Visit Attendance Patterns in Nurse-Family Partnership Community Sites.

We examined visit attendance patterns of mothers enrolled in the Nurse-Family Partnership (NFP) home visitation program and associations between these patterns and characteristics of the families and sites, with the goal of increasing participant engagement. We utilized repeated measures latent class analysis to identify attendance patterns among 66,967 mothers in NFP sites across the USA. Mothers enrolled from 1996 to 2010. Data were collected by home visitors and aggregated by the NFP National Service Office. Five visit attendance patterns were identified. Consistent attenders (22%) remained engaged for the full program and attended 51.3 visits on average. Inconsistent attenders (9%) remained engaged but missed many visits, with an average of 36.4 visits. The remaining patterns were characterized by when participants left the program: early (28%; 6.7 visits), gradually (27%; 19.4 visits), or late (15%; 35.3 visits). Consistent and inconsistent attenders were less likely to use English as their primary language than other participants (R = 0.12; p < .001). Participants with more nurse changes per visit attended were more likely to drop out early (R = 0.11; p < .001). Sites with a higher percent of missing data had smaller portions of mothers who remained consistently engaged in the program over time (b = - 0.032; p < .01) and greater portions in the late (b = 0.007; p < .04) and gradual attrition classes (b = 0.018; p < .01). The large number of participants who dropped out early is concerning. Further exploration of this group may optimize use of resources by improving either retention or targeting of potential participants.

Gestational Weight Gain and Health Outcomes 18 Years Later in Urban Black Women.

OBJECTIVES: Excessive gestational weight gain (GWG) is associated with higher body mass index (BMI) later in life. Increased BMI is associated with health problems, but there is limited evidence linking GWG directly to later health in black women. We examined the association between GWG and health conditions 18 years after a first birth. METHODS: This study was a secondary data analysis of 467 urban black women, enrolled during pregnancy (1990-1991). GWG was the difference between self-reported pre-pregnancy weight and measured weight at delivery. Hypertension, diabetes, obesity, and self-reported health were assessed with self-report and measurements of blood pressure, height, and weight, approximately 18 years after first childbirth. RESULTS: Higher pre-pregnancy BMI was associated with increased probability of each health condition. Higher GWG was associated with hypertension for women with a pre-pregnancy BMI under 21.3 kg/m(2) (P < .05) and obesity for women with a pre-pregnancy BMI under 25.9 kg/m(2) (P < .05). Diabetes and poor health were not associated with GWG. CONCLUSIONS: GWG may impact a mother's hypertension and obesity status 18 years after childbirth for underweight and normal weight women.

African American mothers' self-described discipline strategies with young children in 1992 and 2012.

In this qualitative descriptive study, 30 young, unmarried, low-income African American mothers in Memphis, TN, were interviewed in 2011-2012 about their discipline strategies with their 12- to 19-month-old children. Using content analyses, their strategies were described and compared with those from a similar sample in 1992. Findings suggest both continuity and change during that 20-year period. More mothers in 2011-2012 described the use of distraction and time out, suggesting a wider variety of strategies than were used in 1992. These findings may help clinicians to better understand disciplinary methods in young low-income African American mothers such as these in Memphis. Approaching mothers in a respectful and culturally sensitive manner will help them focus on effective, developmentally appropriate strategies consistent with their own parenting goals.

Patterns of visit attendance in the nurse-family partnership program.

OBJECTIVES: We examined visit attendance patterns in the Memphis trial of the Nurse-Family Partnership and associations between these patterns and family characteristics, outcomes, and treatment-control differences in outcomes. METHODS: We employed repeated measures latent class analysis to identify attendance patterns among the 228 mothers assigned to receive home nurse visits during pregnancy and until the child was aged 2 years, associated background characteristics, outcomes, and treatment-control differences by visit class. Home visits were conducted from June 1990 to March 1994. We collected outcome data from May 1992 to April 1994 and July 2003 to December 2006. RESULTS: We identified 3 visit attendance patterns. High attenders (48%) had the most visits and good outcomes. Low attenders (33%) had the most education and the best outcomes. Increasing attenders (18%) had the fewest completed visits during pregnancy, the poorest intake characteristics, and the poorest outcomes. Treatment-control group differences varied by class, with high and low attenders having better outcomes on some measures than did their control group counterparts. CONCLUSIONS: Three patterns were associated with distinct groups of mothers with different long-term outcomes. Further examination and use of patterns to classify mothers and prioritize resources may improve efficiency in the Nurse-Family Partnership.

Women's reasons for attrition from a nurse home visiting program.

OBJECTIVE: To describe mothers' reasons for leaving a home visiting program early. DESIGN: Qualitative descriptive study using semistructured interviews of mothers who dropped out of the Nurse-Family Partnership (NFP) and two focus groups with nurses and nurse supervisors at an NFP site. SETTING: A New York State site of a NFP home visitation program for low-income new mothers designed to improve the physical and emotional care of children. PARTICIPANTS: Participants included 21 mothers, 8 nurses, and 3 nurse-supervisors. METHODS: Semistructured interviews and focus groups were used to collect data, which were analyzed using content analysis. RESULTS: The program was not perceived to fit a mother's needs when she was overwhelmed with other responsibilities, the nurse did not meet her expectations, the content was not of interest, or the mother did not desire visits after the infant was born. Nurses and mothers described the need for mothers to have organizational and communication skills, such as keeping track of appointments, calling to reschedule, articulating needs, and asking for assistance. Disruptive external influences included nurse turnover and unstable living situations, including frequent moves and crowded housing. Each of these types of barriers had potential to interact with the others, creating complex combinations of challenges to retention. CONCLUSION: NFP retention might be improved by reframing program relevance to individual mothers and increasing maternal organizational and communication skill development.

The influence of social-developmental context and nurse visitation intervention on self-agency change in unmarried adolescent mothers.

Pregnancy among unmarried adolescents has been linked to negative personal control beliefs. In contrast, self-agency beliefs about control over future possibilities have been linked to delay in subsequent childbearing. In this secondary analysis, we examined factors associated with self-agency change in 429 unmarried adolescent mothers from intervention and control groups of a nurse home visitation study. Adolescent mothers who participated in a sustained relationship with a nurse made greater gains in self-agency than did control group mothers (p = .034). Adolescents with lower cognitive ability who were behind their age-appropriate grade level in school made the greatest self-agency gains.

African american mothers' self-described discipline strategies with young children.

AIMS AND OBJECTIVES: African American families have been described as using higher levels of non-abusive physical discipline with their children than European American families. Few if any studies have documented AA families' use of disciplinary strategies in their own words, however, or their reasons for their use. METHODS: In this qualitative study, 51 African American mothers from a 1992 Memphis sample described their disciplinary strategies with their 12 to 19 month old children. RESULTS: Seventy-seven percent of mothers described using verbal teaching along with non-abusive physical discipline, such as tapping their children's hands. Mothers also expressed concern about being too strict, described awareness of their children's developmental limits, and used non-physical disciplinary methods, consistent with positive accepting parent-child relationships. CONCLUSIONS: These findings are important because the low-income girls who experienced such parenting in the 1990s are now young mothers themselves. Current practice guidelines encourage new mothers to think about how they themselves were parented; the knowledge from this study may assist practitioners to engage present-day African American mothers in supportive discussions about physical and non-physical discipline methods with young children.

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.

Acute illness utilization patterns before and after telemedicine in childcare for inner-city children: a cohort study.

The ready access provided by telemedicine benefits families and society but might increase total healthcare utilization with uncertain implications for costs. The objective of this study was to assess the net impact on healthcare utilization of introducing into inner-city childcare a telemedicine model designed to manage acute illness. A cohort study was done using comparable periods before and after introduction of telemedicine for all qualifying children (n = 112) using three innercity childcare centers. Because the utilization histories of these children differed in length, we chose child-months as the unit of analysis. Acute illness visits were ascertained for 1806 child-months among the 112 qualifying children. Following telemedicine startup, children's office and emergency department (ED) visits for illness fell by 1.73 and 0.20/child/year, respectively, replaced by telemedicine visits at 1.07/year. These observations could be misleading, however, because of the possibility of confounding factors. For example, the cohort aged during observation, and illness visits fall with age. Accordingly, in multivariate analysis we adjusted for season of the year, age, and within-child correlation. In this analysis, reduction in illness utilization overall tended toward an increase (rate ratio = 1.26, p = 0.13). The worst-case estimate (based on upper 95% confidence interval for rate ratio) for increase in illness utilization was 3.38 visits/child/year, and the most likely case was an increase of 1.26. Assuming (1) the worst-case effect (largest increase) on overall utilization and (2) reimbursement for ED, office, and telemedicine visits of 350 dollars, 45 dollars, and 45 dollars, respectively, the healthcare system would break even on telemedicine if it replaced 0.50 ED visits per child annually.

