Latest BC Healthy Connections Project Features

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.

The BC Healthy Connections Project (BCHCP) today officially launched Phase II of its scientific evaluation of the Nurse-Family Partnership program.

Developed by Dr. David Olds more than 30 years ago, Nurse-Family Partnership (NFP) involves nurses visiting young, low-income, first-time mothers in their homes, roughly twice a month. These home visits start during pregnancy and continue until children reach their second birthday.

The BCHCP is the first-ever Canadian evaluation of NFP to determine whether the program is more — or less — effective than existing services in BC. The goals of the NFP are to improve pregnancy and parenting outcomes and child health and development, while also helping mothers to become economically self-sufficient.

Until the scientific evaluation is completed NFP is available only through this project. Please see Referral Information, below.

Phase I of the BCHCP actually began more than 18 months ago when 52 public health nurses and 10 supervisors from across the province began their NFP education.

Then, starting in April 2012, these public health nurses began applying their new knowledge and skills by home-visiting more than 200 “guiding clients,” the name given to young women enrolled in the nurse education pilot. Phase I continues still, with public health nurses receiving further education and continuing to visit their guiding clients.

Today, these public health nurses are well prepared for Phase II — involving more than 1,000 mothers and children over the next five years. Using rigorous evaluation methods, half these women will be randomized to receive NFP while half will receive existing services. Child and maternal outcomes will then be compared when mothers and children “graduate” — when children reach their second birthday.

Susan Cumming, a public health nurse with more than 18 year’s experience with Interior Heath in Kamloops, BC, is keen, even though she was initially reluctant to join the BCHCP.

“When I first heard about the project I was ambiguous,” she says. “I wasn’t clear how it differed from the work I was already doing with high-needs families.” Eventually she attended an information workshop and was captivated by a video clip of NFP’s developer David Olds. “He talked about what the nurses did in the US and he quoted one of them saying something along the lines of, ‘it’s the hardest, most rewarding work I’ve ever done.’

“Something in me just tweaked,” Cumming recalls. “This has always been an area I’ve been passionate about.” Despite her vast experience as a public health nurse though, “the learning curve was straight up,” Cumming says — remembering when she first started the education pilot. “In all the years I’ve been a public health nurse, this is the most intense learning I’ve done.”

Cumming has worked with four families as part of Phase I, including 24-year-old Mary* (name has been changed to preserve privacy) who is now the mother of a six-month-old.

“We connected during the fourth month of pregnancy,” Cumming says. “She’s a great mom and a very motivated — very keen client.”

For Mary, in turn, the opportunity to receive one-on-one parenting support from a public health nurse has been “fantastic.”

Mary was recruited into Phase I at the maternity clinic in Kamloops and saw the benefits almost immediately. “It was a bit awkward at first because I’m a little shy,” she says. “But once we got talking I knew it would work out really well. She’s one of those people who’s really easy to talk to.”

Mary says that she’s had many interactions in her 11 months working with Cumming. Perhaps one of the most helpful was related to preparing for labour. “I couldn’t afford the private prenatal classes because they were $140,” she says. Although she did find one free program that was informative, it still didn’t answer all her questions. “I talked to Susan for about 45 minutes and she really helped walk me through all the steps of labour,” Mary says. “I was so much better prepared.”

In fact, Mary’s so impressed she’s encouraging her friends to consider contacting their local public health unit to see if they are eligible to participate in the BCHCP. (See Referral Information, below.)

Cumming also reports that the whole nurse education pilot experience has accelerated her own development as a public health nurse. She particularly appreciates the reflective practice —built into the NFP model — where she meets with her supervisor for one hour every week to discuss families, issues and concerns. “When I first heard about it, it seemed very unfamiliar,” she says. “Now I can honestly say I look forward to it every week because it’s very positive and empowering.”

Most of all, in working with all her guiding clients, Cumming feels that she’s making a difference. “Two of the five guiding principles of NFP are ‘follow the client’s hearts desire’ and ‘only a small change is necessary’.” This keeps her highly motivated to participate in the remainder of the BCHCP — to determine whether NFP can work for young women across BC.

The BCHCP is being funded by the BC Ministry of Health, with support from the BC Ministry of Children and Family Development and five participating BC Health Authorities. As well, funding is being provided by the Mowafaghian Foundation. Charlotte Waddell and Harriet MacMillan are the Nominated Co-Principal Investigators. Susan Jack and Debbie Sheehan are the Co-Principal Investigators. Nicole Catherine is the Scientific Director.

Referral Information

For the duration of the BCHCP recruitment, NFP is accessible only through this scientific evaluation. To be eligible to participate in the BCHCP, women must be: parenting for the first time; aged 24 years or younger; able to speak English; and less than 27 weeks gestation (ideally 10–24 weeks).

Referrals are not made directly to the study. Rather, women should be referred or should self-refer to their local public health unit where a public health nurse will screen them. The study will then be explained and eligibility to participate will be confirmed. Click here for details on how to reach public health and determine eligibility for the BCHCP.