A Comparison of Recruitment Methods for an mHealth Intervention Targeting Mothers: Lessons from the Growing Healthy Program

The impacts of an mHealth intervention targeting parents on health service usage and out-of-pocket costs in the first 9 months of life: The Growing healthy app

Mobile health (mHealth) interventions provide a low-cost, scalable approach to supporting parents with infant feeding advice with the potential to reduce health care visits and associated costs for infant feeding support. This Australian study examined the impact of the Growing healthy (GH) app on health service utilisation and out-of-pocket costs for families in the first 9 months of their infants life. A quasi-experimental study with a comparison group was conducted in 2015-2016 with an mHealth intervention group (GH app, n = 301) and a nonrandomized usual care group (n = 344). The GH app aimed to support parents of young infants with healthy infant feeding behaviours from birth to 9 months of age. App-generated notifications directed parents to age-and feeding-specific content within the app. Both groups completed surveys at baseline when infants were less than 3 months old (T1), at 6 months (T2) and 9 months (T3) of age. At T3, participants reported health services used and any out-of-pocket costs for advice on infant feeding, growth or activity. App users had lower odds (odds ratio: 0.38 95% confidence interval: 0.25, 0.59) of using one or more services and had lower number of visits to a general practitioner (1.0 vs. 1.5 visits, p = 0.003) and paediatrician (0.3 vs. 0.4 visits, p = 0.049) compared to the usual care group. There was no difference in out-of-pocket costs between groups. Provision of an evidenced-based infant feeding app may provide substantial savings to the health system and potentially to parents through fewer primary health care and paediatrician visits.

Testing a Biobehavioral Model of Chronic Stress and Weight Gain in Young Children (Family Stress Study): Protocol and Baseline Demographics for a Prospective Observational Study

BACKGROUND

Chronic stress is an important risk factor in the development of obesity. While research suggests chronic stress is linked to excess weight gain in children, the biological or behavioral mechanisms are poorly understood.

OBJECTIVE

The objectives of the Family Stress Study are to examine behavioral and biological pathways through which chronic stress exposure (including stress from COVID-19) may be associated with adiposity in young children, and to determine if factors such as child sex, caregiver-child relationship quality, caregiver education, and caregiver self-regulation moderate the association between chronic stress and child adiposity.

METHODS

The Family Stress Study is a prospective cohort study of families recruited from 2 Canadian sites: the University of Guelph in Guelph, Ontario, and McMaster University in Hamilton, Ontario. Participants will be observed for 2 years and were eligible to participate if they had at least one child (aged 2-6 years) and no plans to move from the area within the next 3 years. Study questionnaires and measures were completed remotely at baseline and will be assessed using the same methods at 1- and 2-year follow-ups. At each time point, caregivers measure and report their child's height, weight, and waist circumference, collect a hair sample for cortisol analysis, and fit their child with an activity monitor to assess the child's physical activity and sleep. Caregivers also complete a web-based health and behaviors survey with questions about family demographics, family stress, their own weight-related behaviors, and their child's mental health, as well as a 1-day dietary assessment for their child.

RESULTS

Enrollment for this study was completed in December 2021. The final second-year follow-up was completed in April 2024. This study's sample includes 359 families (359 children, 359 female caregivers, and 179 male caregivers). The children's mean (SD) age is 3.9 years (1.2 years) and 51% (n=182) are female. Approximately 74% (n=263) of children and 80% (n=431) of caregivers identify as White. Approximately 34% (n=184) of caregivers have a college diploma or less and nearly 93% (n=499) are married or cohabiting with a partner. Nearly half (n=172, 47%) of the families have an annual household income ≥CAD $100,000 (an average exchange rate of 1 CAD=0.737626 USD applies). Data cleaning and analysis are ongoing as of manuscript publication.

CONCLUSIONS

Despite public health restrictions from COVID-19, the Family Stress Study was successful in recruiting and using remote data collection to successfully engage families in this study. The results from this study will help identify the direction and relative contributions of the biological and behavioral pathways linking chronic stress and adiposity. These findings will aid in the development of effective interventions designed to modify these pathways and reduce obesity risk in children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05534711; https://clinicaltrials.gov/study/NCT05534711.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48549.

Optimizing educational methods for the low FODMAP diet in disorders of gut-brain interaction: A feasibility randomized controlled trial

BACKGROUND

A diet low in fermentable oligo-saccharides, di-saccharides, mono-saccharides and polyols (low FODMAP diet) is complex and clinical effectiveness is achieved with dietitian-led education, although dietitian availability in clinical practice varies. This study aimed to assess the feasibility of undertaking a trial to investigate the clinical and cost-effectiveness of different education delivery methods of the low FODMAP diet in patients with disorders of gut-brain interaction (DGBI).

METHODS

In this feasibility randomized controlled trial, patients with DGBI requiring the low FODMAP diet were randomized to receive one of the following education delivery methods: booklet, app, or dietitian. Recruitment and retention rates, acceptability, symptoms, stool output, quality of life, and dietary intake were assessed.

