Blueprints
Model Programs
Nurse-Family Partnership (NFP)
Program
Background
Many of the most pervasive, intractable,
and costly problems faced by young children and parents
in our society today are a consequence of adverse
maternal health-related behaviors (such as cigarette
smoking, drinking, and drug use) during pregnancy,
dysfunctional infant caregiving, and stressful environmental
conditions that interfere with parental and family
functioning. These problems include infant mortality,
preterm delivery and low birthweight, child abuse
and neglect, childhood injuries, youth violence, closely
spaced pregnancy, and thwarted economic self-sufficiency
on the part of parents. Standard indices of child
health and well-being indicate that many children
in our society are suffering.
- Nine infants out of every thousand in the United
States die before their first birthday. As a result
of high rates of low birthweight (less than 2500
grams or 5 pounds 8 ounces), our infant mortality
rate is worse than 19 other nations, in spite of
dramatic reductions in infant mortality in the last
two decades due to improvements in newborn intensive
care. Low birthweight babies who survive are 50
percent more likely to use special education services
once they enter school than are normal birthweight
controls.
- Over 2.5 million children were reported as being
abused or neglected in 1990, and one in three of
the victims of physical abuse were infants less
than one year of age. Between 1,200 and 1,500 children
die each year as a result of parent or caregiver
maltreatment. Not only is maltreatment morally unacceptable,
but the social consequences are so devastating that
the U.S. Advisory Panel on Child Abuse and Neglect
has called child maltreatment a national emergency.
- Childhood injuries are the leading cause of death
among children aged one to fourteen.
- High rates of violence among adolescents, both
as victims and perpetrators, threaten the safety
and well-being of our neighborhoods. Among young
people aged 15-24, homicide is a leading cause of
death, and for African Americans it is the number
one cause.
- In 1992, 52 percent of the mothers on AFDC had
their first birth as teens, costing the government
approximately $12.8 billion. Rapid successive pregnancy
increases the likelihood of continued welfare dependence
and a host of associated problems.
Evidence indicates that a significant portion of these
problems can be traced to parental behavior—in
particular, to women's health-related behaviors during
pregnancy, to the quality of care that parents provide
to their children, and to women's life choices with
respect to family planning, educational achievement,
and workforce participation. While these problems
cut across all segments of U.S. society, they are
more common among women who begin childbearing as
poor, unmarried adolescents. Low-income, single, adolescent
mothers can have good pregnancy outcomes and children
who do well, but their capacity to care for themselves
and for their children is often compromised by histories
of maltreatment in their own childhood, psychological
immaturity or depression, stressful living conditions,
and inadequate social support. These conditions contribute
to the greater likelihood that socially disadvantaged
parents will abuse cigarettes and other drugs during
pregnancy and will fail to provide adequate care for
their children, often with devastating results.
Women who smoke cigarettes and use other substances
during pregnancy, for example, are at considerable
risk for bearing low birthweight newborns, and their
children are at heightened risk for neurodevelopmental
impairment. Even subtle damage to the fetal brain
can undermine children's intellectual functioning
and capacity for emotional and behavioral regulation.
Parents' capacities to read and respond to their infants'
communicative signals form the basis for children's
sense of security and trust in the world and their
belief in their capacity to influence that world.
Breaches of that trust have long-term consequences,
especially when caregiving dysfunction is combined
with neurodevelopmental impairment on the part of
the child.
A longitudinal study of a large Danish sample of
children and their families found that children who
experienced the combination of birth complications
and parental rejection in the first year of life were
at substantially increased risk for violent criminality
at age 18 in comparison to children who experienced
only birth complications or parental rejection alone.
While only 4.5 percent of the sample experienced both
birth complications and parental rejection, that group
accounted for 18 percent of all violent crimes among
those 18 years of age. Parental rejection or birth
trauma by itself did not increase the risk for violence.
When risk factors accumulate, the risk for adverse
outcomes increases, often in synergistically vicious
ways.
The problems listed have been resistive to government
intervention over the past thirty years. However,
scientific evidence is accumulating that it is possible
to improve the outcomes of pregnancy, to improve parents'
abilities to care for their children, and to reduce
welfare dependence with programs of prenatal and early
childhood home visitation, but it is not easy. Our
optimism stands in contrast to earlier research on
home visitation. The earlier research was difficult
to interpret because the programs studied were often
not designed to address the needs of parents in sensible
and powerful ways, and the research itself frequently
lacked scientific rigor.
The program of prenatal and infancy home visitation
by nurses described here is distinguished from other
programs by its firm foundation in epidemiology and
theory. The program is based upon an analysis of proximal
risks for the particular outcomes that it is designed
to affect (usually parental behaviors or conditions
in the home that increase the likelihood of adverse
outcomes on the part of the mother or child). It also
is founded upon three interrelated theoretical foundations—self-efficacy,
attachment, and human ecology theories. Each of these
theories addresses different aspects of the developmental
system that contributes to adverse maternal and child
outcomes in vulnerable families.
Theoretical Rationale/Conceptual
Framework
The program has been grounded in theories of human
ecology (Bronfenbrenner, 1979, 1992), self-efficacy
(Bandura, 1977, 1982), and human attachment (Bowlby,
1969). The earliest formulations of the program gave
greatest emphasis to human ecology, but as the program
has evolved, it has been grounded more explicitly
in theories of self-efficacy and human attachment.
Human
Ecology Theory
The original formulation
of this program was based in large part on Bronfenbrenner's
theory of human ecology. Human ecology theory
emphasizes the importance of social contexts
as influences on human development. Parents'
care of their infants, from this perspective,
is influenced by characteristics of their families,
social networks, neighborhoods, communities,
and cultures, and interrelations among these
structures. Bronfenbrenner's original theoretical
framework has been elaborated more recently
(with greater attention to individual influences)
in his person-process-context model of research
on human development. |
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The person elements of the model are reflected
in the program components that have to do with behavioral
and psychological characteristics of the parent
and child. In the formulation of the theoretical
foundations of the program, parents, and especially
mothers, are considered both developing persons
and the primary focus of the preventive intervention.
Particular attention is focused on parents' progressive
mastery of their roles as parents and as adults
responsible for their own health and economic self-sufficiency.
This program emphasizes parent development because
parents' behavior constitutes the most powerful
and potentially alterable influence on the developing
child, particularly given parents' control over
their children's prenatal environment, their face-to-face
interaction with their children postnatally, and
their influence on the family's home environment.
The concept of process encompasses parents' interaction
with their environment as well as the intrapsychic
changes that characterize their mastery of their
roles as parents and providers. Three aspects of
process emphasized here relate to individuals' functioning:
(1) program processes (e.g., the ways in which the
visitors work with parents to strengthen parents'
competencies); (2) processes that take place within
parents (i.e., the influence of their psychological
resources—developmental histories, mental
health, and coping styles—on behavioral adaptation);
and (3) parents' interaction with their children,
other family members, friends, and health and human
service providers. For the sake of simplicity, the
discussion of these processes has been integrated
below into the person (parent) part of the model.
The focus on parents elaborated here is not intended
to minimize the role that contextual factors such
as economic conditions, cultural patterns, racism,
and sexism play in shaping the opportunities that
parents are afforded. Most of those features of
the environment, however, are outside of the influence
of preventive interventions provided through health
and human service systems. Certain contexts, nevertheless,
are affected by parents' adaptive competencies.
It is these features of the environment that the
current program attempts to affect, primarily by
enhancing parents' social skills. The aspects of
context that we are most concerned about have to
do with informal and formal sources of support for
the family, characteristics of communities that
can support or undermine the functioning of the
program and families, the impact of going to school
or working on family life, as well as cultural conditions
that need to be taken into consideration in the
design and conduct of the program.
One of the central hypotheses of ecological theory
is that the capacity of the parentchild relationship
to function effectively as a context for development
depends on the existence and nature of other relationships
that the parent may have. The parentchild relationship
is enhanced as a context for development to the
extent that each of these other relationships involves
mutual positive feelings and that the other parties
are supportive of the developmental activities carried
on in the parentchild relationship. Conversely,
the developmental potential of the parentchild relationship
is impaired to the extent that each of the other
relationships in which the parent is involved consists
of mutual antagonism or interference with the developmental
activities carried on in the parentchild relationship.
Limitations
of Human Ecology Theory.
Compared
to other developmental theories, Bronfenbrenner's
framework provides a more extended and elaborated
conception of the environment. The original
formulation of the theory, however, tended to
treat the immediate settings in which children
and families find themselves as shaped by cultural
and structural characteristics of the society.
Little consideration was given to the role that
adults (in particular parents) play in selecting
and shaping the settings in which they find
themselves. While many investigators today reason
that the personal characteristics that influence
individuals' selection and shaping of their
contexts have genetic origins, we have chosen
to determine the extent to which and the means
by which healthy choices and adaptive behaviors
can be promoted. |
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Consequently, self-efficacy and attachment theories
were integrated into the model to provide a broader
conception of the parentsetting relationship. The
integration of these theories allows for a conceptualization
of development that encompasses truly reciprocal
relationships in which settings, children, and other
adults influence parental behavior, and in which
parents simultaneously select and shape their settings
and interpersonal relationships.
Self-Efficacy Theory
Self-efficacy theory provides a useful framework
for promoting women's health-related behavior during
pregnancy, care of their children, and personal
development. According to Bandura, differences in
motivation, behavior, and persistence in efforts
to change a wide range of social behaviors are a
function of individuals' beliefs about the connection
between their efforts and their desired results.
According to this view, cognitive processes play
a central role in the acquisition and retention
of new behavior patterns. In selfefficacy theory,
Bandura distinguishes outcome expectations from
efficacy expectations. Outcome expectations are
individuals' estimates that a given behavior will
lead to a given outcome. Efficacy expectations are
individuals' beliefs that they can successfully
carry out the behavior required to produce the outcome.
It is efficacy expectations that affect both the
initiation and persistence of coping behavior. Individuals'
perceptions of selfefficacy can influence their
choice of activities and settings, and can determine
how much effort they will put forth in the face
of obstacles.
Limitations of Self-Efficacy
Theory. While self-efficacy theory provides
powerful insights into human motivation and behavior,
it is limited in several respects. The first limitation
is that it is primarily a cognitive-behavioral theory.
It attends to the emotional life of the mother and
other family members only through the impact of
behavior on women's beliefs or expectations, which
in turn affect emotions. Many people have experienced
multiple adversities in the form of overly harsh
parenting, rejection, or neglect that often contribute
to a sense of worthlessness, depression, and cynicism
about relationships. Self-efficacy gives inadequate
attention to methods of helping parents cope with
these features of their personal history or the
impact of those early experiences on their care
of their children. We have augmented the theoretical
underpinnings of the program regarding these social
and emotional issues with attachment theory (discussed
below).
The second limitation is that self-efficacy attends
to environmental influences in a cursory way. People
can give up because they do not believe that they
can do what is required, but they also can give
up because they expect that their efforts will meet
with punitiveness, resistance, or unresponsiveness.
While Bandura acknowledges that adversity and intractable
environmental conditions are important factors in
the development of individuals' sense of futility,
the structure of those environmental forces is not
the subject of Bandura's theory. In other words,
individuals' feelings of helplessness and futility
are not simply intrapsychic phenomena, but are connected
to environmental contexts that provide limited opportunities
and that fail to nurture individuals' growth and
well-being. The structure of those environmental
influences is the primary subject of human ecology
theory, discussed above.
Attachment Theory
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Historically, this program
owes much to Bowlby's theory of attachment. Attachment
theory posits that human beings (and other primates)
have evolved a repertoire of behaviors that promote
interaction between caregivers and their infants
(such as crying, clinging, smiling, signaling),
and that these behaviors tend to keep specific
caregivers in proximity to defenseless youngsters,
thus promoting their survival, especially in emergencies.
Humans (as well as many other species) are biologically
predisposed to seek proximity to specific caregivers
under times of stress, illness, or fatigue in
order to promote survival. This organization of
behavior directed toward the caregiver is attachment.
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In recent years, a growing body of evidence indicates
that caregivers' levels of responsivity to their
children can be traced to caregivers' own childrearing
histories and attachment-related experiences. Caregivers'
attachment-related experiences are thought to be
encoded in "internal working models" of
self and others that create styles of emotional
communication and relationships that either buffer
the individual in times of stress or that lead to
maladaptive patterns of affect regulation and create
feelings of worthlessness. Differences in internal
working models, according to attachment theorists,
have enormous implications for mothers' capacities
for developing sensitive and responsive relationships,
especially with their own children.
Limitations of Attachment
Theory. Attachment theory provides a rich
set of insights into the origins of dysfunctional
caregiving and possible preventive interventions
focused on parent-visitor and parent-child relationships.
It gives scant attention to the role that individual
differences in infants may play as independent influences
on parental behavior, and it provides inadequate
attention to issues of parental motivation for change
in caregiving. Moreover, it minimizes the importance
of the current social and material environment in
which the family is functioning as influences on
parents' capacities to care for their children.
For more systematic treatments of these issues,
we turned to self-efficacy and human ecology theories
(discussed above).
Summary of the Role
of Theory and Epidemiology in Program Design
The program and its specific intervention strategies
have been built upon:
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The program of home visitation
begins during pregnancy and continues through
the child's second birthday. Each family is assigned
a nurse who visits families about once every other
week during pregnancy and the first two years
of the child's life. To the extent possible, programs
should keep the s ame nurse assigned to a family
for the entire time they participate in the program.
Program process studies have shown that program
effectiveness tends to decline when families are
served by more than one nurse over the course
of their participation. |
The nurses use program protocols that are designed
to accomplish three overriding goals: (1) the improvement
of pregnancy outcomes; (2) the improvement of the
child's health and development; and (3) the improvement
of the mothers' own personal development. In the
home visits, the nurses promote three aspects of
maternal functioning: (a) health-related behaviors
during pregnancy and the early years of the child's
life; (b) the care parents provide to their children;
and (c) parents' family planning, educational achievement,
and participation in the work force. In the service
of these three goals, the nurses link families with
needed health and human services and involve other
family members and friends in the pregnancy, birth,
and early care of the child.
The nurses use detailed assessments, record-keeping
forms, and protocols to guide their work with families
but adapt the content of their home visits to the
individual needs of each family. They provide a
comprehensive educational program designed to promote
parents' and other family members' effective physical
and emotional care of their children. The nurses
also help women clarify their goals and develop
problem-solving skills to enable them to cope with
the challenges of completing their education, finding
work, and planning future pregnancies. Developing
a close working relationship with the mother and
her family, the nurses help mothers identify small
achievable objectives that can be accomplished between
visits that, if met, will build mothers' confidence
and motivation to manage the demands of caregiving
and become economically self-sufficient.
The program focuses on specific parental behaviors
and modifiable environmental conditions that are
associated with adverse outcomes in each of the
domains identified as program goals. The protocols
and record keeping system are designed to reinforce
home visitors' focus on program goals and theoretical
foundations of the program.
The nurses are scheduled to visit families once
a week for the first month after registration and
then every other week through delivery. After delivery
the nurses are scheduled to visit once a week for
the first six weeks of the baby's life and then
every other week until the 21st month postpartum.
From 21 to 24 months postpartum, the nurses visit
once a month. In these visits, which typically last
from 60-90 minutes, the nurses work to achieve the
goals and objectives outlined above, employing clinical
interventions that are grounded in theories of human
ecology, attachment, and self-efficacy. It should
be noted, however, that some mothers are in crises
that interfere with their consistently keeping scheduled
appointments. Although the nurses make every effort
to follow the specified schedule of visits, they
are allowed to visit more frequently when families
exhibit crises that would warrant more intensive
support. In addition, although there are specified
domains of program content that are developmentally
organized and expected to be covered during particular
periods, families exhibit considerable variation
in their expressed needs. This leads to substantial
individual variation in the amount of time that
may be spent on particular program content areas.
All of this leads to variation in the amount and
content of the program experienced by any one family.
The program nevertheless adheres to a core set of
program goals, content, and methods.
Evidence of Program Effectiveness
For low-income women and their children, the program
has been successful in:
- improving women's prenatal health-related behaviors
(especially reducing cigarette smoking and improving
diet);
- reducing pregnancy complications, such as hypertensive
disorders and kidney infections;
- reducing harm to children, as reflected in fewer
cases of child abuse and neglect and injuries
to children revealed in their medical records;
- improving women's own personal development,
indicated by reductions in the rates of subsequent
pregnancy, an increase in spacing between first
and second born children, a reduction in welfare
dependence, and reductions in behavioral problems
due to substance abuse and in criminal behavior
on the part of mothers who were unmarried and
from low-income households at registration during
pregnancy; and
- reducing criminal and antisocial behavior on
the part of the 15-year old children as indicated
by fewer arrests, convictions/violations of probation,
and days of consuming alcohol.
The cost of the program, from the standpoint of
government spending, is recovered by the time the
children reach four years of age, and the cost savings
to government and society exceed the cost of the
program by a factor of at least 4:1 over the child's
lifetime.
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