Edited by: Allen C. Meadors, Independent Researcher, Seven Lakes, NC, United States
Reviewed by: Sherry L. Edwards, University of North Carolina at Pembroke, United States; Armin D. Weinberg, Baylor College of Medicine, United States
This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Recruitment and engagement challenges are well-documented in childhood obesity treatment studies (
The current study attempts to expand this literature by examining recruitment and engagement (i.e., retention and participation) strategies from a comparative effectiveness research (CER) trial and family-based childhood obesity (FBCO) treatment intervention targeting a high need, medically underserved, rural region. Using a case study approach, researchers analyzed qualitative interview data across the 3-year study from three stakeholder groups that included academic partners, community partners, and parent study participants. The primary aims were to explore the assets and challenges to the various recruitment and engagement strategies attempted during the lifespan of the study and to highlight insights into effective practices and recommendations to help build sustainable systems to engage rural families in FBCO interventions.
The study takes place in the Dan River Region (DRR), located in south central Virginia. It includes a small city, Danville, surrounded by large rural areas and small towns. The DRR is a federally designated, medically underserved area with challenging social determinants for poor health outcomes such as high poverty, unemployment, and minority concentrations (
The current study evolved from a preliminary Community-Based Participatory Research (CBPR) study in the DRR that adapted and piloted
This CER included three cohorts of families, recruited and randomized over the 3-year study period. In brief,
The decision to focus on recruitment and engagement within this case study was driven from consistent struggles to meet milestones in these areas, despite numerous evidence-based practices and adaptations to address challenges. As illustrated in
Timeline of milestones and data collection events with recruitment and engagement strategiesa for milestone achievement. aStrategies indicate cumulative efforts, with additional strategies at cohorts 2 and 3 adding to those from cohort 1, respectively.
This case study focused upon recruitment and engagement data garnered from qualitative interviews collected annually over the 3-year project with academic CAB partners and community CAB and PAT partners, and at each follow-up assessment with parent study participants. The University of Virginia's Institutional Review Board approved this research. Prior to participating, all interviewees provided written consent.
As seen in
As former participants in either the pilot or current study, PAT partners represented families targeted by the FBCO efforts. They took leadership over open source recruitment (i.e., community promotion), engaged with families and program facilitators during classes, and provided support via phone and texts to participants. PAT membership fluctuated from five to seven members, with all receiving a monthly stipend of $100–$200 depending upon activities and responsibilities.
Interested families were screened for eligibility criteria (i.e., child BMI percentile ≥85, English speaking, and no child contraindications for participation). The majority of the 139 enrolled children (70%) and 128 enrolled parents (75%) were obese. Over half the children were black (45%) or other minorities (8%), lived in single parent homes (55%), and were enrolled in Medicaid (62%). About one-third of parents (average age of 39) had a household income of < $20,000 (29%), were unemployed (32%), had a high school diploma or less (30%), and a less than adequate health literacy score (29%).
During the study, a total of 288 interviews were conducted with five academic CAB partners, nine community CAB partners, seven PAT partners, and 100 parent study participants (
Sample size for academic CAB partners, community CAB and PAT partners, and parent study participants.
Academic CAB partner | 5 | 5 | 5 | 15 |
Community CAB partner | 9 | 8 | 5 | 22 |
PAT partner | 5 | 5 | 7 | 17 |
Parent study participant | 86 | 88 | 60 | 234 |
CAB and PAT partners participated in three annual interviews conducted and recorded by an independent evaluator using a semi-structured interview script. The script was developed from a capacity framework guided by CBPR principles (
Parent study participants from each cohort participated in face-to-face interviews at 3-, 6-, and 12-month follow-up assessments. Trained researchers probed about recruitment and randomization processes and intervention adherence, usefulness, and satisfaction. Children were also interviewed at these assessment points; however, the focus of these interviews was more upon individual and family behavior changes and general satisfaction with the program (iChoose only) than with recruitment and engagement facilitators and obstacles. Their data added little value to the purpose of this paper and therefore is not included. Incentives of $25 for 3-month and $50 for the 6-and 12-month follow-ups were offered to study participants. Interviews lasted 10–20 min. Researchers summarized responses on paper and recorded verbatim responses when possible.