KEY RESULTS

Fifty-one patients were randomized with a recruitment rate of 2.4 patients/month and retention of 48 of 51 (94%). Nobody in the booklet group strongly agreed that this education delivery method enabled them to self-manage symptoms without further support, compared to 7 of 14 (50%) in the dietitian group (p = 0.013). More patients reported adequate relief of symptoms in the dietitian group (12, 80%) compared with the booklet group (7, 39%; p = 0.026), but not when compared to the app group (10, 63%, p > 0.05). There was a greater decrease in the IBS-SSS score in the dietitian group (mean -153, SD 90) compared with the booklet group (mean -90, SD 56; p = 0.043), but not when compared with the app group (mean -120, SD 62; p = 0.595).

CONCLUSIONS & INFERENCES

Booklets were the least acceptable education delivery methods. Dietitian-led consultations led to high levels of clinical effectiveness, followed by the app, while the dietitian was superior to booklets alone. However, an adequately powered clinical trial is needed to confirm clinical effectiveness of these education delivery methods.

Resources used and trusted regarding child health information by culturally and linguistically diverse communities in Australia: An online cross-sectional survey

BACKGROUND

Parents' play a proactive role in seeking health information to ensure optimal growth and development for their children. To date, very little is known about the differences between information seeking behaviour for child health and engagement with resources between culturally and linguistically diverse (CALD) and non-CALD parents.

OBJECTIVE

To investigate the differences in resources used and trusted for information related to child health behaviours and engagement with online features among CALD and non-CALD respondents in Australia.

METHODS

An analysis of a theory informed online cross-sectional survey was conducted using data from 122 CALD and 399 non-CALD parents who had a child younger than 24 months or were currently pregnant in Australia. Descriptive statistics and chi-squared were used to compare the differences, and logistic regression models were used to identify factors associated with using health resources.

RESULTS

The most trusted sources for information reported by respondents were health professionals (76.2 %), websites run by health professionals (59.5 %), and government websites (53.2 %). Social media was significantly more trusted as a source of information for child health behaviours among CALD respondents than non-CALD respondents (odds ratio (OR) 1.92, P = 0.01). In contrast, booklets/ pamphlets and friends were significantly more trusted by non-CALD parents than for CALD parents (OR 0.54, P = 0.02). General search engines were used very frequently among CALD respondents for child health information (39.3 % vs 24.1 %, p = 0.013). Overall, the most common features respondents enjoyed on websites were images (81 %), videos (40.1 %), and discussion forums (39.9 %). CALD respondents significantly favoured videos (p = 0.003) while non-CALD respondents preferred obtaining information through attachments (p < 0.001).

CONCLUSIONS

Despite parents' reporting health professionals, websites run by health professionals, and government websites as trustworthy, general search engines and social media were still the most frequently used information source for parents with young children. Credible resources parents deem as trustworthy should take into account effective and engaging means of disseminating information that are accessible to both CALD and non-CALD communities.

Planting Seeds for the Future: Scoping Review of Child Health Promotion Apps for Parents

BACKGROUND

Increasingly, parents use child health promotion apps to find health information. An overview of child health promotion apps for parents currently does not exist. The scope of child health topics addressed by parent apps is thus needed, including how they are evaluated.

OBJECTIVE

This scoping review aims to describe existing reported mobile health (mHealth) parent apps of middle- to high-income countries that promote child health. The focus centers on apps developed in the last 5 years, showing how the reported apps are evaluated, and listing reported outcomes found.

METHODS

A scoping review was conducted according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews) guidelines to identify parent apps or web-based programs on child health promotion published between January 2016 and June 2021 in 5 databases: PubMed, ERIC, IEEE Xplore, Web of Science, and Google Scholar. Separate sources were sought through an expert network. Included studies were summarized and analyzed through a systematic and descriptive content analysis, including keywords, year of publication, country of origin, aims/purpose, study population/sample size, intervention type, methodology/method(s), broad topic(s), evaluation, and study outcomes.

RESULTS

In total, 39 studies met the inclusion criteria from 1040 database and 60 expert-identified studies. Keywords reflected the health topics and app foci. About 64% (25/39) of included studies were published after 2019 and most stemmed from the United States, Australian, and European-based research. Studies aimed to review or evaluate apps or conducted app-based study interventions. The number of participants ranged from 7 to 1200. Quantitative and qualitative methods were used. Interventions included 28 primary studies, 6 app feasibility studies, and 5 app or literature reviews. Eight separate topics were found: parental feeding and nutrition, physical activity, maternal-child health, parent-child health, healthy environment, dental health, mental health, and sleep. Study intervention evaluations cited behavior change theories in 26 studies and evaluations were carried out with a variety of topic-specific, adapted, self-developed, or validated questionnaires and evaluation tools. To evaluate apps, user input and qualitative evaluations were often combined with surveys and frequently rated with the Mobile App Rating Scale. Outcomes reported some positive effects, while several intervention studies saw no effect at all. Effectively evaluating changes in behavior through apps, recruiting target groups, and retaining app engagement were challenges cited.

