Recruitment and retention strategies in mental health trials - A systematic review

Recruiting Young People for Digital Mental Health Research: Lessons From an AI-Driven Adaptive Trial

BACKGROUND

With increasing adoption of remote clinical trials in digital mental health, identifying cost-effective and time-efficient recruitment methodologies is crucial for the success of such trials. Evidence on whether web-based recruitment methods are more effective than traditional methods such as newspapers, media, or flyers is inconsistent. Here we present insights from our experience recruiting tertiary education students for a digital mental health artificial intelligence-driven adaptive trial-Vibe Up.

OBJECTIVE

We evaluated the effectiveness of recruitment via Facebook and Instagram compared to traditional methods for a treatment trial and compared different recruitment methods' retention rates. With recruitment coinciding with COVID-19 lockdowns across Australia, we also compared the cost-effectiveness of social media recruitment during and after lockdowns.

METHODS

Recruitment was completed for 2 pilot trials and 6 minitrials from June 2021 to May 2022. To recruit participants, paid social media advertising on Facebook and Instagram was used, alongside mailing lists of university networks and student organizations or services, media releases, announcements during classes and events, study posters or flyers on university campuses, and health professional networks. Recruitment data, including engagement metrics collected by Meta (Facebook and Instagram), advertising costs, and Qualtrics data on recruitment methods and survey completion rates, were analyzed using RStudio with R (version 3.6.3; R Foundation for Statistical Computing).

RESULTS

In total, 1314 eligible participants (aged 22.79, SD 4.71 years; 1079, 82.1% female) were recruited to 2 pilot trials and 6 minitrials. The vast majority were recruited via Facebook and Instagram advertising (n=1203; 92%). Pairwise comparisons revealed that the lead institution's website was more effective in recruiting eligible participants than Facebook (z=3.47; P=.003) and Instagram (z=4.23; P<.001). No differences were found between recruitment methods in retaining participants at baseline, at midpoint, and at study completion. Wilcoxon tests found significant differences between lockdown (pilot 1 and pilot 2) and postlockdown (minitrials 1-6) on costs incurred per link click (lockdown: median Aus $0.35 [US $0.22], IQR Aus $0.27-$0.47 [US $0.17-$0.29]; postlockdown: median Aus $1.00 [US $0.62], IQR Aus $0.70-$1.47 [US $0.44-$0.92]; W=9087; P<.001) and the amount spent per hour to reach the target sample size (lockdown: median Aus $4.75 [US $2.95], IQR Aus $1.94-6.34 [US $1.22-$3.97]; postlockdown: median Aus $13.29 [US $8.26], IQR Aus $4.70-25.31 [US $2.95-$15.87]; W=16044; P<.001).

CONCLUSIONS

Social media advertising via Facebook and Instagram was the most successful strategy for recruiting distressed tertiary students into this artificial intelligence-driven adaptive trial, providing evidence for the use of this recruitment method for this type of trial in digital mental health research. No recruitment method stood out in terms of participant retention. Perhaps a reflection of the added distress experienced by young people, social media recruitment during the COVID-19 lockdown period was more cost-effective.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621001092886; https://tinyurl.com/39f2pdmd; Australian New Zealand Clinical Trials Registry ACTRN12621001223820; https://tinyurl.com/bdhkvucv.

Effectiveness, efficacy, acceptability, and feasibility of trauma-informed depression, anxiety, and substance use prevention programs for young people aged 12-25 years: A mixed-methods systematic review

BACKGROUND

Mental ill-health and substance use bear significant public health burden on young people. Prevention is key. Trauma-informed approaches to prevention of mental ill-health and substance use demonstrate significant promise, yet it is unclear how well existing approaches work for young people targeting mental ill-health and substance use. This review aimed to assess the effectiveness, feasibility, and acceptability of trauma-informed mental ill-health and/or substance use prevention programs for young people.

METHODS

We searched the PsycINFO, CINAHL, Embase, MEDLINE, and Cochrane Library reference databases for peer-reviewed studies of trauma-informed mental ill-health and/or substance use prevention programs for young people published between 2013 and 2022. Studies in any language were included and reference lists of included articles were scanned for additional studies of relevance.

RESULTS

In total, 30 studies were included in this review, comprising five randomized controlled trials (RCTs), seven non-RCTs, 10 quasi-experimental designs, and eight qualitative studies. Among the 30 studies, 27 unique trauma-informed prevention interventions were detailed. Eighteen studies reported statistically significant decreases in mental ill-health, and two studies reported significant decreases in substance use outcomes among participants, up to 6 months following the interventions. Most preventative interventions with statistically significant effects were selective (rather than universal or indicated) in their approach (n = 10, 55%). Broad acceptability and feasibility of trauma-informed prevention programs was observed among studies reporting this information though most quantitative studies were at high risk of bias and/or did not include a control group, whilst qualitative studies tended to report research conducted without a priori research aims.

DISCUSSION

This review synthesizes for the first-time evidence on the effectiveness (or efficacy), feasibility, and acceptability of trauma-informed mental ill-health and/or substance use programs for young people, especially for those exposed to traumatic or adverse experiences. While there are promising efficacy outcomes, further research conducting rigorous, well-powered RCTs is required for large-scale evaluation and scaling of the potential preventative benefits of such programs.

Perinatal emotional skills groups for women and birthing people with borderline personality disorder: outcomes from a feasibility randomised controlled trial

BACKGROUND

There is no clear evidence about how to support people with borderline personality disorder (BPD) during the perinatal period. Perinatal emotional skills groups (ESGs) may be helpful, but their efficacy has not been tested.

AIMS

To test the feasibility of conducting a randomised controlled trial (RCT) of perinatal ESGs for women and birthing people with BPD.

METHOD

Two-arm parallel-group feasibility RCT. We recruited people from two centres, aged over 18 years, meeting DSM-5 diagnostic criteria for BPD, who were pregnant or within 12 months of a live birth. Eligible individuals were randomly allocated on a 1:1 ratio to ESGs + treatment as usual (TAU), or to TAU. Outcomes were assessed at 4 months post randomisation.

RESULTS

A total of 100% of the pre-specified sample (n = 48) was recruited over 6 months, and we obtained 4-month outcome data on 92% of randomised participants. In all, 54% of participants allocated to perinatal ESGs attended 75% of the full group treatment (median number of sessions: 9 (interquartile range 6-11). At 4 months, levels of BPD symptoms (adjusted coefficient -2.0, 95% CI -6.2 to 2.1) and emotional distress (-2.4, 95% CI -6.2 to 1.5) were lower among those allocated to perinatal ESGs. The directionality of effect on well-being and social functioning also favoured the intervention. The cost of delivering perinatal ESGs was estimated to be £918 per person.

CONCLUSIONS

Perinatal ESGs may represent an effective intervention for perinatal women and birthing people with BPD. Their efficacy should be tested in a fully powered RCT, and this is a feasible undertaking.

TRIAL REGISTRATION

ISRCTN80470632.

Energetic activity for depression in young people aged 13-17 years: the READY feasibility RCT

Background

Prevalence of depression is increasing in young people. Behaviour change interventions providing benefits equal to or greater than talking therapies or pharmacological alternatives are needed. Exercise could be beneficial for young people with depression, but we lack robust trials of its effectiveness.

Objective

To test whether an exercise intervention targeting young people with depression is feasible, including recruitment and retention of young people, recruitment and training of exercise professionals and intervention delivery.

Design

Three-arm cluster feasibility randomised controlled trial with embedded process evaluation and health economic data collection.

Setting

Local community venues in Hertfordshire, Bedfordshire and Norfolk.

Participants

Young people aged 13-17 years experiencing mild to moderate low mood or depression (indicated by scoring 17-36 on the Child Depression Inventory version 2) identified by mental health services, schools or self-referral.

Interventions

Participants were randomised to one of three groups: high-intensity exercise, low-intensity exercise or a social activity control. Group sessions ran twice-weekly for 12 weeks delivered by registered exercise professionals, supported by mental health support workers.

Main outcome measures

Referral, recruitment and retention rates; attendance at group sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data, and adverse events measured at baseline and at 3 and 6 months; resource use; and reach and representativeness.

Results

Of 321 referrals to the study, 173 were assessed for eligibility, and of the target sample size of 81, 15 were recruited and 14 were randomised (one withdrew). The retention rate was 71.4% and attendance at intervention sessions was > 67%; data completeness was > 80% for baseline assessments. Follow-up completion rate at 14 weeks was > 80% for most outcomes, with 50% for accelerometer data in the low-intensity group. Trial processes and the intervention were acceptable to young people. Barriers to and facilitators of intervention delivery were identified.

Limitations

Findings highlighted challenges around recruitment, delivery of exercise interventions and informed ways of addressing barriers to recruitment for future studies. The study was conducted between October 2020 and August 2022 and consequently the COVID-19 pandemic had a disruptive impact on implementation.

Conclusions

A large randomised trial of the effectiveness of the intervention is not feasible using the current study design, but issues relating to recruitment could be addressed with further work.

Future work

Developing appropriate recruitment strategies via triage services, general practitioner practices, schools and social media and early engagement with the local Clinical Research Network to support recruitment to the study would address the significant shortfalls identified. Young people who are deemed unsuitable for mental health services should be followed up to be offered participation in such interventions. Collaborations between the NHS services and sports delivery partners should consider in-person contact with young people rather than remote consultations. Recruiting through general practitioner practices is effective and relatively inexpensive. The role of community engagement (socialmedia, public health agencies, community groups) needs to be further explored. Strong public and patient involvement and engagement via young people advisory groups is important to ensure that research is relevant to young people.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/78/10.

'Facilitators and barriers to recruitment in mental health research: A survey of psychiatrists and psychiatry registrars in training'

OBJECTIVE

To explore the attitudes of Royal Australian and New Zealand College of Psychiatrists (RANZCP) consultants and registrars towards recruitment of patients in mental health research. Specifically, we aimed to measure potential barriers and facilitators for recruitment and comment on strategies for improvement.

METHOD

A survey was distributed to 287 consultant and trainee psychiatrists working across South Australian public mental health services. The survey was hosted via SurveyMonkey and ran for 5 weeks from April to June 2023. Participant's attitudes were recorded through use of Likert scale, yes/no and free-text response.

RESULTS

In total, 88 responses were collected, corresponding to a 30.7% response rate. Participants were interested in mental health research, with 90.7% reading articles and 61.4% reporting personal research engagement. The factors that rated most highly as recruitment barriers were unawareness of current studies, competing clinical demands and not prioritising recruitment. Factors felt most strongly to facilitate recruitment included the presence of an onsite research assistant and the clinician viewing the trial as clinically relevant.

CONCLUSIONS

While attitudes towards research were generally positive, many barriers to recruitment were identified. Increased advertising of current studies, presence of an onsite research assistant and reduction in clinicians' workload are likely to improve clinicians' capacity to recruit.

Ethical Considerations in the Design and Conduct of Clinical Trials of Artificial Intelligence

Importance

Safe integration of artificial intelligence (AI) into clinical settings often requires randomized clinical trials (RCT) to compare AI efficacy with conventional care. Diabetic retinopathy (DR) screening is at the forefront of clinical AI applications, marked by the first US Food and Drug Administration (FDA) De Novo authorization for an autonomous AI for such use.

Objective

To determine the generalizability of the 7 ethical research principles for clinical trials endorsed by the National Institute of Health (NIH), and identify ethical concerns unique to clinical trials of AI.

Design, Setting, and Participants

This qualitative study included semistructured interviews conducted with 11 investigators engaged in the design and implementation of clinical trials of AI for DR screening from November 11, 2022, to February 20, 2023. The study was a collaboration with the ACCESS (AI for Children's Diabetic Eye Exams) trial, the first clinical trial of autonomous AI in pediatrics. Participant recruitment initially utilized purposeful sampling, and later expanded with snowball sampling. Study methodology for analysis combined a deductive approach to explore investigators' perspectives of the 7 ethical principles for clinical research endorsed by the NIH and an inductive approach to uncover the broader ethical considerations implementing clinical trials of AI within care delivery.

Results

A total of 11 participants (mean [SD] age, 47.5 [12.0] years; 7 male [64%], 4 female [36%]; 3 Asian [27%], 8 White [73%]) were included, with diverse expertise in ethics, ophthalmology, translational medicine, biostatistics, and AI development. Key themes revealed several ethical challenges unique to clinical trials of AI. These themes included difficulties in measuring social value, establishing scientific validity, ensuring fair participant selection, evaluating risk-benefit ratios across various patient subgroups, and addressing the complexities inherent in the data use terms of informed consent.

Conclusions and Relevance

This qualitative study identified practical ethical challenges that investigators need to consider and negotiate when conducting AI clinical trials, exemplified by the DR screening use-case. These considerations call for further guidance on where to focus empirical and normative ethical efforts to best support conduct clinical trials of AI and minimize unintended harm to trial participants.

A Controlled Evaluation of a Psychosocial Outreach Support Program for Adults with Severe Mental Illness

Objective: Serious mental illness (SMI) remains a leading cause of disability worldwide. However, there is limited Australian evidence of community-based programs to enhance the psychosocial wellbeing of adults experiencing SMI. Foundations is a long-term community-based psychosocial outreach support program delivered in Tasmania, Australia. A longitudinal non-randomised controlled trial was conducted to examine the effectiveness of the Foundations program on adults' psychosocial functioning, clinical symptomology, and hospital readmissions, in comparison to standard care only. Method: Participants were adults aged 18-64 years experiencing SMI. Control participants received standard clinical care only. Intervention participants were engaged in the Foundations program in addition to standard care. Data were collected at program commencement, midpoint, closure, and six-months post-closure. Linear mixed modelling was used to examine differences between groups. Results: Intervention participants achieved better psychosocial functioning in comparison to the control group by program closure and at six-month follow-up. No significant differences were observed for clinical mental health symptomology or hospital readmission rates. Length of readmission stay was significantly shorter for intervention participants. Conclusions: The findings highlight the additional value of community-based, recovery-oriented, psychosocial outreach support alongside clinical mental health care to enhance the psychosocial wellbeing of adults experiencing SMI.

Utilising quantitative methods to study the intersectionality of multiple social disadvantages in women with common mental disorders: a systematic review

Women are at greater risk of common mental disorders. The intersectionality concept provides a framework to examine the effects of multiple social disadvantages on women's mental health. We conducted a systematic review to collect and analyse information to identify the quantitative methodologies and study designs used in intersectional research to examine women's mental health and multiple social disadvantages. Included studies used accepted statistical methods to explore the intersectional effects of gender and one or more types of social disadvantage from the PROGRESS-Plus inequity framework: a place of residence, race/ethnicity, occupation, gender/ sex, religion, education, socioeconomic status, social capital (O'Neill et al. J Clin Epidemiol 67:56-64, 2014). The scope of this systematic review was limited to studies that analysed common mental disorders in women and men comparatively. Studies focusing on only one gender were excluded, ensuring a comprehensive comparative analysis of the intersection of social disadvantages in mental health.Twelve papers were included in the narrative synthesis (Table 1). Eight of the included papers (67%) reported an intersectional effect of gender and one or more additional types of social disadvantage. The multiplicative effect of gender and socioeconomic status on the risk of common mental disorders was the most commonly reported interaction. This systematic review shows that multiplicative and simultaneous interactions of multiple social disadvantage increase the risk of common mental disorders experienced by women. Moreover, it underlines the potential for quantitative research methods to complement qualitative intersectionality research on gender and mental health. The findings of this systematic review highlight the importance of multiple social disadvantage in understanding the increased risk of mental health experienced by women.

Chronic pain trials often exclude people with comorbid depressive symptoms: A secondary analysis of 346 randomized controlled trials

BACKGROUND

Chronic pain and depression are common comorbid conditions, but there is limited evidence-based guidance for management of the two conditions together. In recent years, there has been an increase in the number of chronic pain randomized controlled trials that collect depression outcomes, but it is unknown how often these trials include people with depression or significant depressive symptoms. If trials do not include participants representative of real-world populations, evidence and guidance generated from these trials risk being inapplicable for large proportions of the target population, or worse, risk harm. Thus, in order to identify pathways to improve the conduct of clinical trials, the aims of this study were to (1) estimate the proportion of randomized controlled trials evaluating chronic pain interventions and reporting depression outcomes that include participants with significant depressive symptoms; and (2) assess the variability of inclusion proportions by pain type, intervention type, gender, country of origin, and publication year.

METHODS

Studies were extracted from an umbrella review of interventions for chronic pain that reported depression outcomes. Screening and data extraction were completed in duplicate and conflicts were resolved by a third author. Randomized controlled trials with at least 50% adult participants and validated depression scales were included, and randomized controlled trials with populations whose mean scores were at or above depression thresholds at baseline were considered to have included participants with depression.

RESULTS

Of the 346 randomized controlled trials analyzed, 142 (41%) included participants with depression. Eight pain-type groups and nine intervention types were identified. Randomized controlled trials investigating fibromyalgia and mixed chronic pain had the highest proportion of participants with depression, whereas studies of arthritis and axial pain had among the lowest. Randomized controlled trials from the United States had a significantly lower inclusion proportion compared with non-US studies, especially for studies on arthritis. The increase in inclusion proportion by publication year was driven by the increase in fibromyalgia studies.

DISCUSSION AND CONCLUSION

This study highlights opportunities to improve the conduct of chronic pain clinical trials. The majority of randomized controlled trials s analyzed evaluated participants without significant depressive symptoms at baseline, thus the findings synthesized in systematic reviews and subsequent guidelines are most applicable to the subset of real-world populations that do not have significant depressive symptoms. As well, systemic biases around psychological conditions and gender may be important contributors to differences in the study of depression in fibromyalgia compared with common conditions such as arthritis and axial pain. In order to better inform clinical practice, future research must intentionally include individuals with comorbid depression in trials of common chronic pain conditions, and consider methods to mitigate biases that may distort study design.

Use of social media in recruiting young people to mental health research: a scoping review

OBJECTIVES

This review explored the literature on the use of social media in recruiting young people, aged 13-18 years, to mental health research. It aimed to identify barriers and facilitators to recruitment and strategies to improve participation in future research.

DESIGN

Scoping review.

DATA SOURCES

Articles published between January 2011 and February 2023 were searched for on PubMed, Scopus, Medline (via EBSCOhost) and Cochrane Library databases.

ELIGIBILITY CRITERIA

Studies that outlined social media as a recruitment method and recruited participants aged 13-18 years.

DATA EXTRACTION AND SYNTHESIS

Data was extracted by two reviewers independently and cross-checked by a third reviewer. Data on study design, aims, participants, recruitment methods and findings related specifically to social media as a recruitment tool were collected.

RESULTS

24 journal articles met the inclusion criteria. Studies were predominantly surveys (n=13) conducted in the USA (n=16) recruiting via Facebook (n=16) and/or Instagram (n=14). Only nine of the included articles provided a summary of success and reviewed the efficacy of social media recruitment for young people in mental health research. Type of advertisement, the language used, time of day and the use of keywords were all found to be factors that may influence the success of recruitment through social media; however, as these are based on findings from a small number of studies, such potential influences require further investigation.

CONCLUSION

Social media recruitment can be a successful method for recruiting young people to mental health research. Further research is needed into recruiting socioeconomically marginalised groups using this method, as well as the effectiveness of new social media platforms.

REGISTRATION

Open Science Framework Registry (https://osf.io/mak75/).

Protocol Development for a Qualitative Methodological Study Within a Trial (Qual-SWAT): The KARMA-Dep-2 Trial

Background

Despite methodological improvements in clinical trial design and conduct more generally, methodological limitations persist in trials concerning mental health care. A qualitative Study Within A Trial (Qual-SWAT), embedded in the KARMA-Dep-2 host trial, will be undertaken to explore and gain an understanding of two methodological questions in randomised trials specific to mental health care: (1) what are the key barriers and enablers of participation in randomised trials in mental health; and (2) how can randomised trials become part of routine mental health care. These issues will be examined from patient-participant and clinician- / researcher-participant perspectives, in alignment with PRioRiTy research themes.

Methods

A descriptive qualitative study design will be used. Data will be collected via one-to-one semi-structured interviews, conducted via Microsoft Teams. The interview data will be analysed using Braun and Clarke's Thematic Analysis approach. One-to-one interviews will be conducted with three participant groups ( N = 30): 1) host trial patient-participants ( n = 10); 2) potentially eligible host trial patient-participants who refused enrolment in the host trial ( n = 10); and 3) clinician- / researcher-participants who are associated with work on the host trial ( n = 10).

Ethics and dissemination

Ethical approval has been granted by St. Patrick's Mental Health Services Research Ethics Committee, Ireland (Ref: Protocol 09/20). When the study is completed, a report will be prepared and submitted to the Health Research Board (HRB). Findings will be shared with the host trial team and study participants, and submitted for publication.

Host trial registration

ClinicalTrials.gov ( NCT04939649); EudraCT ( 2019-003109-92). Official title: Ketamine as an Adjunctive Therapy for Major Depression - A Randomised Controlled Trial: [KARMA-Dep (2)].

Protocol Development for a Qualitative Methodological Study Within a Trial (Qual-SWAT): The KARMA-Dep-2 Trial

Background

Despite methodological improvements in clinical trial design and conduct more generally, methodological limitations persist in trials concerning mental health care. A qualitative Study Within A Trial (Qual-SWAT), embedded in the KARMA-Dep-2 host trial, will be undertaken to explore and gain an understanding of two methodological questions in randomised trials specific to mental health care: (1) what are the key barriers and enablers of participation in randomised trials in mental health; and (2) how can randomised trials become part of routine mental health care. These issues will be examined from patient-participant and clinician- / researcher-participant perspectives, in alignment with PRioRiTy research themes.

Methods

A descriptive qualitative study design will be used. Data will be collected via one-to-one semi-structured interviews, conducted via Microsoft Teams. The interview data will be analysed using Braun and Clarke's Thematic Analysis approach. One-to-one interviews will be conducted with three participant groups ( N = 30): 1) host trial patient-participants ( n = 10); 2) potentially eligible host trial patient-participants who refused enrolment in the host trial ( n = 10); and 3) clinician- / researcher-participants who are associated with work on the host trial ( n = 10).

Ethics and dissemination

Ethical approval has been granted by St. Patrick's Mental Health Services Research Ethics Committee, Ireland (Ref: Protocol 09/20). When the study is completed, a report will be prepared and submitted to the Health Research Board (HRB). Findings will be shared with the host trial team and study participants, and submitted for publication.

Host trial registration

ClinicalTrials.gov ( NCT04939649); EudraCT ( 2019-003109-92). Official title: Ketamine as an Adjunctive Therapy for Major Depression - A Randomised Controlled Trial: [KARMA-Dep (2)].

Access to therapy for child sexual abuse survivors: Preliminary dialogue of barriers and facilitators between caregivers

BACKGROUND

Difficulties in access to therapy were highlighted by COVID-19 measures restricting in-person gatherings. Additional challenges arise when focusing on caregivers of child sexual abuse (CSA) survivors in particular, which are a population that has been historically difficult to engage with due to issues of stigma and confidentiality.

OBJECTIVES

To present preliminary qualitative results from caregivers of CSA survivors.

METHODS

This study was conducted with caregivers of CSA survivors. Two hybrid webinar/focus groups were conducted using a video conferencing platform in fall of 2021 with two groups of stakeholders (11 caregivers and 5 moderators/clinical staff at Little Warriors, an intensive episodic treatment facility). Sessions were recorded, transcribed, and thematically-analyzed using standard qualitative methodology.

RESULTS

A total of 11 caregivers contributed to the data. Themes include: (1) Challenges of starting and maintaining treatment (i.e., emotional impact of intake day, challenges of enrolling), (2) Therapeutic benefits of specialized treatment (i.e., feeling safe and supported and the importance of trauma-informed care), and (3) Barriers and facilitators of treatment (i.e., avenues to scale-up and self-care).

CONCLUSION

The importance of a strong therapeutic alliance was highlighted by both caregivers/clinical staff and further support is needed for families post-treatment. The present hybrid webinar/focus group also achieved engagement goals in a population that is typically difficult to reach. Overall, the response rate (12%) was equivalent to reported registrant attendance rates for general business to consumer webinars and the recommended focus group size. This preliminary approach warrants replication in other populations outside our clinical context.

A Cardiovascular Risk Optimization Program in People With Schizophrenia: A Pilot Randomized Controlled Clinical Trial

BACKGROUND

Cardiovascular disease is one of the leading causes of premature death in people with schizophrenia. Some modifiable factors that have been implicated include unhealthy lifestyle, medication side effects, and physical comorbidities. The goal of this study was to assess the efficacy of a 6-month, multifactorial cardiovascular risk intervention to reduce cardiovascular risk (CVR) in people with schizophrenia.

METHODS

We conducted a 2-arm, parallel, randomized clinical trial in a regional mental health center. Participants with at least 1 poorly controlled cardiovascular risk factor (CVRF) (hypertension, diabetes mellitus, hypercholesterolemia, or tobacco smoking) were randomly assigned to the intervention group or to a control group. The subjects in the intervention group received a patient-centered approach that included promoting a healthy lifestyle, pharmacological management of CVRFs, psychotropic drug optimization, and motivational follow-up [Programa d'optimització del RISc CArdiovascular (PRISCA)]. The main outcome was change in CVR as assessed using the Framingham-REGICOR function, after 6 months compared with the baseline in both groups.

RESULTS

Forty-six participants were randomly assigned to the PRISCA group (n=23) or the control group (n=23). The most prevalent CVRFs at baseline were hypercholesterolemia (84.8%) and tobacco smoking (39.1%). The PRISCA group showed a significant reduction in the REGICOR score (-0.96%; 95% CI: -1.60 to -0.32, P=0.011) after 6 months (relative risk reduction of 20.9%), with no significant changes in the control group (0.21%; 95% CI: -0.47 to 0.89, P=0.706). In the PRISCA group, low-density lipoprotein cholesterol also decreased significantly (-27.14 mg/dL; 95% CI: -46.28 to -8.00, P=0.008).

CONCLUSION

A patient-centered, multifactorial cardiovascular risk intervention improved CVR in people with schizophrenia after 6 months, which was achieved mainly by improving the lipid profile.

Challenges in reaching patients with severe mental illness for trials in general practice-a convergent mixed methods study based on the SOFIA pilot trial

BACKGROUND

Patients with severe mental illness (SMI) die prematurely due to undetected and inadequate treatment of somatic illnesses. The SOFIA pilot study was initiated to mend this gap in health inequity. However, reaching patients with SMI for intervention research has previously proven difficult. This study aimed to investigate the recruitment of patients with SMI for the SOFIA pilot study in 2021.

METHODS

We used a mixed-method convergent design. The qualitative material comprised 20 interviews with general practitioners (GPs) and staff, during patient recruitment. The quantitative data consisted of process data on baseline characteristics, GPs reported reasons for excluding a patient, reported reasons for patients declining participation, and registered data from a Danish population of patients with SMI. We used thematic analysis in the qualitative analysis and descriptive statistics for the quantitative analysis. Pillar integration was used for integrating the material.

RESULTS

Our findings show that selection bias occurred in the pilot study. We describe four main themes based on the integrated analysis that highlights selection issues: (1) poor data quality and inconsistency in defining severity definitions troubled identification and verification, (2) protecting the patient and maintaining practice efficiency, (3) being familiar with the patient was important for a successful recruitment, and (4) in hindsight, the GPs questioned whether the target population was reached.

CONCLUSIONS

In the light of theories of professions and street-level bureaucracy, we find that the main drivers of the patient selection bias occurring in the SOFIA pilot study were that 1) GPs and staff mended eligibility criteria to protect certain patients and/or to minimize workload and maintain efficiency in the practice 2) the data from the GP record systems and the digital assessment tool to assist recruitment was not optimal. Interventions targeting this patient group should carefully consider the recruitment strategy with a particular focus on professionals' discretionary practices and information technology pitfalls.

TRIAL REGISTRATION

The pilot trial protocol was registered on the 5th of November 2020. The registration number is NCT04618250 .

Widening participation - recruitment methods in mental health randomised controlled trials: a qualitative study

BACKGROUND

Barriers to mental health research participation are well documented including distrust of services and research; and stigma surrounding mental health. They can contribute to a lack of diversity amongst participants in mental health research, which threatens the generalisability of knowledge. Given the recent widespread use of the internet in medical research, this study aimed to explore the perspectives of key partners on the use of online (e.g. social media) and offline (e.g. in-person) recruitment as an approach to improving diversity in mental health randomised controlled trials (RCTs).

METHODS

Face-to-face and online interviews/focus groups with researchers working in mental health and Patient and Public Involvement partners in the United Kingdom. Recordings were transcribed and analysed using a combination of inductive and deductive thematic analysis.

RESULTS

Three focus groups and three interviews were conducted with a total N = 23 participants. Four overarching themes were identified: (1) recruitment reach; (2) Demographic factors that affect selection of recruitment method; (3) safety of technology, and; (4) practical challenges. Five main factors were identified that affect the choice of recruitment method: age, complexity of mental health problem and stigma, cultural and ethnicity differences and digital divide. The use of online methods was considered more accessible to people who may feel stigmatised by their mental health condition and with a benefit of reaching a wider population. However, a common view amongst participants was that online methods require closer data monitoring for quality of responders, are not fully secure and less trustworthy compared to offline methods that enable participants to build relationships with health providers. Funding, staff time and experience, organisational support, and technical issues such as spam or phishing emails were highlighted as practical challenges facing online recruitment. All participants agreed that using a hybrid approach tailored to the population under study is paramount.

CONCLUSIONS

This study highlighted the importance of offering a flexible and multifaceted recruitment approach by integrating online with offline methods to support inclusivity and widening participation in mental health research. The findings will be used to develop considerations for researchers designing RCTs to improve recruitment in mental health research.

Recruitment and Retention Strategies for Underrepresented Populations and Adults With Arthritis in Behavioral Interventions: A Scoping Review

OBJECTIVE

To identify strategies used to recruit and retain underrepresented populations and populations with arthritis or fibromyalgia (FM) into behavioral programs targeting exercise, physical activity, or chronic disease self management.

METHODS

Five bibliographic databases were searched for articles published between January 2000 and May 2022. The search focused on strategies and best practices for recruiting and retaining underrepresented populations or populations with arthritis or FM into disease self-management or physical activity/exercise programs. Abstracts and full-text articles were screened for inclusion by 2 independent reviewers, and 2 reviewers extracted data from included articles.

RESULTS

Of the 2,800 articles, a total of 43 publications (31 interventions, 8 reviews, 4 qualitative/descriptive studies) met criteria and were included. The majority of studies focused on physical activity/exercise (n = 36) and targeted African American (n = 17), Hispanic (n = 9), or arthritis populations (n = 7). Recruitment strategies that were frequently used included having race- or community-matched team members, flyers and information sessions in areas frequented by the population, targeted emails/mailings, and word of mouth referrals. Retention strategies used included having race- or community-matched team members, incentives, being flexible, and facilitating attendance. Most studies used multiple recruitment and retention strategies.

CONCLUSION

This scoping review highlights the importance of a multifaceted recruitment and retention plan for underrepresented populations and populations with arthritis or FM in behavioral intervention programs targeting exercise, physical activity, or chronic disease self management. Additional research is needed to better understand the individual effects of different strategies and the costs associated with the various recruitment/retention methods in underrepresented populations and populations with arthritis.

Effectiveness of a Lifestyle Intervention for People With a Severe Mental Illness in Dutch Outpatient Mental Health Care: A Randomized Clinical Trial

Importance

People with a severe mental illness (SMI) have a life expectancy reduced by 10 to 20 years compared with the general population, primarily attributable to cardiometabolic disorders. Lifestyle interventions for people with SMI can improve health and reduce cardiometabolic risk.

Objective

To evaluate the effectiveness of a group-based lifestyle intervention among people with SMI in outpatient treatment settings compared with treatment as usual (TAU).

Design, Setting, and Participants

The Severe Mental Illness Lifestyle Evaluation (SMILE) study is a pragmatic cluster randomized clinical trial performed in 8 mental health care centers with 21 flexible assertive community treatment teams in the Netherlands. Inclusion criteria were SMI, age of 18 years or older, and body mass index (calculated as weight in kilograms divided by height in meters squared) of 27 or greater. Data were collected from January 2018 to February 2020, and data were analyzed from September 2020 to February 2023.

Interventions

Weekly 2-hour group sessions for 6 months followed by monthly 2-hour group sessions for another 6 months, delivered by trained mental health care workers. The intervention targeted overall lifestyle changes, emphasizing establishing a healthy diet and promoting physical activity. TAU (control) did not include structured interventions or advice on lifestyle.

Main Outcomes and Measures

Crude and adjusted linear mixed models and multivariable logistic regression analyses were performed. The main outcome was body weight change. Secondary outcomes included changes in body mass index, blood pressure, lipid profiles, fasting glucose level, quality of life, self-management ability, and lifestyle behaviors (physical activity and health, mental health, nutrition, and sleep).

Results

The study population included 11 lifestyle intervention teams (126 participants) and 10 TAU teams (98 participants). Of 224 included patients, 137 (61.2%) were female, and the mean (SD) age was 47.6 (11.1) years. From baseline to 12 months, participants in the lifestyle intervention group lost 3.3 kg (95% CI, -6.2 to -0.4) more than those in the control group. In the lifestyle intervention group, people with high attendance rates lost more weight than participants with medium and low rates (mean [SD] weight loss: high, -4.9 [8.1] kg; medium, -0.2 [7.8] kg; low, 0.8 [8.3] kg). Only small or no changes were found for secondary outcomes.

Conclusions and Relevance

In this trial, the lifestyle intervention significantly reduced weight from baseline to 12 months in overweight and obese adults with SMI. Tailoring lifestyle interventions and increasing attendance rates might be beneficial for people with SMI.

Trial Registration

Netherlands Trial Register Identifier: NTR6837.

Insight in schizophrenia is associated with psychoeducation and social support: Testing a new more comprehensive insight tool in Turkish schizophrenia patients

Insight is a continuous and multidimensional phenomenon, including awareness of having an illness, the presence of symptoms and accurate symptom attribution, the need for treatment, and the consequences of treatment. Good insight into illness is associated with better adherence to treatment, better cognitive, psychosocial, and vocational functioning along with less symptom severity, decreased relapses, and hospitalizations. Several tools are used for insight evaluation. We recruited 90 patients diagnosed with schizophrenia and analyzed the forms of 58 patients. The patients completed the VAGUS-SR (self-rated), Beck Cognitive Insight Scale, Knowledge About Schizophrenia Questionnaire, and Multidimensional Scale of Perceived Social Support (MSPSS). Clinicians performed a mental status examination and completed the Positive and Negative Syndrome Scale, Schedule for the Assessment of Insight, VAGUS-CR (clinician-rated), Calgary Depression Scale for Schizophrenia, and Clinical Global Impressions. We found that the level of insight evaluated using the VAGUS forms increased with knowledge regarding schizophrenia. Upon investigating the relationship between perceived social support and insight, we identified a relationship between VAGUS-CR and only significant other subscales of MSPSS, and between one of the VAGUS-SR scale sub-dimensions and significant other and total scores of MSPSS. Our findings also suggest that the VAGUS-SR and VAGUS-CR scales can be used to evaluate insight in Turkish populations. The positive relationship between perceived social support and insight emphasizes the importance of increasing social support through interventions aimed at improving insight. Our data also highlighted the value of psychoeducational studies in this patient group. Considering the multidimensional effects of insight on patients with schizophrenia, it would be beneficial to use scales such as VAGUS, which allow the insights of individuals to be evaluated in detail by both the clinician and the patient.

Empirical progression criteria thresholds for feasibility outcomes in HIV clinical trials: a methodological study

INTRODUCTION

Pilot and feasibility trials use predetermined thresholds for feasibility outcomes to decide if a larger trial is feasible. These thresholds may be derived from the literature, observational data, or clinical experience. The aim of this study was to determine empirical estimates for feasibility outcomes to inform future HIV pilot randomized trials.

METHODS

We conducted a methodological study of HIV clinical trials indexed in the past 5 years (2017-2021) in the PubMed database. We included trials of people living with HIV individually randomized to any type of intervention and excluded pilot trials and cluster randomized trials. Screening and data extraction were conducted in duplicate. We computed estimates for recruitment, randomization, non-compliance, lost to follow-up, discontinuation, and the proportion analyzed using a random effects meta-analysis of proportions and reported these estimates according to the following subgroups: use of medication, intervention type, trial design, income level, WHO region, participant type, comorbidities, and source of funding. We report estimates with 95% confidence intervals.

RESULTS

We identified 2122 studies in our search, of which 701 full texts were deemed relevant, but only 394 met our inclusion criteria. We found the following estimates: recruitment (64.1%; 95% CI 57.7 to 70.3; 156 trials); randomization (97.1%; 95% CI 95.8 to 98.3; 187 trials); non-compliance (3.8%; 95% CI 2.8 to 4.9; 216 trials); lost to follow-up (5.8%; 95% CI 4.9 to 6.8; 251 trials); discontinuation (6.5%; 95% CI 5.5 to 7.5; 215 trials); analyzed (94.2%; 95% CI 92.9 to 95.3; 367 trials). There were differences in estimates across most subgroups.

CONCLUSION

These estimates may be used to inform the design of HIV pilot randomized trials with careful consideration of variations due to some of the subgroups investigated.

Cost-effectiveness of peer-supported self-management for people discharged from a mental health crisis team: methodological challenges and recommendations

Background

Mental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution.

Methods

Participants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively.

Results

Four hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained.

Discussion

There was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes.

Experiences of participating in a problem-solving intervention with workplace involvement in Swedish primary health care: a qualitative study from rehabilitation coordinator's, employee's, and manager's perspectives

BACKGROUND

Work-directed interventions that include problem-solving can reduce the number of sickness absence days. The effect of combining a problem-solving intervention with involvement of the employer is currently being tested in primary care in Sweden for employees on sickness absence due to common mental disorders (PROSA trial). The current study is part of the PROSA trial and has a two-fold aim: 1) to explore the experiences of participating in a problem-solving intervention with workplace involvement aimed at reducing sickness absence in employees with common mental disorders, delivered in Swedish primary health care, and 2) to identify facilitators of and barriers to participate in the intervention. Both aims targeted rehabilitation coordinators, employees on sickness absence, and first-line managers.

METHODS

Data were collected from semi-structured interviews with participants from the PROSA intervention group; rehabilitation coordinators (n = 8), employees (n = 13), and first-line managers (n = 8). Content analysis was used to analyse the data and the Consolidated Framework for Implementation Research was used to group the data according to four contextual domains. One theme describing the participation experiences was established for each domain. Facilitators and barriers for each domain and stakeholder group were identified.

RESULTS

The stakeholders experienced the intervention as supportive in identifying problems and solutions and enabling a dialogue between them. However, the intervention was considered demanding and good relationships between the stakeholders were needed. Facilitating factors were the manual and work sheets which the coordinators were provided with, and the manager being involved early in the return-to-work process. Barriers were the number of on-site meetings, disagreements and conflicts between employees and first-line managers, and symptom severity.

CONCLUSIONS

Seeing the workplace as an integral part of the intervention by always conducting a three-part meeting enabled a dialogue that can be used to identify and address disagreements, to explain CMD symptoms, and how these can be handled at the workplace. We suggest allocating time towards developing good relationships, provide RCs with training in handling disagreements, and additional knowledge about factors in the employee's psychosocial work environment that can impair or promote health to increase the RCs ability to support the employee and manager.

Establishing Requirements for Technology to Support Clinical Trial Retention: Systematic Scoping Review and Analysis Using Self-determination Theory

BACKGROUND

Retaining participants in clinical trials is an established challenge. Currently, the industry is moving to a technology-mediated, decentralized model for running trials. The shift presents an opportunity for technology design to aid the participant experience and promote retention; however, there are many open questions regarding how this can be best supported. We advocate the adoption of a stronger theoretical position to improve the quality of design decisions for clinical trial technology to promote participant engagement.

OBJECTIVE

This study aimed to identify and analyze the types of retention strategies used in published clinical trials that successfully retain participants.

METHODS

A systematic scoping review was carried out on 6 electronic databases for articles published from 1990 to September 2020, namely CINAHL, The Cochrane Library, EBSCO, Embase, PsycINFO, and PubMed, using the concepts "retention," "strategy," "clinal trial," and "clinical research." This was followed by an analysis of the included articles through the lens of self-determination theory, an evidence-based theory of human motivation.

RESULTS

A total of 26 articles were included in this review. The motivational strategies identified in the clinical trials in our sample were categorized into 8 themes: autonomy; competence; relatedness; controlled motivation; branding, communication material, and marketing literature; contact, tracking, and scheduling methods and data collection; convenience to contribute to data collection; and organizational competence. The trials used a wide range of motivational strategies. Notably, the trials often relied on controlled motivation interventions and underused strategies to support intrinsic motivation. Moreover, traditional clinical trials relied heavily on human interaction and "relatedness" to support motivation and retention, which may cause problems in the move to technology-led decentralized trials. We found inconsistency in the data-reporting methods and that motivational theory-based approaches were not evident in strategy design.

CONCLUSIONS

This study offers direction and a framework to guide digital technology design decisions for future decentralized clinical trials to enhance participant retention during clinical trials. This research defines previous clinical trial retention strategies in terms of participant motivation, identifies motivational strategies, and offers a rationale for selecting strategies that will improve retention. It emphasizes the benefits of using theoretical frameworks to analyze strategic approaches and aid decision-making to improve the quality of technology design decisions.

The Feasibility of Implementing Remote Measurement Technologies in Psychological Treatment for Depression: Mixed Methods Study on Engagement

BACKGROUND

Remote measurement technologies (RMTs) such as smartphones and wearables can help improve treatment for depression by providing objective, continuous, and ecologically valid insights into mood and behavior. Engagement with RMTs is varied and highly context dependent; however, few studies have investigated their feasibility in the context of treatment.

OBJECTIVE

A mixed methods design was used to evaluate engagement with active and passive data collection via RMT in people with depression undergoing psychotherapy. We evaluated the effects of treatment on 2 different types of engagement: study attrition (engagement with study protocol) and patterns of missing data (engagement with digital devices), which we termed data availability. Qualitative interviews were conducted to help interpret the differences in engagement.

METHODS

A total of 66 people undergoing psychological therapy for depression were followed up for 7 months. Active data were gathered from weekly questionnaires and speech and cognitive tasks, and passive data were gathered from smartphone sensors and a Fitbit (Fitbit Inc) wearable device.

RESULTS

The overall retention rate was 60%. Higher-intensity treatment (χ21=4.6; P=.03) and higher baseline anxiety (t56.28=-2.80, 2-tailed; P=.007) were associated with attrition, but depression severity was not (t50.4=-0.18; P=.86). A trend toward significance was found for the association between longer treatments and increased attrition (U=339.5; P=.05). Data availability was higher for active data than for passive data initially but declined at a sharper rate (90%-30% drop in 7 months). As for passive data, wearable data availability fell from a maximum of 80% to 45% at 7 months but showed higher overall data availability than smartphone-based data, which remained stable at the range of 20%-40% throughout. Missing data were more prevalent among GPS location data, followed by among Bluetooth data, then among accelerometry data. As for active data, speech and cognitive tasks had lower completion rates than clinical questionnaires. The participants in treatment provided less Fitbit data but more active data than those on the waiting list.

CONCLUSIONS

Different data streams showed varied patterns of missing data, despite being gathered from the same device. Longer and more complex treatments and clinical characteristics such as higher baseline anxiety may reduce long-term engagement with RMTs, and different devices may show opposite patterns of missingness during treatment. This has implications for the scalability and uptake of RMTs in health care settings, the generalizability and accuracy of the data collected by these methods, feature construction, and the appropriateness of RMT use in the long term.

Development of a Positive Psychology Well-Being Intervention in a Community Pharmacy Setting

Background: Community pharmacies are well-placed to deliver well-being interventions; however, to date, nothing has been produced specifically for this setting. The aim of this study was to develop a positive psychology intervention suitable for a community pharmacy setting with the goal of increasing the well-being of community members. Methods: Intervention development consisted of three steps: Step 1-identify the evidence-base and well-being model to underpin the basis of the intervention (Version 1); Step 2-model the intervention and gather user feedback to produce Version 2, and Step 3-revisit the evidence-base and refine the intervention to produce Version 3. Results: Findings from nine studies (seven RCTs, one cross-sectional, one N-1 design plus user feedback were applied to model a 6-week 'Prescribing Happiness (P-Hap)' intervention, underpinned by the PERMA model plus four other components from the positive psychology literature (Three Good Things, Utilising Your Signature Strengths in New Ways, Best Possible Selves and Character Strengths). A PERMA-based diary was designed to be completed 3 days a week as part of the intervention. Conclusions: This work is an important development which will direct the future implementation of interventions to support well-being in this novel setting. The next stage is to gain the perspectives of external stakeholders on the feasibility of delivering the P-Hap for its adoption into community pharmacy services in the future.

Shifting the discourse on disability: Moving to an inclusive, intersectional focus

Individuals with disabilities comprise one of the largest marginalized groups in the United States and experience systemic barriers in health care. In Westernized communities, disability has historically been conceptualized via the medical model, which considers disability an individual-level deficit in need of correction. Although other models of disability (e.g., social model) have been developed to address the medical model's ableist shortcomings, these fail to consistently acknowledge intersectionality. Specifically, these models fail to consider that (a) a disabled individual may hold other marginalized or oppressed identities and (b) these intersecting oppressions may exacerbate health inequities. Intersectionality, which originates from Black feminist literature, describes the ways that systems of power and oppression (e.g., racism, sexism) interact to form an individual's unique experience. To date, the intersection of disability and other marginalized identities has been neglected in psychology and related fields, leaving little guidance for how scholars, clinicians, and other stakeholders can address disability via an intersectional lens. The present article discusses how a disability-affirmative, intersectional approach can serve as a strategy for challenging and reforming oppressive systems across the field of psychology. We assert that, ultimately, this approach has the potential to optimize and expand access to equitable, inclusive mental health care, and we propose actionable steps psychologists can take in research, practice, training, and policy in pursuit of this aim. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Lessons learned from recruiting into a longitudinal remote measurement study in major depressive disorder

The use of remote measurement technologies (RMTs) across mobile health (mHealth) studies is becoming popular, given their potential for providing rich data on symptom change and indicators of future state in recurrent conditions such as major depressive disorder (MDD). Understanding recruitment into RMT research is fundamental for improving historically small sample sizes, reducing loss of statistical power, and ultimately producing results worthy of clinical implementation. There is a need for the standardisation of best practices for successful recruitment into RMT research. The current paper reviews lessons learned from recruitment into the Remote Assessment of Disease and Relapse- Major Depressive Disorder (RADAR-MDD) study, a large-scale, multi-site prospective cohort study using RMT to explore the clinical course of people with depression across the UK, the Netherlands, and Spain. More specifically, the paper reflects on key experiences from the UK site and consolidates these into four key recruitment strategies, alongside a review of barriers to recruitment. Finally, the strategies and barriers outlined are combined into a model of lessons learned. This work provides a foundation for future RMT study design, recruitment and evaluation.

Effectiveness of recruitment strategies for a social media literacy E-intervention for young adults with body dissatisfaction: cost, time, diversity, and completion

Digital interventions are becoming increasingly popular for the treatment of body dissatisfaction and eating disorders. However, participant recruitment to online interventions poses a challenge. This study examined differences between a variety of recruitment strategies to a digital intervention in terms of number of participants recruited, cost, study personnel time, completion rates, and demographic characteristics of participants.Participants (N = 395) aged 18-25 years (79.5% women) were recruited to take part in an online body image intervention and asked how they heard about the program (e.g., through Facebook, a flyer on a university campus). Strategies of recruitment, including researcher time required and cost were recorded throughout the project. Cost and time effectiveness, study and intervention completion rates, and participant demographics for each recruitment approach were explored.Facebook paid advertising recruited n = 241 participants (78.0% women), with $29.81 cost per completer, and researcher time per completer at 2.41 minutes. Facebook unpaid advertising was also effective, recruiting n = 130 participants (78.5% women), with $0.00 external cost per completer, and time per completer at 20.43 minutes. Other strategies, both online and face-to-face, were far less effective in recruiting participants. Men proved difficult to recruit using any strategy.Facebook advertising was an effective tool for recruiting young adults to this online intervention, although further research should identify effective strategies to recruit men for similar interventions.

The mediating role of post-traumatic stress disorder symptoms in the relationship between childhood adversities and depressive symptoms in two samples

BACKGROUND

Childhood adversities have been increasingly recognized as a significant risk factor for depression. However, the underlying mediating mechanism between childhood adversities and depression requires further investigation. The literature shows that childhood adversities are also closely associated with post-traumatic stress disorder (PTSD) symptoms and that PTSD symptoms can predict depressive symptoms. It remains unexplored whether PTSD symptoms can act as a mediator between childhood adversities and depression.

OBJECTIVES

The primary goal of this study was to examine whether PTSD symptoms would mediate the relationship between childhood adversities and depressive symptoms.

PARTICIPANTS AND SETTING

We examined in a convenience sample of Hong Kong adults aged 18 or above (N = 418) whether PTSD symptoms would mediate the relationship between childhood adversities and depressive symptoms. We then examined and compared the results with those in another convenience sample of Chinese-speaking young adults (mainly from Taiwan and Hong Kong) aged between 18 and 24 (N = 205). Participants in both samples completed online surveys that included measures of childhood adversities, PTSD symptoms and depressive symptoms.

RESULTS

Childhood adversities were significantly associated with depressive symptoms; and this relationship was mediated by PTSD symptoms in both samples.

CONCLUSION

This study is one of very few studies demonstrating that PTSD symptoms mediate the relationship between childhood adversities and depressive symptoms. Our findings suggest that addressing unresolved PTSD symptoms for adults with childhood adversities may help in preventing or treating depressive symptoms. Therefore, PTSD symptoms should be taken into account in the prevention and management of depression.

Effectiveness of incentives to improve the reach of health promotion programs- a systematic review and meta-analysis

The reach (i.e., enrollment, engagement, and retention) of health promotion evidence-based programs (EBPs) at the participant level has been challenging. Incentives based on behavioral economics may be used to improve EBP reach. We aimed to systematically review and synthesize the evidence of the effectiveness of incentives as a dissemination strategy to increase EBP reach. We conducted a literature search in PubMed, SCOPUS, EMBASE, Cochrane Review and Cochrane CENTRAL for articles published between January 2000 and March 2020 to identify incentive strategies used to increase program reach among health promotion EBPs. Inclusion criteria included studies published in English, experimental or quasi-experimental designs, comparison of incentive to non-incentive or control strategies, and reported on reach (n = 35 health promotion studies). Monetary incentives using cash and a fixed schedule of reinforcement were the most used incentive schemes (71%). Incentives alone or combined with other strategies as a multicomponent approach were effective in improving program enrollment, engagement, and retention. Specifically, incentive strategies were associated with higher odds of program enrollment (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.82-4.24; n = 10) and retention (OR, 2.54, 95% CI, 1.34-4.85; n = 9) with considerable heterogeneity (I² = 94% and 91%, respectively). Incentives are a promising individual-level dissemination strategy to improve the reach of health promotion EBPs. However, understanding the optimal amount, type, frequency, and target of incentives, and how incentives fit in a multicomponent approach in different contexts requires further research.

Nutrition programmes for individuals living with disadvantage in supported residential settings: a scoping review

OBJECTIVE

Health inequities such as chronic disease are significantly higher among individuals living with disadvantage compared with the general population and many are reported to be attributable to preventable dietary risk factors. This study provides an overview of the current nutrition interventions for individuals living with extreme disadvantage, in supported residential settings, to develop insights into the development and implementation of policies and practices to promote long-term nutritional health and well-being.

DESIGN

A scoping review searched Scopus, ProQuest, CINAHL Plus, MEDLINE, and Web of Science databases using the terms 'resident', 'nutrition', 'disadvantage', 'intervention' and their synonyms, with particular emphasis on interventions in residential settings.

SETTING

Residential services providing nutrition provision and support.

PARTICIPANTS

People experiencing extreme disadvantage.

RESULTS

From 5262 articles, seven were included in final synthesis. Most interventions focused on building food literacy knowledge and skills. Study designs and outcome measures varied; however, all reported descriptive improvements in behaviour and motivation. In addition to food literacy, it was suggested that interventions need to address behaviour and motivations, programme sustainability, long-term social, physical and economic barriers and provide support for participants during transition into independent living. Socio-economic issues remain key barriers to long-term health and well-being.

CONCLUSIONS

In addition to food literacy education, future research and interventions should consider utilising an academic-community partnership, addressing nutrition-related mental health challenges, motivation and behaviour change and a phased approach to improve support for individuals transitioning into independent living.

Potential of Online Recruitment Among 15-25-Year Olds: Feasibility Randomized Controlled Trial

Background

Recruiting young people for health and intervention studies by traditional methods has become increasingly challenging. The widespread access to the internet may offer new strategies for online recruitment.

Objective

This study aims to assess the feasibility of online recruitment for a randomized controlled trial evaluating the effectiveness of Mindhelper, an online national youth mental health promotion service. The target group was young Danes aged 15-25 in need of mental health promotion.

Methods

Advertisements for recruitment were set up on Facebook and Instagram. Browser history was collected for a subsample of participants. We compared basic characteristics of participants who completed the baseline survey and those who did not, as well as of participants who completed the follow-up survey and those who were lost to follow-up. The significance of these differences was tested with the Pearson chi-square test.

Results

A total of 560 Danes aged 15-25 were recruited within 1 month (ie, had completed the baseline survey). Among these participants, 356 (63.6%) were at risk of developing depression or stress. The average advertisement price per participant completing the baseline questionnaire was 31 DKK (approximately €4 [US $4.2]). The follow-up survey was sent to 545 participants, of whom 318 (58.3%) completed the survey. No statistically significant differences were observed in baseline characteristics of participants who completed the follow-up and those who were lost to follow-up in terms of gender (P=.45), age (P=.35), occupation (P=.17), cohabitation (P=.90), mental well-being (P=.26), mental illness (P=.44; impact of the illness, P=.05), or use of the internet when having a hard time (P=.92).

Conclusions

We conclude that it is feasible to recruit young Danes online for a large-scale randomized controlled trial assessing the effectiveness of Mindhelper.

Trial Registration

ClinicalTrials.gov NCT04650906; https://clinicaltrials.gov/ct2/show/NCT04650906

Demographic Imbalances Resulting From the Bring-Your-Own-Device Study Design

Digital health technologies, such as smartphones and wearable devices, promise to revolutionize disease prevention, detection, and treatment. Recently, there has been a surge of digital health studies where data are collected through a bring-your-own-device (BYOD) approach, in which participants who already own a specific technology may voluntarily sign up for the study and provide their digital health data. BYOD study design accelerates the collection of data from a larger number of participants than cohort design; this is possible because researchers are not limited in the study population size based on the number of devices afforded by their budget or the number of people familiar with the technology. However, the BYOD study design may not support the collection of data from a representative random sample of the target population where digital health technologies are intended to be deployed. This may result in biased study results and biased downstream technology development, as has occurred in other fields. In this viewpoint paper, we describe demographic imbalances discovered in existing BYOD studies, including our own, and we propose the Demographic Improvement Guideline to address these imbalances.

The effect of personalised versus non-personalised study invitations on recruitment within the ENGAGE feasibility trial: an embedded randomised controlled recruitment trial

BACKGROUND

Recruitment into clinical trials is challenging and there is a lack of evidence on effective recruitment strategies. Personalisation of invitation letters is a potentially pragmatic and feasible way of increasing recruitment rates at a low-cost. However, there is a lack of evidence concerning the effect of personalising of study invitation letters on recruitment rates.

METHODS

We undertook a Study Within A Trial (SWAT) to investigate the effect of personalised versus non-personalised study invitation letters on recruitment rates into the host feasibility trial ENGAGE, a feasibility study of an internet-administered, guided, Low Intensity Cognitive-Behavioural Therapy based self-help intervention for parents of children previously treated for cancer. An intervention group (n = 254) received a personalised study invitation letter and the control group (n = 255) received a non-personalised study invitation letter. The primary outcome was the proportion of participants in the intervention group and the control group enrolled into the ENGAGE host feasibility trial. Secondary outcomes relating to the recruitment and screening process, and retention were examined. Differences in proportions between groups for the primary and secondary outcomes were estimated using logistic regression.

RESULTS

Of the 509 potential participants, 56 (11.0%) were enrolled into the ENGAGE host feasibility trial: personalised: 30/254 (11.8%) and non-personalised: 26/255 (10.2%). No statistically significant effect on personalisation of enrolment was found (OR 1.18, 95% CI 0.68-2.06). No statistically significant differences were found for any secondary outcome.

CONCLUSIONS

Personalisation of study invitations had no effect on recruitment. However, given the small study sample size in the present SWAT, and lack of similar embedded recruitment RCTs to enable a meta-analysis, additional SWATs to examine the personalisation of study invitation letters are warranted.

TRIAL REGISTRATION

ISRCTN57233429 ; ISRCTN18404129 ; SWAT 112, Northern Ireland Hub for Trials Methodology Research SWAT repository (2018 OCT 1 1231) ( https://www.qub.ac.uk/sites/TheNorthernIrelandNetworkforTrialsMethodologyResearch/FileStore/Filetoupload,939618,en.pdf ).

Developing an online, searchable database to systematically map and organise current literature on retention research (ORRCA2)

BACKGROUND

Addressing recruitment and retention challenges in trials is a key priority for methods research, but navigating the literature is difficult and time-consuming. In 2016, ORRCA (www.orrca.org.uk) launched a free, searchable database of recruitment research that has been widely accessed and used to support the update of systematic reviews and the selection of recruitment strategies for clinical trials. ORRCA2 aims to create a similar database to map the growing volume and importance of retention research.

METHODS

Searches of Medline (Ovid), CINAHL, PsycINFO, Scopus, Web of Science Core Collection and the Cochrane Library, restricted to English language and publications up to the end of 2017. Hand searches of key systematic reviews were undertaken and randomised evaluations of recruitment interventions within the ORRCA database on 1 October 2020 were also reviewed for any secondary retention outcomes. Records were screened by title and abstract before obtaining the full text of potentially relevant articles. Studies reporting or evaluating strategies, methods and study designs to improve retention within healthcare research were eligible. Case reports describing retention challenges or successes and studies evaluating participant reported reasons for withdrawal or losses were also included. Studies assessing adherence to treatments, attendance at appointments outside of research and statistical analysis methods for missing data were excluded. Eligible articles were categorised into one of the following evidence types: randomised evaluations, non-randomised evaluations, application of retention strategies without evaluation and observations of factors affecting retention. Articles were also mapped against a retention domain framework. Additional data were extracted on research outcomes, methods and host study context.

RESULTS

Of the 72,904 abstracts screened, 4,364 full texts were obtained, and 1,167 articles were eligible. Of these, 165 (14%) were randomised evaluations, 99 (8%) non-randomised evaluations, 319 (27%) strategies without evaluation and 584 (50%) observations of factors affecting retention. Eighty-four percent (n = 979) of studies assessed the numbers of participants retained, 27% (n = 317) assessed demographic differences between retained and lost participants, while only 4% (n = 44) assessed the cost of retention strategies. The most frequently reported domains within the 165 studies categorised as 'randomised evaluations of retention strategies' were participant monetary incentives (32%), participant reminders and prompts (30%), questionnaire design (30%) and data collection location and method (26%).

CONCLUSION

ORRCA2 builds on the success of ORRCA extending the database to organise the growing volume of retention research. Less than 15% of articles were randomised evaluations of retention strategies. Mapping of the literature highlights several areas for future research such as the role of research sites, clinical staff and study design in enhancing retention. Future studies should also include cost-benefit analysis of retention strategies.

Adapting Peer Researcher Facilitated Strategies to Recruit People Receiving Mental Health Services to a Tobacco Treatment Trial

INTRODUCTION

One of the most challenging aspects of conducting intervention trials among people who experience severe mental illness (SMI) and who smoke tobacco, is recruitment. In our parent "QuitLink" randomized controlled trial (RCT), slower than expected peer researcher facilitated recruitment, along with the impact of COVID-19 pandemic restrictions, necessitated an adaptive recruitment response. The objectives of the present study were to: (i) describe adaptive peer researcher facilitated recruitment strategies; (ii) explore the effectiveness of these strategies; (iii) investigate whether recruitment strategies reached different subgroups of participants; and (iv) examine the costs and resources required for implementing these strategies. Finally, we offer experience-based lessons in a Peer Researcher Commentary.

METHODS

People were included in the RCT if they smoked at least 10 cigarettes a day and were accessing mental health support from the project's two partnering mental health organizations in Victoria, Australia. The majority of people accessing these services will have been diagnosed with SMI. Recruitment occurred over 2 years. We began with peer facilitated recruitment strategies delivered face-to-face, then replaced this with direct mail postcards followed by telephone contact. In the final 4 months of the study, we began online recruitment, broadening it to people who smoked and were accessing support or treatment (including from general practitioners) for mental health and/or alcohol or other drug problems, anywhere in the state of Victoria. Differences between recruitment strategies on key participant variables were assessed. We calculated the average cost per enrolee of the different recruitment approaches.

RESULTS

Only 109 people were recruited from a target of 382: 29 via face-to-face (March 2019 to April 2020), 66 from postcards (May 2020 to November 2020), and 14 from online (November to December 2020 and January to March 2021) strategies. Reflecting our initial focus on recruiting from supported independent living accommodation facilities, participants recruited face-to-face were significantly more likely to be living in partially or fully supported independent living (n = 29, <0.001), but the samples were otherwise similar. After the initial investment in training and equipping peer researchers, the average cost of recruitment was AU$1,182 per participant-~US$850. Face-to-face recruitment was the most expensive approach and postcard recruitment the least (AU$1,648 and AU$928 per participant).

DISCUSSION

Peer researcher facilitated recruitment into a tobacco treatment trial was difficult and expensive. Widely dispersed services and COVID-19 restrictions necessitated non-face-to-face recruitment strategies, such as direct mail postcards, which improved recruitment and may be worthy of further research.

CLINICAL TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines. The trial sponsor was the University of Newcastle, NSW, Australia.

Factors affecting participant recruitment and retention in borderline personality disorder research: a feasibility study

Background

Previous studies have shown that stigma is a major barrier to participation in psychiatric research and that individuals who participate in psychiatric research may differ clinically and demographically from non-participants. However, few studies have explored research recruitment and retention challenges in the context of personality disorders.

Aim

To provide an analysis of the factors affecting participant recruitment and retention in a study of borderline personality disorder among general psychiatric inpatients.

Methods

Adult inpatients in a tertiary psychiatric hospital were approached about participating in a cross-sectional study of borderline personality disorder. Recruitment rates, retention rates, and reasons for declining participation or withdrawing from the study were collected. Demographic characteristics were compared between participants and non-participants and between patients who remained in the study and those who withdrew.

Results

A total of 71 participants were recruited into the study between January 2018 and March 2020. Recruitment and retention rates were 45% and 70%, respectively. Lack of interest was the most commonly cited reason for non-participation, followed by scheduling conflicts and concerns regarding mental/physical well-being. Age and sex were not predictors of study participation or retention.

Conclusions

More research is needed to explore patients’ perspectives and attitudes towards borderline personality disorder diagnosis and research, determine effects of different recruitment strategies, and identify clinical predictors of recruitment and retention in personality disorder research.

Strategies for Recruiting People With Dementia to Music Therapy Studies: Systematic Review

Positive effects of music therapy for people with dementia and their family carers are reported in a growing number of studies. However, small sample sizes or low recruitment rates often limit the success of these research studies. More adequately powered evidence-based studies are needed to impact policy and funding in dementia care. This systematic review examined recruitment strategies in music therapy clinical trials involving people living with dementia and/or their family carers. Eligible studies described enrolment, consent, accrual, or recruitment methods as well as recruitment or consent rates. Thirty studies with a total of 1,192 participants were included. Recruitment and conversion rates in residential aged care facilities (RACFs) (14 studies) were substantially higher than in community-based studies (16 studies). Whereas studies in RACFs most commonly recruited participants through staff approaching residents face-to-face or conversing with residents' legal guardians, community-based studies utilized a vast array of strategies, including staff referral, demonstrations/information sessions by researchers, advertisements, and direct contact with residents. Recruitment rates are likely to be higher when recruiters have an existing relationship with potential participants and when an independent third-party dementia organization is involved. Randomized controlled trials led to equally or greater recruitment conversion rates than other designs. Findings suggest that recruitment in dementia trials is complex, challenging, and needs thorough planning and consideration to be time- and cost-effective. Future studies should include reporting of recruitment strategies, enrolment rates, and related aspects so that researchers can better design recruitment strategies and estimate resources needed to reach the target sample size.

Postoperative Outcomes Following Total Hip and Knee Arthroplasty in Patients with Pain Catastrophizing, Anxiety, or Depression

BACKGROUND

The relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes.

METHODS

A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes.

RESULTS

We recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P = .005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P = .002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P = .041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P = .002). CRC patients demonstrated inferior VAS pain (P = .001), Oxford (P < .0001), and HHS/KSS (P = .025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P = .025; HADS-D, P = .030) and Oxford (HADS-A, P = .001; HADS-D, P = .030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P < .05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P < .05).

CONCLUSION

TJA patients who are anxious, depressed, or pain catastrophizing have inferior preoperative and postoperative pain and function. However, as compared to their preoperative status, clinically significant improvement can be expected following hip/knee arthroplasty.

Recruiting Low-Income African American Men in Mental Health Research: A Community-Based Participatory Research Feasibility Study

African Americans (AAs) are 20% more likely to develop serious psychological distress compared to Whites but are less likely to use mental health services. The study objective was to evaluate the effectiveness of recruitment strategies to engage AA fathers in a mental health intervention.

Using the community-based participatory research (CBPR) approach, a community-academic partnership (CAP) developed and implemented direct and indirect referral strategies to engage AA fathers in a mental health intervention. Direct referral strategies focused on community partner identification of potentially eligible participants, providing information about the study (i.e., study flyer), and referring potential participants to the study. Indirect referrals included posting flyers in local businesses frequented by AA men, radio advertisements, and social media posts from community organizations.

From January to October 2019, 50 direct and 1388 indirect referrals were documented, yielding 24 participants screened and 15 enrolled. Of all participants screened, 58% were referred through indirect referral, 38% were referred directly by community partners, and 4% of the participants were referred through both direct and indirect referrals. Twenty percent of those exposed to the direct referral methods and 1% of those exposed to the indirect referral methods were enrolled. The indirect referrals accounted for 60% of enrollment, whereas the direct referrals accounted for 33.3% of enrollment.

Collaborating with the community partners to engage hard-to-reach populations in mental health studies allowed for broad dissemination of recruitment methods, but still resulted in low participant accrual. Additional focus on increasing direct referral methods appears to be a fruitful area of CBPR.

Peer-delivered Cognitive Behavioral Therapy-based Intervention Reduced Depression and Stress in Community Dwelling Adults With Diabetes and Chronic Pain: A Cluster Randomized Trial

BACKGROUND

Finding effective, accessible treatment options such as professional-delivered cognitive behavioral therapy (CBT) for medically complex individuals is challenging in rural communities.

PURPOSE

We examined whether a CBT-based program intended to increase physical activity despite chronic pain in patients with diabetes delivered by community members trained as peer coaches also improved depressive symptoms and perceived stress.

METHODS

Participants in a cluster-randomized controlled trial received a 3-month telephonic lifestyle modification program with integrated CBT elements. Peer coaches assisted participants in developing skills related to adaptive coping, diabetes self-management goal-setting, stress reduction, and cognitive restructuring. Attention controls received general health advice with an equal number of contacts but no CBT elements. Depressive symptoms and stress were assessed using the Centers for Epidemiologic Studies Depression and Perceived Stress scales. Assessments occurred at baseline, 3 months, and 1 year.

RESULTS

Of 177 participants with follow-up data, 96% were African Americans, 79% women, and 74% reported annual income <$20,000. There was a significant reduction in perceived stress in intervention compared to control participants at 3-months (β = -2.79, p = .002 [95% CI -4.52, -1.07]) and 1 year (β = -2.59, p < .0001 [95% CI -3.30, -1.87]). Similarly, intervention participants reported significant decreases in depressive symptoms at 3-months (β = -2.48, p < .0001 [95% CI -2.48, -2.02]) and at 1 year (β = -1.62, p < .0001 [95% CI -2.37, -0.86]).

CONCLUSIONS

This peer-delivered CBT-based program improved depressive symptoms and stress in individuals with diabetes and chronic pain. Training community members may be a feasible strategy for offering CBT-based interventions in rural and under-resourced communities.

CLINICAL TRIAL REGISTRATION

NCT02538055.

A pilot comparison of medical records sensitivity perspectives of patients with behavioral health conditions and healthcare providers

This pilot study compares medical record data sensitivity (e.g., depression is sensitive) and categorization perspective (e.g., depression categorized as mental health information) of patients with behavioral health conditions and healthcare providers using a mixed-methods approach employing patient's own EHR. Perspectives of 25 English- and Spanish-speaking patients were compared with providers. Data categorization comparisons resulted in 66.3% agreements, 14.5% partial agreements, and 19.3% disagreements. Sensitivity comparisons obtained 54.5% agreement, 11.9% partial agreement, and 33.6% disagreements. Patients and providers disagreed in classification of genetic data, mental health, drug abuse, and physical health information. Factors influencing patients' sensitivity determination were sensitive category comprehension, own experience, stigma towards category labels (e.g., drug abuse), and perception of information applicability (e.g., alcohol dependency). Knowledge of patients' sensitivity perceptions and reconciliation with providers could expedite the development of granular and personalized consent technology.

Improved self-esteem and activity levels following a 12-week community activity and healthy lifestyle programme in those with serious mental illness: A feasibility study

BACKGROUND

Those with serious mental illness (SMI) including both psychotic and affective disorders are recognized to have a premature mortality compared to the general population, at least in part due to elevated cardiovascular risk profile.

AIM

To examine the effect of a 12-week, pragmatic, sustainable, low-cost intervention involving community activity, nutritional advice and exercise that could be accessible to patients attending a community clinic.

METHODS

Participants (N = 35) with SMI attending a community mental health service who were considered at risk of metabolic syndrome were referred by their clinical teams to a specialized healthy activity and nutritional programme. The intervention involved participation in exercise, dietary education and targeted lifestyle advice focused on community activities. Data on physical health and clinical parameters were collected pre- and post-intervention.

RESULTS

Physical activity increased following the intervention along with a statistically significant increase in self-esteem scores. There was no significant reduction in body mass index or lowering of anxiety and depression scores.

CONCLUSIONS

It is feasible to develop a relatively low-cost, community-based physical activity programme, integrating both nutritional advice and healthy activities. This may lead to improved outcomes in cardiovascular risk profile and improved life expectancy.

Recruiting and retaining young adults: what can we learn from behavioural interventions targeting nutrition, physical activity and/or obesity? A systematic review of the literature

OBJECTIVE

To describe strategies used to recruit and retain young adults in nutrition, physical activity and/or obesity intervention studies, and quantify the success and efficiency of these strategies.

DESIGN

A systematic review was conducted. The search included six electronic databases to identify randomised controlled trials (RCT) published up to 6 December 2019 that evaluated nutrition, physical activity and/or obesity interventions in young adults (17-35 years). Recruitment was considered successful if the pre-determined sample size goal was met. Retention was considered acceptable if ≥80 % retained for ≤6-month follow-up or ≥70 % for >6-month follow-up.

RESULTS

From 21 582 manuscripts identified, 107 RCT were included. Universities were the most common recruitment setting used in eighty-four studies (79 %). Less than half (46 %) of the studies provided sufficient information to evaluate whether individual recruitment strategies met sample size goals, with 77 % successfully achieving recruitment targets. Reporting for retention was slightly better with 69 % of studies providing sufficient information to determine whether individual retention strategies achieved adequate retention rates. Of these, 65 % had adequate retention.

CONCLUSIONS

This review highlights poor reporting of recruitment and retention information across trials. Findings may not be applicable outside a university setting. Guidance on how to improve reporting practices to optimise recruitment and retention strategies within young adults could assist researchers in improving outcomes.

Factors Influencing Successful Recruitment of Racial and Ethnic Minority Patients for an Observational HIV Cohort Study in Washington, DC

The process of recruiting racial and ethnic minority persons living with HIV (PLWH) is important for research studies to ensure inclusivity of underrepresented groups. To understand factors associated with recruitment of minority PLWH, this study examined the recruitment process of PLWH for an observational study of their routine medical care at 14 clinics in Washington, DC. Research assistant (RA) recruiters were interviewed to assess their consenting processes and strategies. Data were collected on clinic services, patient demographics, and recruitment logs of patient approaches for obtaining informed consent resulting in agreement or refusal. A median of 96% of eligible patients was approached to obtain consent, yielding a median consent rate of 78% across all sites. A total of 8438 patients consented and 1326 refused study participation. Clinical sites with more comprehensive services had higher consent rates. black/African American and Hispanic/Latinx PLWH consented or refused study participation in similar proportions, while significantly more white patients enrolled than refused. More men, compared with women, enrolled than refused study participation. The most frequent reasons for refusing study participation were the lack of interest in research (33.2%) and no specific reason provided (28%). RAs identified that effective recruitment strategies used culturally sensitive approaches, built rapport with patients, and obtained provider support for the study. Recruitment strategies that are gender sensitive to address the disparity of underrepresentation of women, address perceived barriers, and examine clinic-specific services are needed to maximize research participation for minority PLWH to improve prevention and health outcomes.

Perspectives of Trial Staff on the Barriers to Recruitment in a Digital Intervention for Psychosis and How to Work Around Them: Qualitative Study Within a Trial

BACKGROUND

Recruitment processes for clinical trials of digital interventions for psychosis are seldom described in detail in the literature. Although trial staff have expertise in describing barriers to and facilitators of recruitment, a specific focus on understanding recruitment from the point of view of trial staff is rare, and because trial staff are responsible for meeting recruitment targets, a lack of research on their point of view is a key limitation.

OBJECTIVE

The primary aim of this study was to understand recruitment from the point of view of trial staff and discover what they consider important.

METHODS

We applied pluralistic ethnographic methods, including analysis of trial documents, observation, and focus groups, and explored the recruitment processes of the EMPOWER (Early Signs Monitoring to Prevent Relapse in Psychosis and Promote Well-being, Engagement, and Recovery) feasibility trial, which is a digital app-based intervention for people diagnosed with schizophrenia.

RESULTS

Recruitment barriers were categorized into 2 main themes: service characteristics (lack of time available for mental health staff to support recruitment, staff turnover, patient turnover [within Australia only], management styles of community mental health teams, and physical environment) and clinician expectations (filtering effects and resistance to research participation). Trial staff negotiated these barriers through strategies such as emotional labor (trial staff managing feelings and expressions to successfully recruit participants) and trying to build relationships with clinical staff working within community mental health teams.

CONCLUSIONS

Researchers in clinical trials for digital psychosis interventions face numerous recruitment barriers and do their best to work flexibly and to negotiate these barriers and meet recruitment targets. The recruitment process appeared to be enhanced by trial staff supporting each other throughout the recruitment stage of the trial.

Engaging in Late-Life Mental Health Research: a Narrative Review of Challenges to Participation

Purpose of review

This narrative review seeks to ascertain the challenges older patients face with participation in mental health clinical research studies and suggests creative strategies to minimize these obstacles.

Recent findings

Challenges to older adults’ engagement in mental health research include practical, institutional, and collaboration-related barriers applicable to all clinical trials as well as more personal, cultural, and age-related patient barriers specific to geriatric mental health research. Universal research challenges include (1) institutional barriers of lack of funding and researchers, inter-researcher conflict, and sampling bias; (2) collaboration-related barriers involving miscommunication and clinician concerns; and (3) practical patient barriers such as scheduling issues, financial constraints, and transportation difficulties. Challenges unique to geriatric mental health research include (1) personal barriers such as no perceived need for treatment, prior negative experience, and mistrust of mental health research; (2) cultural barriers involving stigma and lack of bilingual or culturally matched staff; and (3) chronic medical issues and concerns about capacity.

Summary

Proposed solutions to these barriers include increased programmatic focus on and funding of geriatric psychiatry research grants, meeting with clinical staff to clarify study protocols and eligibility criteria, and offering transportation for participants. To minimize stigma and mistrust of psychiatric research, studies should devise community outreach efforts, employ culturally competent bilingual staff, and provide patient and family education about the study and general information about promoting mental health.

Retaining participants in community-based health research: a case example on standardized planning and reporting

Background

Effective strategies for participant retention are critical in health research to ensure validity, generalizability and efficient use of resources. Yet standardized guidelines for planning and reporting on retention efforts have been lacking. As with randomized controlled trial (RCT) and systematic review (SR) protocols, retention protocols are an opportunity to improve transparency and rigor. An RCT being conducted in British Columbia (BC), Canada provides a case example for developing a priori retention frameworks for use in protocol planning and reporting.

Methods

The BC Healthy Connections Project RCT is examining the effectiveness of a nurse home-visiting program in improving child and maternal outcomes compared with existing services. Participants (N = 739) were girls and young women preparing to parent for the first time and experiencing socioeconomic disadvantage. Quantitative data were collected upon trial entry during pregnancy and during five follow-up interviews until participants’ children reached age 2 years. A framework was developed to guide retention of this study population throughout the RCT. We reviewed relevant literature and mapped essential retention activities across the study planning, recruitment and maintenance phases. Interview completion rates were tracked.

Results

Results from 3302 follow-up interviews (in-person/telephone) conducted over 4 years indicate high completion rates: 90% (n = 667) at 34 weeks gestation; and 91% (n = 676), 85% (n = 626), 80% (n = 594) and 83% (n = 613) at 2, 10, 18 and 24 months postpartum, respectively. Almost all participants (99%, n = 732) provided ongoing consent to access administrative health data. These results provide preliminary data on the success of the framework.

Conclusions

Our retention results are encouraging given that participants were experiencing considerable socioeconomic disadvantage. Standardized retention planning and reporting may therefore be feasible for health research in general, using the framework we have developed. Use of standardized retention protocols should be encouraged in research to promote consistency across diverse studies, as now happens with RCT and SR protocols. Beyond this, successful retention approaches may help inform health policy-makers and practitioners who also need to better reach, engage and retain underserved populations.

Trial registration

ClinicalTrials.gov, NCT01672060. Registered on 24 August 2012.

Study within a trial (SWAT) protocol. Investigating the effect of personalised versus non-personalised study invitations on recruitment: An embedded randomised controlled recruitment trial

Introduction

Recruitment into clinical trials is a common challenge experienced by healthcare researchers. Currently, there is little evidence regarding strategies to improve recruitment into clinical trials. However, preliminary research suggests the personalisation of study invitation letters may increase recruitment rates. As such, there is a need to investigate the effectiveness of personalisation strategies on trial recruitment rates. This study within a trial (SWAT) will investigate the effect of personalised versus non-personalised study invitation letters on recruitment rates into the host trial ENGAGE, a feasibility study of an internet-administered, guided, Cognitive-Behavioural Therapy (CBT) based self-help intervention for parents of children previously treated for cancer.

Methods

An embedded randomised controlled trial (RCT) will investigate the effectiveness of a personalised study invitation letter including the potential participant’s name and address compared with a standard, non-personalised letter without name or address, on participant recruitment rates into the ENGAGE study. The primary outcome is differences in the proportion of participants recruited, examined using logistic regression. Results will be reported as adjusted odds ratios with 95% confidence intervals.

Discussion

Even moderate effects of the personalisation of study invitation letters on recruitment rates could be of significant value by shortening study length, saving resources, and providing a faster answer to the clinical question posed by the study. This protocol can be used as a template for other researchers who wish to contribute to the evidence base for trial decision-making, by embedding a similar SWAT into their trial.

Trial registration

ISRCTN 57233429; ISRCTN 18404129; SWAT 112, Northern Ireland Hub for Trials Methodology Research SWAT repository (2018 OCT 1 1231).

A Web- and Mobile-Based Intervention for Comorbid, Recurrent Depression in Patients With Chronic Back Pain on Sick Leave (Get.Back): Pilot Randomized Controlled Trial on Feasibility, User Satisfaction, and Effectiveness

BACKGROUND

Chronic back pain (CBP) is linked to a higher prevalence and higher occurrence of major depressive disorder (MDD) and can lead to reduced quality of life. Unfortunately, individuals with both CBP and recurrent MDD are underidentified. Utilizing health care insurance data may provide a possibility to better identify this complex population. In addition, internet- and mobile-based interventions might enhance the availability of existing treatments and provide help to those highly burdened individuals.

OBJECTIVE

This pilot randomized controlled trial investigated the feasibility of recruitment via the health records of a German health insurance company. The study also examined user satisfaction and effectiveness of a 9-week cognitive behavioral therapy and Web- and mobile-based guided self-help intervention Get.Back in CBP patients with recurrent MDD on sick leave compared with a waitlist control condition.

METHODS

Health records from a German health insurance company were used to identify and recruit participants (N=76) via invitation letters. Study outcomes were measured using Web-based self-report assessments at baseline, posttreatment (9 weeks), and a 6-month follow-up. The primary outcome was depressive symptom severity (Center for Epidemiological Studies-Depression); secondary outcomes included anxiety (Hamilton Anxiety and Depression Scale), quality of life (Assessment of Quality of Life), pain-related variables (Oswestry Disability Index, Pain Self-Efficacy Questionnaire, and pain intensity), and negative effects (Inventory for the Assessment of Negative Effects of Psychotherapy).

RESULTS

The total enrollment rate with the recruitment strategy used was 1.26% (76/6000). Participants completed 4.8 modules (SD 2.6, range 0-7) of Get.Back. The overall user satisfaction was favorable (mean Client Satisfaction Questionnaire score=24.5, SD 5.2). Covariance analyses showed a small but statistically significant reduction in depressive symptom severity in the intervention group (n=40) at posttreatment compared with the waitlist control group (n=36; F_1,76=3.62, P=.03; d=0.28, 95% CI -0.17 to 0.74). Similar findings were noted for the reduction of anxiety symptoms (F_1,76=10.45; P=.001; d=0.14, 95% CI -0.31 to 0.60) at posttreatment. Other secondary outcomes were nonsignificant (.06≤P≤.44). At the 6-month follow-up, the difference between the groups with regard to reduction in depressive symptom severity was no longer statistically significant (F_1,76=1.50, P=.11; d=0.10, 95% CI -0.34 to 0.46). The between-group difference in anxiety at posttreatment was maintained to follow-up (F_1,76=2.94, P=.04; d=0.38, 95% CI -0.07 to 0.83). There were no statistically significant differences across groups regarding other secondary outcomes at the 6-month follow-up (.08≤P≤.42).

CONCLUSIONS

These results suggest that participants with comorbid depression and CBP on sick leave may benefit from internet- and mobile-based interventions, as exemplified with the positive user satisfaction ratings. The recruitment strategy via health insurance letter invitations appeared feasible, but more research is needed to understand how response rates in untreated individuals with CBP and comorbid depression can be increased.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00010820; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010820.