The Recruitment and Retention Connection

1. The Recruitment and Retention Connection  Connie Wiemann, PhD Baylor College of Medicine Houston, TX Cwiemann@bcm.edu Introduce self, expertise Ground rules Slides Need to make this relevant to you so expect questions and comments along the wayIntroduce self, expertise Ground rules Slides Need to make this relevant to you so expect questions and comments along the way

2. Learning Objectives Identify 5+ strategies for recruiting and retaining adolescents / partners / families in Prevention and Care Demonstration Projects Describe ways to use adolescents / partners / families to guide recruitment and retention practices. Could have been more broadCould have been more broad

3. Your Experiences What are some of the barriers/problems that you have encountered in your attempts to recruit adolescent mothers/fathers/family members into either your Care program or its evaluation? What are some of the barriers/problems that you have encountered in your attempts to recruit adolescent mothers/fathers/family members into either your Care program or its evaluation?

4. A Child in Your Life Evaluation of parent education program 20 sites randomized into 4 groups Health department, school, social service agency, clinic Video, booklet, both, neither N=88 parenting teens Recruitment/implementation by site 6 modules (6-7 weeks) Discipline, feeding, play/stimulation, stress/coping, using support, early child development Site leaders conducted program, external group conducted evaluation and were blind to group status Evaluated integrity of the treatment using post-module implementation discussion limited in combined media group, more difficult to get through both components Video by self most effective, then combined, then bookletSite leaders conducted program, external group conducted evaluation and were blind to group status Evaluated integrity of the treatment using post-module implementation discussion limited in combined media group, more difficult to get through both components Video by self most effective, then combined, then booklet

5. A Child in Your Life 88% retention at 3-mo Process evaluation Attendance, implementation, post-module Outcome evaluation Knowledge, attitudes, behavior Traveled to teens, 1:1 interview Incentives for program and evaluation Site leaders conducted program, external group conducted evaluation and were blind to group status Evaluated integrity of the treatment using post-module implementation discussion limited in combined media group, more difficult to get through both components Video by self most effective, then combined, then bookletSite leaders conducted program, external group conducted evaluation and were blind to group status Evaluated integrity of the treatment using post-module implementation discussion limited in combined media group, more difficult to get through both components Video by self most effective, then combined, then booklet

6. A Child in Your Life 27% failed to attend one session Social service agencies vs. schools Averaged 4.1 sessions Main findings Which group did best? Discussion limited in combined media Site leaders conducted program, external group conducted evaluation and were blind to group status Evaluated integrity of the treatment using post-module implementation discussion limited in combined media group, more difficult to get through both components Video by self most effective, then combined, then bookletSite leaders conducted program, external group conducted evaluation and were blind to group status Evaluated integrity of the treatment using post-module implementation discussion limited in combined media group, more difficult to get through both components Video by self most effective, then combined, then booklet

7. Adolescent Motherhood Project Epidemiologic study, 12-18yo Hospital post-partum ward N=932 (multi-ethnic) <10% refusal, highest for SS Latinas Initial interview, survey mailed at 3, 6, 12, 18, 24, 48 months 80% return across 24 months Phone, clinic, travel to teens Incentives, logo, raffle Epi study of drug use, also examined many other outcomes so did not need to agree to participate in an intervention or an evaluation Epi study of drug use, also examined many other outcomes so did not need to agree to participate in an intervention or an evaluation

