In this Papers Podcast, Assistant Professor Nicole Catherine discusses her JCPP paper ‘Effectiveness of nurse-home visiting in improving child and maternal outcomes prenatally to age two years: a randomised controlled trial (British Columbia Healthy Connections Project)‘ (https://doi.org/10.1111/jcpp.13846).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- Insight into the cohort that participated in the study.
- Potential follow-up studies using the same cohort, including further research into assessments of language, reading, and academic ability later on in childhood.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Dr. Nicole Catherine is an Assistant Professor and Associate Director, Children’s Health Policy Centre in the Faculty of Health Sciences at Simon Fraser University, Vancouver, British Columbia, Canada. Dr. Catherine also holds the Canada Research Chair in Child Health Equity and Policy, Tier II. She conducts research on the early prevention of child health inequities and on ensuring inclusion of underserved children– in both research and policy-making.
Transcript
[00:00:10.019] Caroline Priscott: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Caroline Priscott, a Midwife by background, with 20 years’ experience in the field, including six years as a Team Leader, caring for women and birthing people with significant vulnerabilities, such as mental health conditions. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today, I’m interviewing Assistant Professor Nicole Catherine, Canada Research Chair Tier 2, in Child Health Equity and Policy, at Simon Fraser University in Vancouver, Canada. Nicole is the author of the paper, “Effectiveness of Nurse-Home Visiting in Improving Child and Maternal Outcomes Prenatally to Age Two Years,” a randomised controlled trial, British Columbia Healthy Connections project, recently published in the Journal of Child Psychology and Psychiatry.
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Nicole, thank you so much for joining us today, to discuss what is truly a fascinating piece of research. Can we start with an introduction about who you are and what you do?
[00:01:37.340] Dr. Nicole Catherine: Hi, Caroline, you already gave me a great introduction. So, I live and work on the traditional and unseeded lands of the Coast Salish people, on lands that are now called Vancouver, in British Columbia, Canada. But I grew up in Scotland, so I do have a bit of an accent.
I’m an Assistant Professor in the Children’s Health Policy Centre, in the Faculty of Health Sciences, at Simon Fraser University. I moved out to Canada after my undergrad degree, and I’ve been focusing on child health research for many years now, and my research currently focuses on three main areas. The first is better inclusion of children who are experiencing disadvantage, in both research and in policy. The second is evaluating early childhood prevention initiatives, starting really early in life, so as early as possible in pregnancy. And the third area is working closely with policymakers, and this is to ensure that my research is both meaningful and it has the greatest potential to make a difference for children.
I’m with the Children’s Health Policy Centre, in the Faculty of Health Sciences, at Simon Fraser University, and I’ve been with the centre for many years now. And we collectively focus on improving the wellbeing for all children and public policies really needed to reach that goal. And we are quite a unique centre in British Columbia and Canada, in that we really just focus on children, especially early childhood, and work very closely with policymakers. So, a large part of our work has been producing high quality, systematic review methods on early prevention and treatment for the common childhood mental disorder. So, that’s called “The Quarterly,” and that’s published every quarter on our website, and you can see that at childhealthpolicy.ca.
And a big part of our centre too was pulling off this large, early prevention initiative and randomised controlled trial, the “BC Healthy Connections project.” And collectively, we just make sure that we’re doing research that is very meaningful to policymakers, that’s very much our goal. So, we work closely with them, identify important policy windows, what they need, conduct rapid reviews, or do large, ten-year long trials, really just wanting to make sure that what we do is very rigorous, high quality, and again, very meaningful and much needed.
And so, the project and paper I’m going to talk about today really encompasses reaching children, evaluating early prevention starting in pregnancy, and really working with policymakers right from the start.
[00:04:17.389] Caroline Priscott: Thank you. Let’s turn to your paper now, can you give us a brief overview to set the scene?
[00:04:22.210] Dr. Nicole Catherine: Yeah, this paper reports on the main outcomes from our large, Canadian public health randomised controlled trial, that evaluated the effectiveness of an early prevention programme on improving child outcomes. And the programme’s called “Nurse-Family Partnership,” or NFP, it’s known as “Family Nurse Partnership” in the UK, and it focuses on young, first time mums and their children who are coping with socioeconomic disadvantage. And NFP involves intensive home visits by Nurses, starting early in pregnancy, and right through until children reach their second birthday.
And the programme itself was developed about 40 years ago in the United States, and through three trials there and follow-up of that research, it has shown many enduring benefits in America, like on prenatal substance exposure, and reduced child maltreatment, and mental health and cognitive development. But beyond a pilot study in Ontario, Canada, NFP had never been rigorously tested before. So, we didn’t know if the same benefits for children and mothers would result here, particularly given Canada’s different health and social programmes and services compared to the US.
So, in 2011, the province in British Columbia made quite a significant investment and sponsored the large-scale Canadian trial of NFP, and we call it the “BC Healthy Connections project.” So, it’s led by myself and Charlotte Wadell, at our Children’s Health Policy Centre at Simon Fraser University, and it’s in collaboration with a number of Researchers across Canada, including McMaster University. And there were four of the five regional health authorities across British Columbia were implementation partners, and they funded all of the nursing salaries, NFP nursing education, and the programme delivery costs. And so, together we had a lot of fun over the 12 years of the trial, and overall, the implementation was a huge success.
[00:06:14.139] Caroline Priscott: Thank you. You’ve touched on the methods, but can you tell us a little bit more about the methodology used?
[00:06:20.490] Dr. Nicole Catherine: Well, the families were at the heart of this trial. We enrolled 739 girls and young women, who were aged less than 25 years. And at the time they were experiencing socioeconomic disadvantage, which we defined as limited income, no access to education, or being single. And they were preparing to parent for the first time, and they went on to have 737 children who were part of the trial.
And so, our research team invested an extraordinary amount of time ensuring that the mums knew that their contributions were important. Many were coping with unstable housing, having moved three or more times in the previous year, and they had no money for mobile phones or data for us to phone them. So we invested a lot of time trying to stay in touch with the mums, to make sure that they could be included, that their experiences could be heard via the research data.
And so, we were very pleased that the majority did complete all six research interviews, and were still with us by the time the children reached two-years-old. We were also fortunate that the data collection was completed in 2019, prior to the onset of the pandemic. And the trial itself was pragmatic, it was a real world trial, so the delivery of Nurse-Family Partnership was embedded within public health existing services, and this was also to ensure that NFP could become a sustainable component of public health services.
[00:07:41.569] Caroline Priscott: Really comprehensive, thank you. And what were the key findings? What were the things that stood out for you?
[00:07:47.650] Dr. Nicole Catherine: I would say there were three main takeaways. The first is that were able to reach and enrol a cohort that were experiencing unacceptable levels of disadvantage, and this represents the population that NFP was designed to help. So, at trial entry, on our baseline research interview, many reported that they were experiencing mental health problems, intimate partner violence, unstable housing, really limited income, so they reported less than $10,000 Canadian per year, which is less then £6,000 per year. And this is all while they were pregnant and preparing to parent for the first time. And so this unacceptable levels of disadvantage was news to some of our public health partners, who were initially unsure whether this level of disadvantage existed in British Columbia. And so what this trial has shown is that more needs to be done to reach and include these pregnant girls and young women and their children.
And the second main message is that British Columbia may have more robust systems in place supporting this cohort of mums. We didn’t see any benefits on our primary outcome, which was child injuries, and we measured this with robust linked data from Outpatient, Emergency Room and hospital encounters. And we also didn’t see benefits on cognition in a subgroup of children who were observed directly in their home, using a regular psychometric approach.
But what we did see was some programme benefits on outcomes measured through maternal self-report. And we found that NFP mothers reported lower prenatal cannabis use, and for a subgroup that were smokers, fewer cigarettes smoked in pregnancy. And this is important, because we know that any substance exposure during pregnancy can negatively impact foetal child development.
And then, so our recent paper in the Journal of Child Psychology and Psychiatry this summer showed that reductions in child externalising problem behaviours, by age two, and this is important as early problem behaviours are a marker for later mental health problems, and increasing the risk for long-term mental disorders that may require added services. We also found improved vocabulary production by age two, and we know that children with sustained language delays later in childhood usually have those difficulties as young as age two years, so introducing early services can help.
And so, overall, because our findings rely on maternal self-report, which are subject to bias, like recall bias, or social desirability, we recommend follow-up of longer-term outcomes across childhood and adolescence, which is similar to the England trial and the American trials which have found sustained benefits from age four onwards.
[00:10:22.450] Caroline Priscott: That’s really interesting, thank you. I’m particularly interested in NFP’s potential to influence health for longer-term. There is reference in this paper to other studies that did see the benefits to child reading achievement by age seven. Do you have any future plans to follow-up on assessments of language, reading and academic ability, later on in childhood, for this cohort that participated in your study?
[00:10:43.070] Dr. Nicole Catherine: Yes, yes, we do, and that reference was the England trial of “Family Nurse Partnership,” where they didn’t see any benefits by age two years, but when they did the longer-term follow-up, they did see some benefits by age seven. So, yeah, we are definitely going to be doing follow-up of longer-term outcomes. We know that trials in the US and in England have shown that these child’s added benefits may emerge over time, and so, in particular, in adolescence, in the American trials too. So, our Children’s Health Policy Team, we’re pursuing new funding to examine data linkages on child and maternal health, in education, in socioeconomic outcomes across middle childhood and adolescence, and we’ll also do in person follow-up interviews with the families as well.
We also had, for our population in our trial, we had a high proportion of indigenous participants, who identified as First Nation, Métis or Inuit, and this was despite no specialised referral pathways for the population. So, our team’s going to – is now working with indigenous partners here in British Columbia, including the First Nations Health Authority, Métis Nation of British Columbia, and others, on a series of reports, using and interpreting the longitudinal trial data on the indigenous mums and children. And then with indigenous leadership, potentially exploring and culturally adapting and evaluating NFP’s indigenous knowledge and methods.
[00:12:05.980] Caroline Priscott: Finally, what would be your take home message to healthcare professionals reading your paper?
[00:12:10.790] Dr. Nicole Catherine: It’s important to reach and include the voices of marginalised families, who are more likely to experience structural and systemic barriers to engaging with public health. And sadly, they’re traditionally labelled as “hard to reach,” and therefore they are just – they drop out of research, we can’t find them, they’re moving around, they’re not answering their phone, the NFP Nurse can’t stay in touch with them, they’ve never responded, so they just get dropped from the caseload, and someone else comes on, or they’re just dropped from research. And so, the mums and their children are then excluded or invisible in the research and the policies and programme, when, in fact, the responsibility and the onus really is on us, as Researchers and healthcare professionals, to address barriers and better reach and include these mums and children, to ensure maternal child equity.
[00:12:58.360] Caroline Priscott: Thank you ever so much, Nicole. For more details on Assistant Professor Nicole Catherine, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.