Introduction

As a home visiting program for first-time mothers, Nurse-Family Partnership (NFP), a nurse home visiting program (Olds, 2006), centers its efforts on improving pregnancy outcomes, child health and development, and life course outcomes for families facing socioeconomic inequalities through the skills and expertise of nurses. In NFP, clients participate in home visits with a nurse who provides support, education, and quality care to mothers during their pregnancy and up to 2 years postpartum. The evidence-based NFP intervention offers information on pregnancy and postpartum, parenting, and child developmental milestones. Home visiting programs are associated with positive outcomes, including decreased adverse pregnancy-related outcomes and higher levels of social engagement in children (Cho et al., 2017). NFP, in particular, has been associated with improved pregnancy outcomes, increased maternal educational attainment and employment, lower rates of childhood injuries and maltreatment, and increased language development in children (Flowers et al., 2020; Olds et al., 2007).

Despite these promising outcomes, attrition remains a significant concern and undermines program effectiveness (Holland et al., 2014). Attrition rates in NFP, defined as disengaging with the program prior to two years postpartum, are estimated to be between 38 and 68% (Hernández et al., 2019; O’Brien et al., 2012). Black mothers have been found to have the highest attrition rates compared to NFP clients of other races (O’Brien et al., 2012), with an attrition rate of 68.1% between 2015 and 2019 (National Service Office for Nurse Family Partnership & Child First, 2019). Understanding and addressing program attrition are essential to maximizing the impact and reach of NFP. By identifying and addressing factors that contribute to attrition, such as logistical challenges, the program can be made more accessible and appealing to a wider subset of mothers and their families. Taking a proactive approach not only maximizes the reach of the program’s positive outcomes but also has the potential to contribute to the overall well-being of families by equipping them with tools and knowledge that can aid in navigating the complexities of child health, safety, and development. To that end, several studies have investigated factors contributing to retention and attrition in home visiting programs using qualitative methods.

Qualitative methods are uniquely suited to understanding the complex factors that contribute to program attrition because they allow researchers to explore the depth of the lived experiences and perspectives of program clients in a way that is difficult to capture quantitatively (Prosek & Gibson, 2021). Therefore, employing qualitative methods can provide valuable insights into the reasons why mothers drop out of NFP, which can then be leveraged to enhance program design and delivery. Accordingly, findings suggest that contributors to program attrition in NFP include competing priorities and life demands, negligible support, inflexibility of program delivery, and poor nurse-client fit (Beasley et al., 2018; Hernández et al., 2019; Holland et al., 2014; O’Brien et al., 2012).

Notably, even though racial disparities in program retention and attrition are likely to reduce home visiting programs’ desired impact on health disparities, many qualitative studies examining attrition in NFP have not reported the demographic characteristics or racial group identification of clients interviewed. Additionally, existing qualitative investigations into program attrition in NFP have not explored the experiences, perspectives, or attrition motives across racial groups. Further, studies have not intentionally examined how race-related factors may influence program engagement and rates of attrition in NFP. As a result, there is a significant gap in the literature concerning Black mothers’ experiences in home visiting programs, including NFP, despite the fact they are more likely to experience maternal health inequities rooted in racism that is prevalent in healthcare, social services, and economic opportunities (Taylor et al., 2019).

In low-income urban communities, Black individuals may be regarded as “hard to reach” due to challenges related to instability in residence, work status, and phone services and “high risk” due to their increased risk of death from chronic diseases (Office of Minority Health, 2019; Woolfolk & Unger, 2009). Moreover, the structural and institutional racism that has historically affected Black communities, and continues to do so, such as legally endorsed reproductive coercion and abuse, constraints in educational and employment prospects, and segregation of residential areas, have contributed to mistrust within the Black community against healthcare and social service systems, leading to a reluctance to engage with these systems and instead relying on support systems that may be more informal (Prather et al., 2016, 2018; Woolfolk & Unger, 2009).

Therefore, it may not come as a surprise that Black women are more likely to withdraw from home visiting programs like NFP. Nevertheless, the literature is limited in the discussion of Black mothers’ experiences in home visiting programs. In order for NFP to address the unique and intersecting factors that contribute to disparities in program engagement and inequities among Black families, it is critical to investigate attrition among Black mothers. Understanding the factors that influence program attrition among Black mothers is essential to adequately address barriers to sustained engagement in NFP and to increase access to the positive health outcomes associated with the program.

