Recruitment and retention of homeless mentally ill participants in research

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven.

METHODS

This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms.

DISCUSSION

The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

Recruitment and retention of homeless individuals with mental illness in a housing first intervention study

Background

Homeless individuals with mental illness are challenging to recruit and retain in longitudinal research studies. The present study uses information from the Vancouver site of a Canadian multi-city longitudinal randomized controlled trial on housing first interventions for homeless individuals. We were able to recruit 500 participants and retain large number of homeless individuals with mental illness; 92% of the participants completed the 6-month follow up interview, 84% the 24-month follow up, while 80% completed all follow-up visits of the study.

Purpose

In this article, we describe the strategies and practices that we considered as critical for successful recruitment and retention or participants in the study.

Methods

We discuss issues pertaining to research staff hiring and training, involvement of peers, relationship building with research participants, and the use of technology and social media, and managing challenging situations in the context of recruitment and retention of marginalized individuals.

Conclusions

Recruitment and retention of homeless participant with mental illness in longitudinal studies is feasible. It requires flexible, unconventional and culturally competent strategies. Longitudinal research projects with vulnerable and hidden populations may benefit from extensive outreach work and collaborative approaches that are based on attitudes of mutual respect, contextual knowledge and trust.

Recruiting, Linking, and Retaining High-risk Transgender Women into HIV Prevention and Care Services: An Overview of Barriers, Strategies, and Lessons Learned

Despite disproportionately high HIV prevalence rates and high risk for HIV acquisition and transmission, trans women in the United States are less likely than other high-risk populations to be aware of their HIV status or to perceive HIV infection as a serious health threat. Furthermore, concurrently high rates of unstable housing, few legal employment opportunities, lack of social support, and distrust of social service providers limit trans women's interest or ability to be recruited by, retained within, or linked into HIV prevention and care services. This article provides an overview of the barriers that prevent many high-risk trans women from being recruited, linked, and retained within HIV prevention and care services as well as accessing HIV testing services, and discusses several strategies for overcoming these barriers. Best practices in working with high-risk trans women include hiring trans women indigenous to the local trans communities, designing culturally specific recruitment and retention strategies including the creation of living "community maps" to ensure successful community outreach, the construction of a trans women-specific CAB to create dialogue with community stakeholders including consumers, and extensive cultural sensitivity training for staff and community collaborators to sensitize them to the specific needs of high-risk trans women participants.

Crowdsourcing for conducting randomized trials of internet delivered interventions in people with serious mental illness: A systematic review

OBJECTIVE

Online crowdsourcing refers to the process of obtaining needed services, ideas, or content by soliciting contributions from a large group of people over the Internet. We examined the potential for using online crowdsourcing methods for conducting behavioral health intervention research among people with serious mental illness (SMI).

METHODS

Systematic review of randomized trials using online crowdsourcing methods for recruitment, intervention delivery, and data collection in people with SMI, including schizophrenia spectrum disorders and mood disorders. Included studies were completed entirely over the Internet without any face-to-face contact between participants and researchers.

DATABASES AND SOURCES

Medline, Cochrane Library, Web of Science, CINAHL, Scopus, PsychINFO, Google Scholar, and reference lists of relevant articles.

RESULTS

We identified 7 randomized trials that enrolled N=1214 participants (range: 39 to 419) with SMI. Participants were mostly female (72%) and had mood disorders (94%). Attrition ranged from 14% to 81%. Three studies had attrition rates below 25%. Most interventions were adapted from existing evidence-based programs, and consisted of self-directed education, psychoeducation, self-help, and illness self-management. Six studies collected self-reported mental health symptoms, quality of life, and illness severity. Three studies supported intervention effectiveness and two studies showed improvements in the intervention and comparison conditions over time. Peer support emerged as an important component of several interventions. Overall, studies were of medium to high methodological quality.

CONCLUSION

Online crowdsourcing methods appear feasible for conducting intervention research in people with SMI. Future efforts are needed to improve retention rates, collect objective outcome measures, and reach a broader demographic.

What Works? An Empirical Perspective on How to Retain Youth in Longitudinal Human Immunodeficiency Virus (HIV) and Substance Risk Reduction Studies

BACKGROUND

Low retention rates are a problem for longitudinal studies involving adolescents, and this is particularly true for justice-involved youth.

METHODS

This study evaluates (1) strategies used to retain high-risk adolescents participating in a longitudinal research project; (2) the extent to which retention efforts were different in a justice-involved versus a non-justice-involved (school-based) sample; and (3) differential characteristics of justice-involved versus school-based adolescents that might explain differences in retention difficulty.

