Home visiting by paraprofessionals and by nurses: A randomized, controlled trial
Home visiting by paraprofessionals and by nurses: A randomized, controlled trial
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DOI：
10.1542/peds.110.3.486
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发表时间：
2002-09-01
期刊：
影响因子：
8
通讯作者：
Talmi, A
中科院分区：
文献类型：
--
作者：
Olds, DL;Robinson, J;Talmi, A
Objective.为了研究家访的有效性，由辅助人员和护士作为单独的手段，改善孕产妇和儿童健康时，这两种类型的访问者在一个程序模型，已被证明是有效的培训时，由护士提供。在科罗拉多丹佛的公共和私人护理机构进行了一项随机对照试验。1178名连续怀孕的妇女，以前没有活产，有资格获得医疗补助或没有私人健康保险，被邀请参加。735名妇女被随机分为对照组、辅助组或护士组，护士在怀孕期间平均完成6.5次家访，从出生到孩子第二个生日平均完成21次家访。准专业人员在怀孕期间平均完成了6.3次家访，从出生到孩子第二个生日平均完成了16次家访，主要结果包括怀孕期间妇女尿可替宁的变化;妇女在怀孕期间使用辅助服务;随后的怀孕和分娩，教育成就，劳动力参与和福利使用;母婴反应互动;家庭的家庭环境;婴儿对恐惧刺激的情绪脆弱性和对喜悦和愤怒刺激的低情绪活力;以及儿童的语言和心理发展，气质和行为问题。准专业访问的母亲，儿童对，其中母亲有较低的心理资源相互作用，比他们的对照组（99.45比97.54标准分）。没有其他统计学上显著的副作用。与对照组相比，护士访问的吸烟者从摄入到怀孕结束的可替宁水平下降更大（259.0 vs 12.32 ng/ mL）;在研究儿童的第二个生日时，护士访问的女性随后怀孕较少（29%对41%）和生育率（12%对19%）;他们推迟了随后的怀孕更长的时间间隔;在他们第一个孩子出生后的第二年，他们比对照组的女性工作得更多（6.83vs5.65个月）。护士探访的母子对比对照组的母子对更有反应性（100.31 vs 98.99标准分）。在6个月大时，与对照组婴儿相比，接受护士探访的婴儿在对恐惧刺激做出反应时表现出情绪脆弱性的可能性较小（16%比25%），而心理资源较低的女性所生的接受护士探访的婴儿在对喜悦和愤怒刺激做出反应时表现出低情绪活力的可能性较小（24%比40%和13%比33%）。在21个月时，护士访问的儿童出生的妇女与低心理资源不太可能表现出语言延迟（7%比18%），并在24个月，他们表现出上级心理发展指数得分（90.18比86.20）比他们的对照组。护士对妇女使用辅助产前服务、教育成就、福利使用或其子女的气质或行为问题的影响没有统计学意义。对于大多数结果，无论是访问者产生显着影响，辅助专业人员的影响通常是护士产生的影响的一半左右。当在产前和婴儿家访的模型程序培训，辅助人员产生的小的影响，很少达到统计学或临床意义;缺乏统计学意义的一些结果可能是由于有限的统计能力来检测小的影响。护士产生了显着的影响范围广泛的孕产妇和儿童的结果。
Objective. To examine the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health when both types of visitors are trained in a program model that has demonstrated effectiveness when delivered by nurses.Methods. A randomized, controlled trial was conducted in public- and private-care settings in Denver, Colorado. One thousand one hundred seventy-eight consecutive pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were invited to participate. Seven hundred thirty-five women were randomized to control, paraprofessional, or nurse conditions.Nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the children's second birthdays. Paraprofessionals completed an average of 6.3 home visits during pregnancy and 16 visits from birth to the children's second birthdays.The main outcomes consisted of changes in women's urine cotinine over the course of pregnancy; women's use of ancillary services during pregnancy; subsequent pregnancies and births, educational achievement, workforce participation, and use of welfare; mother-infant responsive interaction; families' home environments; infants' emotional vulnerability in response to fear stimuli and low emotional vitality in response to joy and anger stimuli; and children's language and mental development, temperament, and behavioral problems.Results. Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control-group counterparts (99.45 vs 97.54 standard score points). There were no other statistically significant paraprofessional effects.In contrast to their control-group counterparts, nurse-visited smokers had greater reductions in cotinine levels from intake to the end of pregnancy (259.0 vs 12.32 ng/ mL); by the study child's second birthday, women visited by nurses had fewer subsequent pregnancies (29% vs 41%) and births (12% vs 19%); they delayed subsequent pregnancies for longer intervals; and during the second year after the birth of their first child, they worked more than women in the control group (6.83 vs 5.65 months).Nurse-visited mother-child pairs interacted with one another more responsively than those in the control group (100.31 vs 98.99 standard score points). At 6 months of age, nurse-visited infants, in contrast to their control-group counterparts, were less likely to exhibit emotional vulnerability in response to fear stimuli (16% vs 25%) and nurse-visited infants born to women with low psychological resources were less likely to exhibit low emotional vitality in response to joy and anger stimuli (24% vs 40% and 13% vs 33%). At 21 months, nurse-visited children born to women with low psychological resources were less likely to exhibit language delays (7% vs 18%); and at 24 months, they exhibited superior mental development (90.18 vs 86.20 Mental Development Index scores) than their control-group counterparts. There were no statistically significant program effects for the nurses on women's use of ancillary prenatal services, educational achievement, use of welfare, or their children's temperament or behavior problems.For most outcomes on which either visitor produced significant effects, the paraprofessionals typically had effects that were about half the size of those produced by nurses.Conclusions. When trained in a model program of prenatal and infancy home visiting, paraprofessionals produced small effects that rarely achieved statistical or clinical significance; the absence of statistical significance for some outcomes is probably attributable to limited statistical power to detect small effects. Nurses produced significant effects on a wide range of maternal and child outcomes.