Changes in maternal depressive symptoms across the postpartum year at well child care visits.

OBJECTIVE: To describe the incidence, continuation, and resolution of symptoms during the postpartum year in urban women experiencing high depressive symptom levels at one or more well child care visits. METHODS: As part of a prior study of postpartum depressive symptoms, demographic data and the Edinburgh Postnatal Depression Scale (EPDS) were systematically collected from pediatric records of a clinic that routinely screens mothers with the EPDS at each first-year well child care visit. To explore the course of depressive symptoms throughout the postpartum year in this pilot study, we included only data from the records that had at least one EPDS > or = 10 (N = 100), a score indicating a high likelihood for clinically significant depressive symptoms. RESULTS: Among 49 women who completed the EPDS at least once before 3 months and between 3 and 11 months postpartum, 33% had high symptom levels throughout the year, 41% improved after the first 3 months, and 26% developed high symptom levels after the first 3 months. CONCLUSIONS: Postpartum depressive symptoms persist in many women throughout the postpartum year. Routine screening throughout the year might better identify both a subgroup of women who develop new symptoms during the year, as well as the women whose symptoms persist.

Self-recognition of and provider response to maternal depressive symptoms in low-income Hispanic women.

BACKGROUND: One quarter of mothers of young children experience high levels of depressive symptoms, and only half are identified by themselves or their providers. Little is known about what factors influence maternal and provider recognition of depression. We use data from the San Mateo County, California, Prenatal to Three project to explore self-recognition, provider response, and referral among low-income Hispanic mothers of infants and toddlers. The goals are (1) to describe the patterns of self-recognition of maternal depression, maternal reporting of health professional response, and referrals for mental health services as related to depression severity and (2) to identify determinants of self-recognition, provider response, and mental health referrals. METHODS: Our sample consists of 218 nonpregnant Hispanic mothers in San Mateo County. Self-recognition was defined as an affirmative answer to the question, "Have you thought that you needed help with sadness or depression since your child was born?" High depressive symptoms were defined as a score of > or =10 on the Edinburgh Postnatal Depression Scale (EPDS). We performed chi-square and logistic regression analyses. RESULTS: Twenty-eight percent responded that they needed help with depression since the birth of their baby. Less than half discussed depressive feelings with their provider. Depression recognition factors differed between mothers and health professionals. CONCLUSIONS: Maternal depression is prevalent among Hispanic women on Medicaid but is not readily detected by women or providers. Women and providers use different cues to identify depression, possibly leading to communication discrepancies. Further research on the factors that influence self-recognition and provider recognition of maternal depression is needed.

Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation.

