Latest BC Healthy Connections Project Features

When 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.”

Health 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.

Nurse-Family Partnership (NFP) is a prevention program that starts far earlier than most other public health interventions. It begins before children are even born — ideally by the 16th week of pregnancy. Its aim? To improve the lives of young mothers and their children. To achieve this, public health nurses make frequent home visits, building a trusting relationship with young first-time mothers and supporting them to nurture and protect their children.

NFP’s early start also presents a unique opportunity to study some of the biological mechanisms influencing health, starting even before birth. This is the subject of the Healthy Foundations Study, funded by the Canadian Institutes for Health Research, being led by Andrea Gonzalez (pictured above), assistant professor with the Offord Centre for Child Studies at McMaster University. The study is being conducted in collaboration with the Children’s Health Policy Centre at Simon Fraser University – and in collaboration with the BC Ministries of Health and Children and Family Development and BC’s Fraser and Vancouver Coastal Health Authorities.

Associated with the BC Healthy Connections Project — BC’s scientific evaluation of NFP, funded by the BC Ministry of Health with support from the BC Ministry of Children and Family Development — the Healthy Foundations Study is examining biological markers of health outcomes for children over the first two years of life. By collecting hair samples, saliva and cheek swabs from infants and consenting mothers, Gonzalez will be able to track changes in stress responses and the way genes work.

We all encounter mild stressors every day — such as unexpected changes in plans, disagreements with friends, family or co‐workers, or losing something. And we all develop different ways to deal with these stressors. Through the Healthy Foundations Study, Gonzalez is hoping to learn how pregnancy and new motherhood may be stressful to the mothers, and how the babies may respond to this stress. The study is also looking at whether NFP may affect the way that moms and babies cope with stress, and how this may influence later infant development. So this study will compare outcomes for children whose mothers receive NFP coupled with existing services to those whose mothers receive existing services only.

“We think that experiences you’re exposed to as an infant may influence a whole host of health outcomes later on,” Andrea Gonzalez says. And NFP aims to improve outcomes for children, and for their families.

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.

Harriet MacMillan sees the BC Healthy Connections Project (BCHCP) through a unique set of lenses.

One involves her role as the Chedoke Health Chair in Child Psychiatry at the Offord Centre for Child Studies at McMaster University. There, she co-led a Hamilton-based project piloting Nurse Family Partnership several years ago. Looking through that lens, she is eager to see Canadian young mothers-to-be get more help — via Nurse-Family Partnership (NFP). Basically, this program sees public health nurses frequently visiting young, pregnant women — in their own homes — from early in pregnancy until their children turn two years old.

Another lens comes from MacMillan’s position as BCHCP nominated co-principal investigator — along with Charlotte Waddell from Simon Fraser University. Here, MacMillan primarily wants to ensure the rigorous demands of a randomized controlled trial of NFP are met.

“I think it’s such an important study and it’s wonderful we have the opportunity to conduct this trial in BC,” she says. “The collaboration between the scientific team and the BC policy makers is terrific.”

In helping launch the Hamilton pilot project several years ago, MacMillan worked with a team adapting the American NFP materials to meet Canadian needs and standards. For example, in the US, each nurse is responsible for 25 young mothers-to-be. “In Canada, partly due to issues like geographic distance, we determined it should be no more than 20,” she says. As well, even though both countries support breast-feeding, “Canada tends to put a bigger emphasis on it.”

The pilot project also examined the whole referral process. MacMillan recalls: “We asked, are we able to get referrals and are we able to recruit women?” And once women did join the project, the team asked: “Do both the women and the nurses find NFP acceptable?” Indeed, the pilot project showed that NFP referrals were feasible, and that women and nurses both welcomed NFP.

“I think it’s fair to say that these young mothers were a high-risk group, but basically what we found was that once they were on board and engaged, they really seemed to appreciate the program.”

As for whether the program will succeed in Canada the answer remains to be seen. “My hope is that we will see similar benefits associated with NFP here as compared with the US trials,” MacMillan says.

“NFP is such a unique program where nurses develop this special relationship with mothers prenatally, such that mothers become very tuned in to the needs of their child, and so we hope it will improve outcomes for both mothers and their children.”

Note that 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.

As a midwife in the Okanagan Valley, Suzanne Lobb sees pregnant women who fit every description – from younger to older, from poor to wealthy, and from many different cultural backgrounds. But regardless of their background, each woman receives the same initial message. “We give everyone a card and encourage them to call public health,” Lobb says. “Once they’re out of our care — six weeks after they deliver — it’s easier for them to stay connected to services in the community if they have a stronger connection to public health.”

In the Okanagan Valley, Lobb works with a number of women who are either “young, transient or single parents.” The key issue she identifies is solo-parenting, sometimes because the women’s partners need to leave the community to find sustainable jobs. “There’s also a large number of very young, very transient women who are single parents,” she says, referring to women who often have to move from place to place because they have no home of their own. “And a lot of dads are in and out of the picture,” she adds. Apart from everything else, this often means that the women don’t have the emotional support they need.

That’s one of the reasons why Lobb is a big believer in the BC Healthy Connections Project. “I support the study because I think it’s important to know whether Nurse-Family Partnership is effective,” she says. In her own practice she’s noticed that young women who sometimes have to miss midwifery appointments can often still attend support groups offered by other community-based organizations. “That kind of support is really valuable to those young women,” she says, adding that one-on-one assistance provided by a nurse might be even more effective.

As a mother of three, herself Lobb delivers almost 50 babies each year. She wants to see all of them grow into healthy, happy adults. “I really want to see the study succeed,” she says.

Note that 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.