The present study sought to describe and provide insight into the experiences, perspectives, and barriers faced by Black mothers in NFP. Given the exploratory nature of this study, there was not a specific hypothesis being tested, but instead, we sought to understand an important phenomenon: how Black mothers in NFP experienced the program, what factors shaped their perspectives, and what they valued in the program. More specifically, we were interested in how these perspectives influenced their decisions to remain in the program as a first step in understanding the factors that contribute to program engagement and retention to inform the improvement of NFP and similar home visiting interventions for Black clients. The findings are meant to both inform program decision making and to provide context for future evaluation of implementation outcomes.

Methods

Study Design and Setting

Between November 2020 and March 2021, we conducted and analyzed semi-structured qualitative interviews with Black women, using emergent thematic analysis, following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007). This study was approved by the Colorado Multi-Institutional Review Board.

Participants

Purposive sampling was used to identify Black clients who previously participated in the NFP program. We emailed study announcements to nursing supervisors and administrators at selected NFP sites across the country whose client population included at least 25% identifying as Black/African American and whose implementation data indicated either higher or lower attrition of Black clients compared to White clients at the same site. The four participating sites then provided the study team with contact lists for clients who self-identified as Black or African American and had completed the program through graduation at 24 months postpartum. Individuals still participating in the program were excluded. Additional participants were subsequently recruited with snowball sampling.

The sample included 21 Black NFP clients (Mage = 25.6, SDage = 4.35) who completed the program from four NFP sites in Texas, Florida, and Pennsylvania. Participant demographic characteristics are listed in Table 1.

Table 1 Sociodemographic characteristics of participants (N = 21)
Full size table

Data Collection

A semi-structured qualitative interview guide (Appendix 1) was developed to guide topic selection and question refinement in order to elicit open-ended responses from interviewees. The interview guide was based on the published literature and refined with consultation from current NFP nurses. The interview guide was pilot tested to improve the clarity and consistency of questions. Participants were asked to describe their decision to enroll in the program, their experiences while in the program, and their decision to continue participating in the program. They were also asked to provide their perspectives on the program offerings and reasons for program discontinuation by other Black clients.

Semi-structured qualitative interviews were conducted with Black NFP clients who completed participation in the program. Program completion was defined as graduating from NFP at 24 months postpartum. All interviews were conducted over the phone by a doctoral student in psychology trained in qualitative methods (N.D.). Participants were aware from the recruitment methods that the interviewer was a Black woman of birthing age and she began the interview with a statement that the goal was to better understand the experiences of Black NFP clients and was not intended to evaluate their participation in the program and that responses would be anonymous.

The interviewer repeated back to the participants their descriptions and invited additional clarification and elaboration. Each interview was an average of 45 min, audio-recorded, professionally transcribed verbatim, and spot-checked for accuracy. After each interview, the interviewer completed a debriefing form, which was discussed with the analytic team after interviews. Interviews were conducted until thematic saturation was reached. The analytic team decided that thematic saturation had been reached when there was no new content being identified for at least three interviews in a row, with repetitious interviews (Guest et al., 2006; Hennink et al., 2017).

Data Analysis

Potentially identifying details of participants and nurses were removed from transcripts. Transcripts were coded in Atlas.ti, Version 9.0.16 (ATLAS.Ti Scientific Software Development GmbH, 2020), using deductive domains derived from the interview guide to capture key points (Tracy, 2019). To achieve consensus in coding, interview transcripts were independently analyzed by two investigators, a PhD-level qualitative methodologist (B.D.H.) and a doctoral student trained in qualitative methods (N.D.), and iteratively compared until consensus was reached. Consensus was reached after three transcripts, and two more transcripts were independently double-coded to ensure consensus had been achieved and to reach 20% double-coding. One investigator coded and summarized the remaining interviews (N.D.), with a third investigator, who is a pediatric physician and familiar with NFP (M.A.) spot-checking summaries. Matrix analysis with emergent thematic analysis was used to summarize and analyze themes across interviews by domain (Crabtree, 1999). Two members of the research team (B.D.H., N.D.) independently identified key themes from the matrix and then compared themes; strong inter-rater reliability was observed throughout this process. A third investigator (M.A.) reviewed and reconciled the themes generated; discrepancies were resolved by consensus. Only M.A. was a practicing physician with a research focus on maternal and child health; other members of the qualitative team were methodologic experts. Incorporating multiple perspectives, maintaining methodological rigor, and systematically checking and reconciling discrepancies supported the research team’s ability to conduct a comprehensive analysis.

