Latest BC Healthy Connections Project Features

There are 300 family doctors in Vancouver but no one knows exactly how many of them provide maternity care. There’s no list, no registry. At best, policy-makers can determine how many doctors deliver babies based on who has hospital privileges.

“But there’s a lot more maternity care providers than those who actually deliver babies,” says Joanne Wooldridge. “The challenge for us in Vancouver is the sheer number.”

As Regional Leader for Early Childhood Development, Wooldridge is helping spearhead recruitment for the BC Healthy Connections Project (BCHCP) in Vancouver Coastal Health. This means finding and connecting with doctors, midwives and nurse practitioners, and persuading them of the value of the project aimed at evaluating the effectiveness of the Nurse-Family Partnership (NFP).

NFP is an intensive maternal and child health program that provides disadvantaged young women — who are preparing to parent for the first time — with one-on-one home visits with public health nurses throughout pregnancy, continuing until children reach their second birthday. According to studies in the US, this sort of partnership empowers mothers to create better lives for their children and themselves. (The BCHCP will determine whether this is also true for BC mothers and children.)

Finding the primary care practitioners who can refer young women isn’t always easy but it’s smoother now the BC government is asking all primary caregivers to refer pregnant women to public health as soon as possible. Furthermore, it’s really easy to refer.

Once Wooldridge and her team identify and speak with a practitioner, they know the pitch they want to make. “In terms of the young women, particularly the ones 19 and younger, they’re going to receive support from public health to improve their life conditions,” Wooldridge says. “A strong connection can be a stabilizing influence for them.”

Housing is another issue. In Vancouver in particular, finding a place to live is so expensive that a large number of young people — especially those on low income — may not have a home. “They’re not homeless,” Wooldridge says. “But they’re effectively couch-surfing and this makes them especially vulnerable.” Public health nurses can help identify housing options and sort out better life opportunities for them.

Increasingly, midwives are also becoming an important group to reach. Some 20 percent of deliveries in Vancouver are managed by midwives. And while two decades ago their clientele might have been largely middle-class women, today they’re serving a different demographic. “Midwives tend to have a reasonable proportion of high-risk clients,” Wooldridge says, “and they often attract people who are not particularly trusting of the healthcare system.”

The good news, according to Wooldridge, is that her team sees “almost all women when they deliver,” in order to provide post-natal care. This allows them to follow up and figure out why women might not have been referred to public health. Most often, she says, it’s a result of someone going to the doctor or midwife too late. “If they were eligible for the BCHCP, we loop back to that physician or midwife and let them know that.”

As well, the Vancouver Coastal Health team makes a point of going back to practitioners who make public health referrals, thanking them and letting them know how the process has worked. “They’ve told us that over and over again that that feedback is critical,” Wooldridge says. “They will remember to refer [again] if they see the benefit in their own patients.”

Note that NFP is available only through the BC Healthy Connections Project for the duration of recruitment. Practitioners or young pregnant women can click here for details on how to reach public health and determine eligibility for the BCHCP.

As a Nurse-Family Partnership (NFP) nurse supervisor with Fraser Heath, Monica Smith* understands that participants — disadvantaged young women preparing to parent for the first time — can face some challenging life situations. And these challenges can have an impact on the nurses helping them.

That’s why Smith’s team of eight public health nurses holds a case conference every two weeks. The value? To allow nurses to provide expertise and support for each other.

“One of the nurses on my team recently said ‘this is the most worthwhile thing I’ve done because it helps me really understand my clients’,” Smith recalls.

Preparing for the case conference is a big job in itself. The public health nurse must fill out a detailed form describing the young mothers in detail and assessing their risks, goals and plans in a variety of areas.

At the conference itself, which acts like a large brainstorming session, the nurse asks for help in areas in which she — or the young participant — may be stuck or struggling. “It’s a way that really connects that nurse to the larger group of nurses,” Smith says. “It’s very empowering. These young women are not alone and these nurses are not alone.”

Smith says her team experiences an enormous amount of heartache, as a result of the challenging life conditions faced by the young moms or moms-to-be. “It’s hard to experience that sadness,” she says. “If we didn’t come together to share that, I don’t think we’d be able to continue.”

