Katarina’s story• The pregnancy was not planned and Katarina and the father had known each

other in a short period of time. Nevertheless, they agreed to carry out the pregnancy and "make the best of it". It was unclear whether they could move together: it was difficult to find an apartment that was big enough and at the same time cheap enough so that they would be able to handle it. The father had dropped out of highschool and worked temporary in a warehouse. Katarina had just finished high school, she had no job or study place. Katarina lived together with her mother and a younger brother. The mother was a big support for her. She had seldom contact with her father; He lived in another part of the country. During the follow-up at the midwife during pregnancy, Katarina gradually tells more about an upbringing, characterized by bad relationships and complicated relationships with her parents. For a period she lived at a child welfare institution

Nurse Family Partnership/Familie for første gang

• A structured, intensive home visiting program, delivered by nurses

• A preventive program, with a psycho-educational approach, focusing on adaptive behavior change

• Evidence that greatest benefit is to families with the poorest outcomes , i.e. mothers with low psychological resources (low educational achievement, limited family support and poor mental health)

• A licensed program , with measures to ensure fidelity to program model

• High degree of intensity, depth and skill

Brief overview NFP program

• First time mothers/parents

• Voluntary

• Homevisit (all follow up is in the home to the woman and her family)

• Recruitment to the program as early as possible during pregnancy, no later than in pregnancy week 28

• Last until the age of 2 years for the child

• Strength based and change focused approach, built on the parents wish to do the best for their child

• There is a magic window during pregnancy … it’s a time whenthe desire to be a good motherand raise a healthy, happy childcreates motivation to overcomeincredible obstacles includingpoverty, instability or abuse withthe help of a well-trained nurse

David Olds, Founder Nurse-Family

Partnership

Developed since the 70’s

• Developed by professor David Olds at the University of Colorado, Denver

• Evidensbased

• 3 RCT

• Well documented program

• Improving continuously

Family-Nurse-Partnership in UK

• https://www.youtube.com/watch?v=qXB1q_KO3P0

Why test the Nurse-Family Partnership in Norway?

• The evidence base (espec. child maltreatment and maldev.)

– Promising results in other countries

– Comes with obligations to collect and use evidencestrategically

o Building a data system for quality control, learning and continuous programme enhancement (in-house)

o External evaluations and research (independent)

• The international community of experience, sharing and learning

Addaptations for NFP in Norway

• First time morthers/parents in especially challenging

life situations (clinical process oriented inclusion)

• Offered in addition to «services as usual»

• The NFP nurses are specially trained public health

nurses and midwives

Priciples for the implementation

• No assumptions about program effectiveness in a new society

• NFP is a work in progress – always looking to learn and improve

• Need to test in every new context:

– Population needs

– Health and social systems

– Culture

• Aim to build in-country capacity and knowledge for sustainability

• Collaboration : each society contributes to global evidence on

development in early life and inequalities

• Nursing practice is the foundation for NFP

NFP Outcomes

To improve mothers’

life-course development

by helping mothers develop a vision for the life they

want for themselves and their children and make

choices consistent with their values around planning of subsequent pregnancies, finishing their education,

and finding work

To improve pregnancy outcomes for both the mother

and the child

by helping women improve their

prenatal health and behavior

by helping parents provide competent early care of their

children

To improve children’s health

and development

Client centred priciples

NFP has five client centred principles that nurses work from:

1. The client is the expert on her own life

2. Focus on strengths

3. Follow the client’s hearts desire

4. Clients identify solutions that work for them

5. Only a small change is necessary

Theories

• Bronfenbrenner’s Human Ecological Theory (1979)

• Bowlby’s Attachment Theory (1969)

• Bandura’s mestringsteori (1977)

Focus on the importance of the family's social context, the parents' emotional accessibility and responsiveness, motivation and self-efficacy

Human Ecological Theory

The different systems in the environment and the relationship

between the systems, shape the child's development

Both the environment and the biology affect the child's development

The environment affects the child and the child has an influence on

the environment

Bronfenbrenner

Attachment Theory

• The quality of early attachment affects the child's emotional and social development in addition to future relationships and mental health.

John Bowlby

Social Cognitive and Self-efficacy Theory

Albert Bandura

• Self-efficacy is a person’s belief in his or her ability to succeed in a particular situation.

• Bandura described these beliefs as determinants of how people think, behave, and feel.

Tools in NFP

- Motivational Interview- Therapeutic relationships- Home Visit Guidelines (developed for each period)- Dyadic assessment tools (NBO, Marte Meo, PIPE)- Data collection and assessments (ASQ, ASQ;SE,

PHQ9, GAD7)- Supervision (one to one) weekly- Team meetings, weekly- Home visit with “supervisor follow”

- Support from Phsycologist and Child welfare expert- Collaboration with the other services

Education in NFP

• Three modules in the NFP program with 5 day training by Ann Rowe and Tine G. Aaserud

• Motivational intervju by Tom Barth• Attachment and mental health by Gro Vatne Brean og

Astri Lindberg• Newborn Behavioral Observation (NBO) by Unni T.

