Phase 3. Evaluation of NFP in Canada

Building on the early McMaster-Hamilton program adaptation and pilot work, in 2010, the British Columbia (BC) Ministry of Health and Ministry of Children and Family Development invited the Children’s Health Policy Centre at Simon Fraser University (SFU) to explore the options for evaluating NFP in BC, in consultation with the McMaster-Hamilton team and with David Olds, NFP’s founder. At the same time BC convened a Provincial Advisory Committee (PAC) comprising senior representatives from regional Health Authorities and other relevant organizations to seek province-wide consensus on proceeding with a large-scale NFP evaluation.

The BC Healthy Connections Project (BCHCP) was then launched in early 2012 – comprising a large, province-wide randomized controlled trial (RCT) evaluating the program among a sample of 739 families. The RCT is being led by SFU (Charlotte Waddell, Nicole Catherine and Debbie Sheehan) in close collaboration with McMaster University (Harriet MacMillan and Susan Jack). A Scientific Team also supports the RCT including members from the University of BC (Ron Barr and Colleen Varcoe); the University of Victoria (Lenora Marcellus); McMaster University (Michael Boyle, Amiram Gafni and Andrea Gonzalez); SFU (Lawrence McCandless); and the Public Health Agency of Canada (Lil Tonmyr).

The BC RCT’s main outcome indicators reflect NFP’s goals and include: 1) prenatal substance use; 2) child mental health at age two years; 3) child cognitive development at age two years; 4) child injuries by age two years (the primary outcome indicator); and 5) maternal subsequent pregnancies at 24 months postpartum. As well, data are being gathered on related measures including socioeconomic status, child physical health outcomes, parenting, and the ability of families to access needed health and social services. The RCT is also setting the stage for future cost analyses through the services data collection.

Enrollment in the BC RCT started in the fall of 2013, following research ethics approvals, in close coordination with participating Health Authorities. A study team based at SFU in Vancouver are collecting data directly from participants (mothers and children) through in-person and telephone interviews and assessments, as well through accessing provincial health datasets on crucial outcome indicators such as child injuries.

In December 2016, RCT recruitment closed with 739 families enrolled – and with 744 babies having been born. Families are being followed over two-and-a-half years (NFP’s duration) through until late 2019. Initial reports are now being prepared on participants’ characteristics on RCT enrollment, when girls and young women were in early pregnancy. All RCT results will become available later in 2020–2021.

Funding for the BC RCT (2011–2021) is being provided by the BC Ministry of Health with support from the BC Ministry of Children and Family Development – with Fraser, Interior, Island and Vancouver Coastal Health Authorities covering all associated nursing costs. The BCHCP RCT has garnered donor support from the Djavad Mowafaghian and R. and J. Stern Family Foundations as well.

The BC RCT is embedded within BC’s public health system – ensuring that findings can be readily taken up in policy and practice. Ongoing policy-practice-research collaborations also guide the project. Reflecting this “integrated knowledge exchange” approach, a Steering Committee oversees the BC RCT. This Committee comprises: 1) lead policymakers from the BC’s Ministry of Health [Warren O’Briain (2012-2018), Wendy Trotter (2018-)] and the BC Ministry of Children and Family Development (Rob Lampard); 2) the BC Ministry of Health Provincial NFP Coordinator (Donna Jepsen); and 3) lead BC-based Scientific Team members (Charlotte Waddell and Nicole Catherine). The BC PAC also continues to provide input to the BCHCP.

To learn more about the BC Healthy Connections Project RCT please see:

1) A scientific overview of the project.
Waddell, C., Catherine, N. & Sheehan, D. for the BC Healthy Connections Project Scientific Team. (2016). BC Healthy Connections Project: Scientific Overview. Children’s Health Policy Centre, Faculty of Health Sciences, Simon Fraser University.

2) A journal article describing the RCT protocol.
Catherine, N.L.A., Gonzalez, A., Boyle, M., Sheehan, D., Jack, S.M., Hougham, K.A., McCandless, L., MacMillan, H.L. & Waddell, C. for the British Columbia Healthy Connections Project Scientific Team. (2016). Improving children’s health and development in British Columbia through nurse home visiting: A randomized controlled trial protocol. BMC Health Services Research, 16, 349.

3) A series of features on the BC Healthy Connections Project.

4) For more information on the BC Healthy Connections Project RCT, please contact Nicole Catherine at the Children’s Health Policy Centre in the Faculty of Health Sciences at SFU.

BC RCT on NFP’s effectiveness: Dr. Nicole Catherine, BC Healthy Connections Project; Children’s Health Policy Centre, Faculty of Health Sciences, SFU,  1-778-782-7775/ Nicole_catherine@sfu.ca

The BCHCP RCT also supports two adjunctive studies: 1) a process evaluation, which is examining how NFP is being implemented and delivered in BC, led by Susan Jack (McMaster( and funded by the Public Health Agency of Canada; and 2) the Healthy Foundations Study, which is examining biological markers of stress in a sub-sample of RCT children, led by Andrea Gonzalez (McMaster) and funded by the Canadian Institutes of Health Research.

Embedding process evaluations within RCTs provides valuable insight about contextual influences on the implementation and delivery of complex interventions across diverse communities. Adjunctive to the main RCT, a process evaluation was designed to explore and describe among BC’s five participating health authorities:

• How the NFP home visitation program is being implemented and delivered;
• If the intervention is delivered with fidelity to the NFP core model elements;
• The dose of the intervention delivered and received;
• Strategies to enroll clients in the program, promote the development of a therapeutic relationship, and the factors that influence client retention;
• Factors that influence the retention of public health nurses and supervisors to deliver this complex public health intervention;
• Contextual factors at the client, health care provider, organizational and community levels that influence implementation and delivery of NFP (including between urban and rural contexts); and
• How public health nurses identify and address issues related to child welfare improvement, intimate partner violence, and mental health including substance use.

The process evaluation is a mixed methods study being conducted over a five-year period (2013 to 2018). Both quantitative data (e.g., team meeting and supervision documentation; case conference forms; program fidelity measures) and qualitative data (e.g., interviews and focus groups with PHNs, supervisors, and public health managers/directors) are being analyzed in this evaluation to bring together the strengths of both research traditions to compare, corroborate and explain results and variances across the five health authorities. Findings from the BCHCP process evaluation will also inform ongoing adaptations and refinements to the Canadian NFP program materials.

A journal article describing the protocol for the BCHCP process evaluation:
Jack, S.M., Sheehan, D., Gonzalez, A., MacMillan, H.L., Catherine, N., Waddell, C., for the BCHCP Process Evaluation Research Team. (2015). British Columbia Healthy Connections Project process evaluation: A mixed methods protocol to describe the implementation and delivery of the Nurse-Family Partnership in Canada. BMC Nursing, 14, 47.

For more information on the BCHCP process evaluation, please contact Dr. Susan Jack, School of Nursing, McMaster University (jacksm@mcmaster.ca).

It is well established that adverse early experiences have enduring effects on cognitive, mental and physical health outcomes. In July 2013, funding was received from the Canadian Institutes of Health Research to embed the Healthy Foundations Study within the BC RCT. Led by Dr. Andrea Gonzalez, with the Offord Centre for Child Studies at McMaster University, the Healthy Foundations study aims to explore the impact of NFP longitudinally on biological outcomes in mothers and their children in a sub-sample of RCT participants in Fraser and Vancouver Coastal Health. With home visits beginning early in pregnancy, NFP presents a unique opportunity to study some of the biological mechanisms influencing health, starting even before birth. Changes will be tracked in stress responses and the way genes work by collecting hair samples, saliva and cheek swabs from infants and consenting mothers. By comparing outcomes for children whose mothers receive NFP coupled with existing services (n=200) to those whose mothers receive existing services only (n=200), findings from the Healthy Foundations Study will lead to greater understanding of the biology of early adversity and how NFP may have the potential to reverse its detrimental effects. Such findings can provide a powerful framework with which to inform basic and applied research, practice and policy.

A journal article describing the protocol for the Healthy Foundations Study:
Gonzalez, A., Catherine, N., Boyle, M., Jack, S.M., Atkinson, L., Kobor, M., Sheehan, D., Tonmyr, L., Waddell, C., MacMillan, H.L., on behalf of the Healthy Foundations Study Team. (2018). Healthy Foundations Study: A randomised controlled trial to evaluate biological embedding of early-life experiences. BMJ Open, 8:e018915.

For more information about the Healthy Foundations Study, please contact Dr. Andrea Gonzalez, Department of Psychiatry and Behavioural Neurosciences, McMaster University (gonzal@mcmaster.ca).