RESULTS

Compared with the school-based youth, justice-involved youth required significantly more phone calls to be successfully reached. Additionally, baseline substance use (alcohol and marijuana use frequency) was higher in the justice-involved sample and significantly related to retention difficulty.

CONCLUSIONS

High retention rates for justice-involved and substance-using youth are possible with focused efforts on frequent communication and effortful contact.

Aversion to injection limits acceptability of extended-release naltrexone among homeless, alcohol-dependent patients

BACKGROUND

Ending homelessness is a major priority of the Department of Veteran Affairs (VA), and alcohol use can be a barrier to stable housing. Clinical trials suggest that depot extended-release naltrexone (XR-NTX) is efficacious in reducing alcohol consumption among alcohol-dependent subjects.

METHODS

An open-label, randomized pilot study sought to examine the feasibility and effectiveness of XR-NTX versus oral naltrexone to improve alcohol consumption and housing stability among homeless, alcohol-dependent veterans at the Providence Veteran Affairs Medical Center.

RESULTS

Of 215 potential candidates approached over a 16-month recruitment period, only 15 agreed to consider study entry and 7 were randomized. The primary reasons given for refusal were not wanting an injection; fear of needles; and not wanting to change drinking habits. Only 1 participant in the XR-NTX group returned after the first injection. Three participants in the oral naltrexone group attended all 7 visits and had good outcomes.

CONCLUSIONS

Although XR-NTX has demonstrated efficacy in reducing heavy drinking, limited acceptance of the injection might reduce its effectiveness among homeless, alcohol-dependent patients.

The effect of telephone-based interpersonal psychotherapy for the treatment of postpartum depression: study protocol for a randomized controlled trial

BACKGROUND

Substantial data indicate potential health consequences of untreated postpartum depression (PPD) on the mother, infant, and family. Studies have evaluated interpersonal psychotherapy (IPT) as treatment for PPD; however, the results are questionable due to methodological limitations. A comprehensive review of maternal treatment preferences suggests that mothers favor 'talking therapy' as a form of PPD treatment. Unfortunately, IPT is not widely available, especially in rural and remote areas. To improve access to care, telepsychiatry has been introduced, including the provision of therapy via the telephone.

METHODS/DESIGN

The purpose of this randomized controlled trial is to evaluate the effect of telephone-based IPT on the treatment of PPD. Stratification is based on self-reported history of depression and province. The target sample is 240 women. Currently, women from across Canada between 2 and 24 weeks postpartum are able to either self-identify as depressed and refer themselves to the trial or they may be referred by a health professional based on a score >12 on the Edinburgh Postnatal Depression Scale (EPDS). Following contact by the trial coordinator, a detailed study explanation is provided. Women who fulfill the eligibility criteria (including a positive diagnostic assessment for major depression) and consent to participate are randomized to either the control group (standard postpartum care) or intervention group (standard postpartum care plus 12 telephone-based IPT sessions within 12 to 16 weeks, provided by trained nurses). Blinded research nurses telephone participants at 12, 24, and 36 weeks post-randomization to assess for PPD and other outcomes including depressive symptomatology, anxiety, couple adjustment, attachment, and health service utilization. Results from this ongoing trial will: (1) develop the body of knowledge concerning the effect of telephone-based IPT as a treatment option for PPD; (2) advance our understanding of training nurses to deliver IPT; (3) provide an economic evaluation of an IPT intervention; (4) investigate the utility of the EPDS in general clinical practice to identify depressed mothers; and (5) present valuable information regarding PPD, along with associated couple adjustment, co-morbid anxiety and self-reported attachment among a mixed rural and urban Canadian population.

TRIAL REGISTRATION

Current Controlled Trials Ltd. ISRCTN88987377.

The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities

Introduction Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city, $110 million demonstration project and provides the rationale for key scientific decisions. Methods A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project. Trial registration number This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.

Strategies to recruit and retain college smokers in cessation trials

Techniques to recruit and retain college fraternity and sorority members who reported past 30-day smoking into a cessation trial are described. Recruitment efforts included relationship-building, raffles, and screening survey administration during existing meetings. Surveys were administered to 76% (n = 3,276) of members in 30 chapters, 79% of eligible members agreed to participate, and 76% of those completed assessments and were enrolled in the trial (n = 452). The retention rate was 73%. Retention efforts included cash incentives, flexible scheduling, multiple reminders, chapter incentives, and use of chapter members as study personnel. Retention was not related to demographic, behavioral, or group characteristics. The strategies of partnership, convenience, and flexibility appear effective and may prove useful to investigators recruiting similar samples.

Telephone-based assessments to minimize missing data in longitudinal depression trials: a project IMPACTS study report

PURPOSE

Missing data in clinical efficacy and effectiveness trials continue to be a major threat to the validity of study findings. The purpose of this report is to describe methods developed to ensure completion of outcome assessments with public mental health sector subjects participating in a longitudinal, repeated measures study for the treatment of major depressive disorder. We developed longitudinal assessment procedures that included telephone-based clinician interviews in order to minimize missing data commonly encountered with face-to-face assessment procedures.

METHODS

A pre-planned, multi-step strategy was developed to ensure completeness of data collection. The procedure included obtaining multiple pieces of patient contact information at baseline, careful education of both staff and patients concerning the purpose of assessments, establishing good patient rapport, and finally being flexible and persistent with phone appointments to ensure the completion of telephone-based follow-up assessments. A well-developed administrative and organizational structure was also put in place prior to study implementation.

RESULTS

The assessment completion rate for the primary outcome for 310 of 504 subjects who enrolled and completed 52 weeks (at the time of manuscript) of telephone-based follow-up assessments was 96.8%.

CONCLUSION

By utilizing telephone-based follow-up procedures and adapting our easy-to-use pre-defined multi-step approach, researchers can maximize patient data retention in longitudinal studies.

The effects of failing to include hard-to-reach respondents in longitudinal surveys

OBJECTIVES

We sought to determine whether failure to locate hard-to-reach respondents in longitudinal studies causes biased and inaccurate study results.

METHODS

We performed a nonresponse simulation in a survey of 498 low-income women who received cash aid in a California county. Our simulation was based on a previously published analysis that found that women without children who applied for General Assistance experienced more violence than did women with children who applied for Temporary Assistance to Needy Families. We compared hard-to-reach respondents whom we reinterviewed only after extended follow-up effort 12 months after baseline with other respondents. We then removed these hard-to-reach respondents from our analysis.

RESULTS

Other than having a greater prevalence of substance dependence (14% vs 6%), there were no significant differences between hard- and easy-to-reach respondents. However, excluding the hard to reach would have decreased response rates from 89% to 71% and nullified the findings, a result that did not stem primarily from reduced statistical power.

CONCLUSIONS

The effects of failure to retain hard-to-reach respondents are not predicable based on respondent characteristics. Retention of these respondents should be a priority in public health research.

Do STD clinic patients who consent to sexual health research differ from those who decline? Findings from a randomized controlled trial with implications for the generalization of research results

OBJECTIVES

This study determined whether patients from an STD clinic who agreed to participate in behavioral research are representative of the overall patient population.

STUDY DESIGN

Patients attending an STD clinic (N = 2694) were invited to participate in sexual risk-reduction research. Those who accepted (consenters) were compared to those who declined (nonconsenters) on data obtained from the medical chart.

RESULTS

Overall, 58% of eligible patients consented to participation. Logistic regression analyses indicated that consenting to participate was associated with female sex [odds ratio (OR) = 1.86], nonwhite race (OR = 2.16), having completed at least some college (OR = 1.70), being a returning patient (OR = 1.21), and having a greater number of sexual partners in the past 3 months (OR = 6.95) (all P's <0.05).

CONCLUSIONS

Patients who agreed to participate had more education, were more familiar with the setting, and were more vulnerable to HIV/STD (as suggested by epidemiologic research). Efforts to enhance participation by an even greater percentage of patients might target these predictors of participation by enhancing risk awareness and providing preemptive reassurances regarding the research process and setting.

Predictors of participation and attrition in a health promotion study involving psychiatric outpatients

Participant selection biases can reduce the generalizability of research findings and lead to misestimates of intervention effectiveness. The authors examined factors associated with study participation and attrition among psychiatric outpatients recruited for the initial phase of a health promotion trial. Medical records were reviewed to obtain HIV-risk and substance abuse data, as well as psychiatric and demographic characteristics of potential participants. Of 895 eligible outpatients, 67% (n = 601) consented to participate, among whom 69% (n = 415) completed all baseline appointments. Compared with nonconsenters, consenters were more likely to be at risk for drug problems and to receive care from clinics serving more impaired patients. Study completion was associated with older age, a psychiatric diagnosis other than adjustment disorder, and a recent sexually transmitted disease diagnosis. These findings suggest that patients who could most benefit from risk reduction interventions are more likely to participate.