CONCLUSIONS

New parents are a key target group for child health apps, but evaluating child health promotion apps remains a challenge. Whether tailored to parent needs or adapted to the specific topic, apps should be rooted in a transparent theoretical groundwork. Applicable lessons for parent apps from existing research are to tailor app content, include intuitive and adaptive features, and embed well-founded parameters for long-term effect evaluation on child health promotion.

Ecological Momentary Assessment of Heavy Episodic Drinking in the Early Postpartum Period: A Feasibility Study

Background

Postpartum mothers are at heightened risk for heavy episodic drinking (HED). Research with this population is critical to developing acceptable and effective tailored interventions, but new mothers who use alcohol are often reluctant to engage in research due to stigma and fear of child removal. This study examined feasibility of recruitment and ecological momentary assessment (EMA) in early postpartum mothers with histories of HED.

Methods

Participants were recruited via Facebook and Reddit and completed 14 days of EMA surveys. Baseline characteristics, recruitment feasibility, and EMA feasibility and acceptability were examined. Participants attended focus groups to further inform quantitative data.

Results

Reddit yielded a larger proportion of eligible individuals than Facebook, and 86% of the final enroled sample was recruited via Reddit. The average compliance rate of 75% is in line with other studies of similar populations. Half the sample reported alcohol use, and 78% reported the urge to drink at least once, supporting feasibility of EMA for collecting alcohol use data. Participants reported low burden and high acceptability of the study on both quantitative and qualitative measures. Baseline low maternal self-efficacy was associated with greater EMA compliance, and first-time mothers reported lower EMA burden compared to veteran mothers. College graduates, and participants with lower drinking refusal self-efficacy and greater alcohol severity were more likely to report alcohol use on EMA.

Conclusions

Future studies should consider Reddit as a recruitment strategy. Findings generally support feasibility and acceptability of EMA to assess HED in postpartum mothers.

Enrollment and Retention of Participants in Remote Digital Health Studies: Scoping Review and Framework Proposal

BACKGROUND

Digital technologies are increasingly used in health research to collect real-world data from wider populations. A new wave of digital health studies relies primarily on digital technologies to conduct research entirely remotely. Remote digital health studies hold promise to significant cost and time advantages over traditional, in-person studies. However, such studies have been reported to typically suffer from participant attrition, the sources for which are still largely understudied.

OBJECTIVE

To contribute to future remote digital health study planning, we present a conceptual framework and hypotheses for study enrollment and completion. The framework introduces 3 participation criteria that impact remote digital health study outcomes: (1) participant motivation profile and incentives or nudges, (2) participant task complexity, and (3) scientific requirements. The goal of this study is to inform the planning and implementation of remote digital health studies from a person-centered perspective.

METHODS

We conducted a scoping review to collect information on participation in remote digital health studies, focusing on methodological aspects that impact participant enrollment and retention. Comprehensive searches were conducted on the PubMed, CINAHL, and Web of Science databases, and additional sources were included in our study from citation searching. We included digital health studies that were fully conducted remotely, included information on at least one of the framework criteria during recruitment, onboarding or retention phases of the studies, and included study enrollment or completion outcomes. Qualitative analyses were performed to synthesize the findings from the included studies.

RESULTS

We report qualitative findings from 37 included studies that reveal high values of achieved median participant enrollment based on target sample size calculations, 128% (IQR 100%-234%), and median study completion, 48% (IQR 35%-76%). Increased median study completion is observed for studies that provided incentives or nudges to extrinsically motivated participants (62%, IQR 43%-78%). Reducing task complexity for participants in the absence of incentives or nudges did not improve median study enrollment (103%, IQR 102%-370%) or completion (43%, IQR 22%-60%) in observational studies, in comparison to interventional studies that provided more incentives or nudges (median study completion rate of 55%, IQR 38%-79%). Furthermore, there were inconsistencies in measures of completion across the assessed remote digital health studies, where only around half of the studies with completion measures (14/27, 52%) were based on participant retention throughout the study period.

CONCLUSIONS

Few studies reported on participatory factors and study outcomes in a consistent manner, which may have limited the evidence base for our study. Our assessment may also have suffered from publication bias or unrepresentative study samples due to an observed preference for participants with digital literacy skills in digital health studies. Nevertheless, we find that future remote digital health study planning can benefit from targeting specific participant profiles, providing incentives and nudges, and reducing study complexity to improve study outcomes.

Randomized controlled trial of Sunnyside: Individual versus group-based online interventions to prevent postpartum depression

BACKGROUND

Postpartum depression (PPD) is a serious mental health problem that has a prevalence rate of nearly 20% in the first three months after delivery. The purpose of this study was to evaluate the benefit of Sunnyside, an internet-based cognitive-behavioral intervention, delivered in a group format compared to the same intervention delivered individually for the prevention of PPD.

METHOD

210 people between 20- and 28-weeks gestation and who scored between 5 and 14 on the PHQ-8 and who did not meet criteria for major depression were recruited online. The Inventory of Depression and Anxiety Symptoms (IDAS), the Hamilton Rating Scale for Depression (HAMD), and the depression and anxiety modules of the MINI were obtained at baseline, post-treatment, and 12-weeks postpartum. Intervention adherence was measured by site usage.

