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Original Investigation |

Effects of Home Visits by Paraprofessionals and by Nurses on Children:  Follow-up of a Randomized Trial at Ages 6 and 9 Years

David L. Olds, PhD1; John R. Holmberg, PsyD1; Nancy Donelan-McCall, PhD1; Dennis W. Luckey, PhD2; Michael D. Knudtson, MS1; JoAnn Robinson, PhD3
[+] Author Affiliations
1Department of Pediatrics, School of Medicine, University of Colorado Denver, Aurora
2Department of Biostatistics and Informatics, Colorado Public School of Health, University of Colorado Denver, Aurora
3Department of Human Development and Family Studies, University of Connecticut, Storrs
JAMA Pediatr. 2014;168(2):114-121. doi:10.1001/jamapediatrics.2013.3817.
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Importance  The Nurse-Family Partnership delivered by nurses has been found to produce long-term effects on maternal and child health in replicated randomized trials. A persistent question is whether paraprofessional home visitors might produce comparable effects.

Objective  To examine the impact of prenatal and infancy/toddler home visits by paraprofessionals and by nurses on child development at child ages 6 and 9 years.

Design, Setting, and Participants  Randomized trial in public and private care settings in Denver, Colorado, of 735 low-income women and their first-born children (85% of the mothers were unmarried; 47% were Hispanic, 35% were non-Hispanic white, 15% were African American, and 3% were American Indian/Asian).

Interventions  Home visits provided from pregnancy through child age 2 years delivered in one group by paraprofessionals and in the other by nurses.

Main Outcomes and Measures  Reports of children’s internalizing, externalizing, and total emotional/behavioral problems, and tests of children’s language, intelligence, attention, attention dysfunction, visual attention/task switching, working memory, and academic achievement. We hypothesized that program effects on cognitive-related outcomes would be more pronounced among children born to mothers with low psychological resources. We report paraprofessional-control and nurse-control differences with P < .10 given similar effects in a previous trial, earlier effects in this trial, and limited statistical power.

Results  There were no significant paraprofessional effects on emotional/behavioral problems, but paraprofessional-visited children born to mothers with low psychological resources compared with control group counterparts exhibited fewer errors in visual attention/task switching at age 9 years (effect size = −0.30, P = .08). There were no statistically significant paraprofessional effects on other primary outcomes. Nurse-visited children were less likely to be classified as having total emotional/behavioral problems at age 6 years (relative risk [RR] = 0.45, P = .08), internalizing problems at age 9 years (RR = 0.44, P = .08), and dysfunctional attention at age 9 years (RR = 0.34, P = .07). Nurse-visited children born to low-resource mothers compared with control-group counterparts had better receptive language averaged over ages 2, 4, and 6 years (effect size = 0.30, P = .01) and sustained attention averaged over ages 4, 6, and 9 years (effect size = 0.36, P = .006). There were no significant nurse effects on externalizing problems, intellectual functioning, and academic achievement.

Conclusions and Relevance  Children born to low-resource mothers visited by paraprofessionals exhibited improvement in visual attention/task switching. Nurse-visited children showed improved behavioral functioning, and those born to low-resource mothers benefited in language and attention but did not improve in intellectual functioning and academic achievement.

Trial Registration  clinicaltrials.gov Identifier: NCT00438282 and NCT00438594.

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