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Background Effective strategies for participant retention are critical in health research to ensure validity, generalizability and efficient use of resources. Yet standardized guidelines for planning and reporting on retention efforts have been lacking. As with randomized controlled trial (RCT) and systematic review (SR) protocols, retention protocols are an opportunity to improve transparency and rigor. An RCT being conducted in British Columbia (BC), Canada provides a case example for developing a priori retention frameworks for use in protocol planning and reporting. Methods The BC Healthy Connections Project RCT is examining the effectiveness of a nurse home-visiting program in improving child and maternal outcomes compared with existing services. Participants (N = 739) were girls and young women preparing to parent for the first time and experiencing socioeconomic disadvantage. Quantitative data were collected upon trial entry during pregnancy and during five follow-up interviews until participants’ children reached age 2 years. A framework was developed to guide retention of this study population throughout the RCT. We reviewed relevant literature and mapped essential retention activities across the study planning, recruitment and maintenance phases. Interview completion rates were tracked. Results Results from 3302 follow-up interviews (in-person/telephone) conducted over 4 years indicate high completion rates: 90% (n = 667) at 34 weeks gestation; and 91% (n = 676), 85% (n = 626), 80% (n = 594) and 83% (n = 613) at 2, 10, 18 and 24 months postpartum, respectively. Almost all participants (99%, n = 732) provided ongoing consent to access administrative health data. These results provide preliminary data on the success of the framework. Conclusions Our retention results are encouraging given that participants were experiencing considerable socioeconomic disadvantage. Standardized retention planning and reporting may therefore be feasible for health research in general, using the framework we have developed. Use of standardized retention protocols should be encouraged in research to promote consistency across diverse studies, as now happens with RCT and SR protocols. Beyond this, successful retention approaches may help inform health policy-makers and practitioners who also need to better reach, engage and retain underserved populations. Trial registration ClinicalTrials.gov, NCT01672060. Registered on 24 August 2012.

Introduction Le Nurse-Family Partnership (NFP) est un programme de visites à domicile destiné aux nouvelles jeunes mères défavorisées sur le plan socioéconomique. Les données issues de trois essais contrôlés randomisés (ECR) américains ont solidement démontré l’efficacité des interventions quant à l’amélioration de l’issue de la grossesse, de la santé et du développement des enfants ainsi que de l’autonomie économique des mères. Cependant, l’efficacité du NFP dans le contexte canadien des services de santé et des services sociaux, qui diffère de celui des États-Unis, reste à déterminer. Cet article vise à décrire le processus complexe suivi pour adapter la recherche sur le NFP et mettre ainsi en oeuvre ce programme au Canada. Méthodologie L’évaluation menée au Canada se divise en trois étapes : 1) adaptation de l’intervention, 2) mise à l’épreuve de l’intervention dans des études de faisabilité et d’acceptabilité à petite échelle et 3) réalisation d’un ECR et d’une évaluation du processus dans le cadre de l’étude intitulée British Columbia Healthy Connections Project (BCHCP). Cette évaluation à grande échelle permettra d’enrichir la base de données probantes du NFP par la tenue d’une étude supplémentaire sur les mécanismes biologiques susceptibles de témoigner de la relation entre l’intervention et les effets sur le comportement des enfants. Résultats L’adaptation de la documentation du NFP pour les visites à domicile est un processus continu. Un projet pilote a montré la faisabilité du recrutement des femmes admissibles au NFP. Il a aussi révélé qu’il était préférable au Canada que le NFP soit mis en oeuvre par les organismes de santé publique et que les infirmières et infirmiers en santé publique (ISP) s’occupent des interventions. Enfin, il a montré que ce programme intensif de visites à domicile a bénéficié d’une réception positive de la part des clientes, des membres de leur famille et des fournisseurs de soins de santé. Les prochaines étapes – à savoir l’ECR et l’évaluation du processus – ont été entamées dans le cadre du BCHCP. Ce projet jettera les bases d’une évaluation à long terme des principaux résultats en matière de santé publique concernant des familles hautement vulnérables.

Objective To report on the relationship between delivery method (cesarean vs. vaginal) and type (planned vs. unplanned) and breastfeeding initiation in hospital and continuation to 6 weeks postpartum as self‐reported by study participants. Design Quantitative sequential mixed methods design. Setting Women were recruited from 11 hospital sites in Ontario, Canada. Participants Participants included 2,560 women age 16 years or older who delivered live, full‐term, singleton infants. Methods Data were collected from an in‐hospital questionnaire, hospital records, and a 6‐week postpartum interview. Results Ninety‐two percent of women reported initiating breastfeeding, and 74% continued to 6 weeks. The method of delivery, when defined as cesarean versus vaginal, was not a determining factor in breastfeeding initiation in hospital or in the early postdischarge period. An unexpected delivery method (i.e., unplanned cesarean or instrument‐assisted vaginal deliveries) was associated, at a statistically significant level, with an increased likelihood of initiating breastfeeding and continuation to 6 weeks postdischarge. Conclusion Breastfeeding can be considered a coping strategy that serves to normalize an abnormal experience and allows the individual to once again assume control. These unexpected results warrant further investigation to understand why women make the decision to initiate breastfeeding, why they choose to continue breastfeeding, and how they can be supported to achieve exclusive breastfeeding as recommended for infants in the first 6 months.

Objectives: International agencies are required to adapt, pilot and then evaluate the effectiveness of the Nurse-Family Partnership (NFP) prior to broad implementation of this public health intervention. The objectives of this qualitative case study were to: 1) determine whether the NFP can be implemented in Canada with fidelity to the US model, and 2) identify the adaptations required to increase the acceptability of the intervention for service providers and families. Participants: 108 low-income, first-time mothers in Hamilton, Ontario, received the NFP intervention. In-depth interviews were conducted with NFP clients (n=38), family members (n=14) and community professionals (n=24). Setting: Hamilton, Ontario. Intervention and Data Collection: An intensive nurse home visitation program delivered to women starting early in pregnancy and continuing until the child was two years old. Processes to adapt and implement the NFP were explored across seven focus groups with public health nurses and managers. Eighty documents were reviewed to identify implementation challenges. Data were analyzed using directed content analysis. Outcomes: The NFP model elements are acceptable to Canadian health care providers, public health nurses and families receiving the intervention. The primary adaptation required was to reduce nurse caseloads from 25 to 20 active clients. Recommendations for adapting and implementing all model elements are described. Conclusion: The NFP model requires minor adaptations to increase the acceptability of the intervention to Canadian stakeholders. A consistent approach to adapting the NFP program in Canada is necessary as provincial jurisdictions commit themselves to supporting an experimental evaluation of the effectiveness of the NFP.

IntroductionAdverse early experiences are associated with long-lasting disruptions in physiology, development and health. These experiences may be ‘biologically embedded’ into molecular and genomic systems that determine later expressions of vulnerability. Most studies to date have not examined whether preventive interventions can potentially reverse biological embedding. The Nurse-Family Partnership (NFP) is an evidence-based intervention with demonstrated efficacy in improving prenatal health, parenting and child functioning. The Healthy Foundations Study is an innovative birth cohort which will evaluate the impact of the NFP on biological outcomes of mothers and their infants.Methods and analysisStarting in 2013, up to 400 pregnant mothers and their newborns were recruited from the British Columbia Healthy Connections Project—a randomised controlled trial of the NFP, and will be followed to child aged 2 years. Women were recruited prior to 28 weeks’ gestation and then individually randomised to receive existing services (comparison group) or NFP plus existing services (intervention group). Hair samples are collected from mothers at baseline and 2 months post partum to measure physiological stress. Saliva samples are collected from infants during all visits for analyses of stress and immune function. Buccal swabs are collected from infants at 2 and 24 months to assess DNA methylation. Biological samples will be related to child outcome measures at age 2 years.Ethics and disseminationThe study received ethical approval from seven research ethics boards. Findings from this study will be shared broadly with the research community through peer-reviewed publications, and conference presentations, as well as seminars with our policy partners and relevant healthcare providers. The outcomes of this study will provide all stakeholders with important information regarding how early adversity may lead to health and behavioural disparities and how these may be altered through early interventions.Trial registration numberNCT01672060; Pre-results.

Objective: To examine infant feeding practices up to 8 weeks postpartum in Hamilton-Wentworth. Methods: A cross-sectional survey of 227 women using a pre-discharge, selfadministered questionnaire, medical record review and follow-up telephone interview. Results: Breastfeeding initiation rate was 85%. By 6–8 weeks postpartum, 30% of women had stopped breastfeeding; 55% had switched to formula within the first 14 days. Infants who did not receive supplementation in hospital were 2.49 times more likely than infants who received supplementation to breastfeed for at least 6 weeks. Although 54% of mothers who initiated breastfeeding reported receiving formula gift packs, no association was found. Conclusions: The breastfeeding initiation rate appears to have increased in Hamilton-Wentworth since 1995. However, this study reinforces the need to address early cessation and infant supplementation, and raises concern about violation of the WHO/UNICEF International Code of Marketing of Breastmilk Substitutes through mailing of formula coupons.

Whether children with autistic spectrum disorders (ASD) and their families are receiving recommended assessments and services is poorly known. This pilot study examined service receipt as reported by parents of young children with ASD (n = 64) from four specialty centers in Canada. While almost all children had a speech and language assessment (94%), less than half had psychological (42%), or genetic (31%) testing. Speech and language (88%) and occupational (78%) therapies were the most frequently received treatments. Overall, certain findings did not correspond to recent recommended practice guidelines. Future studies should obtain more detailed information on assessments and treatments received from larger and more representative samples to better determine the quality of care received by families with children with ASD.

Across-sectional survey of postpartumwomen following discharge from five hospitals in Ontario, Canada, examined breastfeeding patterns and risk factors for early discontinuation. Consenting mothers completed self-administered questionnaires prior to discharge (n = 1250) and telephone interviews at 4 weeks postdischarge (n = 875). Breastfeeding initiation rates for women completing the interview varied from 82% to 96% across the sites. Continuation rates rapidly declined, with 13% to 24% ofwomen who had initiated breastfeeding switching to formula by 4 weeks postpartum. Perceived inadequate milk supply, difficulty with breastfeeding techniques, and sore nipples were the main reasons reported. Risk factors for breastfeeding cessation included not completing high school; intention to breastfeed less than 4 months; not anticipating the use of a “mom's group” or “drop-in center”; one or more maternal visits to a family physician; length of postpartum stay greater than 48 hours; unmet need for care or help with breastfeeding; and received advice, information, or support about formula feeding.

Background This survey's objective was to provide planning information by examining utilization patterns, health outcomes and costs associated with existing practices in the management of postpartum women and their infants. In particular, this paper looks at a subgroup of women who score ≥ 12 on the Edinburgh Postnatal Depression Survey (EPDS). Methods The design is cross-sectional with follow-up at four weeks after postpartum hospital discharge. Five Ontario hospitals, chosen for their varied size, practice characteristics, and geographic location, provided the setting for the study. The subjects were 875 women who had uncomplicated vaginal deliveries of live singleton infants. The main outcome measures were the EPDS, the Duke UNC Functional Social Support Questionnaire and the Health and Social Services Utilization Questionnaire. Results EPDS scores of ≥ 12 were found in 4.3 to 15.2% of otherwise healthy women. None of these women were being treated for postpartum depression. Best predictors of an EPDS score of ≥ 12 were lack: of confident support, lack of affective support, household income of Conclusions Primary care physicians, midwives, and public health nurses need to screen for depression at every opportunity early in the postpartum period. A mother's expression of undue concern about her own or her baby's health may be predictive of postpartum depression. Flexible, mother-focused support from community providers may decrease the prevalence of postpartum depression.

The Ontario Mother and Infant Survey examined health and social service utilization of postpartum women and newborn infants from five hospital sites. A cross-sectional multi-language survey design with longitudinal follow-up was used: 1,250 eligible, consenting women completed a self-report questionnaire in hospital and 875 women participated in a structured telephone interview at four weeks post-discharge. Rates of newborn infant readmission ranged from 2.4% to 6.7%. The best predictors of readmission were: main source of household income was other than employment; maternal self-rating of health was poor; mother anticipated inadequate help and support at home following discharge; mother received help from friends/neighbours following discharge; and mother had concern about infant care and behaviour. Readmission was not associated with length of postpartum hospital stay. The study findings suggest that there is a complex relationship between infant health care needs, family resources and provider practices that produces clinically important, site-specific readmission patterns.

This systematic review investigated the relationship between early childhood caries (ECC) and breastfeeding. The systematic review methodology used by the Cochrane Collaboration was modified and adopted for this review. 28 of 151 articles (18.5%) were relevant for the study and were rated as strong (0), moderate (3), weak (9) or very weak (16). Validity scores indicated whether a study met the reviewer’s criteria for research rigour. The percentage of studies that received a passing score for each criterion examined were: study design (3.6%), confounders (21%), data collection method (54%), definition of ECC (57%), dental health practices (28%) and infant feeding practices (4%). A lack of methodological consistency related to the study of the association of breastfeeding and ECC, and inconsistent definitions of ECC and breastfeeding, make it difficult to draw conclusions. Moderate articles indicate that breastfeeding for over one year and at night beyond eruption of teeth may be associated with ECC. Due to conflicting findings in less rigorous research studies, no definitive time at which an infant should be weaned was determined, and parents should begin an early and consistent mouth care regime.

Objective: To examine trends and regional variations in perinatal mortality and low birthweight (LBW) and regional variations in socioeconomic risk factors. Methods: Population-based study of Central West Region of Ontario with approximately 28,000 births annually during the period 1988–1995 using vital statistics records and Census data. Results and Conclusions: There was no significant change in the perinatal mortality rate averaging 9.4 per 1,000 births per year. The LBW rate increased from 49.7 to 54.8 per 1,000, while the prematurity rate increased from 56.1 to 75.8 per 1,000. Significant variation occurred in outcomes among different regions, which was partially explained by socio-economic factors. The increases in LBW and prematurity rate emphasize the need for effective targeted services and programs. In their planning and implementation, regional variations in socio-economic factors, and other factors such as: the availability and utilization of services and barriers to access in services, require further evaluation and consideration.

Background Few studies have explored the experiences of low income mothers participating in nurse home visiting programs. Our study explores and describes mothers' experiences participating in the Nurse-Family Partnership (NFP) Program, an intensive home visiting program with demonstrated effectiveness, from the time of program entry before 29 weeks gestation until their infant's first birthday. Methods A qualitative case study approach was implemented. A purposeful sample of 18 low income, young first time mothers participating in a pilot study of the NFP program in Hamilton, Ontario, Canada partook in one to two face to face in-depth interviews exploring their experiences in the program. All interviews were digitally recorded and transcribed verbatim. Conventional content analysis procedures were used to analyze all interviews. Data collection and initial analysis were implemented concurrently. Results The mothers participating in the NFP program were very positive about their experiences in the program. Three overarching themes emerged from the data: 1. Getting into the NFP program; 2. The NFP nurse is an expert, but also like a friend providing support; and 3. Participating in the NFP program is making me a better parent. Conclusions Our findings provide vital information to home visiting nurses and to planners of home visiting programs about mothers' perspectives on what is important to them in their relationships with their nurses, how nurses and women are able to develop positive therapeutic relationships, and how nurses respond to mothers' unique life situations while home visiting within the NFP Program. In addition our findings offer insights into why and under what circumstances low income mothers will engage in nurse home visiting and how they expect to benefit from their participation.

Nurse-Family Partnership is a nurse home visitation program that aims to improve the lives of young mothers and their children. The program focuses on women who are parenting for the first time and experiencing socioeconomic disadvantage. Nurse visits start as early in pregnancy as possible and continue until the child reaches age two years. The program has proven effective in the United States – improving children’s mental health and development and maternal wellbeing, and showing long-term cost-effectiveness. But it is not known whether the same benefits will be obtained in Canada, where public services differ. The British Columbia Healthy Connections Project therefore involves a randomized controlled trial evaluating Nurse-Family Partnership’s effectiveness compared with existing (usual) services in improving children’s mental health and early development and mother’s life circumstances. The trial’s main aims are to: reduce childhood injuries by age two years (primary outcome indicator); reduce prenatal nicotine and alcohol use; improve child cognitive and language development and behaviour at age two years; and reduce subsequent pregnancies by 24 months postpartum. Potential explanatory factors such as maternal mental health (including self-efficacy) are also being assessed, as is the program’s impact on exposure to intimate-partner violence. To inform future economic evaluation, data are also being collected on health and social service access and use. Eligible and consenting participants (N = 1040) are being recruited prior to 28 weeks gestation then individually randomized to receive existing services (comparison group) or Nurse-Family Partnership plus existing services (intervention group). Nurse-Family Partnership is being delivered following fidelity guidelines. Data are being collected during in person and telephone interviews at: baseline; 34–36 weeks gestation; and two, 10, 18 and 24 months postpartum. Additional data will be obtained via linkages from provincial datasets. Recruitment commenced in October 2013 and will continue for approximately three years. This trial will provide important information about the generalizability of Nurse-Family Partnership to the Canadian context. Findings will be published in peer-reviewed journals and shared with policymakers and practitioners through extensive public health collaborations already underway. Registered July 18, 2013 with ClinicalTrials.gov Identifier: NCT01672060 .

Background The Nurse-Family Partnership is a home visitation program for first-time, socially and economically disadvantaged mothers. The effectiveness of this public health intervention has been well established in the United States; however, whether the same beneficial outcomes will be obtained within the Canadian context is unknown. As part of the British Columbia Healthy Connections Project, which includes a trial comparing Nurse-Family Partnership’s effectiveness with existing services in British Columbia, we are conducting a process evaluation to describe and explain how the intervention is implemented and delivered across five regional Health Authorities. Methods A convergent parallel mixed methods research design will be used to address the process evaluation objectives. The principles of interpretive description will guide all sampling, data collection and analytic decisions in the qualitative component of the study. The full population of public health nurses and supervisors (n = 71) will discuss their experiences of implementing and delivering the program in interviews (or focus groups). Managers (n = 5–15) responsible for this portfolio will also be interviewed annually. Fidelity reports with quantitative data on the reach and the dose of the intervention will be collected and analyzed. Summaries of team meetings and supervisory sessions will be analyzed. Data will be used to compare, corroborate and explain results and variances across the five regional Health Authorities. Discussion The process evaluation results will be of immediate instrumental use to the program implementers to inform intervention delivery. Findings will contribute to the emerging body of evidence surrounding: 1) professional nurse home visitation practice issues; 2) best practices for meeting the needs of families living in rural and remote communities; 3) a deeper understanding of how health and social issues such as mental health problems including substance misuse and exposure to intimate partner violence affect a young mother’s capacity to parent; and 4) strategies to support professionals from the primary care, public health and child welfare sectors to work collaboratively to meet the needs of children and families who are at risk or experiencing maltreatment.