How does Nurse-Family Partnership work in Canada?

Nurse-Family Partnership aims to improve the lives of young, first-time mothers and their children. Developed nearly 45 years ago by David Olds and colleagues in the US, the program starts early — in pregnancy, before children are even born. It involves intensive home visits by public health nurses and continues until children reach their second birthday. The program particularly focuses on girls and young women and their children who are facing disadvantages such as limited income.

Public health nurses provide the home visits — up to 65 in total over two-and-a-half years. Nurses delivering the program receive extensive education. As well, they receive resources to use in the visits, and ongoing supervision and support.

Three US randomized controlled trials (RCTs) have been conducted on Nurse-Family Partnership, with follow-up now reported for more than 20 years. The program has shown robust and enduring benefits for children and mothers including:

  • reduced prenatal nicotine exposure
  • improved parenting
  • reduced child injuries
  • improved child mental health
  • improved child cognitive development
  • improved economic self-sufficiency for mothers.

Two independent research groups have also studied the costs versus benefits of Nurse-Family Partnership in the US. The Rand Corporation estimates a net return of US $2.88 for every dollar invested. And these returns nearly double for the highest-risk families, at US $5.70 for every dollar invested. The Washington State Institute for Public Policy found similar results. They estimate a net return of more than US $18,000 for every family served. Both analyses calculated averted spending across multiple public sectors over 10-15 years following program completion including:

  • healthcare
  • justice system
  • income assistance, and
  • child welfare.

Other groups have now evaluated Nurse-Family Partnership outside the US. An RCT in the Netherlands found it achieved many benefits when compared with existing health and social services when children were age three years. There, the adapted Nurse-Family Partnership program known as VoorZorg:

  • reduced prenatal nicotine exposure
  • increased breastfeeding
  • improved parenting, and
  • reduced intimate-partner violence.

An RCT in England, meanwhile, found limited benefits compared with existing services for children at two years of age, and improved school readiness by age five years, with significantly more children attaining the expected reading level by age seven years.

Different findings across the American, Dutch and English trials affirm why countries outside the US need to rigorously evaluate Nurse-Family Partnership before they use it. Interventions may have different outcomes in different countries. This may occur because existing services differ from the US, or because RCT study design, populations and outcome indicators differ.

Because of these issues, the program’s developers ask that countries interested in Nurse-Family Partnership go through three distinct steps:

  1. adapt the program to the local context
  2. assess feasibility and acceptability in a small-scale pilot study
  3. test the program in a large-scale RCT

The BC Healthy Connections Project represents the Canadian RCT.

Nurse-Family Partnership was first adapted to add Canadian content at McMaster University. Starting in 2008, the program was then piloted with 100 families in Hamilton, Ontario. The pilot showed that the program was well received by families, nurses and other healthcare providers, and community agencies — demonstrating acceptability and feasibility.

In 2011, the BC Ministry of Health with support from the BC Ministry of Children and Family Development decided to sponsor a large-scale scientific evaluation of Nurse-Family Partnership. Its goal is to determine how the program can improve the lives of children and mothers compared with BC’s existing health and social services. Called the BC Healthy Connections Project, the evaluation used RCT methods to evaluate NFP in a sample of 739 mothers and 737 children (2011–2022).

The Children’s Health Policy Centre at Simon Fraser University led the scientific evaluation — with collaborators from across BC and Canada. Collaborators include scientists at McMaster University, the University of BC, the University of Victoria and the Public Health Agency of Canada.

BC Healthy Connections Project Steering and Provincial Advisory Committees provide further guidance for the work. Three of BC’s regional Health Authorities are responsible for nursing costs, NFP delivery and referred participants to the RCT study team:

  • Fraser Health
  • Interior Health
  • Island Health

Charlotte Waddell and Harriet MacMillan were the Nominated Co-Principal Investigators for the BC Healthy Connections Project. Nicole Catherine was the Scientific Director and Co-Principal Investigator. Susan Jack and Debbie Sheehan were also Co-Principal Investigators. Donna Jepsen was the Provincial Nurse-Family Partnership Coordinator with the Ministry of Health (2012–2021). Karen Ramsay-Cline is the Senior Provincial Manager-NFP with the Ministry of Health (2021 – present).

After nurses received their education and after research ethics approvals were obtained, the Children’s Health Policy Centre launched BC’s Nurse-Family Partnership RCT in October 2013. Recruitment closed in December 2016 and the CHPC study team followed each of the 739 mothers and 737 children until the children reached their second birthday in 2019. Findings show that NFP reduces some forms of prenatal substance exposure.

Findings on other main outcome indicators including child injuries, child cognition and language and problem behaviours at age two years, and maternal lifecourse will be available in 2022. Reports on other outcome indicators such as intimate partner violence will follow.

The BC Healthy Connections Project also includes two associated studies:

  • A Process Evaluation, looking at nurses’ experiences with program implementation in select local health areas across BC (completed). Funded by the Public Health Agency of Canada, this study will help suggest future adaptations for BC and Canadian delivery of Nurse-Family Partnership.
  • The Healthy Foundations Study, looking at biological markers of health and development. Funded by the Canadian Institutes of Health Research, this study will measure how Nurse-Family Partnership may influence children’s physiological response to stress (findings available from 2023 onwards).

The BC Ministry of Health funded the BC Healthy Connections Project RCT, with support from the BC Ministry of Children and Family Development, and from four regional Health Authorities. The Djavad Mowafaghian Foundation, the R. and J. Stern Family Foundation, and the Canada Research Chairs Program have provided additional supports.

Referral Information

For more information on referrals to the program in Fraser Health, Interior Health and Island Health or the public health prenatal program in Vancouver Coastal Health, please contact your family doctor, nurse-practitioner or midwife, or local Health Authority.

The following links give more information on Nurse-Family Partnership. Note that the program is in different stages of development, evaluation and implementation around the world: