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.

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.

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.

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.

As a scientific interviewer, Elsa Langdon* now regularly meets with people she wouldn’t otherwise have the privilege of knowing.

Her role, as part of the BC Healthy Connections Project (BCHCP) — a scientific study evaluating the Nurse-Family Partnership program — puts her face to face with young women who’ve dealt with a variety of life experiences. Some have not always had all the supports they needed. Some are living on low income. Some have struggled with finishing school, or with health problems. And now they’re pregnant for the first time.

An intensive child and maternal health program, Nurse-Family Partnership (NFP) gives young women who are preparing to parent for the first time one-on-one home visits with public health nurses throughout their pregnancy. These visits continue until children reach their second birthday. The BCHCP is the first Canadian scientific evaluation of this program.

Says Langdon: “It’s been amazing to me to see how strong these women are. Despite all the challenges they face, they still have so much hope for the future. That’s had a big impact on me.”

Langdon’s job is to speak with all participants in the study (only 50% receive Nurse-Family Partnership; the remainder receive existing health and social services) and track their experiences about being new mothers over two-and-half years.

What has struck Langdon the most is how much she has in common with these women. “A realization that’s been slowly washing over me is this sense of how similar we all are,” she says. “If you read about their lives on a piece of paper you may think, ‘They’re so different from me. We have nothing in common.’ But when I sit down and talk [to them], I realize they have the same worries, the same concerns that I do.”

She has also been surprised by the enthusiasm of the participants. “At the beginning I didn’t expect that,” she says. “We were taking up a lot of time and asking a lot of questions. I thought we’d be more of a burden.” Instead, the women taking part often express their gratitude, saying that being in the study gives them a voice. One young woman, in particular, said it made her “feel she was part of something that was bigger,” Langdon says. “It was great to know she saw it as a positive thing.”

Note that Nurse-Family Partnership 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.

When a public health nurse discovered that a young mom in the Nurse-Family Partnership (NFP) program was reading the book Getting Things Done, by productivity expert David Allen, she was surprised.

But that’s exactly what makes the program so unique and valuable, says nursing supervisor Amanda Nazari.*

An intensive child and maternal health program, Nurse-Family Partnership provides selected first-time moms with one-on-one home visits with public health nurses throughout their pregnancy. The visits continue until children reach their second birthday.

“This nurse had shared with me how incredible it was to visit this participant,” Nazari says. A “profoundly contemplative person” who gives her own life tremendous thought, the mom had started to read the book and incorporate some of the principles into her own life. Then she shared what she had learned with her nurse.

“For the nurse, that makes it learning too,” Nazari notes. “In NFP we talk about the parallel process. Sometimes it’s about participants’ lives and their journeys. But at other times they have things to teach us.”

Nazari particularly appreciates what she describes as her own “vicarious experiences” with young moms, through the six nurses she supervises. “The whole basis of NFP is that it’s such a terrific opportunity to support these young women,” Nazari says.

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.

* Name has been changed to protect privacy.

Charlotte Waddell believes children are so important that society should ensure their wellbeing even before they are born. So, together with a large team of research and policy collaborators, she is studying the effectiveness of the landmark Nurse-Family Partnership program in Canada for the first time. The study is called the BC Healthy Connections Project (BCHCP).

Nurse-Family Partnership (NFP) is a home visiting program. It involves public health nurses providing intensive supports to disadvantaged young women who are preparing to parent for the first time. Visits start early in pregnancy and continue until children reach their second birthday. The young women develop long-term relationships with the nurses, which is a crucial part of how the program works.

The BCHCP involves a randomized controlled trial of the program’s impact – looking at mothers’ wellbeing, and at children’s health and development from birth through age two. In essence, the research team will compare NFP with BC’s existing maternal and child health and social services.

BC’s participating Health Authorities are seeking 1,000 mothers and children to take part in the BCHCP over the next two years. But beyond this, Waddell hopes that the research team can follow these children and families for 10 years or more. The goal? To look at mental health and development as children progress through early, middle childhood and into their adolescent years.

“We know from US studies that many program benefits actually show up much later – in 10, 15 or 20 years,” Waddell says. “So, in a sense, completing the immediate evaluation of Nurse-Family Partnership is just the first step.”

For example, the team would like to learn whether Nurse-Family Partnership helps prevent kids from developing serious anxiety, depression, behaviour and substance misuse problems. As well, the team is curious about how Nurse-Family Partnership might affect academic achievement – from school entry into the high school years. There are other potential benefits, too, such as reducing the number of children going into foster care – and even reducing mortality for children and mothers.

Beyond these potential benefits for children, it may turn out that Nurse-Family Partnership is a good fiscal investment. In the US, NFP has shown a return on investment of more than $18,000 for every family served. This includes savings across healthcare, income support, youth justice, child protection and other public sectors. “So we’re setting the stage to test cost effectiveness, too.”

But the real reason to care? Says Waddell: “It’s about making sure that all BC children have the chance to flourish and meet their potential.”

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 eligibility for the BCHCP.

Scientific interviewers who work with the BC Healthy Connections Project (BCHCP) speak to women about some of the most emotionally intense experiences of their young lives. Their first pregnancy. Their relationships. The financial — and other — challenges they face. Their future job prospects. Their education.

Interviewer Vivian Lehman* remembers one mother-to-be especially well. Lehman expressed how much she appreciated the woman taking the time to share her experiences. “She sat there for a minute and looked at me and said, ‘I’m happy I did this and I really hope it can help improve services,’ ” Lehman recalls.

The woman had had experience with foster care and had grown up without much support. But the interview gave her the chance to have her voice heard. She was 18 years old.

“To have [young women] relate these feelings back to you is really powerful,” Lehman says, and she herself remains moved by the potential of her role. Her job is to interview participants in the project, tracking both their successes and the challenges they face.

Lehman believes the BCHCP, which is a scientific study of the Nurse-Family Partnership, will help show if there are benefits to adding new programs to support young first-time mothers facing socio-economic disadvantages compared to what’s currently available.

An intensive child and maternal health program, Nurse-Family Partnership provides disadvantaged young women who are preparing to parent for the first time with one-on-one home visits with public health nurses throughout their pregnancy. The visits continue until children reach their second birthday. The BCHCP is the first Canadian scientific evaluation of this program.

Lehman also believes the study will illustrate the challenge of getting information to the young women who need it. “There are quite a few different services [for young pregnant women],” she says, “but you need the right person or the right link to find your way in to them. It can be really hard when you’re young and find yourself pregnant.”

Having the chance to interview participants in the BCHCP is something Lehman describes as a tremendous experience. “It’s an honour to be able to peek into their lives,” she says. “It’s really a privilege.”

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 more information.

* Name has been changed to protect privacy