<p>To compare hospital-based utilization for early childhood injuries between program recipients and local-area comparison families following statewide implementation of an evidence-based home visitation program, and to describe site-level program variation. Propensity score matching on baseline characteristics was used to create a retrospective cohort of Nurse-Family Partnership (NFP) clients and local area matched comparison women. The main outcome, a count of injury visit episodes, was enumerated from Medicaid claims for injuries examined in an emergency department or hospital setting during the first 2 years of life of children born to included subjects. Generalized linear models with a Poisson distribution examined the association between injury episode counts and NFP participation, controlling for other non-injury utilization and stratifying by individual agency catchment area in a fixed effects analysis. The children of NFP clients were more likely in aggregate to have higher rates of injury visits in the first 2 years of life than the children of comparison women (415.2/1,000 vs. 364.2/1,000, P &lt; 0.0001). Significantly higher rates of visits among children of NFP clients for superficial injuries (156.6/1,000 vs. 132.6/1,000, P &lt; 0.0001) principally accounted for the attributable difference in injury visit rates between groups. Among more serious injuries, no significant difference in injury visit rates was found between NFP clients and comparison women. The proportion of children with at least one injury visit varied from 14.5 to 42.5% among individual sites. Contrary to prior randomized trial data, no reductions in utilization for serious early childhood injuries were demonstrated following statewide implementation of an evidence-based home visitation program. Significant program variation on outcomes underscores the challenges to successful implementation.</p>

<p><b>BACKGROUND: </b>The influence of community context on the effectiveness of evidence-based maternal and child home visitation programs following implementation is poorly understood. This study compared prenatal smoking cessation between home visitation program recipients and local-area comparison women across 24 implementation sites within one state, while also estimating the independent effect of community smoking norms on smoking cessation behavior.</p><p><b>METHODS: </b>Retrospective cohort design using propensity score matching of Nurse-Family Partnership (NFP) clients and local-area matched comparison women who smoked cigarettes in the first trimester of pregnancy. Birth certificate data were used to classify smoking status. The main outcome measure was smoking cessation in the third trimester of pregnancy. Multivariable logistic regression analysis examined, over two time periods, the association of NFP exposure and the association of baseline county prenatal smoking rate on prenatal smoking cessation.</p><p><b>RESULTS: </b>The association of NFP participation and prenatal smoking cessation was stronger in a later implementation period (35.5% for NFP clients vs. 27.5% for comparison women, p &lt; 0.001) than in an earlier implementation period (28.4% vs. 25.8%, p = 0.114). Cessation was also negatively associated with county prenatal smoking rate, controlling for NFP program effect, (OR = 0.84 per 5 percentage point change in county smoking rate, p = 0.002).</p><p><b>CONCLUSIONS: </b>Following a statewide implementation, program recipients of NFP demonstrated increased smoking cessation compared to comparison women, with a stronger program effect in later years. The significant association of county smoking rate with cessation suggests that community behavioral norms may present a challenge for evidence-based programs as models are translated into diverse communities.</p>

<p><b>BACKGROUND: </b>Chronic school absenteeism and frequent school changes, particularly among younger children, may be antecedents for the high rates of school failure and subsequent dropout among youth in foster care. However, the relationship of foster care experience to absenteeism and school change has not been well studied.</p><p><b>OBJECTIVE: </b>This study examined the association of placement experience with absenteeism and changing schools among 209 urban children in foster care enrolled in public elementary schools.</p><p><b>METHODS: </b>A cohort of children aged 5 to 8 years who entered non-relative or kinship foster care from 2006-2008 were followed longitudinally for 2 years from entry into foster care. Children residing in foster care were categorized at the end of the study as early stable, late stable, or unstable, if they achieved a permanent placement prior to 45 days, between 45 days and 9 months, or failed to do so within 9 months, respectively. Children who reunified home were classified as a fourth category. Poisson regression, controlling for baseline factors, was used to compare days absent and number of schools attended across categories of placement experience.</p><p><b>RESULTS: </b>Among the 209 children, 51% were male, 79% were African American, and 55% were initially placed with kin. One third of children reunified home; among children who did not reunify, one half was early stable, and a third was unstable. Adjusted rates of school absenteeism increased in stepwise fashion as children's placements became more unstable; children with unstable placements were 37% more likely to be absent than those with early placement stability (p=0.029). Children who reunified during the study demonstrated the highest rates of absenteeism; however, there was no significant difference in absenteeism before or after reunification. Number of schools attended increased as stability worsened, with the standardized rate of schools attended reaching 3.6 schools (95% CI 3.1-4.1) over a two year period among children in unstable placements.</p><p><b>CONCLUSIONS: </b>The relationship between placement experience and school absenteeism and school change illustrates the need to better coordinate the educational experience of high-risk children in foster care. The secondary finding of high absenteeism among children in the process of returning home illustrates that educational challenges for youth may be equally if not more concerning among the greater majority of youth in child welfare who remain home with birth parents.</p>

<p>Little is known about how the challenges faced by caregivers influence the variation in social, emotional, and behavioral (SEB) outcomes of youth placed in kinship versus non-relative foster care. This study examined SEB symptoms among youth in kinship and non-relative foster care settings, hypothesizing that changes in caregiver depression would modify children's change in behavior over time. Child Behavior Checklist (CBCL) assessments of 199 children placed with kinship and non-relative foster care providers in a Mid-Atlantic city were conducted at time of placement and 6-12 months post-placement. Linear regression estimated CBCL change scores for youth across placement type and caregiver depression trajectories. Kinship caregivers were more likely to become depressed or remained depressed than non-relative foster caregivers. Youth in kinship care always exhibited better change in SEB outcomes than youth in non-relative foster care, but these positive outcomes were principally observed among families where caregivers demonstrated a reduction in depression over time or were never depressed. Adjusted change scores for non-relative foster care youth were always negative, with the most negative scores among youth whose caregivers became depressed over time. Caregiver well-being may modify the influence of placement setting on SEB outcomes for youth placed into out-of-home care. Findings lend to policy relevance for child welfare systems that seek kinship settings as a panacea to the challenges faced by youth, without allocating resources to address caregiver needs.</p>