BACKGROUND: Common acute illness challenges everyone involved in child care. Impoverished inner-city families, whose children are most burdened by morbidity and whose reliance on child care is most important, are those least equipped to deal with this challenge. OBJECTIVE: To assess the impact of telemedicine on absence from child care due to illness (ADI). DESIGN/METHODS: A before-and-after design with historical and concurrent controls was used to study ADI in 5 inner-city child care centers in Rochester, New York, between January 1, 2001, and June 30, 2003. Enrollment averaged 138 children per center, of whom Medicaid covered 66%. Center 5 provided only concurrent controls. Telemedicine service began in the first 4 centers in a staggered fashion starting in May 2001. Baseline data on ADI before availability of telemedicine were collected in each center for a minimum of 18 weeks. The telemedicine model for diagnosis and treatment of common acute problems involved both real-time and store-and-forward information exchange between a child and telemedicine assistant in child care and an office-based telemedicine clinician. Devices used were an all-purpose digital camera (with attachments designed to facilitate capture of ear, nose, throat, skin, and eye images) and an electronic stethoscope. ADI indexed illness that had interrupted care and education for children and burdened both parents and the community with work loss and health care-related costs. Detailed attendance records and staff and parent interviews provided data. The total number of days of attendance expected from all registered children over the course of a week (total child-days) served as the denominator in calculating rates for ADI. The center-week served as the primary unit of analysis. This study is descriptive in character; statistics are not inferential but instead serve to summarize observations. RESULTS: For the 400 weeks of valid observations contributed by the 5 centers, the mean ADI was 6.41 absences per 100 child-days per week. In bivariate analysis, predictors of ADI were children's mean age, child care center, proportion of children covered by Medicaid, season of the year, and availability of telemedicine. ADI during weeks with telemedicine (4.07 absences per 100 child-days) was less than half that during weeks without telemedicine (8.78 absences per 100 child-days). After adjusting for potentially confounding variables using the generalized estimating equations method, telemedicine remained the strongest predictor of ADI. A 63% reduction in ADI was attributable to telemedicine, an effect similar to the 59% variation in ADI with season of the year. During the 201 total weeks that telemedicine services were available, 940 telemedicine encounters occurred. Telemedicine clinicians for these 940 encounters recommended exclusion from child care for 7.0% and in-person visits for 2.8% of the children. In surveys, parents indicated that 91.2% of telemedicine contacts allowed them to stay at work and that 93.8% of problems managed by telemedicine would otherwise have led to an office or emergency department visit. CONCLUSIONS: Telemedicine holds substantial potential to reduce the impact of illness on health and education of children, on time lost from work in parents, and on absenteeism in the economy.

Prevalence of maternal depressive symptoms in low-income Hispanic women.

BACKGROUND: Maternal depression can have significant repercussions for the health and well-being of mothers and children. In primarily white middle-income populations, approximately 15% of mothers experience depression. Among ethnically and socioeconomically diverse populations, the prevalence of maternal depression has not been as well established. However, the highest rates have been observed among low-income women. Because information about minority, underserved women is particularly sparse, we utilize data from the San Mateo County, California, Prenatal to Three project to describe the prevalence and self-recognition of depressive symptoms among low-income Hispanic mothers of infants and toddlers. METHOD: Telephone interviews of a random sample of women who received Medicaid and gave birth in San Mateo County provided our sample of 218 nonpregnant Hispanic mothers. High levels of depressive symptoms were defined as a score of > or =10 on the Edinburgh Postnatal Depression Scale (EPDS). We performed descriptive analyses and analyses of variance. RESULTS: Twenty-three percent of mothers reported high levels of depressive symptoms. Half of them recognized a need for help with depression. CONCLUSIONS: High levels of maternal depressive symptoms were prevalent among the Hispanic women on Medicaid, but only half of the women experiencing these symptoms identified themselves as needing help with depression.

Detection of postpartum depressive symptoms by screening at well-child visits.

OBJECTIVE: To assess 1) the feasibility of universal postpartum depression screening during well-child visits in the first year of life, 2) the prevalence of postpartum depressive symptoms among mothers who attend first-year well-child visits, 3) detection of postpartum depressive symptoms in a pediatric clinic before and after universal screening at each first-year well-child visit, and 4) social work referrals before and after universal screening. METHODS: The practice instituted universal screening for postpartum depressive symptoms during first-year well-child visits using the Edinburgh Postnatal Depression Scale (EPDS). We randomly selected 110 infant medical records before (cohort 1) and 110 after (cohort 2) screening was initiated. Measures included demographics, notation of depression or depressive symptoms in the well-child visit note, and referral for depression. EPDS scores were collected for cohort 2 only. Before-after comparisons were made for detection of depression or depressive symptoms and mental health referrals. RESULTS: The EPDS was included in the medical record in 46% of well-child visits. Eighty-eight percent of these forms were completed. Twenty-one percent of completed EPDS forms had scores > or =10, and 27% of women who completed the EPDS had scores > or =10 sometime during the postpartum year. There was a significant increase in documentation of depressive symptoms with the EPDS after initiation of universal screening (1.6% of visits [cohort 1] vs 8.5% [cohort 2]). Social work referrals for mental health reasons increased significantly (0.2% of visits [cohort 1] to 3.6% [cohort 2]). CONCLUSIONS: Women with high levels of postpartum depressive symptoms are common in an urban population and can be detected at well-child visits throughout the first postpartum year by pediatricians using a standardized screening tool. Because screening for depression during well-child visits is feasible using a standardized screening instrument, pediatricians can play an active role in early detection and referral for postpartum depression.