Introduction

The overall goal of public health practice is to prevent disease and promote health, and thereby make the general population both healthier and safer.1 This is achieved through activities such as investigating health hazards, educating the public about various health-related issues, and linking individuals to health services and other resources. But public health practitioners also recognise the critical need for research and evaluation to identify effective intervention strategies for public health-related risks, as this evidence forms the basis of sound public health policies and decision making.2

Home visiting has been well established as an important public health strategy for supporting vulnerable families’ health and social well-being. Home visiting aims to strengthen relationships between parents and their young children, enhance child health and development, and connect families to health services. Home visits by nurses and trained paraprofessionals typically begin in the prenatal period and continue through the first few years of a child’s life. Studies from the past two decades show that home visiting improves pregnancy and birth outcomes,3–5 reduces instances of child injury or maltreatment,3 4 6 and supports children’s development at school entry.3 5 Our recent work evaluating the Families First Home Visiting (FFHV) programme, which provides home visiting services to Indigenous and non-Indigenous families in Manitoba, Canada (‘Indigenous’ being the collective term for the original peoples of North America and their descendants; three broad groups are recognised in Canada: First Nations, Métis and Inuit), has shown that participation in the programme is associated with increased rates of childhood vaccination7 and fewer instances of child injury or maltreatment,8 and with lower rates of children being taken into care of child protective services.8 As well, FFHV is associated with reduced economic disparities in health and social outcomes between participating families and the general population.9

These evaluations of FFHV also provided anecdotal evidence that up to 40% of the families enrolled in the FFHV programme are Indigenous; however, literature describing engagement of Indigenous families in public health initiatives is scarce. The few studies available tend to suggest that Canadian Indigenous families are not always well connected to the public health system,10 11 and there are many factors that likely contribute to this circumstance, including their experience of ongoing intergenerational trauma as a result of the residential school system, mistrust of public services and other social determinants of health.12–14 This is an important literature gap to address, because the unique historical and cultural factors that Indigenous families experience may alter the impact of home visiting programmes designed for and delivered to the general population. And while home visiting has been shown to be a promising intervention for improving public health at a population level, it is not known whether programmes like FFHV are effective specifically for Indigenous families. In this study, we partnered with First Nations researchers and programme leaders to examine whether FFHV is effective at improving public health outcomes for Manitoba First Nations families living in conditions of risk.

Methods

Study cohort development

The study cohort comprised all Manitoba First Nations families with children born in 2003–2009 who met the eligibility criteria for FFHV. Eligibility for FFHV is determined by a two-stage process, as shown in figure 1. Public health nurses conduct a universal newborn screen in the postpartum period to collect information on biological, social and demographic factors such as First Nations identity, birth weight, mother’s age, education, marital status, mental health and social isolation. Families with three or more risk factors that challenge their parenting and increase the risk of poor child outcomes are then further assessed using the Parent Survey, a 10-item questionnaire based on the Kempe Family Stress Checklist.18 Families with a score of 25 or more are eligible for FFHV.

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Figure 1

Study cohort development The flow chart identifies the number of First Nations families with births in 2003–2009 who were eligible for the Families First Home Visiting (FFHV) programme in Manitoba, Canada. PSS, Parent Survey Score.

In our study, we identified 5824 First Nations families who scored ‘at risk’ on the universal newborn screen (figure 1). Among these, 789 families had a Parent Survey score less than 25, and so were not eligible for FFHV. Among the remaining 5035 families, 2895 families had Parent Survey scores greater than or equal to 25, and so were eligible for the programme. Parent Survey scores for the final 2140 families were missing from the database. We used multiple imputations to estimate the missing Parent Survey scores. Briefly, using data from the universal newborn screen (see table 1), we applied Markov Chain Monte Carlo methods to fill in missing values 10 times, generating 10 complete data sets with the SAS V.9.4 MIANALYZE procedure. The results from the 10 complete data sets were then combined using MIANALYZE to reflect the fact that uncertainty still remains regarding the unknown values and to provide inferential results that are statistically valid according to the methods of Rubin.23 Using these methods, we determined that 1459 families among those with missing scores were eligible for FFHV (figure 1). The final study cohort included 4010 families with newborns, among whom 1681 families received the programme (exposed group) and 2329 families who met the eligibility criteria for FFHV but did not enrol in the programme (comparison group).

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Table 1

Confounding variables

Results

Before comparing public health outcomes between First Nations families who enrolled in FFHV and who were eligible but not enrolled, we made an effort to balance their characteristics by applying IPTWs (table 2). Before weighting, mothers in families who received FFHV were more likely to have been screened prenatally by a public health nurse, diagnosed with substance abuse, be socially isolated, experience relationship distress with parenting partner, diagnosed with depression and/or anxiety, and have a history of child abuse than mothers from families who did not receive FFHV. Recipients of FFHV were also less likely than non-recipients to be a single parent, to have smoked during their pregnancies or to be of low income. After weighting, the standardised differences between characteristics were reduced to less than 10%, confirming that these characteristics were more evenly balanced and thus the study groups were more comparable.