8. Adolescent Motherhood Project Follow-up samples did not differ from initial sample Tobacco, alcohol, other drug use Depressive symptoms Breastfeeding decision, duration Intimate partner violence Repeat pregnancy, condom use Social support from FOB High school enrollment/completion TAOD � highest use among Caucasian and acculturated Mexican-Americans returned to prepg use rates by 18 months many adolescent mothers stopped using altogether, others started Depressive symptoms � highest in first 3 months, with > 90% of those who experienced DS doing so by 12mo most with DS at 24 and 48 months had experienced them by 12 mo Breastfeeding � 55% MA, 45% C, 15% AA determinants of the decision to breastfeed differed by race/ethnic group duration � no r/e differences 43% bf for <=3wks fewer bf role models, more likely to have attended prenatal classes, least likely to report considering bf next chlid IPV � at baseline: 12% IPV in last 12 months, other forms of violence such as family and community more common, AOD by both perpetrator and victimization IPV � 24 months: 21% at 3 months, 13% by 24 months; of those experiencing IPV, severe IPV increased from 40% to 62%, 72 during pg also within 24 months; 78% at 3mo not during pregnancy Repeat pregnancy and condom use: IPV important predictor of these phenomenon as well Social support � absent fathers within r/e group: weekly alcohol, drug use; gang involvement; IPV, short relationship TAOD � highest use among Caucasian and acculturated Mexican-Americans returned to prepg use rates by 18 months many adolescent mothers stopped using altogether, others started Depressive symptoms � highest in first 3 months, with > 90% of those who experienced DS doing so by 12mo most with DS at 24 and 48 months had experienced them by 12 mo Breastfeeding � 55% MA, 45% C, 15% AA determinants of the decision to breastfeed differed by race/ethnic group duration � no r/e differences 43% bf for <=3wks fewer bf role models, more likely to have attended prenatal classes, least likely to report considering bf next chlid IPV � at baseline: 12% IPV in last 12 months, other forms of violence such as family and community more common, AOD by both perpetrator and victimization IPV � 24 months: 21% at 3 months, 13% by 24 months; of those experiencing IPV, severe IPV increased from 40% to 62%, 72 during pg also within 24 months; 78% at 3mo not during pregnancy Repeat pregnancy and condom use: IPV important predictor of these phenomenon as well Social support � absent fathers within r/e group: weekly alcohol, drug use; gang involvement; IPV, short relationship

9. STI Intervention Evaluation of STD intervention Theory based Non pregnant 16 to 21 yrs Multi-cultural population Community reproductive health clinic Conceptual framework is transtheoretical model of change Who are the 41% refusers? Reasons for refusal � time, work, school, transportation, urine screen, not interested Small gifts, logoConceptual framework is transtheoretical model of change Who are the 41% refusers? Reasons for refusal � time, work, school, transportation, urine screen, not interested Small gifts, logo

10. STI Intervention Randomized intervention vs. std care 41% refusal Time, work, school, transport., urine screen, not interested Higher for Latinas 2-week intervention (69%) 6-mo visit intervention, assessment 70% intervention, 82% control 12-mo assessment (61%, 68%)

11. Obesity Study 20 severely overweight Latina adolescents and families, 12-19 yrs Health clinics Home interviews Recruiters � bilingual, health care providers, young adult

12. Recruitment Basics Preliminary questions The consent process Consult experts Recruiters Protocols These are some of the things you�ll need to think about as you begin recruitment or you may wish to consider if you are in the midst of recruitment.These are some of the things you�ll need to think about as you begin recruitment or you may wish to consider if you are in the midst of recruitment.

13. Preliminary Questions Why conduct an evaluation? Why use a particular study design? Who is responsible for recruitment? What role do different project and site staff play? Does this feel like a team effort? Am I comfortable doing this? Which potential participants to approach and how? Why conduct an evaluation? Give me 5 reasons�. gain understanding of program operation � are you doing what you think you are doing? For duplication elsewhere. to document program effectiveness to examine strengths and weaknesses of the program to obtain further funding for services, to retain effective programs when one is better than the other, or combine programs provides continuing feedback so that program can be adjusted to identify program components responsible for change so that future programs can be more efficient, cost effective provides data to promote program to the community consider decisions you will want to make while planning evaluation Process (how and to what extent program being implemented, who reached, problems), impact (skills, attitudes, intermediary variable) and outcomes (educational attainment, immunizations, repeat pregnancy) based evaluations Why randomize to groups? Only way to tell if group differences are due to intervention vs. some other factor (internal validity) Not all pregnancy and parenting teens can receive your intervention Why conduct an evaluation? Give me 5 reasons�. gain understanding of program operation � are you doing what you think you are doing? For duplication elsewhere. to document program effectiveness to examine strengths and weaknesses of the program to obtain further funding for services, to retain effective programs when one is better than the other, or combine programs provides continuing feedback so that program can be adjusted to identify program components responsible for change so that future programs can be more efficient, cost effective provides data to promote program to the community consider decisions you will want to make while planning evaluation Process (how and to what extent program being implemented, who reached, problems), impact (skills, attitudes, intermediary variable) and outcomes (educational attainment, immunizations, repeat pregnancy) based evaluations Why randomize to groups? Only way to tell if group differences are due to intervention vs. some other factor (internal validity) Not all pregnancy and parenting teens can receive your intervention

14. Informed Consent Intervention vs. evaluation consent What is the big deal? Consenting adolescents and their parents Requirements for adolescents Informed consent vs. coercion Barriers Incentives to return forms Confidentiality in practice Confidentiality � think about your own experience at the doctors � do you want your business shared?Confidentiality � think about your own experience at the doctors � do you want your business shared?

