Barriers to Nurse Home Visitation Retention with Post-Partum Mothers

Background: Nurse home visitation programs have wide support and demonstrate promising outcomes for new mothers. Post-partum depression and high levels of stress increase the risk of maltreatment. Therefore adding services to address these issues in existing nurse home visitation services may improve outcomes.  However, all home visitation programs experience high rates of attrition, which may limit intervention effects.  Evidence suggests that a number of factors contribute to attrition in home visitation services.  Models vary in the content of the services and eligibility criteria for participants.  It is unclear if similar factors predict retention in a program that targets higher risk mothers, enrolls after birth and is not limited to first time mothers. This study uses qualitative interviews with mothers engaged in a study of enhanced home visitation to address maternal depression and stress to better understand retention.

Methods: The present study is part of a small, randomized control trial of the feasibility and effectiveness of offering an adapted version of Problem Solving Therapy (called Problem Solving Tools or PST) as part of nurse home visitation to address stress and depression.  Participants were randomized into two treatment groups based on measures of presenting symptoms of stress and/or depression and a control group.  Due to safety concerns, mothers with depression scores over the clinical cutoff were excluded from randomization, automatically offered treatment, and referred to a prepaid psychiatric support.  The present study is limited to participants assigned to treatment. Qualitative interviews were analyzed to identify factors related to continuing with the nurse home visitation. Grounded theory was used to identify themes in the interview transcripts using Atlas T.I. 

Results: While attrition in the study was quite low, mothers frequently discontinued home visitation within a few months. Four key themes emerged around barriers to remaining in treatment.  The first theme involved programmatic burden and the competing demands of family, friends, and employment.  A second theme identified by a large portion of participants was program flexibility, or lack thereof. While most mothers reported a positive regard to the program, length of services was identified as a barrier.  The majority of mothers reported wanting the service to be longer. Participants reported usage of program skills even though the program was not completed.

Implications: There are a number of key takeaways from this study for service providers and researchers.  For service providers, the findings suggest that higher risk post-partum mothers see the initial benefit of services but are sensitive to burden. Several suggested the need for more flexibility in days and times of service delivery.  Interestingly, participants reported they found the material useful despite not completing the program.  PST is a straightforward skill-based intervention that is outlined in written materials.  Our findings suggest value in providing programmatic materials early in the home visitation process as participants that drop out may still make use of the intervention. Further research is necessary to explore how service platforms like nurse home visiting are used.  Comparing dosage of exposure to skills versus number of visits may be important to consider.