RESULTS

Across self-report and interview measures of depression there were no significant differences in outcome between the group and the individual versions of the program. Rates of major depression and generalized anxiety disorder in the postpartum period were low and adherence to the conditions was similarly high. Participants in the individual condition were significantly more satisfied than participants in the group condition (p < 0.05).

LIMITATIONS

The sample was predominantly white (85%) and recruited online, which may limit generalizability.

CONCLUSIONS

The group intervention was not more effective than the individual intervention. However, ignoring groups, many measures improved over time. The results of this study provide evidence that mood symptoms improve when participating in an online preventive intervention for postpartum depression.

Protocol for the Let's Grow randomised controlled trial: examining efficacy, cost-effectiveness and scalability of a m-Health intervention for movement behaviours in toddlers

INTRODUCTION

Despite being an important period for the development of movement behaviours (physical activity, sedentary behaviour and sleep), few interventions commencing prior to preschool have been trialled. The primary aim of this trial is to assess the 12-month efficacy of the Let's Grow mHealth intervention, designed to improve the composition of movement behaviours in children from 2 years of age. Let's Grow is novel in considering composition of movement behaviours as the primary outcome, using non-linear dynamical approaches for intervention delivery, and incorporating planning for real-world implementation and scale-up from its inception.

METHODS AND ANALYSIS

A randomised controlled trial will test the effects of the 12-month parental support mHealth intervention, Let's Grow, compared with a control group that will receive usual care plus electronic newsletters on unrelated topics for cohort retention. Let's Grow will be delivered via a purpose-designed mobile web application with linked SMS notifications. Intervention content includes general and movement-behaviour specific parenting advice and incorporates established behaviour change techniques. Intervention adherence will be monitored by app usage data. Data will be collected from participants using 24-hour monitoring of movement behaviours and parent report at baseline (T₀), mid-intervention (T₁; 6 months post baseline), at intervention conclusion (T₂; 12 months post baseline) and 1-year post intervention (T₃; 2 years post baseline). The trial aims to recruit 1100 families from across Australia during 2021. In addition to assessment of efficacy, an economic evaluation and prospective scalability evaluation will be conducted.

ETHICS AND DISSEMINATION

The study was approved by the Deakin University Human Ethics Committee (2020-077). Study findings will be disseminated through publication in peer-reviewed journals, presentation at scientific and professional conferences, and via social and traditional media.

TRIAL REGISTRATION NUMBER

ACTRN12620001280998; U1111-1252-0599.

Adaptive Text Messaging for Postpartum Risky Drinking: Conceptual Model and Protocol for an Ecological Momentary Assessment Study (Preprint)

Background

Risky drinking is prevalent among women of childbearing age. Although many women reduce their drinking during pregnancy, more than half return to prepregnancy levels during the early postpartum period. Risky drinking in new mothers may be associated with negative child and maternal health outcomes; however, new mothers are unlikely to seek treatment for risky drinking because of stigma and fear of child protective service involvement. SMS text messaging is a promising approach for reaching non–treatment-seeking new mothers at risk because of risky drinking. SMS text messaging interventions (TMIs) are empirically supported for alcohol use, but a tailored intervention for new mothers does not exist. This study aims to fill this gap by developing a just-in-time adaptive TMI for postpartum risky drinking.

Objective

The objectives of this paper are to present a preliminary conceptual model of postpartum risky drinking and describe the protocol for conducting an ecological momentary assessment (EMA) study with new mothers to inform the refinement of the conceptual model and development of the TMI.

Methods

This paper presents a preliminary conceptual model of postpartum risky drinking based on the motivational model of alcohol use, social cognitive theory, and temporal self-regulation theory. The model proposes three primary intervention targets: motivation, self-efficacy, and self-regulation. Theoretical and empirical literature in support of the conceptual model is described. The paper also describes procedures for a study that will collect EMA data from 30 participants recruited via social media and the perinatal Central Intake system of New Jersey. Following the baseline assessment, EMA surveys will be sent 5 times per day for 14 days. The assessment instruments and data analysis procedures are described.

Results

Recruitment is scheduled to begin in January 2022 and is anticipated to conclude in March 2022. Study results are estimated to be published in July 2022.

Conclusions

The study findings will enhance our understanding of daily and momentary fluctuations in risk and protective factors for risky drinking during the early postpartum period. The findings will be used to refine the conceptual model and inform the development of the TMI. The next steps for this work include the development of intervention components via an iterative participatory design process and testing of the resulting intervention in a pilot microrandomized trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36849

The experience of remote recruitment for Essential Coaching for Every Mother during the coronavirus disease 2019 pandemic

Introduction and aims:

Due to physical distancing recommendations because of the COVID-19 pandemic, recruitment approaches for perinatal research needed to shift from in-person to remote. The purpose of this study is to describe the recruitment and retention of women for an mHealth intervention study for Essential Coaching for Every Mother.

Methods:

Three methods were used for recruitment: social media, posters in hospital, and media outreach. First time mothers were eligible for enrollment antenatally (37+ weeks) and postnatally (<3 weeks). Eligibility screening occurred remotely via text message. Outcomes were days to recruit 75 participants, eligibility vs. ineligibility rates, dropout and exclusion reasons, survey completion rates, perinatal timing of enrollment, and recruitment sources.

