Nurse home visiting program

Monday 8 November 2010 8:52AM (view full episode)

In the US nurse home visiting programs are very successful. They've been set up to help vulnerable mothers and children. This program is now being trialled in some Aboriginal communities in Australia.

  • Download our extended interview with Dr David Olds.
    [Duration: 14 minutes 6.53 MB]

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This is the transcript of the extended interview with David Olds.

Norman Swan: You might recall Richard Ayah talking about the importance of regular visits by a community health worker to pregnant women or young mothers.

Well this idea of home visiting, at least by nurses, has been long deployed in some developed countries like Britain. In the United States it's being used, with great results, to help vulnerable mothers and children. And it's now being trialled in some Aboriginal communities in Australia.

One of the pioneers in the US was David Olds. David is a developmental psychologist and Director of the Prevention Research Centre for Family and Child Health at the University of Colorado Denver.

David Olds: Children growing up in social disadvantage have higher rates of early child health and developmental problems, they are at greater risk for not succeeding in school, at greater risk for exhibiting disregulated behaviour that often takes the form of criminality and substance abuse once they reach adolescence and interestingly I think children who are born into adverse stressful environments from pregnancy in the early years of the child's life are also at greater risk for later adult chronic disease and illness. So there's a whole continuum of early health problems and developmental problems that are associated with social disadvantage that we think we can alter, move the dial along by improving specific aspects of prenatal health, specific qualities of care the children receive early in the child's life. The corresponding piece that this program tries to affect is parents own economic self sufficiency. Families where mothers are socially disadvantaged are more likely to drop out of school, less likely to become gainfully employed or have any kind of consistent career improvement and the lifetime earnings are compromised. They are also more likely to have rapid successive pregnancies and that contributes to this set of problems. So you can see Norman we pretty much covered the map.

Norman Swan: We have, and why are nurses home visiting programs, why did that start, was there evidence. I mean they had home visiting in Britain for many years probably longer than the United States is that where you got the idea from. Why nurse home visiting as the vehicle for this?

David Olds: Well we recognised that it was important to improve parental behaviour and in early conditions that children were experiencing. So much of that takes place in the home.

Norman Swan: And what sort of parental behaviours are you talking about here?

David Olds: Well we're talking about tobacco use, alcohol use, use of other substances, inadequate diets, lack of understanding of what specific obstetric complications are and the need for prompt and reliable treatment of those problems. So when we're dealing with prenatal health, especially we believed that it was really important that we have nurses involved with families as the primary leads in working with families because they would view nurses as providers who have legitimacy.

Norman Swan: So there's no stigma attached to a social worker coming in.

David Olds: That's right exactly and they have the clinical knowledge to be able to address those problems competently.

Norman Swan: So what happens?

David Olds: Nurses first of all explain what they are there to do and basically the message is to mothers and other family members is that we're here to help you have a healthy pregnancy, to make sure your baby is going to be OK, to help you help your baby develop well after delivery and to help you accomplish what you want in life.

Norman Swan: And where does the referral come from?

David Olds: Nurses work primarily in the US with sources of primary care. As a matter of fact that is the primary source of referral here in the five indigenous health services where the program is being trialled right now.
Norman Swan: And what do they do when they go into the house?

David Olds: They'll take blood pressures, they'll do health assessments but mostly it's talk and mostly it's listen because their goal is to elicit what we think are parents natural instincts to want to protect themselves but most importantly their children. Human beings are endowed with this instinct and that we can rely on that instinct to support reliable and adaptive behavioural change. It's very complicated of course but the evidence is that nurses can be successful in helping families, mothers reduce their tobacco use, to improve their diets, to reduce the rates of hypertensive disorders of pregnancy. There's evidence that among women who smoke the rates of preterm delivery and low birth weight are lowered in nurse visited families compared to those that are randomly assigned to control groups. So there's a lot of focus on these specific health risks that can compromise foetal development.

Norman Swan: And what about, which is where Australia has been a bit of a leader internationally, parenting skills, is the nurse trained to impart some of those, should the parents want to hear about it?

