokers decreased significantly from 18.2% at program enrollment to 15.7% at the 36th week of pregnancy at the replication sites; the overall proportion of women’s use of other substances (marijuana, alcohol, illicit drugs) also decreased significantly from 2.4% at program enrollment to 1.6% at the 36th week of pregnancy. The percent of premature infants was 9% compared to 11% in the trials and the percent of low birth infants was 8%, comparable to that observed in the trials. The percent of women with one or more subsequent pregnancies within 24 months following the birth of the first child was 33%, which compares favorably with the results of the trials (28 to 36% depending on the racial and ethnic composition of the study population).
Conclusions: While we are cautiously optimistic about program implementation at our replication sites, we have identified two areas of concern: (a) the lower rates of completed visits following birth of the infant (a factor that may be related to higher levels of participant attrition than observed in the trials) and (b) home visitors’ under emphasis on maternal role development during the infancy and toddler stages. Preliminary analyses of selected indicators of the health of the women and children enrolled in the program suggest that the program is continuing to achieve its intended effects as it is replicated outside of research settings, although the strength of effects is somewhat less than that observed in the trials.
Implications: Effective translation of a research intervention into evidence-based practice requires careful planning.
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