Results:

Recruitment ran from 15 July to 19 September 2020 (67 days) with 200 potential participants screened and 88 enrolled. It took 50 days to enroll 75 participants. Women recruited antenatally were more likely to receive all intervention messages (68 vs. 19%) and miss fewer messages (6.4 vs. 13.8) than women enrolled postnatally. Participants heard about the study through family/friends (31%), news (20%), Facebook groups/ads (30%), posters (12%), or other (7%).

Conclusion:

Antenatal recruitment resulted in participants enrolling earlier and receiving more messages. Remote recruitment was a feasible way to recruit, with word of mouth and media outreach being most successful, followed by Facebook.

Use of Facebook, Instagram, and Twitter for recruiting healthy participants in nutrition-, physical activity-, or obesity-related studies: a systematic review

BACKGROUND

There are limited systematic reviews exploring the use of social media for recruiting participants specifically for nutrition-, physical activity-, and obesity-related studies.

OBJECTIVES

The aim was to conduct a systematic review on the effectiveness of using social media (Facebook, Instagram, and Twitter) for recruiting healthy participants in nutrition-, physical activity-, or obesity-related studies.

METHODS

Studies were identified from 5 databases and included if they reported the number of participants recruited by social media (Facebook, Instagram, or Twitter) vs. traditional (print, e-mail, etc.). The effectiveness of recruitment was compared between methods by study procedures (in-person vs. online procedures). The cost-effectiveness of methods was also explored. The protocol was published in the Prospero database (ID# CRD42020204414).

RESULTS

Twenty-six studies were included. Among studies with both types of recruitment methods, 49% of the sample was reached through traditional methods, 40% through social media, and the rest by other methods. For in-person study procedures, the median number of participants recruited using social media was 19 (range: 3-278) and for online study procedures, it was 298 (range: 3-17,069). Median recruitment cost using social media (n = 14 studies) was $11.90 (range: $0-517) per participant, while this varied considerably for traditional methods depending on how it was calculated ($214, $18.9-$777). The ratio of participants reached vs. recruited was 0.12%; the overall ratio of participants interactions vs. recruited was 21.2%.

CONCLUSIONS

For in-person study procedures, traditional recruitment methods were more effective than social media, but for online study procedures, about half reported that social media was more effective. While more potential participants were reached through social media, only 21.2% of those who interacted with ads were enrolled. With the increased use of social media, their use for recruitment may be more frequent; therefore, future reviews may show different results.

Depressed and Socioeconomically Disadvantaged Mothers' Progression Into a Randomized Controlled Mobile Mental Health and Parenting Intervention: A Descriptive Examination Prior to and During COVID-19

Infants of low-income and depressed mothers are at high risk for poor developmental outcomes. Early parenting mediates infant experiences from birth, and early intervention can support sensitive and responsive parent practices that optimize infant outcomes via promoting developmental competencies. However, low-income and depressed mothers experience substantial challenges to participating in early intervention. They also have extremely limited access to interventions targeting depression. Interventions targeting maternal depression and parent practices can improve maternal and infant outcomes. Mobile internet-based interventions overcome numerous barriers that low-resource mothers face in accessing home-based interventions. Pandemic-related stressors likely reduce family resources and exacerbate distress of already heavily-burdened mother-infant dyads. During crises such as the COVID-19 pandemic, evidence-based remote coaching interventions are paramount. This article reports on a mobile intervention for improving maternal mood and increasing parent practices that promote infant development. An ongoing randomized controlled trial study provided a unique opportunity to monitor progression from referral to intervention initiation between two groups of depressed mothers: those prior to the pandemic and during the pandemic. The study also examines mother and infant characteristics at baseline. The sample consisted primarily of Black mothers experiencing extreme poverty who self-referred to the study in a large southern city, which is one of the most income disparate in the United States. Prior to the pandemic, 97% of study participants successfully progressed from consent to intervention, as compared to significantly fewer–86%–during the pandemic. Mother-infant dyads during COVID-19, as compared to those prior to COVID-19, displayed similar pre-intervention demographic characteristics and intrapersonal characteristics.

Community midwives' and health visitors' experiences of research recruitment: a qualitative exploration using the Theoretical Domains Framework

BACKGROUND

Successful research is frequently hampered by poor study recruitment, especially in community settings and with participants who are women and their children. Health visitors (HVs) and community midwives (CMs) are well placed to invite young families, and pregnant and postnatal women to take part in such research, but little is known about how best to support these health professionals to do this effectively.

AIM

This study uses the Theoretical Domains Framework (TDF) to explore the factors that influence whether HVs and CMs invite eligible patients to take part in research opportunities.

METHOD

HVs (n = 39) and CMs (n = 22) working in four NHS Trusts and one community partnership in England completed an anonymous, online survey with open-ended questions about their experiences of asking eligible patients to take part in the research. Qualitative data were analysed using directed content analysis and inductive coding to identify specific barriers and enablers to patient recruitment within each of the 14 theoretical domains.