Findings

Several key themes were identified related to client perspectives on the nurse-client relationship, reasons for program continuation, and suggested reasons for attrition of other Black clients. Key findings are described below.

Theme 1: Experiences with Nurses Were Favorable—“A nurse, but also an ally”

Most often, clients were referred to NFP through their healthcare center or doctor, where they were informed about the program criteria (e.g., first-time moms) and that the program would be inclusive of home visits and education by an assigned nurse. Clients agreed the primary reason behind their decisions to enroll in NFP was to gain education and support about their pregnancy, baby, and motherhood as first-time mothers. Additionally, clients had favorable early impressions of the program, most often attributed to their experiences with their NFP nurse. Clients described their nurses as committed, helpful, and supportive.

I felt very affirmed the whole time, like when I met [my nurse] it was like it was something very organic. She came in as a nurse, but also as an ally. So it was very much a “I am here for you,” which is unlike any experience I had had with a medical professional before. A lot of times, it’s like “ugh what do you need? Here this, take Tylenol, whatever.” But she was like, “this is a conversation. What do you want to do? What do you want to talk about? What do you need help with?” and I had never had that experience before. (P2)

Overwhelmingly, clients reported strong, positive nurse-client relationships, with many describing their nurses as supportive and nonjudgmental. In terms of support, being able to count on their nurses to be dependable and available with education and resources was very important to clients. Some clients cited their nurse’s dependability and support as a significant factor in their ability to open up during their participation in the program. Likewise, being able to be open and honest with their nurse hinged on nurses displaying no judgment to mothers regardless of their life situation.

[My nurse] was great. She never judged me. I can feel it from so many angles, where people was looking. And, you know, it looked like your stereotypical single mom with no job, and no, it’s just a low point. I’m trying to get back up there. And she really kept me, you know, her and my mom, really kept me from, like, just sulking into depression. (P5)

[My nurse] was really sweet. I love her to death. She was very supportive. I’m a pretty shy person, so it took me quite a while to open up and she noticed that and she would always commend me on being a strong woman and congratulating me on all the goals and stuff that we had written down together. Just making me feel like ... Helping me understand that I was doing the best that I can, and I was actually doing a good job. So, we had a very close relationship once I stopped being so shy and opened up to her a little more. But she didn’t like pressure me or anything, she was always very sweet and just told me that she was there for me and if I needed anything then she was always a listening ear and helping hand. (P15)

Clients often described their relationship with their nurse as more than just a client-nurse arrangement. Often, nurses were described as a mentor, a friend, or a part of the family for clients. Several clients were in school or actively working towards major life goals during their time in the program. These clients often felt that their nurse took on the role of a mentor, offering advice and guidance in areas related to their goals, such as nursing school or career planning. Clients describing their nurse as a part of the family often referred to their nurse’s strong relationship with their child as a significant contributor to that elevated relationship.

She’s really been a mentor to me, more so. When she came, we would do activities. Sometimes she would say, “lets meet here.” It wasn’t always at my house, sometimes she would say, “Let’s go and have lunch,” and then sit down and talk and do it. So, it wasn’t like mundane and boring. And also, too with me being in school, we would talk about school stuff. Bettering myself, career-wise. So, she was more like a mentor. (P20)

I didn’t think I would stay in it as long as I was. But I had a good experience because the nurse that I was matched up with was perfect and I felt that she went beyond her job to help me and she didn't do the bare minimum. She did amazing. She helped my family tremendously. Not just me, she helped my mom, everybody. She ended up being like family. (P7)

My nurse, she would come to the house. We had the best conversations. She was like a therapist in a way. She provided support in multiple areas. (P13)

Theme 2a: Reasons for Continued Program Engagement—Access to Reliable Health Information

Many clients highlighted access to reliable health information and education regarding pregnancy, childbirth, and new motherhood as a significant contributor to their continued engagement in NFP. Several clients noted that they often sought information online through search engine queries, but often encountered conflicting information leading to skepticism and uncertainty. Many expressed that knowing they had access to a dedicated nurse to whom they could ask questions each week alleviated the burden of finding and appraising the reliability of information found online. Clients reported that having a reliable source of education during their pregnancy and motherhood was helpful and something that they looked forward to each week.

I liked the [NFP] model. I liked how supportive everyone seemed. Having an actual nurse, you know, I can talk with somebody through pregnancy and stuff like that but talking to somebody who cared about the medical side of pregnancy and taking your weight, taking your blood pressure. Those were important. Like I said, I am a Black woman. There are certain things people expect from Black mothers health-wise. There are certain things people dismiss from Black mothers health-wise. But I always felt like I could trust [my nurse]. If I had a question about something I was experiencing health-wise, she would answer it to the best of her ability. If she didn’t know, she would find out. (P14)

Anything I had a question about she would help answer it. And if she didn’t know the answer, she would come the next week with more knowledge about the area I was asking her about. (P13)

Well, I think just the program being helpful in general. Sometimes if you Google something you might have a question about, it might not be accurate or you might get different answers. And then you're just searching and searching and it might not really answer whatever questions that you need answered. So having my nurse I can call, text her or wait until I see her at the visit and then get the information that I need. (P16)

Theme 2b: Reasons for Continued Program Engagement—Client-Directed Support

The most cited factor for continued engagement in the program was the client-directed support provided by their nurse. This support was characterized by focused attention and a personalized approach where nurses consistently prioritized the individual needs of their clients. While the nurse-client relationship is a professional one, clients often expressed that the attentiveness and genuine interest their nurses showed in their personal desires, goals, and challenges led to a strong, supportive bond. This led to clients feeling like meeting their nurse was not an obligation, but rather an opportunity for personal growth and self-expression that they wanted to participate in. Clients particularly valued their nurse’s understanding, commitment to their individual needs, flexibility, and dependability, all of which were factors that contributed to their continuation of the program.

The idea that she would always ask me what I wanted to talk about. It was about me. That feels very like selfish, but I don’t think that Black women often enough get asked what they want. . . Nobody asks us “what do you want to do?” in a way that’s earnest and in a way that where [Black women] don’t have to consider what the hell other people want. To have somebody to come and ask me… “what do you want to do?” . . . She asked that, and for somebody to just really mean it, it was so small but it meant so much to me to have somebody who was really, truly interested in what I wanted to talk about. (P4)

Theme 3: Racial Concordance—Racially Concordant Nurse-Client Pairing

Less than half the sample had racially concordant nurse-client pairings. About half of the sample, including all those assigned a Black nurse, felt that the race of their nurse mattered. Clients who reported having been assigned to a Black NFP nurse described feeling more comfortable, a stronger connection, and better understood by their nurse. Clients explained that having a Black nurse created, or would have created, space for them to be more open and more honest with their nurse, with little concern of judgment. Some clients gave the example of not having to be as concerned about their hair during home visits with a Black nurse. Clients not only felt that they could be more honest with a Black nurse, but they felt that a Black nurse could be more honest with them. Additionally, a Black nurse would understand and empathize with experiences that were culturally relevant to being Black and being a Black woman, such as old Black Wives Tales and experiences of racism.

I do feel like sometimes other Black women get me a lot better. I find myself explaining more things to non-Black people than I would to a Black person… there is also something about Blackness in addition to motherhood that is very unique. It’s something about trusting the [nurse] because they may have gone through it or trusting the [nurse] because they’re not gonna judge you. You know, the idea that this person, and we look alike, is here to help me because we live in this world and country that doesn’t value us. (P18)

Yes. I personally feel like ... I just feel like it does. I just feel more comfortable a little bit. I feel like nobody knows about Black people more than Black people. It felt more comfortable to have somebody of your own race to understand the experience of a Black woman. (P13)

However, it is notable that only clients who did not have a Black nurse expressed that their nurse’s character was more important to them than race. Accordingly, common character traits that emerged as particularly significant to clients included being open-minded, genuine, and relating to clients on current sociopolitical or cultural issues that were especially impactful to the Black community.