Analysis of the qualitative data were conducted in two phases (
Phase two analysis was completed by the Principal Investigator and Study Coordinator. Together they used a deductive approach to thematically categorize codes into eight higher level study needs that present at the stakeholder/organization and the individual levels (
Recommendations for stakeholder/organization level needs.
1. |
• Normalize failures as part of the research process and encourage problem solving |
2. |
• Create eligibility criteria that is not too exclusive to the needs of the community |
3. |
• Create feedback loops to share best practices and challenges for engaging participants |
Recommendations for participant level needs.
1. |
• Educate the target population on the role of research in combatting childhood obesity |
2. |
• Assess attendance barriers prior to enrollment and throughout the study |
3. |
• Market strategically to communities with higher needs/risks |
4. |
• Provide additional support to maintain healthy lifestyle changes |
5. |
• Create a childhood obesity awareness campaign within the targeted community |
At the stakeholder/organization level, three thematic needs emerged: (1) improve readiness of stakeholders to conduct CBPR research, (2) develop sustainable participant referral protocols, and (3) develop feasible and sustainable participant engagement protocols. As illustrated in
Despite strong initial assets to meet stakeholder/organization level needs, the study under-performed with regard to milestones and expectations for recruitment and engagement. Suggestions to address these challenges included a number of already enacted strategies (see
At the participant level, five thematic needs for target population improvements emerged: (1) level of comfort and trust with research, (2) accessibility to the intervention, (3) awareness and understanding of the study, (4) acceptance of the intervention, and (5) readiness to engage in an obesity treatment study. As seen in the assets outlined in
Similar to the stakeholder/organization level needs, challenges outweighed assets and many of the recruitment and engagement milestones were not met. Regardless, existing strategies such as using community members from trusted local organizations and the targeted population to recruit and implement the study (see
With regard to stakeholder/organization level needs, academic CAB, community CAB, and PAT partners' perceptions of assets and challenges aligned similarly. However, there were notable difference in perceptions between these study stakeholders and the parent study participants for these needs. While parent study participants had opportunity to discuss issues surrounding their participation, they were much less likely than the community stakeholders to identify system level assets or barriers and largely kept their comments at the participant level. As noted later in the discussion, this disparity may also be a result of methodological differences in the intention and structure of the interview scripts in which study participants were not specifically prompted to reflect at the system level.
At the participant level, academic CAB partners were more likely than community CAB partners, PAT partners, and parent study participants to acknowledge target population's distrust of research. However, community CAB partners identified pathways to increase comfort through provision of interventions that clearly address key community burdens. All interviewee groups stressed challenges to accessibility and assets to intervention acceptability; however, CAB members mentioned challenges to acceptability less frequently than did PAT partners and parent study participants. Intervention acceptability, according to parent study participants, was particularly impacted by the level of satisfaction with randomization and intervention components. Finally, relative to enrolled parent study participants, CAB and PAT partners were less likely to perceive assets and more likely to perceive challenges to participant readiness to engage in a childhood obesity study.
Findings across the lifespan of our study demonstrated a pattern of recruitment and engagement challenges. These struggles were not fully anticipated by the CAB and PAT due to the application of evidence-based strategies that were previously successful with this target population (
When considering the recommendations supported by our qualitative case study, it is clear that full system-changes are necessary to improve recruitment and engagement in similar childhood obesity studies being conducted in comparable health disparate regions. Potential changes to community and organizational structures that provide opportunities and access to these studies in a way that ensures broad exposure across the intended audience are likely to be the most impactful. While we note that participant readiness is both an asset (from parent study participant perspectives) and a challenge (from CAB participant perspectives), it is critical to avoid the assumption that the challenge of low recruitment is based on an unmotivated intended audience. As such, our recommendations include a strong focus on ensuring target population awareness and access to research, including trust building opportunities. Likewise, we focus on system changes that could influence norms related to how initial recruitment and sustained engagement can be supported at the research and community-system level.