The association between First Nations families being enrolled in FFHV and their children receiving a complete series of vaccinations is shown in table 3. Estimates of the ATE, the average programme effect on vaccination across the entire eligible population, show a significant association between families receiving FFHV and their children being vaccinated at ages 1 and 2: the probability of children in FFHV families completing a vaccination series was higher than for children from non-FFHV families; as well, the adjusted risk ratio for complete vaccination at ages 1 and 2 was significant. Moreover, when families’ characteristics were weighted so that they were similar to those enrolled in FFHV (ATT) and to those not enrolled in FFHV (ATU), effect estimates of the risk ratio were still significant, the latter indicating that FFHV would potentially have been able to improve rates of vaccination completion for children in the comparison group if their families had been enrolled in the home visiting programme. The γ values demonstrate that unmeasured confounders would have to be very strong in order to negate this effect.

Table 4 shows the association between enrolment in FFHV and parental involvement in the Healthy Baby Community Support Program. Estimates of the ATE demonstrate that FFHV families were more likely than non-FFHV families to attend the community support programme during the prenatal or postnatal period. The risk ratios between the two groups were also significant for estimates of the ATE, ATT and ATU, suggesting (as above) that families eligible for FFHV but not enrolled would potentially have been more likely to attend a community support programme if they had been receiving FFHV. These results were also deemed robust to unmeasured confounding as shown by the γ sensitivity values.

We observed no association between FFHV enrolment and child development at age 5, as measured by the EDI (online supplementary table S4). We examined the relationship between FFHV enrolment and children scoring as developmentally vulnerable in each of the five domains of the EDI. We also looked at the relationship between FFHV and a ‘vulnerable’ score in any one, two or three EDI domains (data not shown for two and three domains). These results indicate that FFHV, a programme delivered in the early years of a child’s life, was not associated with improved developmental outcomes at school entry for First Nations children.

Discussion

This study examines the role of home visiting in influencing public health outcomes among Manitoba First Nations families living off-reserve and enrolled in the provincially funded FFHV programme. Although FFHV is associated with improved health and social outcomes in the general population of Manitoba, evidence for First Nations families who enrolled in the programme has been lacking until now. In the current study, we found that enrolment in FFHV was associated with higher rates of childhood vaccination and greater participation in parenting support groups among First Nations families living in conditions of risk. Our results also indicated that families who were eligible for FFHV but did not enrol would potentially also see a significant benefit if they could be encouraged to participate in the programme.

Efforts made to ensure the cultural safety of public health initiatives for Indigenous people are important for programme uptake and efficacy. Several guiding frameworks for addressing inequities in Indigenous public health in a culturally safe way have emerged, most notably from Australia,28 29 while Canada has to some extent lagged behind in ensuring that provincial and national public health policies support Indigenous health and well-being.30 31 In Manitoba, the FFHV programme strives to employ Indigenous home visitors in areas where many Indigenous people live and encourage all staff to participate in cultural training. Staff are taught to recognise the historical and current realities of colonisation experienced by Indigenous peoples in Canada that add to their parenting challenges, including the racism they face and the multigenerational trauma that is the legacy of Canada’s residential school system.13 Structural barriers such as economic disparities, substandard housing conditions, poor access to health services and inadequate staffing in remote communities also play a role in the marginalisation of Indigenous people.32–34 As a result of these and other challenges, First Nations individuals, families and communities experience high rates of mental disorders and family violence,35 factors that may make it difficult for them to engage in a public health intervention.

Home visiting programmes like FFHV can mitigate some of these adverse influences by building on the strengths of First Nations peoples and helping families facing multiple challenges gain confidence in their parenting skills, create a nurturing environment for their children and rebuild trust in the public health system. The positive outcomes we saw in this study, which include higher rates of childhood vaccinations (and thus greater contact with the public healthcare system) and stronger connections to community resources through the Healthy Baby Community Support Program, suggest that the family-centred and strength-based approaches on which FFHV is based are effective at improving these aspects of public health. Whether FFHV is truly culturally safe for First Nations families has not yet been evaluated.

Despite the encouraging results for vaccination rates and community connections, we did not detect any association between FFHV enrolment and child development at age 5, as measured by the EDI. This is perhaps not surprising, given that previous evaluations of FFHV similarly demonstrated little association between programme participation and child development indicators. For example, neither EDI scores nor levels of reading to children changed among FFHV families in the general population of Manitoba.17 36 It is possible that FFHV alone is not sufficient for improving child development scores, suggesting the need for programme enhancements or connections with other early childhood programmes.

A significant proportion (58%) of eligible First Nations families in our study did not receive any services from FFHV. Other authors have also documented challenges in engaging and retaining families living in conditions of risk (sometimes termed ‘hard-to-reach families’) in programmes and improving child outcomes at a population level.37 38 Some of the reasons families may not participate include family factors (mistrust of service providers, mental disorders, no telephone) and public health system challenges (high workloads, insufficient resources to accommodate all families, lack of experience with at-risk families). The very characteristics that prevent hard-to-reach families from participating in programmes like home visiting may influence how they respond to programme staff, the curriculum and the way the programme is implemented.39 For example, some families may not be open to developing a relationship with a home visitor. However, our findings indicate that the positive outcomes seen in participating families would be likely to occur even in hard-to-reach families. This suggests that greater investments in encouraging programme participation would be worthwhile and programme enhancements should be considered by administrators striving to achieve maximum programme impact.