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BC Healthy Connections Project Update

June 5, 2017

Here is a progress update on the BC Healthy Connections Project — a scientific evaluation of the Nurse-Family Partnership (NFP).

We closed recruitment in the randomized controlled trial (RCT) last December with 739 families enrolled across four of the five participating regional Health Authorities: 406 from Fraser Health; 84 from Vancouver Coastal Health; 122 from Interior Health; and 127 from Island Health. To date, more than 700 babies have been born to participants, including 11 sets of twins. The BCHCP is continuing with data collection on all women and children until the end of 2019.

Across these four Health Authorities, 215 children and women have now graduated from the study. We’re staying in touch with families after they graduate — to invite them to participate in future follow-up studies, for example, to see how children are doing when they reach kindergarten. Preliminary papers will be released later in 2017 with main study findings to follow after all the families have graduated later in 2020.

NFP is a home visiting program providing intensive supports to young women who are living on low income and preparing to parent for the first time. This innovative public health program is delivered over two-and-a-half years, beginning prenatally and continuing until children reach their second birthday. It aims to improve children’s mental health and development while also improving mothers’ life circumstances.

This evaluation of NFP is the first in Canada and is being led by the Children’s Health Policy Centre at SFU. We are doing this together with scientific collaborators at McMaster University, UBC and the University of Victoria. The project is also being conducted in close collaboration with policy partners in the BC Ministry of Health and the BC Ministry of Children and Family Development — and in Fraser, Vancouver Coastal, Island, Interior and Northern Health Authorities.

As well as the RCT, the BC Healthy Connections Project includes two adjunctive studies, both federally funded. One is a nursing Process Evaluation, which aims to learn how Nurse-Family Partnership can best be adapted for use in BC. It is being conducted in all five participating regional Health Authorities. The other is the Healthy Foundations Study, which is assessing biological markers of stress in children who are receiving NFP, versus those who are not. It is being conducted in Fraser and Vancouver Coastal Health Authorities. Results for Process Evaluation are being released on an ongoing basis, while preliminary Healthy Foundations reports are expected in early 2018.

With study recruitment closed, (and BCHCP data collection ongoing), BC leads the country by being the first province to now be offering Nurse-Family Partnership to all eligible women who are interested. In parallel to the BCHCP, all regional Health Authorities have opened the program to everyone, with no need for randomization to control and intervention groups.

To make or receive a referral to Nurse-Family Partnership please contact:

  1. Your nurse practitioner, family doctor or midwife, or
  2. Your local Health Authority:

 


Study milestone reached

December 14, 2016

BC Healthy Connections recruitment closing as planned

Recruitment into the randomized controlled trial known as the BC Healthy Connections Project (BCHCP) closed on Dec. 16.

This recruitment — which started three years ago, in October 2013 — stood at 739 families at time of closure, a sample size large enough to estimate the effects of the Nurse-Family Partnership (NFP) program in BC. Some 100 of these families have already completed the research study.

With NFP, public health nurses visit young women who are pregnant and preparing to parent for the first time. Aimed at mothers whose circumstances place them at risk for vulnerability, the program provides them with home visits and intensive supports until their child’s second birthday. NFP starts very early in life — prenatally — allowing it to influence child development right from the start.

“We’re very proud to be reaching this study milestone,” says Scientific Director, Nicole Catherine. Her feeling is echoed by another study lead, Charlotte Waddell, who emphasizes the teamwork involved. “This has been an enormous team effort — involving the Ministries of Health and Children and Family Development, and nurses and communities and Health Authorities across this province,” she says.

The Children’s Health Policy Centre (CHPC) at Simon Fraser University is leading this scientific evaluation — with others from across BC and Canada. Collaborators include researchers at McMaster University, the University of BC, the University of Victoria and the Public Health Agency of Canada. (The BC Ministry of Health is funding the project, with support from the BC Ministry of Children and Family Development, as well as from regional Health Authorities.)

The CHPC study team is following each of the 739 families until they all finish a series of interviews. The team has conducted more than 2,500 research interviews with families to date. More than 600 babies have already been born to participating families, including eight sets of twins.

Scientific Director Catherine says that while scientific rigour is at the heart of this project, the CHPC study team has remained strongly committed to the human side of the undertaking. “Our commitment and our frequent contacts have led to some strong connections between the scientific field interviewers and the mothers,” she says. “We’re learning from new mothers and watching the children grow while we are conducting the research interviews.”

The CHPC study team is collecting and analyzing a wide array of child and maternal health information with a special focus on issues relating to child development, as well as mothers’ wellbeing. Young mothers say they enjoy being part of the project because they feel that their voices are being heard — often for the first time.

Following the closure of recruitment, research data collection and participant tracking will continue until all the children in the study reach two years of age. The team is also obtaining consent to remain in contact with all the families — to lay the foundation for longer-term child follow up over the preschool years and beyond.

Beyond evaluating how NFP works in BC, the BC Healthy Connections Project will also provide new information on young mothers who are coping with disadvantages such as living on low income, or struggling to find secure housing. This is a population that has often been underserved. So as a first step to help, the CHPC study team is aiming to provide initial reports by mid-2017. These reports will provide descriptive characteristics on study participants, including information on social determinants of health, as well as service access and use during pregnancy. The results on how well NFP works will follow once data collection closes.

According to BC’s longstanding intentions, regional Health Authorities will begin offering NFP to all eligible women — as a program embedded within other public health services — starting Dec. 17. The regional Health Authorities, together with the BC Ministry of Heath, are responsible for all aspects of planning and implementing the ongoing delivery of NFP as a provincial program from here.

Meanwhile, the BC Healthy Connections Project research team will continue collecting and analyzing data. When all 739 families have completed the study, in just over two-and-a-half-years from now, information on NFP’s effectiveness will be used to further improve BC’s child and maternal public health programs.

More information on the BC Healthy Connections Project is available here. More information on NFP open enrollment, is available here.


Interior Health Authority works to see NFP continue

October 11, 2016

When Roger Parsonage watched a Kamloops Nurse-Family Partnership (NFP) graduation event for young mothers and their toddlers back in May, he was struck by what the ceremony represented.

Mothers and their children stood at the centre of the room. Nurses stood close by. And, in a semicircle at the back, stood everyone else from Interior Health.

“It struck me it was really representative of how [NFP] works,” said Parsonage, Director of Population Health for Interior Health. “You put the mom and baby at the centre, you have the nurses close by and then you have a larger team supporting them.”

Parsonage is new to child and maternal health, but he’s already a big believer in the NFP program. This landmark intensive home visiting program, which has been operating in the US for almost 40 years, sees public health nurses visiting young women who are pregnant and preparing to parent for the first time. Public health nurses provide the women with home visits and supports until the child’s second birthday.

Although the program is still undergoing its first Canadian scientific evaluation — via a randomized controlled trial, or RCT, through the BC Healthy Connections Project — Parsonage is already making plans for what to do when recruitment for the evaluation closes in December.

In short, he’s determined to see the program continue. “It’s really, really evident that this program leads to a very close bond between the moms and the nurses,” he says. “It opens a door to a level of support that we wouldn’t have otherwise.’’

But for Interior Health, the geographic distances involved remain an enormous challenge. “You really have to drive it to appreciate it, and realize just how far apart these communities are,” Parsonage says. “You go through huge pockets of ‘nothing’ but stunning beauty.” For the nurses, this means lots of driving time. And in turn, this means they have less time to spend with families. Making matters more challenging, socioeconomic status tends to be lower in rural and remote areas so the need for NFP is even higher.

The solution? Parsonage is investigating the possibility of using telehealth technology, meaning that some — but not all — of the visits would be via mobile video conferences. Replacing even a portion of the in-person visits with telehealth would make the system more efficient by reducing driving time for nurses. “We’re consulting with the Ministry about whether we can provide the service in this way without compromising fidelity,” he says. “If we can do that, it will allow us to extend the reach.” BC will consult with NFP’s founder, David Olds, regarding similar work occurring in the US.

Penny Liao-Lusssier, the Maternal Child Health Manager for Interior Health, is equally enthusiastic about NFP. “A highly vulnerable population is welcoming the nurses into their homes,” she says. “The fact that nurses are being invited really demonstrates the trust that is there.”

So far, 700 families have enrolled in the RCT through the BC Healthy Connections Project – with 350 receiving NFP plus existing services, and 350 receiving existing services alone. Sixty families have now completed the study. An additional 300 families have received NFP through the “guiding client” pilot, which involved nurses honing their NFP skills before starting the trial. And a further 150 families are receiving NFP through a Process Evaluation that is running in parallel with the RCT.

The BC Healthy Connections Project is investigating how NFP works in BC – following study participants through into 2019. Meanwhile Health Authorities are beginning to deliver NFP to all qualified families, outside of the study, starting in December. Practitioners or young pregnant women can click here for more information.


Why BC needs to do ‘both/and’ when it comes to health

June 6, 2016

young first-time momsWhen talking about the healthcare system, Jan Tatlock likes to quote Albert Einstein. He defined insanity as, “doing the same thing and expecting a different result.”

For Tatlock, director of public health for BC’s Island Health Authority on Vancouver Island, insanity means spending money only on the sick and otherwise ignoring public health and prevention.

“If we want the madness to stop, we have to make a modest investment,” she says, arguing that at least five cents of every healthcare dollar should go to public health. By way of comparison, she points to the millions of dollars BC invests in surgery every year. She doesn’t call that a bad thing. Instead, she argues that it should be supplemented with more public health interventions as well. “If we don’t do both acute care and public health, we are not going to have the changes that we want. It’s not an ‘either/or’ situation — it’s a ‘both/and.’ ”

For Tatlock Nurse-Family Partnership (NFP) is a good example of a public health approach.

With NFP, public health nurses visit young women who are pregnant and preparing to parent for the first time — providing them with home visits and intensive supports until the child’s second birthday. NFP starts earlier than any other early childhood program, which allows it to influence development right from the start. NFP also has the potential to profoundly alter the trajectory of children’s lives, in part because it focuses on families who are coping with challenges like housing insecurity or low income — reducing the negative impact of any early adversity. In turn, this can contribute to a lifetime of wellbeing and resilience for children.

NFP has been thoroughly tested in the US, and has also been evaluated in the Netherlands and England as they have different health and social services systems. But the BC Healthy Connections Project is the first Canadian evaluation of NFP. Through this project, NFP’s effectiveness is being measured compared to existing services across the province.

In the US, NFP has led to net public savings of $18,000 per family over 10 years. But one of the challenges, Tatlock says, is that these savings take time to accumulate and they frequently occur in systems outside of healthcare, such as justice and foster care. “But that’s how it works,” she says. “Given time, the mum is more likely to be employed and doing well.” And, more importantly, she can provide better care and her child is likely to have a more positive future.

As well, NFP has been good news for nurses delivering the program. The Health Authority is hearing about much more job satisfaction and seeing decreased sick time and decreased attrition. “What we’re finding is that nurses in NFP are loving it,” Tatlock says. “This is the work they’ve always wanted to do and there’s incredible value when they see such meaning in their jobs.”

Tatlock especially likes the way NFP focuses on children and women who, more typically, are last on the public attention list. “We should be making them first,” she says, “because our population is aging. We want them to be as healthy as possible.”

For those who think the BC Healthy Connections’ cohort of young, disadvantaged first-time mums is too small a group to focus on, Tatlock argues that NFP can and should be embedded with overall public health programming — as part of a broader commitment to child and maternal health. So Island Health offers both NFP and other, similar programs that aren’t necessarily limited to young, first-time mothers and their children. “Our approach allows nurses to engage at an intensity determined by the women themselves,” she says. “Some may choose not to engage while others may be open to additional or more intensive services.”

But if it ever comes to the question of acute care versus public health, Tatlock argues passionately that both approaches are necessary. “We’re all pulling on the same lever,” she says. “But we need to do it together.”


Helping children by working “upstream”

March 21, 2016

upstreamHealth policymakers and practitioners often use words like “downstream” or “upstream” to describe the vastly different points at which people may receive care.

Downstream means late in the process, well after the onset of a problem, and often long after a problem has become entrenched. For example, a child who is treated for an anxiety disorder — even if that treatment is successful — is getting help downstream.

But give the child a prevention program, before they have a disorder, and you’ve moved “upstream.” And in doing this, a few things can happen. You can immediately improve the quality of the child’s life — by reducing their distress and removing impediments to their healthy development. You can also alter the trajectory of a young child’s life, by reducing the negative impact of adversity. In turn, this can contribute to a lifetime of well-being and resilience. Upstream interventions can also save healthcare costs, for example, by reducing emergency room visits.

Better yet, you can help the mother as well as the child — before the child is even born. Then you’re moving upstream in way that’s likely to make the most profound difference.

That’s the motivation for Lenora Marcellus, pictured above, an Associate Professor in the School of Nursing at the University of Victoria. A member of the BC Healthy Connections Project scientific team, her original background is in neonatal intensive care. “A lot of the work I’ve done is downstream, when women haven’t been supported when they’ve needed it most, early on,” she says. She notes that much of her work in these hospital settings was with families who were struggling with disadvantages such as not having enough to live on, or not being able to get prevention programs themselves when they needed them.

Marcellus has also volunteered for almost 20 years with a young mothers’ group in her community and has seen first-hand the many challenges faced by young parents. Her experience providing downstream intensive healthcare services is what motivates her to embrace the goals of the BC Healthy Connections Project, which involves an evaluation of the Nurse-Family Partnership (NFP) program.

With NFP, public health nurses visit young women who are in early pregnancy and preparing to parent for the first time — providing them with home visits and intensive supports until the child’s second birthday. The program starts earlier than any other early childhood program, making it a decidedly upstream approach.

For the BC Healthy Connections’ evaluation, NFP is being compared with BC’s existing prenatal and early childhood services. The goal is to learn whether BC can replicate positive results from other countries. These results have shown that NFP can improve prenatal health, parenting, and children’s mental health and development, while also lifting young mothers out of poverty.

According to Marcellus, BC Health Authorities already try to help new moms with highly complex challenges, so they can help their children. But these families need extra supports and it’s often hard for them to get them. That’s why she’s so committed to the BC Health Connections Project.

“With NFP, the public health nurse brings a really unique set of skills,” Marcellus says of the program. “They’re developing a relationship and connecting with the new moms. What’s more, the meeting takes place in the mom’s own home or wherever feels safe for her. That’s very different from a professional setting.”

Although the teen pregnancy rate has declined in BC, young moms continue to be a vulnerable population because these very young women also have other challenges, Marcellus says. They can be invisible, stigmatized or judged. Just as bad, they often fall between the cracks when it comes to getting help. “We know that in society today it’s pretty hard to be an independent adult in our very expensive province,” Marcellus says.

“We could call it a pay now or pay later opportunity,” she says, adding that she would much rather see society pay now. “Investing in programs like NFP is likely to pay huge dividends over generations — for families and communities at large.”
The Nurse-Family Partnership is available only through the BC Healthy Connections Project for the duration of study recruitment. Practitioners or young pregnant women can click here for more information.


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