Our case study retrospectively evaluated stakeholder and participant interviews for recruitment and engagement indicators that were not explicitly intended by the interview protocols. Consequently, direct questions about recruitment and engagement were not consistently asked in the same manner over time or across interviewee groups. Furthermore, parent study participant data was only gathered from retained participants at follow-up assessments and does not include perspectives on recruitment and engagement from families that completely disengaged. Therefore, quantified analysis of the qualitative data should be interpreted cautiously when examining differences among key stakeholder responses. This approach to the data was meant to provide insight into the importance of multiple perspectives in painting a holistic picture of assets, challenges, and opportunities surrounding recruitment and engagement within the study. Due to the above mentioned methodological constraints, frequency of themes cannot suggest relative importance of one asset, challenge, or recommendation over another. However, a frequently mentioned theme may indicate something that is obvious to one or more of these interviewee groups and therefore provides insight into priorities and how they might fit together.
When examining the frequencies reported by the four interviewee groups, it is clear that a single perspective approach would have resulted in less complete and meaningful feedback on recruitment and engagement strategies within the study. For instance, enrolled parent study participants emphasized their readiness to participate in a childhood obesity treatment study and their positive perceptions of the interventions' acceptability. However, CAB and PAT members who experienced the recruitment and engagement efforts understood barriers for the larger target population. Likewise, while academic CAB members appeared to conclude that mistrust and discomfort with research hindered recruitment, community CAB members saw this as more of a mismatch between research and its ability to address community needs. Yet, parent study participants indicated research mistrust was largely due to randomization procedures. Furthermore, community partners and parent study participants were more inclined to understand intervention accessibility barriers than academic partners not living in the region.
In addition to providing a more holistic picture as to the assets, challenges, and opportunities related to recruitment and engagement, frequency patterns also suggested small nuances in the priorities of the interviewee groups. For instance, academic partners wished to improve the health of the targeted population. Additionally they wished to develop systems to continue research efforts with established partners. Thus, while community CAB and PAT partners were aware of the challenges related to building partner capacity at the organizational/systems level, these challenges may have been perceived more keenly by academic partners. Similarly, parent study participants' focus on assets and challenges related to the accessibility and acceptability of the interventions may suggest that they prioritized finding resources to meet their immediate family needs. Overall, the consistent approach of examining the data for prevalence of themes across stakeholders provided rich content information directly relevant to the strengths and pitfalls of our study. These findings may be relevant to other practitioners and researchers who work with populations that face numerous barriers to participation in research.
Recruitment and engagement are perhaps the highest hurdles to overcome for FBCO and other interventions examining health behavior change, particularly for those engaging underserved, rural populations (
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving human participants were reviewed and approved by Institutional Review Board for Health Sciences Research University of Virginia. The patients/participants provided their written informed consent to participate in this study.
JZ and PE designed the overall study and methodology with substantial input from D-JB and JH. The focus of the manuscript was conceived by D-JB and JZ with support from PE, MY, and JH. Data analysis for this study was completed by D-JB, MY, and BP under the supervision of D-JB. As community partners in this project, JW, DM, and KE provided feedback on content interpretation. D-JB and JZ drafted the paper with section contributions from MY and editing from MY, PE, and JH. All authors provided feedback on the manuscript draft and approved the final version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We would like the acknowledge all of the CAB members, past and present, for their time and dedication in the study planning processes. Specifically, we recognize CAB members who have been instrumental in designing, planning, and launching this study: Jason Bookheimer, Beth Thomas, Stephanie Phelps, Deana Jones, Paige Shelton, Marsha Mendenhall, and Stacey Ensminger. We would also like to thank all the PAT members for their commitment and enthusiasm for this study. We especially acknowledge the unwavering support from our PAT members Wanda Breedlove, Pamela Carter-Taylor, Julie Matejko, Misty Roveta, Tia Yancy, Katlyn Cardoza, and Mindy Greiner.
The Supplementary Material for this article can be found online at: