Recruitment of lactating women into a randomized dietary intervention: Successful strategies and factors promoting enrollment and retention

Practice nurse-supported weight self-management delivered within the national child immunisation programme for postnatal women: a feasibility cluster RCT

BACKGROUND

Pregnancy is a high-risk time for excessive weight gain. The rising prevalence of obesity in women, combined with excess weight gain during pregnancy, means that there are more women with obesity in the postnatal period. This can have adverse health consequences for women in later life and increases the health risks during subsequent pregnancies.

OBJECTIVE

The primary aim was to produce evidence of whether or not a Phase III trial of a brief weight management intervention, in which postnatal women are encouraged by practice nurses as part of the national child immunisation programme to self-monitor their weight and use an online weight management programme, is feasible and acceptable.

DESIGN

The research involved a cluster randomised controlled feasibility trial and two semistructured interview studies with intervention participants and practice nurses who delivered the intervention. Trial data were collected at baseline and 3 months later. The interview studies took place after trial follow-up.

SETTING

The trial took place in Birmingham, UK.

PARTICIPANTS

Twenty-eight postnatal women who were overweight/obese were recruited via Birmingham Women's Hospital or general practices. Nine intervention participants and seven nurses were interviewed.

INTERVENTIONS

The intervention was delivered in the context of the national child immunisation programme. The intervention group were offered brief support that encouraged self-management of weight when they attended their practice to have their child immunised at 2, 3 and 4 months of age. The intervention involved the provision of motivation and support by nurses to encourage participants to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. The role of the nurse was to provide regular external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a record card in their child's health record ('red book') or using the online programme. The behavioural goal was for women to lose 0.5-1 kg per week. The usual-care group received a healthy lifestyle leaflet.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of a Phase III trial to test the effectiveness of the intervention, as assessed against three traffic-light stop-go criteria (recruitment, adherence to regular self-weighing and registration with an online weight management programme).

RESULTS

The traffic-light criteria results were red for recruitment (28/80, 35% of target), amber for registration with the online weight loss programme (9/16, 56%) and green for adherence to weekly self-weighing (10/16, 63%). Nurses delivered the intervention with high fidelity. In the qualitative studies, participants indicated that the intervention was acceptable to them and they welcomed receiving support to lose weight at their child immunisation appointments. Although nurses raised some caveats to implementation, they felt that the intervention was easy to deliver and that it would motivate postnatal women to lose weight.

LIMITATIONS

Fewer participants were recruited than planned.

CONCLUSIONS

Although women and practice nurses responded well to the intervention and adherence to self-weighing was high, recruitment was challenging and there is scope to improve engagement with the intervention.

FUTURE WORK

Future research should focus on investigating other methods of recruitment and, thereafter, testing the effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12209332.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 49. See the NIHR Journals Library website for further project information.

Feasibility and acceptability of a brief routine weight management intervention for postnatal women embedded within the national child immunisation programme in primary care: randomised controlled cluster feasibility trial

BACKGROUND

The prevalence of obesity in women continues to rise and pregnancy is a high-risk time for excessive weight gain. The period after childbirth represents an opportunity to offer women support to manage their weight. The primary aim here was to investigate the acceptability and feasibility of delivering a self-management intervention to postnatal women to support weight loss, embedded within the national child immunisation programme.

METHODS

The research involved a randomised controlled cluster feasibility trial. Data were collected at baseline and 3 months later. Twenty-eight postnatal women living with overweight or obesity were recruited via Birmingham Women Hospital or general practices. Babies are routinely immunised at 2, 3 and 4 months of age; the intervention was embedded within these appointments. The intervention involved brief motivation/support by practice nurses to encourage participants to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme, when they attended their practice to have their child immunised. The role of the nurse was to provide external accountability for weight loss. Participants were asked to weigh themselves weekly and record this on a record card or using the online programme. The weight goal was for participants to lose 0.5 to 1 kg per week. Usual care received a healthy lifestyle leaflet. The primary outcome was the feasibility of a phase III trial to test the subsequent effectiveness of the intervention, as assessed against three stop-go traffic light criteria (recruitment, adherence to regular self-weighing and registration with an online weight management programme).

RESULTS

The traffic light stop-go criteria results were red for recruitment (28/80, 35% of target), amber for registration with the online weight loss programme (9/16, 56%) and green for adherence to weekly self-weighing (10/16, 63%). Nurses delivered the intervention with high fidelity.

DISCUSSION

Whilst participants and nurses followed the trial protocol well and adherence to self-weighing was acceptable, recruitment was challenging and there is scope to improve engagement with the online weight management programme component of the intervention.

TRIAL REGISTRATION

ISRCTN 12209332 . Registration date is 04/12/18.

Why does the need for medication become a barrier to breastfeeding? A narrative review

PROBLEM

The need for medication during lactation can contribute to the early cessation of breastfeeding.

BACKGROUND

Breastfeeding women may require medication for acute or chronic health conditions. For some women this need for medication can become a barrier to breastfeeding; this is despite the fact that the majority of medications are considered to be compatible with lactation.

AIM

This narrative review aims to investigate factors relating to medicines safety that could contribute to medication unnecessarily becoming a barrier to breastfeeding.

METHODS

A selective literature search using PubMed, Scopus and Google Scholar was conducted over a 6-month period using the search terms "breastfeeding", "lactation", "medication" and "information". Articles were assessed to identify whether they addressed the impact of medication use on the decision to breastfeed.

FINDINGS

Fifty six articles were identified as having appropriate discussion about decision making for the safe use of medication during lactation. Themes identified included variable and conflicting safety advice for medicines; difficulty interpreting risks associated with medicine use; societal pressures faced by the breastfeeding woman; and the varied knowledge and training of health professionals involved in the care of breastfeeding women.

CONCLUSION

Poor quality of information about medicine safety during lactation can contribute to confusion in giving recommendations. This confusion can result in early cessation of breastfeeding or insufficient health care for the breastfeeding woman.

The marketing plan and outcome indicators for recruiting and retaining parents in the HomeStyles randomized controlled trial

Background

Despite the critical importance of successful recruitment and retention to study integrity, reporting of recruitment and retention strategies along with factors associated with successful recruitment and retention of participants in health-related interventions remain rare, especially for health and obesity prevention programs. Thus, the purpose of this article is to retrospectively examine the recruitment and retention marketing plan used in the online HomeStyles randomized controlled trial (RCT) and discuss outcomes associated with completion of the intervention.

Methods

The HomeStyles RCT is an online intervention developed to motivate parents of young children to gain the skills and self-confidence needed to shape home environments and lifestyles to be protective against childhood obesity. Using the seven Ps of services marketing (i.e., people, place, product, physical evidence, price, promotion, and process), a comprehensive and systematic plan for recruitment and retention was implemented and outcomes assessed.

Results

A total of 489 parents with a young child aged 2 to < 6 years were eligible to participate, a final capture rate of 33%. Only 23% of Hispanic participants chose to use the Spanish-language version of HomeStyles intervention materials, below the demand anticipated. However, Hispanic enrollment overall was substantially higher than the U.S. population proportion (i.e., 17%). The number of participants prematurely leaving the study was similar in both treatment groups, indicating attrition was not differential. Completers reported high satisfaction of HomeStyles, using a 1–5 scale (strongly disagree to strongly agree) on guide attractiveness, interestingness, and usefulness. Despite all the retention efforts, the average monthly recruitment accrual rate of ~ 33 eligible enrolled participants at baseline (i.e., 489 participants/15-month recruitment period), declined to ~ 18, 11, 9, and 8 remaining recruited participants/month at midpoint, post, follow-up, and long-term follow-up surveys, respectively. In general, survey completers were significantly more likely to be female and perceived their child’s health status to be better, and they were significantly less likely to be restrictive of their child’s food intake.

Conclusions

The findings of the present study highlight the need for far-reaching, concentrated, and varied recruitment strategies; sufficient time in the research plan for recruitment and retention activities; and creative, tireless, flexible, persistent project staff for health-related interventions.

Employing a Multi-level Approach to Recruit a Representative Sample of Women with Recent Gestational Diabetes Mellitus into a Randomized Lifestyle Intervention Trial

OBJECTIVE

The postpartum period is a window of opportunity for diabetes prevention in women with recent gestational diabetes (GDM), but recruitment for clinical trials during this period of life is a major challenge.

METHODS

We adapted a social-ecologic model to develop a multi-level recruitment strategy at the macro (high or institutional level), meso (mid or provider level), and micro (individual) levels. Our goal was to recruit 100 women with recent GDM into the Balance after Baby randomized controlled trial over a 17-month period. Participants were asked to attend three in-person study visits at 6 weeks, 6, and 12 months postpartum. They were randomized into a control arm or a web-based intervention arm at the end of the baseline visit at six weeks postpartum. At the end of the recruitment period, we compared population characteristics of our enrolled subjects to the entire population of women with GDM delivering at Brigham and Women's Hospital (BWH).

RESULTS

We successfully recruited 107 of 156 (69 %) women assessed for eligibility, with the majority (92) recruited during pregnancy at a mean 30 (SD ± 5) weeks of gestation, and 15 recruited postpartum, at a mean 2 (SD ± 3) weeks postpartum. 78 subjects attended the initial baseline visit, and 75 subjects were randomized into the trial at a mean 7 (SD ± 2) weeks postpartum. The recruited subjects were similar in age and race/ethnicity to the total population of 538 GDM deliveries at BWH over the 17-month recruitment period.

CONCLUSIONS

Our multilevel approach allowed us to successfully meet our recruitment goal and recruit a representative sample of women with recent GDM. We believe that our most successful strategies included using a dedicated in-person recruiter, integrating recruitment into clinical flow, allowing for flexibility in recruitment, minimizing barriers to participation, and using an opt-out strategy with providers. Although the majority of women were recruited while pregnant, women recruited in the early postpartum period were more likely to present for the first study visit. Given the increased challenges of recruiting postpartum women with GDM into research studies, we believe our findings will be useful to other investigators seeking to study this population.

Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis

Post-partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post-partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post-partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self-monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home- or centre-based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta-analysis (1,892 women, age 24-36 years). Studies with self-monitoring had significantly greater weight lost than those without (-4.61 kg [-7.08, -2.15] vs. -1.34 kg [-1.66, -1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (-3.24 kg [-4.59, -1.90] vs. -1.63 kg [-2.16, -1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self-monitoring and take a combined diet-and-exercise approach have significantly greater weight loss in post-partum women.

Recruitment lessons learned from a tailored web-based health intervention Project Y.E.A.H. (Young Adults Eating and Active for Health)

Purpose

– Recruiting college students for research studies can be challenging. The purpose of this paper is to describe the lessons learned in the various recruitment strategies used for enrolling college students in a theory-based, tailored, and web-delivered health intervention at 13 US universities.

Design/methodology/approach

– The community-based participatory research (CBPR) model was used to develop a staged-tailored, web-based, randomized control trial, focussing on eating behavior, physical activity, and stress management. Participant feedback during baseline assessments was used to evaluate recruitment strategies.

Findings

– Findings from this feedback suggest that traditional recruitment strategies, such as newspaper ads and flyers, may not be the best approach for recruiting college students; instead, web-based efforts proved to be a better recruitment strategy.

Research limitations/implications

– This project included results from 13 US universities and thus may not be generalizable: more research is needed to determine successful recruitment methods for 18-24 years old college students.

Originality/value

– This paper lessens the gap regarding successful recruitment strategies for 18-24 years old college students.

Standardizing the evaluation criteria on treatment outcomes of mandibular implant overdentures: a systematic review

PURPOSE

The aim of this review was to analyze the evaluation criteria on mandibular implant overdentures through a systematic review and suggest standardized evaluation criteria.

MATERIALS AND METHODS

A systematic literature search was conducted by PubMed search strategy and hand-searching of relevant journals from included studies considering inclusion and exclusion criteria. Randomized clinical trials (RCT) and clinical trial studies comparing attachment systems on mandibular implant overdentures until December, 2011 were selected. Twenty nine studies were finally selected and the data about evaluation methods were collected.

RESULTS

Evaluation criteria could be classified into 4 groups (implant survival, peri-implant tissue evaluation, prosthetic evaluation, and patient satisfaction). Among 29 studies, 21 studies presented implant survival rate, while any studies reporting implant failure did not present cumulative implant survival rate. Seventeen studies evaluating peri-implant tissue status presented following items as evaluation criteria; marginal bone level (14), plaque Index (13), probing depth (8), bleeding index (8), attachment gingiva level (8), gingival index (6), amount of keratinized gingiva (1). Eighteen studies evaluating prosthetic maintenance and complication also presented following items as evaluation criteria; loose matrix (17), female detachment (15), denture fracture (15), denture relining (14), abutment fracture (14), abutment screw loosening (11), and occlusal adjustment (9). Atypical questionnaire (9), Visual analog scales (VAS) (4), and Oral Health Impact Profile (OHIP) (1) were used as the format of criteria to evaluate patients satisfaction in 14 studies.

CONCLUSION

For evaluation of implant overdenture, it is necessary to include cumulative survival rate for implant evaluation. It is suggested that peri-implant tissue evaluation criteria include marginal bone level, plaque index, bleeding index, probing depth, and attached gingiva level. It is also suggested that prosthetic evaluation criteria include loose matrix, female detachment, denture fracture, denture relining, abutment fracture, abutment screw loosening, and occlusal adjustment. Finally standardized criteria like OHIP-EDENT or VAS are required for patient satisfaction.

Diet or exercise, or both, for weight reduction in women after childbirth

BACKGROUND

Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated.

OBJECTIVES

The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012) and LILACS (31 January 2012). We scanned secondary references and contacted experts in the field. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 April 2013 and added the results to the awaiting classification section of the review.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) and quasi-randomised trials of diet or exercise or both, among women during the postpartum period.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trial quality and extracted data. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Data were analysed with a fixed-effect model. A random-effects model was used in the presence of heterogeneity.

MAIN RESULTS

Fourteen trials were included, but only 12 trials involving 910 women contributed data to outcome analysis. Women who exercised did not lose significantly more weight than women in the usual care group (two trials; n = 53; MD -0.10 kg; 95% confidence interval (CI) -1.90 to 1.71). Women who took part in a diet (one trial; n = 45; MD -1.70 kg; 95% CI -2.08 to -1.32), or diet plus exercise programme (seven trials; n = 573; MD -1.93 kg; 95% CI -2.96 to -0.89; random-effects, T² = 1.09, I² = 71%), lost significantly more weight than women in the usual care group. There was no difference in the magnitude of weight loss between diet alone and diet plus exercise group (one trial; n = 43; MD 0.30 kg; 95% CI -0.06 to 0.66). The interventions seemed not to affect breastfeeding performance adversely.

AUTHORS' CONCLUSIONS

Evidence from this review suggests that both diet and exercise together and diet alone help women to lose weight after childbirth. Nevertheless, it may be preferable to lose weight through a combination of diet and exercise as this improves maternal cardiorespiratory fitness and preserves fat-free mass, while diet alone reduces fat-free mass. This needs confirmation in large trials of high methodological quality. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby.

A comparison of Mediterranean-style and MyPyramid diets on weight loss and inflammatory biomarkers in postpartum breastfeeding women

BACKGROUND

Of postpartum women, 15%-20% retain ≥ 5 kg of their gestational weight gain, increasing risk for adult weight gain. Postpartum women are also in a persistent elevated inflammatory state. Both factors could increase the risk of obesity-related chronic disease. We hypothesized that breastfeeding women randomized to a Mediterranean-style (MED) diet for 4 months would demonstrate significantly greater reductions in body weight, body fat, and inflammation than women randomized to the U.S. Department of Agriculture's (USDA) MyPyramid diet for Pregnancy and Breastfeeding (comparison diet).

METHODS

A randomized, controlled dietary intervention trial was conducted in 129 overweight (body mass index [BMI] 27.2 ± 4.9 kg/m(2)), mostly exclusively breastfeeding (73.6%) women who were a mean 17.5 weeks postpartum. Dietary change was assessed using a validated Food Frequency Questionnaire (FFQ) before and after intervention as well as plasma fatty acid measures (gas chromatography/flame ionization detector [GC/FID]). Anthropometric measurements and biomarkers of inflammation, tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), also were assessed at baseline and 4 months via enzyme-linked immunosorbent assay (ELISA).

RESULTS

Participants in both diet groups demonstrated significant (p<0.001) reductions in body weight (-2.3 ± 3.4 kg and -3.1 ± 3.4 kg for the MED and comparison diets, respectively) and significant (p ≤ 0.002) reductions in all other anthropometric measurements; no significant between-group differences were shown as hypothesized. A significant decrease in TNF-α but not IL-6 was also demonstrated in both diet groups, with no significant between-group difference.

CONCLUSIONS

Both diets support the promotion of postpartum weight loss and reduction in inflammation (TNF-α) in breastfeeding women.

Recruiting and retaining low-income, multi-ethnic women into randomized controlled trials: successful strategies and staffing

Developing effective recruitment and retention strategies in populations with traditionally high attrition rates is critical to the success of Randomized Controlled Trials (RCTs). Data on successful participation of women from low-income, minority populations in RCTs of behavioral interventions are limited. This is problematic given the multiplicity of Healthy People 2020 goals that target health disparities in these populations. This paper reports successful recruitment and retention methods from two separately funded NIH clinical trials of primary care-based prenatal interventions to increase breastfeeding among ethnically diverse, low-income women in urban medical centers in the Bronx, NY. It also presents the required staff effort necessary to conduct such a successful RCT, in terms of full-time equivalents (FTEs). Results include timely recruitment of 941 participants over 29 months, with 98.1% completing >¯¯1 follow-up interview. A recruitment and retention plan that maximized study staff access and availability to the participant, as well as strong study staff rapport with participants, addressed previously reported barriers in this population, optimizing follow-up rates. A qualitative assessment of the participants' study experience suggesting that high retention was due to strong rapport with participants, short interviews requiring little time commitment, and participants' perception of the study as informative, provides further evidence of our approach's effectiveness. Logistical protocol procedures and staff management strategies relating to successful recruitment/retention are provided to propose a practical, cost-effective and translational recruitment-retention plan for other researchers to adopt.

Diet or exercise, or both, for weight reduction in women after childbirth

BACKGROUND

Weight retention after pregnancy may contribute to obesity. It is known that diet and exercise are recommended components of any weight loss programme in the general population. However, strategies to achieve healthy body weight among postpartum women have not been adequately evaluated.

OBJECTIVES

The objectives of this review were to evaluate the effect of diet, exercise or both for weight reduction in women after childbirth, and to assess the impact of these interventions on maternal body composition, cardiorespiratory fitness, breastfeeding performance and other child and maternal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006) and LILACS. We scanned secondary references and contacted experts in the field.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCT) and quasi-randomised trials of diet or exercise or both, among women during the postpartum period.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data. Results are presented using relative risk for categorical data and weighted mean difference (WMD) for continuous data. Data were analysed with a fixed-effect model. A random-effects model was used in the presence of heterogeneity.

MAIN RESULTS

Six trials involving 245 women were included. Women who exercised did not lose significantly more weight than women in the usual care group (one trial; n = 33; WMD 0.00 kg; 95% confidence interval (CI) -8.63 to 8.63). Women who took part in a diet (one trial; n = 45; WMD -1.70 kg; 95% CI -2.08 to -1.32), or diet plus exercise programme (four trials; n = 169; WMD -2.89 kg; 95% CI -4.83 to -0.95), lost significantly more weight than women in the usual care. There was no difference in the magnitude of weight loss between diet and diet plus exercise group (one trial; n = 43; WMD 0.30 kg; 95% CI -0.60 to 0.66). The interventions seemed not to affect breastfeeding performance adversely.

AUTHORS' CONCLUSIONS

Preliminary evidence from this review suggests that dieting and exercise together appear to be more effective than diet alone at helping women to lose weight after childbirth, because the former improves maternal cardiorespiratory fitness level and preserves fat-free mass, while diet alone reduces fat-free mass. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Due to insufficient available data, additional research, with larger sample size, is needed to confirm the results.