At a recent case conference, the team focused on resiliency. Smith was particularly proud of a metaphor one of the nurses articulated, comparing resiliency to a willow tree. “It’s able to stretch and bend and then come back to almost the same shape, but changed,” she says. This resiliency, in turn, enables nurses to better help the young mothers (and the children) through the BC Healthy Connections Project.

Note that NFP is available only through the BC Healthy Connections Project for the duration of recruitment. Practitioners or young pregnant women can click here for details on how to reach public health and determine eligibility for the BCHCP.

*The nurse supervisor’s name has been changed to ensure privacy.

A cheerful young woman with a BA in psychology, Lori Esler* is a scientific interviewer who works with SFU’s Children’s Health Policy Centre on Vancouver Island.

Her job? To interview participants in the BC Healthy Connections Project, an evaluation of the Nurse-Family Partnership (NFP) program that’s taking place over the next five years.

Developed in the US but never before tested in Canada, the Nurse-family Partnership provides intensive public health nursing visits to disadvantaged young women — who are preparing to parent for the first time — starting in pregnancy.  Although eligibility criteria for the project are quite specific — participants must be disadvantaged first-time mothers 24 years or younger — Esler says the group seems very diverse. “When I first meet people they’re polite and a bit reserved,” she says. “But as the interview progresses they open up a little bit more.”

The youngest participants — those under 19 years — may be living temporarily with their parents. Others might be homeless. Many are living on very low income. Some may have suffered serious childhood adversities. “They’re all in totally different situations, which surprised me a little,” Esler says. “But people are just people and I find them so interesting.”

Although she doesn’t know which women are receiving Nurse-Family Partnership (only 50% do), Esler interviews them all. This policy helps ensure the evaluation data are not biased. And everyone she interviews, Esler says, is excited about participating.

“I had one woman say to me, ‘oh my gosh, I’ve a hard time figuring out how to get what I need. If my taking part in this study will help someone else, then I’m really glad to do it.’”

Note that NFP is available only through the BC Healthy Connections Project for the duration of recruitment. Practitioners or young pregnant women can click here for details on how to reach public health and determine eligibility for the BCHCP.

*Name has been changed to protect privacy.

Say the words “Nurse-Family Partnership” (or NFP) and most people will imagine a nurse visiting a mom and her family. But say the words “process evaluation” and most people will likely draw a blank.

A process evaluation, however, is a vital part of scientific studies such as the randomized controlled trial or RCT being conducted through the BC Healthy Connections Project (BCHCP).

A kind of a study of a study, a process evaluation determines how well an intervention is being implemented and what factors may be influencing the outcomes. In the case of the BCHCP, for example, the NFP intervention — home visiting by public health nurses or PHNs — is being delivered to young, low-income women who are preparing to parent for the first time.

But NFP is being delivered in very diverse communities across BC, notes Susan Jack, who is principal investigator for the study’s process evaluation, which is being funded by the Public Health Agency of Canada. “What happens when the program is delivered in smaller communities where there may be more barriers to travel and communication? And are there differences in delivering NFP between urban and rural areas in BC?” she asks. “We’re going to try to understand all these variables.”

NFP, which starts early in pregnancy and continues until children reach their second birthday, has proven successful over 35 years in the US. But this current RCT is the first scientific evaluation of the program in Canada. (NFP’s founder, David Olds, explains why an RCT is necessary.)

The primary participants in the process evaluation, however, won’t be the women and children. They’ll be the PHNs and nursing supervisors who are responsible for NFP visits. “We’ll be interviewing them every six months to explore where they are with the program, the challenges that have come up, their perceptions of the education they’ve received and any gaps that may exist,” Jack says.

The process evaluation will also study how the program is being implemented in five different Health Authorities to meet the needs of families across the province. One of its most important functions is to determine whether the program is being delivered with fidelity to the NFP model,” Jack says, mentioning the high frequency of visits that mothers are offered as an example. “If that’s not happening then we need to know why.” More broadly, the process evaluation will also help us understand BC’s unique context – including the situations faced by PHNs, their supervisors and the families they visit – and the solutions developed by the NFP teams to resolve any emergent challenges.

Another issue for the process evaluation is refining the NFP model to meet the unique needs of young, disadvantaged first-time mothers in BC. These young women are often hard to reach because they may not have stable housing, reliable work or supportive extended families – at a time in their lives when they need a lot of support. PHNs in turn may find it challenging to locate young people who may be highly mobile. Financial difficulties may also lead to some women not having easy access to phones. For example, “many families use phone cards and once the phone card runs out, they don’t have land lines,” Jack says. “Many of the young moms we work with go from family to family, and many of the nurses will struggle with trying to locate them.”

These young women may also not have had good role models to help them learn what a trusting relationship looks like or how to maintain healthy relationships. This will potentially make building a trusting relationship with their NFP PHN more challenging. This is yet another issue that the process evaluation will investigate.

Jack has high hopes for the process evaluation and high praise for the BC PHNs she has met. “The NFP nurses in BC are among the most skilled I’ve ever worked with,” she says. “We’re still refining everything and testing the tools and the procedures. But our work with the BC process evaluation will be a huge benefit for the international NFP community.”

Note that NFP is available only through the BC Healthy Connections Project (BCHCP) for the duration of recruitment. Practitioners or young pregnant women can click here for details on how to reach public health and determine eligibility for the BCHCP.

Solving a problem, not just promoting a program

Canadians and Americans, on average, live in the same types of homes, listen to the same music and watch the same TV shows.

For these reasons, you might expect that a public health program like Nurse-Family Partnership (NFP) would be equally effective in Canada and the US. Yet we can’t necessarily assume this is true.

Although NFP looks extraordinarily positive because it has succeeded for more than 35 years in the US — reducing child maltreatment, improving Children’s mental health and learning, and improving mothers’ economic self-sufficiency — its effectiveness here remains unknown and unproven.

The main reason according to the developer of the program, Dr. David Olds — a professor of pediatrics, psychiatry, and preventive medicine at the University of Colorado, Denver — is Canada’s superior health and social service systems.

“You have a health and human service delivery system that’s better organized and better delivered than in the US,” he says. “And NFP has its greatest benefits for people living in the most disadvantaged circumstances.”

The only way to determine exactly how effective NFP will be in Canada is to put it to the test of a randomized controlled trial or RCT.  BC is now leading the country in being the first to conduct such an RCT. This test involves recruiting a large number of participants and randomly assigning half to receive the program and half to receive existing services. Public health scientists consider the RCT to be the “gold standard” in evaluating program effectiveness.

By comparing the outcomes for those who receive the program versus those who don’t, researchers can precisely quantify the benefits. This comparison helps confirm that improved outcomes are due to the program  — in this case, NFP — rather than due to other factors such as chance. Conducting an RCT also ensures that we understand exactly what outcomes we can achieve with BC mothers and children.

Any complex public health RCT requires significant resources and large teams of people — in this case, including many researchers, policy-makers and public health nurses. But these investments are more than worthwhile given NFP’s promise for improving the lives of BC mothers and children.

Olds is so strongly committed to such scientific rigor that he will not license anyone outside the US to use his program unless they perform an RCT in advance — to see how well NFP works. In addition to the study being conducted here, called the BC Healthy Connections Project, similar work is being done in England and the Netherlands.

“I want to solve a problem, not promote a program,” Olds says, noting that it’s entirely possible that certain subpopulations will respond better than others.  Olds first identified the “problem” at an American inner-city daycare center in the early 1970s. He noticed the difficulties in the lives of low-income children and realized these children needed help much earlier— even before they were born.

This led to him developing a nurse home-visitation program for low-income women about to become first-time parents and their children beginning no later than 27 weeks of pregnancy and continuing until children turned two.

While he acknowledges that RCTs are expensive, Olds says the investment is well worth it. “In the long run, that money is going to be a very small drop in the bucket compared to what society is likely to get out of the program,” he says. For example, US researchers have estimated net returns of $2.88 US for every dollar invested in NFP, with that figure nearly doubling — to $5.70 US — for the most disadvantaged families. Savings were attributed to reduced use of healthcare and social assistance as well as, in one study, reduced child protection costs.

As Olds concludes, “If there’s going to be long-term public commitment to this program, it’s crucial that we all know that it’s producing robust effects in varied community settings. Without knowing how effective the program is, we don’t have the right to say that this the best use of scarce public resources.”

Note that NFP is available only through the BC Healthy Connections Project (BCHCP) for the duration of recruitment. Practitioners or young pregnant women can click here for details on how to reach public health and determine eligibility for the BCHCP.