David Olds: Yes, absolutely. As a matter of fact there's a very rigorous thorough going set of guidelines that nurses use to start eliciting parents concerns about caring for their children during pregnancy. So that once the baby is born this process that we refer to as adaptation to the parenting role is facilitated, they focus a lot on helping parents cope with crying newborns, finding ways of appreciating variations in newborn state, learning how to read their baby's needs more effectively.

Norman Swan: And how often do they go into the house to do that?

David Olds: The recommended schedule is once a week for the first month after registration and then every other week until the baby is born and then once a week after delivery, once a week until babies are six weeks and then every other week until the babies are 21 months and then once a month until babies are 2. And when you factor in participants attrition or drop out of the program, nurses end up delivering about half of the recommended number of visits. And by the way just to let you know in our randomised controlled trial, scientifically controlled trials of the program everyone who is randomised to receive the intervention gets treated as if they had received the entire program.

Norman Swan: So in other words to explain that allows for drop outs, in other words it's called intention to treat, it's the fairest and most honest way of actually assessing your results so it copes with the fact that some people dropped out and participations were low and despite that the results are X.

David Olds: Exactly.

Norman Swan: So let's talk then about the result. You alluded to them before about what the results are at birth. When you actually follow these children up for an extended period of time and you've done randomised trials, which is very rare in this sort of intervention, what do you find?

David Olds: The findings that we're most confident of is the improvements in various aspects of prenatal health, reductions in tobacco use, reductions in hypertensive disorders of pregnancy, improvements in diet. We see significant reductions in childhood injuries.

Norman Swan: Those things that you've just talked about in terms of pregnancy deliver a heavier baby and nearer to term which means that the baby's organs, brains, the baby is delivered in better shape to the world.

David Olds: Exactly and they are more likely to live and they are also more likely to be more capable of adapting to their environments and later succeeding in school and society.

Norman Swan: So you were talking about childhood injuries.

David Olds: Yes. We are seeing consistent impacts on childhood injuries. Childhood injuries are the leading cause of death among children in western societies from age 1 to young adulthood and the findings are consistent. I'm pleased to say that I think that one of the things that's clear though is that the impact on injuries is greater for families living in concentrated social disadvantage. The risks for injuries to children are much greater when there is concentrated social disadvantage and where mothers have fewer psychological resources, personal resources to manage living in poverty and caring for their children. By psychological resources I mean that they have more depression and anxiety and a limited sense of control over their life circumstances.

Norman Swan: So they are less able in that situation to monitor risky behaviour in their children?

David Olds: That's right.

Norman Swan: And what about child development? We hear a lot about ADHD in this group, we hear a lot about autism spectrum disorder and also just simply their intellect doesn't develop the way it should according to the potential.

David Olds: Here's what we're confident in Norman. We see significant improvements in children's language development, reduction in language delays, improvements in children's capacity for sustained attention. We see significant improvements in their reading and math achievement. These effects that I just described to you are concentrated in those children born to mothers who are least capable of caring and managing living in poverty and caring well for their children by virtue of their having high rates of depression and anxiety. There are these effects, we see these overall effects, but if you really look at the data carefully it's for those children born to the most vulnerable mothers that the effects are greatest.

Norman Swan: And is it because the mothers feel better so they have less depression and anxiety and they're given more resilience. What's the story?

David Olds: It's not because they necessarily feel better, I think it's that they are provided with the tools in managing their lives so they are able to cope with adversity more effectively. That includes coping with their children's needs. We don't see at least in the short while, I'm not convinced based on the data that we have, effects on depression and anxiety itself but we are reducing the risks that are associated with depression and anxiety.

Norman Swan: And you mentioned economic self-sufficiency at the beginning and there's no question that poverty is a huge predictor of all this, poverty and lack of education. What results have you had in terms of improving the economic resilience of the family?

David Olds: Yeah. Well first and we think most importantly women are planning subsequent pregnancies in ways that are consistent with their own lives. In other words we see significant increases in the intervals between births of first and second children.

Norman Swan: So their reproduction becomes less spontaneous?

David Olds: Exactly. And in the corresponding piece in this is that they have more stable relationships with their partners and we see significant increases in their employment especially in the second year of the child's life. We see significant increases in earnings. These two findings apply to our trials prior to US welfare reform, you see significant reductions in use of cash assistance and food stamps in our first two trials. In 1996 the US Congress passed welfare reform which put severe lifetime limits on poor families' use of welfare, cash assistance, and in our third trial which was conducted just around the time that welfare reform went into effect and the US economy was super-heated and periods of rapid growth there were no effects on use of welfare in our third trial. But we do see other indications that families are functioning better in terms of employment and earnings.

Norman Swan: Tell me about the trials you are doing in Australia in Indigenous communities.

David Olds: We are not really conducting trials so much right now.

Norman Swan: It's more a pilot program?

David Olds: Pilot programs exactly, what we're really trying to do is make sure that organisations and communities are really fully embracing the program. We are making the appropriate cultural and contextual adaptations, we are working out the teamwork that's needed that we think is crucial between indigenous partnership workers and nurses in delivering the program.

Norman Swan: So in other words you're designing the programs, it's not a superficial adaptation that's actually making it root and branch the way you know it works.

David Olds: Yeah. It's a deep adaptation, it's looking at what kinds of systems need to be in place in order to have some likelihood that we are going to move the dial on these types of outcomes in Indigenous populations here.

Norman Swan: And any results yet you can talk about?

David Olds: No, no outcomes except to say that we have commitment, we have great teams, we're optimistic. It's going to take us a while, I think the kinds of conditions that poor families anywhere have to contend with don't get solved overnight. I think that - we just had a presentation here partly on the history of Aboriginal led health services in Australia that's really evolved as you know over the last 40 years and good progress has been made and I think it's going to take a while for us to develop the capacity to do this really well. The good news is that government is committed to this in a truly serious way so their commitment to closing the gap really is remarkably - when you look at the goals for closing the gap they are almost perfectly aligned with the outcomes that we have achieved in the family partnership in our trials in the US. So we feel in many ways that this is - well frankly, it is an honour for me to be involved with the government and Indigenous health services in trying to help close that gap.

Norman Swan: And the cost?

David Olds: Well I don't honestly know but the cost in US dollars to deliver the program on a per family basis is about $4,500 per year per family. In the US the Washington State Institute and the Rand Corporation have used the results of our trials to estimate the return on investment to the government and society and they've estimated that on a per family basis there is about a $17,000 per family return on investment. So I think it's too soon to say what the actual cost is going to be here in Australia, what I can say is that the human cost and the economic cost of failing to address the needs of socially disadvantaged families everywhere, especially in developed societies is substantial. So, to the degree that there is greater social disadvantage it's likely, on the evidence from the US, that the functional and economical returns are going to be much greater.

Norman Swan: David Olds from the University of Colorado Denver.


Professor David Olds
Developmental Psychologist,
Director of the Prevention Research Centre for Family and Child Health,
University of Colorado,


Dr Norman Swan
Brigitte Seega

Comments (2)

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  • Dr Valerie Yule :

    08 Nov 2010 8:40:51pm

    I was very interested in the Interview with Dr David Olds on Australian Radio National.
    It is clear that nurses visiting parents at risk can have a tremendous effect.

    One of the reasons is the psychological support this gives mothers.
    My work as a clinical child psychologist has included following up disadvantaged children, and I have a collection of their drawings and stories which show, I think, that for children psychological abuse ("I nearly aborted you and I wish I did", "You'll come to no good" etc) affects them much more seriously than physical abuse or sexual abuse. It gets at who they are.

    The nurses can do a tremendous amount in helping mothers to enjoy and appreciate their babies, and never to speak to their children in ways they would not speak to their friends.

      • Anthony Weller :

        02 Dec 2010 11:01:52am

        It is great to hear David Olds and his team's committment to developing the evidence and evaluating this program in the U.S. Also the Nurses and Family Partnership workers are doing great work implementing this program in Australia to help close the Gap on Indigenous Health. There is more information in the newsletters at