15. Consult Experts: Teens and Families Project name What would make it easier to participate, harder What/who is important to your target population Establish teen/family/male partner advisory board Needs assessment What components working, not; changes needed; shifts in needs over time Focus groups, in depth interviews Quotes to illustrate pointsFocus groups, in depth interviews Quotes to illustrate points

16. Recruiters Level of comfort recruiting into program, evaluation Culturally compatible, comfortable Personal biases Know strengths and limitations Train, practice

17. Protocols Develop Recruitment, follow-up, intervention, potential problem situations Pilot Recruitment, intervention, tracking Revise Review Easy to forget once you get started Removes burden, difficult decision-makingRemoves burden, difficult decision-making

18. Recruitment in Practice Follow a script Set positive tone at start of recruitment session Be aware of prior refusers Monitor who agrees/refuses Systematic Recruit by return appointment Diminished recruitment pool over time Celebrate and troubleshoot often Be aware of prior refusers Diminished recruitment pool over timeBe aware of prior refusers Diminished recruitment pool over time

19. Retention Keys Recruitment experience Creativity Think outside the box Be flexible Transportation, child care Incentives, logos, trinkets, bucks Build on personal motivations to participate Belongingness Project ROSE exit interview flexible with appointment, complete assessment at time of appointment help with transportation allowing clients to continue coming to clinic after age cut-off perception that participation helps others project logo trinkets (Key chain, mirror)O to encourage remembering appointments ROSE bucks � letters and money Project ROSE staff phone calls made at various times, leave messages phone interviews not productiveProject ROSE exit interview flexible with appointment, complete assessment at time of appointment help with transportation allowing clients to continue coming to clinic after age cut-off perception that participation helps others project logo trinkets (Key chain, mirror)O to encourage remembering appointments ROSE bucks � letters and money Project ROSE staff phone calls made at various times, leave messages phone interviews not productive

20. Retention Keys Persistence Ongoing needs assessment Why keep coming? Why not coming? How have needs changed? Exit interview Project ROSE exit interview flexible with appointment, complete assessment at time of appointment help with transportation allowing clients to continue coming to clinic after age cut-off perception that participation helps others project logo trinkets (Key chain, mirror)O to encourage remembering appointments ROSE bucks � letters and money Project ROSE staff phone calls made at various times, leave messages phone interviews not productiveProject ROSE exit interview flexible with appointment, complete assessment at time of appointment help with transportation allowing clients to continue coming to clinic after age cut-off perception that participation helps others project logo trinkets (Key chain, mirror)O to encourage remembering appointments ROSE bucks � letters and money Project ROSE staff phone calls made at various times, leave messages phone interviews not productive

21. Tracking Strategies Contact information Drivers� license, SS#, parents, friends, relatives, boyfriend, cell phone, email address Check regularly Recheck if disconnected Mothers can be important contacts Public databases

22. Reminders Appointment cards Telephone How frequently? Computer, IM, text msg Follow-up missed visits

23. Team Meetings Weekly What�s working? What�s not? Communication style Times of day Type of message Strategies attempted Play to team member strengths Recruitment/retention are difficult Celebrate success

24. Travel to Them Home interviews Meet at restaurant, work, school Cell phone messaging, email, website log-in Monitor clinic appointments, food stamp pick-up Piggyback evaluation on other activities

25. Alternate Methods of Data Collection Mail and phone Schools, social service agencies Delivery/birth records, medical/clinical records Those who dropped from intervention Obtain release ahead of time

26. Incentives Type Baby gifts go a long way Setting up home Money, especially around the holidays Raffles Timing Baby pictures on wall of site helpsBaby pictures on wall of site helps

27. Process Evaluation Who did program reach? Attendance/follow-up rates � characteristics Recruitment strategies Delivery of intervention as planned

28. Process Evaluation Reasons for stopping What do they perceive as motivations or barriers Degree of connection to program Feedback on various program components

29. Brainstorming Activity Overcoming Challenges to Recruitment and Retention in Individual Programs � role play?Overcoming Challenges to Recruitment and Retention in Individual Programs � role play?

30. Summary Teens/partners are a moving target Recruitment and retention are about being comfortable, organized, creative, persistent Continue with evaluation even if drop from program