No, I thought [having a Black nurse] would [matter to me], but no. Ideally, I was like I feel like I would relate more to a Black nurse or she might understand my lifestyle a little bit more. But with [my nurse] I looked past her race because I think she was just a nice person in general, so I didn’t care about her being white. I didn’t care about that. (P10)

Not so much. She was really open-minded. She felt like she could relate to me on certain levels . . . She was just real with me and she felt comfortable doing so and that was so cool. (P11)

Among clients to whom the race of their nurse did not matter, several further explained that they understood why it might be for other Black clients, echoing the sentiments of clients who felt like race did matter to them. These clients identified that some clients may feel better understood in a racially concordant nurse-client relationship and that Black nurses would be able to be more honest and understand client experiences of racism.

No [race] didn’t matter to me. Now if I had a different experience in the hospital per se, because you know as an African American woman you may be aware of the medical mishaps that we have as African American women. Now, if that had occurred then maybe I probably would have felt like that would have then something that I could have not talked to her about because she wouldn't understand. But no. (P15).

Theme 4: Suggested Reasons for Program Discontinuation for Other Black Clients

Clients frequently suggested that a reason other Black clients may not continue participation in the program is the aspect of privacy, or rather a sense of invasion of privacy, that may accompany home visits. Given the nature of the program, clients explained that a degree of openness both with the nurse and with welcoming someone with whom one has little to no rapport is necessary. For some Black mothers, clients suggested the sense of invasion of privacy is not unexpected as there is often a sense of lack of trust with both strangers and healthcare providers.

It almost feels like an invasion of privacy or an inconvenience, even though in my opinion, it could be as convenient as you want it to be. But people are uncomfortable with what they don’t know about. . . You know, someone coming into your house and asking you a million questions about yourself and your situation. (P3)

Maybe they feel like it’s an invasion of privacy at some point. Sometimes people shut down and they don't really want anyone asking them things… Just someone coming into your home and asking you questions about how you’re feeling or, I remember questions about my mental health, if I felt depressed or if I felt blue, things like that. Everyone may not be receptive to that. (P14)

In addition to a loss of privacy and judgment, clients also suggested that a challenge to continued participation for Black women may be the inconvenience of scheduling a home visit with a nurse during the daytime due to competing demands, such as work.

Just apprehension about their own personal choices, feeling judged, and just being busy. Some people are working full time jobs, so I can imagine not being able to sit down and devote two hours to a person in the middle of the day. It would be a barrier for some. (P12)

Likewise, suggestions for such barriers were also proposed. Specifically, a client suggested integrating remote appointments with clients as a standard option for those who are unable to routinely host home visits.

In the age of the pandemic, I think it’s taught people the value of telehealth. Maybe like kits, where you give [clients] a scale and a blood pressure machine, that way you can get all of the information that you need. Especially while the child is in utero. We know that a lot of Black women are frontline workers, so maybe really investing in and looking into how crucial telehealth may be for the program. (P21)

Given that the nurse-client relationship was a strong, positive factor in continuing program engagement for clients, they also suggested that not connecting with one’s nurse may be a factor in program discontinuation. Some posited that not liking the assigned nurse was enough to reduce enthusiasm or engagement in the program by Black clients. Others suggested that the nurse’s inability to connect or seem comfortable in the client’s environment may be a significant contributing factor to program discontinuation, suggesting a need for cultural competency and racial sensitivity training for nurses.

It’s more like the relatability thing. A lot of nurses are scared of some areas and stuff like that. Or they see a lot of guys there and they seem uncomfortable. (P19)

Discussion

The current study is among the first to examine the unique experiences and perspectives of Black clients in NFP, providing important insight into the way in which Black mothers perceived the program, the elements that influenced their engagement, and the aspects of the program that they found the most valuable. The findings among all 21 clients were overwhelmingly positive about their experience in NFP. Most often, clients decided to participate in the program for additional support and education from a trained nurse, and all expressed that this expectation was met.

The social support derived from the nurse-client relationship emerged as a crucial factor to clients’ favorable impressions and sustained engagement in the program, a finding that aligns with extant research. For example, participants described their nurses as committed, helpful, and supportive, and indicated that this influenced their sustained engagement in NFP. Similarly, in a prior study, mothers indicated the nurse’s attributes, approach, and the education nurse’s provide as important considerations to their participation in NFP (Beasley et al., 2018). Further, Beasley and colleagues (2018) found mothers, especially those exhibiting low levels of trust, preferred nurses who were personable and experienced with children, available, flexible, caring, and nonjudgmental. This sentiment was echoed in the present study’s sample of Black NFP clients, especially with regard to racially concordant nurse-client pairings. Although many clients in the current sample were in racially discordant nurse-client pairings, Black mothers who were paired with Black and non-Black nurses alike saw value in racial concordance. Black clients explained that racial concordance in the nurse-client relationship is likely to increase perceived trust, increase comfort, and reduce perceived judgment. Given the impracticality of exclusively racially concordant nurse-client pairings, for example, due to racial disparities in the nursing profession (Phillips & Malone, 2014), NFP nurses of all racial identities may benefit from increased cultural competency and racial sensitivity training. Future research should take an integrated qualitative and quantitative (i.e., mixed methods) approach to examine how racial concordance or increased cultural responsiveness by nurses may impact program engagement and client and family outcomes.

Clients identified the characteristic feature of NFP—home visits—as a potential barrier to sustained program engagement by other Black mothers. Specifically, participants suggested that home visits may cause a degree of loss of privacy for other Black clients. Accompanying this loss of privacy may be discomfort and feeling judged or evaluated by their nurse, which clients suggested may be a factor in program discontinuation by other Black mothers previously engaged in NFP. Taken together, these findings align with studies that identified nonjudgment as a pivotal attribute of NFP nurses (Beasley et al., 2018) and a study on another home visiting program that identified perceived loss of autonomy as a parent in the presence of their nurse visitor as a barrier to program engagement for mothers (Wolfe Turner et al., 2020). Effort may be taken to better understand the elements that underlie perceptions of nonjudgement in nurses. For example, this may include examining the influence of the nurse’s personal beliefs and attitudes, the client’s experiences and expectations, and the social exchanges between both parties on perceptions of judgment and nonjudgment.

Home visiting programs are useful in bridging the gap between surviving and thriving for mothers and children (Peacock et al., 2013; Sawyer et al., 2013). The support, education, and care provided by home visiting programs can significantly reduce poor birth outcomes and improve child development outcomes, especially for women with limited resources and facing systemic oppression. However, much work remains to increase equity in health outcomes. There still are many barriers to participation in home visiting programs, including NFP, such as socioeconomic factors, logistical considerations, environmental concerns, and program structure for all potential clients. Given that Black mothers in NFP experience disproportionately higher rates of program attrition than non-Black clients, using a cultural lens to consider the structural and social factors that undermine program engagement for Black women, while applying a health equity framework, is paramount to addressing attrition of Black clients.

It is critical to note that Black mothers do not exist in a vacuum. They are subjected to the structural forces and systems that are beyond their control that result in health inequities. Therefore, home visiting programs such as NFP must institute a health equity agenda which recognizes the diverse range of contextual elements influencing risk and protective factors at various levels and engages the communities they serve (Trinh-Shevrin et al., 2015). Furthermore, addressing health inequities begins with understanding the difficulties that frequently arise at birth and persist throughout early childhood and adolescence, leading to increased probabilities of enduring social and health disparities in adulthood. This recognition is vital to break the cycle and prevent future generations of children from being trapped in the same cycle of disadvantage.

Based on the findings of this qualitative investigation into Black clients’ perspectives, it is clear that the nurse-client relationship is a pivotal factor in program continuation and achieving the aims of NFP. Given the prominence of this relationship in shaping Black client perspectives of NFP, efforts to increase program retention of Black clients may include measures to increase the likelihood of a strong nurse-client alliance. Recruiting a more racially diverse nurse workforce may increase program retention for Black clients. Clients tend to feel more comfortable and understood when they have a nurse who shares their cultural and racial background. A more diverse workforce may help establish a better rapport between the nurse and client, which may increase the likelihood that the client will continue to participate in NFP. Further, consideration for a nurse-client matching system may be beneficial. This system could match clients with a nurse based on shared cultural or racial backgrounds, values, communication styles, client needs in relation to nurse skills, or other meaningful characteristics. Such a system has the potential to help foster more compatible, strong nurse-client relationships, leading to improved program retention for Black clients. Finally, in the event of a poor fit between a nurse and client, allowing and encouraging clients to request a new nurse if their existing nurse-client partnership may reduce rates of program drop-out due to poor nurse-client fit. While clients are not prohibited from requesting a new nurse currently, some clients may feel uncomfortable requesting a new nurse for a variety of reasons. Thus, NFP may consider ways to streamline and reduce barriers to requesting a new nurse.

This study also identified home visits themselves as potential barriers to sustained program engagement for Black clients. Specifically, a loss of privacy and feelings of judgment in one’s home during visits from a nurse emerged as a possible reason for program attrition. Shifting the NFP language and model from “home visits” to “nurse visits” and encouraging clients to choose a neutral meeting location may alleviate concerns of clients feeling judged or uncomfortable. A neutral meeting location may also increase program retention by increasing convenience and access for some Black mothers. Additionally, the program may consider emphasizing to clients that tele-visits with their nurse are an option in lieu of home visits, which has the potential to reduce client burden and provide more convenience and flexibility for clients.

The insights gained from the study are highly relevant to prevention science, particularly in the context of maternal and child health and home visitation programs like Nurse-Family Partnership (NFP). Extending beyond NFP, this study’s findings have relevance to home visitation programs focused on maternal and child health including how the quality of the nurse-client relationship, access to reliable health information, and the impact of racial concordance can influence program retention by Black mothers. Understanding the factors that contribute to program engagement, retention, or attrition is crucial for the development and improvement of effective preventive home visiting interventions. The favorable experiences with nurses and the emphasis on the importance of having supportive, nonjudgmental, and culturally responsive healthcare providers highlight the need for relationship-based care models that are responsive to the unique needs and contexts of diverse populations, especially those at higher risk for adverse maternal and child health outcomes.

Limitations

Despite the significant insights gained from these findings, several limitations must be considered. First, one limitation is selection bias, as this study only included individuals who completed the program. Therefore, the findings, however informative, may not be representative of the experiences of those who dropped out of the program. The reasons for dropping out of the program may differ from the perceived reasons for program attrition by those who stayed in the program. Therefore, the findings may not be generalizable to the entire population of Black clients in NFP, or those who disengaged from the program. Meaningful contextual, individual, and group-level differences may exist between individuals with sustained engagement in NFP and individuals who disengaged or declined engagement with the intervention. Future research examining the perspectives of Black clients in NFP should recruit mothers who did not engage with the program or those who dropped out of NFP at various stages of the intervention.

Relatedly, participants were recruited from only four NFP sites in three US states; thus, the findings may provide only a limited scope of Black client perspectives, which may not be representative of Black client perceptions in other geographic locations. The program’s structure, implementation, and other characteristics may differ across regions, which could affect the factors that contribute to program retention. A qualitative investigation of Black client perspectives inclusive of more NFP sites across the United States may provide meaningful insights from a national perspective. Finally, although this study found that the nurse-client relationship was crucial to Black clients, the study did not consider the experiences of the nurse-client relationship from the perspective of the nurse. It may be useful to consider the nurse’s experiences and perspectives in future research to gain a more nuanced understanding of the complex factors that impact program retention rates among Black clients.

Despite these limitations, this qualitative research study provides valuable insights into the factors that impact program retention rates among individuals who stayed in NFP. Future research may need to address these limitations to gain a more comprehensive understanding of program retention and attrition rates and explore potential solutions to increase program retention rates for all participants in NFP.

Conclusion

Overall, the findings of this study provide valuable insights into how the Nurse-Family Partnership program can improve program retention and better achieve its aims. This study represents an important first step in understanding the experiences of Black clients who complete NFP, which provides foundational insights but also highlights the need for further research on why others may not complete them. In all, by understanding the experiences of Black clients who completed NFP, this study provides evidence-based insights that can inform the design, implementation, and refinement of preventive nurse home visiting programs, ensuring they are more inclusive, culturally responsive, and capable of reducing disparities in health outcomes. Moving forward, it is necessary to extend this research to understand the varied experiences of Black participants who complete, do not complete, and choose not to enroll in NFP to further inform the improvement of NFP and similar interventions.