Vannebo• ASQ og ASQ:SE by Hanne Holme og Kristin Lund• Marte Meo by Ragnhild Onsøien og Kristin Lund• PIPE (Partners in parenting education) by Ann Rowe

One NFP team in each pilotsite

• 1 Supervisor and Teamleader – supervision to each teammember and with the hole team weekly, caseload of 3 families, facilitates collaboration with NFP Advisoryboard and other relevant services

• 4 Family Nurses – caseload of max. 20 families /each FN

• 0,5 Administrator – Manage and support datacollection, reduce administrative work for the team

NFP Advisory board

• National Advisory Board (support in the testing phase)

• A Local Advisory Board in each pilot site (support the NFP team in recruitment and collaboration with the other local services)

Continuously focus on fidelity to the NFP program

• Guidelines for Home Visits

• NFP material,especially developed for the program

• Datacollections and assessments

• Weekly Supervision for the Familynurses

• Team meetings for disscussing cases etc.

• Home visit with “supervisor follow”

• Psychological and child welfare support related to the teams

Defined in Core Model Element

Referral to NFP

• The women will get information about the NFP program by the doctor, gynecologist, midwife, public health nurse, therapists in psychiatry or in drug services, Child Wellfare Services, etc.

• Professional based worry about the womans situation as pregnant and/or as becoming parent based on experiences with violence / abuse in adolescence or current relationship, problems with substance abuse, mental health problems, public health care in their own upbringing, lack of appropriate network / family support / relationship with grandfather and / or partner etc.

Inclusion criteria

• Voluntary• First (planned

completed) pregnancy• Recruited before the

28th week of pregnancy

• Residence within the NFP pilot site, which are two townships in Oslo (Capital), and three municipalituies in Rogaland (District)

Exploring Inteviews (Family Nurse)

One of the following criteria provides a basis for participation

• Experiences of violence / abuse at home

• Challenging experiences from own upbringing (neglect, child welfare)

• Little social support and / or serious conflicts between expectant parents

• Ekspectant parents have mental health problems

• Not in work, education or education and low education

Conditions that are also considered for inclusion purposes are:

• Persistent low income and difficult economy

• Single parent and dependent on social benefits

• Use of tobacco and drugs

Duration and frequency of home visits

• Regulary homevisits (every 2.-3. week)

• More often when establishing relationship and right after birth (every week)

• The nurse and the participant can assess eventually adjustments needed about frequency and length of visit

• Home visits last 60 and 90 minutes

The Homevisit

• Planning before home visit:Use the home visit form from the last home visit to find the topics that were relevant, what was agreed for today's visit, etc.

Home visits:The wishes/needs of the woman / family are first on the agendaFamily Nurse is following guidelines with suggestions for current topicsUse of tools like PIPE, NBO, Marte MeoUse of facilitatorsAssessment forms(eg mental health, violence, substance abuse), as planned for periods in pregnancy, infant and childbirth

Follow-up work after home visits:STAR (assessment of resources / strengths and challenges / concerns)Data collection at every home visit

Pregnancy menu

My Health

My Child

My Life

□ How can I be healthier?

□ How can I stay healthy during pregnancy?

□ How do I get ready to have a baby?

□ What about family planning and sex during pregnancy?

□ What happens after baby is born?

□ What happens to my body when I’m pregnant?

□ What if things don’t go as planned?

□ What should I eat during pregnancy?

□ What will labour and delivery be like?

□ What else?___________________

□ How do I take care of a newborn?

□ How do I talk with my baby’s doctor?

□ How do things like smoking, alcohol,

drugs, & caffeine affect my baby?

□ How is my baby changing as he or she grows?

□ What should I feed my baby? Breastfeeding

□ What should I feed my baby? Formula

□ What else?___________________

□ Goal Setting

□ Grief & Loss

□ How can I pay for the things I want &

need?

□ How much time will I spend taking care of baby?

□ What do I do when I am stressed out?

□ What else?___________________

Taking Care of My Child

My Family & Friends

My Home

□ How can I be the best parent I can be?

□ How do I get ready to be a parent?

□ What do I do when my baby cries?

□ What do I need for a new baby?

□ What else?___________________

□ How can I communicate better with others?

□ How can I find support & services?

□ What if someone is hurting me?

□ What else?___________________

□ How can I keep my home & neighborhood safe?

□ What if I decide to move?

□ What else?___________________

Adaptation for families with other language than Norwegian

• Use of interpreter is recommended in families with other native speakers

• Brochures in English, Urdu, Somali and Arabic

• Menus for home use in addition to Polish and Russian

Data collection and reports

• 14 NFP data forms, filled out with the participants

• Testing and mapping - questionnaire and video/observation

• Dyadic assessments - EAS

Some experiences to date

• Many shared experiences, challenges and learning acrosscountries

- Norway and Bulgaria testing in parallell, many points ofconnection in spite of vastly different circumstances

• Finding a good fit for such a specialized programme with«services as usual» (health, social, child protection, civil sector…) is challenging but an opportunity for learning

• The research community is very supportive and keen to be involved

• Targeted recruitment

External evaluation

1. How is the NFP program implemented in Norway related to1) demarcation of relevant target group2) Recruitment of participants3) adaptation to other welfare services4) validity in the implementation of the program manual

2. What is the significance of affected groups (families, NFP nurses, municipal welfare providers and other services) participation in the NFP program? Do they experience a need for NFP, and what do they experience that NFP participation contributes in their family life?

3. What support is available for outcome achievement and good results (such as healthy pregnancy, child health and development, parents' financial independence) during the trial phase for the participating families?

Thank you for your attention

You are welcome to contact us

Tine G. Aaserud

Clinical Lead NFP Norway

E-post: tga@r-bup.no

Mobil: 93 61 22 03

Kristin Lund

Senioradvisor NFP Norway

E-post: kristin.lund@r-bup.no

Mobil: 41 33 63 23