FINDINGS

Six key TDF domains accounted for 81% of all coded responses. These were (a) environmental context and resources; (b) beliefs about capabilities; (c) social/professional role and identity; (d) social influences; (e) goals; (f) knowledge. Key barriers to approaching patients to participate in the research were time and resource constraints, perceived role conflict, conflicting priorities, and particularly for HVs, negative social influences from patients and researchers. Enablers included feeling confident to approach patients, positive influence from peers, managers and researchers, beliefs in the relevance of this behaviour to health care and practice and good knowledge about the study procedures, its rationale and the research topic. The findings suggest that to improve research recruitment involving HVs and CMs, a package of interventions is needed to address the barriers and leverage the enablers to participant approach.

Minding the Gatekeepers: Referral and Recruitment of Postpartum Mothers with Depression into a Randomized Controlled Trial of a Mobile Internet Parenting Intervention to Improve Mood and Optimize Infant Social Communication Outcomes

Mothers in the United States (U.S.) who are of non-dominant culture and socioeconomically disadvantaged experience depression during postpartum at a rate 3 to 4 times higher than mothers in the general population, but these mothers are least likely to receive services for improving mood. Little research has focused on recruiting these mothers into clinical intervention trials. The purpose of this article is to report on a study that provided a unique context within which to view the differential success of three referral approaches (i.e., community agency staff referral, research staff referral, and maternal self-referral). It also enabled a preliminary examination of whether the different strategies yielded samples that differed with regard to risk factors for adverse maternal and child outcomes. The examination took place within a clinical trial of a mobile intervention for improving maternal mood and increasing parent practices that promote infant social communication development. The sample was recruited within the urban core of a large southern city in the U.S. and was comprised primarily of mothers of non-dominant culture, who were experiencing severe socioeconomic disadvantage. Results showed that mothers self-referred at more than 3.5 times the rate that they were referred by either community agency staff or research staff. Moreover, compared to women referred by research staff, women who self-referred and those who were referred by community gatekeepers were as likely to eventually consent to study participation and initiate the intervention. Results are discussed with regard to implications for optimizing referral into clinical intervention trials.

Associations between parental food choice motives, health-promoting feeding practices, and infants' fruit and vegetable intakes: the Food4toddlers study

Background

Parents influence their infants’ diets and are the providers of healthy foods such as fruit and vegetables. Parental motives can influence infant’s diets directly or through parental feeding practices.

Objective

This study aimed to assess the associations between parental food choice motives and infants’ fruit and vegetable intakes and to examine whether parental feeding practices mediated these associations.

Design

A total of 298 parents participated in the Norwegian Food4toddlers study. Before the child’s first birthday (mean age = 10.9 months), the parents completed an online baseline questionnaire. Five parental food choice motives were assessed: health, convenience, sensory appeal, price, and familiarity. Infants’ fruit and vegetable intakes and three health-promoting feeding practices were also assessed. For each food choice motive and its relation to fruit or vegetable intake, three single mediation models were conducted. Mediation effects were examined using MacKinnon’s product of coefficients procedure, and bootstrap confidence intervals (CIs) were used for inferential testing.

Results

Higher scores on the motive of health were positively associated with infants’ vegetable intake (τ = 0.394, P < 0.001). No other significant associations were found between food choice motives and fruit or vegetable intake. The feeding practice of shaping a healthy environment mediated the relationships between health motive and both fruit (αβ = 0.067, CI: 0.001–0.146) and vegetable (αβ = 0.105, CI: 0.042–0.186) intakes. The feeding practice of encouraging balance and variety mediated the relationships between health motive and vegetable (αβ = 0.085, CI: 0.030–0.150) intake and between sensory appeal motive and vegetable intake (αβ = 0.047, CI: 0.005–0.103).

Conclusion

High levels of parental health motive are associated with higher infant vegetable intake. Our study contributes to understand the structure of parental feeding behaviors that may have implication for nutrition interventions targeting parents.

Recruitment and retention of mothers of preschoolers and school-aged children in a social media-delivered healthy eating intervention: lessons learned from a randomized controlled trial

BACKGROUND

Social media represent cost-effective platforms to advance the dissemination and uptake of health research to improve population health. However, there is limited evidence available to support researchers overcome methodological challenges related to recruitment and retention of participants in studies using social media for delivering behavior change interventions. This study aims to describe the recruitment and the retention strategies used in a randomized controlled trial (RCT) that evaluated a blog-delivered healthy eating intervention among mothers of preschoolers and school-aged children.

METHODS

Eighty-four adult mothers of children aged between two and 12 years old living in Quebec City, Quebec, Canada, were recruited between October 2015 and February 2017 using traditional methods (e.g. institutional email lists, flyers, newspapers, and word of mouth) and Facebook advertisements. Retention rates were calculated at the end of the 6-month intervention and at a 12-month follow-up assessment. Sociodemographic characteristics, Internet use behaviors and retention rates of mothers recruited through traditional methods and Facebook were compared using Wilcoxon-Mann-Whitney tests and Fisher exact tests.

RESULTS

Of the 196 mothers who responded to the recruitment call, 87 (44.4%) were eligible and 84 (42.9%) were randomized to the trial, representing a recruitment success of 76.4% (84/110) from the planned sample size target. Among those, a minority (3.6%) were recruited using Facebook. Those mothers presented similar sociodemographic characteristics to those recruited using traditional methods. Retention rates were 73.8% and 66.7% at 6 and 12 months, respectively, with similar rates between mothers recruited using Facebook and traditional methods. Various challenges associated with population retention were highlighted with lack of time being mothers' main reason for withdrawing from the study.

CONCLUSIONS

The methodological challenges experienced during the conduct of the blog-delivered healthy eating intervention allowed to draw upon several lessons regarding the recruitment process and the retention of mothers of preschoolers and school-aged children to inform future social media-delivered research. Recommendations for future research include exploring mothers' perceptions and preferences to tailor social media recruitment, ensure that interventions are delivered to them using social media platforms that are already integrated into their routine, and are providing remote outcome assessments to increase participant retention.

TRIAL REGISTRATION

Clinical Trial Protocol NCT03156803 . Registered on 17 May 2017, retrospectively registered.

Engagement design in studies on pregnancy and infant health using social media: Systematic review

Social media utilization is prevalent among reproductive-age women. The literature on how researchers engage women in studies using social media platforms is scarce. This systematic review analyzed participant engagement design in studies using social media and focused on pregnancy and infant health.

METHODS

A literature search of EBSCO and PubMed databases was conducted. Included studies had to be completed with quantitative data, focus on pregnancy, postpartum or infant health, and use social media in the research process. A matrix of three engagement designs (passive, interactive, independent) and three research processes (recruitment, data analysis, intervention) was used for analysis.

FINDINGS

Thirty-one articles that reported 30 studies met the inclusion criteria. Of these, four were randomized controlled trials (RCT), four were non-RCT interventions, and 22 were observational/descriptive studies. The main purpose of using social media was for recruitment (n = 16), data analysis (n = 6), intervention (n = 8), or both recruitment and intervention (n = 1). Passive engagement was a fundamental design approach in all studies to access a data source that was either the participant or the data provided by the participants in social media. Interactive engagement, mostly for recruitment and intervention, was to engage participants in completing study enrollment or in interacting with the study team or fellow participants. Independent engagement involved off-line activities and appeared sporadically in intervention studies.

CONCLUSIONS

Passive and interactive engagement designs are more frequently used than independent engagement design. Researchers should select suitable designs when studying pregnancy and infant health using social media.

Google AdWords and Facebook Ads for Recruitment of Pregnant Women into a Prospective Cohort Study With Long-Term Follow-Up

Objectives Several types of epidemiologic studies suffer from decreasing participation rates, resulting in potential selection bias and delay or termination of studies. We aimed to determine the feasibility of online methods for recruitment of pregnant women into a prospective cohort study. Methods In addition to traditional recruitment through prenatal care providers, we advertized participation in the PRegnancy and Infant DEvelopment (PRIDE) Study, an ongoing prospective cohort study with long-term follow-up in The Netherlands enrolling women in early pregnancy, through Google AdWords (30 days) and Facebook Ads (31 and 27 days) campaigns between September 2016 and January 2017. We calculated costs per eligible participant and compared demographics, health-related characteristics, and follow-up rates between participants recruited through online methods and prenatal care providers. Results During the study period, we recruited six women through AdWords (€54.28 per participant), 59 through Facebook (€10.17 per participant), and 327 through prenatal care providers (no valid cost estimate available). Facebook participants seemed to be younger (29.0 vs. 30.7 years), to have a higher body mass-index and/or low/intermediate education (27.0 vs. 24.0 kg/m² and 41 vs. 25%, respectively), and to start prenatal care in secondary care more often (12 vs. 5%) than participants recruited through prenatal care providers. Item non-response and loss to follow-up rates were higher among women recruited online than among those recruited through prenatal care providers. Conclusion Google AdWords did not contribute substantially, but Facebook Ads may complement traditional recruitment methods of pregnant women into prospective cohort studies, despite challenges that may threaten internal validity.

A systematic evaluation of digital nutrition promotion websites and apps for supporting parents to influence children's nutrition

Background

Globally children’s diet quality is poor. Parents are primary gatekeepers to children’s food intake; however, reaching and engaging parents in nutrition promotion can be challenging. With growth in internet and smartphone use, digital platforms provide potential to disseminate information rapidly to many people. The objectives of this review were to conduct a comprehensive and systematic evaluation of nutrition promotion via websites and apps supporting parents to influence children’s nutrition, from three different perspectives: 1) current evidence base, 2) end user (parent) experience and 3) current commercial offerings.

Methods

Three systematic reviews were undertaken of (1) studies evaluating the effectiveness for digital platforms for improving nutrition in children and parents, (2) studies conducting user-testing of digital tools with parents, (3) websites and apps providing lunch-provision information to parents. Searches were conducted in five databases for reviews one and two, and systematic search of Google and App Store for review three. Randomised controlled trials, cohort and cross-sectional and qualitative studies (study two only) were included if published in English, from 2013, with the intervention targeted at parents and at least 50% of intervention content focused on nutrition. Search results were double screened, with data extracted into standardised spreadsheets and quality appraisal of included search results.

Results

Studies evaluating digital nutrition interventions targeting parents (n = 11) demonstrated effectiveness for improving nutrition outcomes, self-efficacy and knowledge. Six of the included randomised controlled trials reported digital interventions to be equal to, or better than comparison groups. User-testing studies (n = 9) identified that digital platforms should include both informative content and interactive features. Parents wanted evidence-based information from credible sources, practical tools, engaging content and connection with other users and health professionals. Websites targeting lunch provision (n = 15) were developed primarily by credible sources and included information-based content consistent with dietary guidelines and limited interactive features. Lunchbox apps (n = 6), developed mostly by commercial organisations, were more interactive but provided less credible information.

Conclusions

Digital nutrition promotion interventions targeting parents can be effective for improving nutrition-related outcomes in children and parents. As demonstrated from the lunchbox context and user-testing with parents, they need to go beyond just providing information about positive dietary changes, to include the user-desired features supporting interactivity and personalisation.

The influence of social media on child feeding practices and beliefs among Hispanic mothers: A mixed methods study

OBJECTIVES

(1) To identify factors that influence child feeding practices and beliefs among Hispanic mothers in a low-income community; (2) to describe the use of social media, other internet websites, and text messaging among Hispanic mothers; and (3) to explore mothers' perceptions of social media and/or text messaging interventions to prevent childhood obesity.

METHODS

Mixed methods descriptive study with a sequential explanatory design. Hispanic mothers (N = 66) from Detroit, Michigan with children between 6 and 36 months of age completed surveys regarding their child feeding practices, the source (s) influencing these practices, and their use of social media, internet, and text messaging. During qualitative interviews (N = 19), we explored mothers' use of social media and internet websites to find child health information as well as mothers' perspectives on social media/internet/text messaging interventions to promote child health.

RESULTS

Most survey respondents were between the ages of 20 and 39 years. One-third of mothers breastfed their child for >6 months; 68% did not introduce solids until their child was older than 6 months. The majority (96%) owned a cellphone; 75% used social media at least once daily. Few mothers indicated that social media and other internet websites influenced their child feeding decisions. During qualitative interviews (N = 19), almost all mothers expressed interest in social media and/or text messaging as a tool to communicate information regarding child health and feeding.

CONCLUSIONS

Hispanic mothers had high rates of social media use and most desired social media/internet/text messaging interventions to promote child health.

Recruitment through media and general practitioners resulted in comparable samples in an RCT on incontinence

OBJECTIVES

The objective of the study was to assess the impact of recruitment strategy on the baseline characteristics of patients recruited in a randomized controlled trial for treating women with urinary incontinence.

STUDY DESIGN AND SETTING

We conducted a cross-sectional analysis of baseline data from an earlier trial. Women were recruited through the media (including social media) or from participating general practices. Baseline characteristics were compared by univariate testing. Logistic regression analysis was performed to study the association between recruitment type and multiple baseline characteristics.

RESULTS

The only differences between recruitment methods were in patient age, with those recruited through the media being significantly older than those recruited through general practice. The mean age difference was 5.0 years (95% confidence interval: 2.2-7.9).

CONCLUSION

Samples recruited through the media and through case identification were largely comparable. Therefore, recruitment through the media may be a viable alternative to recruitment through primary care. This may be especially relevant for research on eHealth treatment for conditions with which patients experience barriers when seeking health care.

A Mixed Methods Study to Explore the Effects of Program Design Elements and Participant Characteristics on Parents' Engagement With an mHealth Program to Promote Healthy Infant Feeding: The Growing Healthy Program

Purpose: Mobile health (mHealth) interventions have great potential to promote health. To increase consumer engagement in mHealth interventions it is necessary to address factors that influence the target demographic. The Growing healthy (GH) program is the first obesity prevention program delivered via a smartphone app and website offering evidence-based information on infant feeding from birth until 9 months of age. This sub-study aimed to explore how the design features, quality of the app and participant characteristics influenced parents' engagement with the GH app. Methods: A sequential mixed methods design was used. The GH app participants (225/301) were considered for this sub-study. Participant app engagement was measured through a purpose-built Engagement Index (EI) using app metrics. Participants were categorized as low, moderately or highly engaged based on their EI score upon completing the 9 months program and were then invited to participate in semi-structured telephone interviews. Participants who used the app program, given an EI score and expressed interest to participate in these interviews were eligible. The interviews explored factors that influenced app engagement including delivery features and quality. Thematic analysis networks was used for analysis. Results: 108/225 expressed interest and 18 interviews were conducted from low (n = 3), moderately (n = 7), or highly (n = 8) engaged participants based on purposeful sampling. Participants defined as highly engaged were likely to be a first-time parent, felt the app content to be trustworthy and the app design facilitated easy navigation and regularly opened the push notifications. Participants defined as having low or moderate engagement were likely to have experience from previous children, felt they had sufficient knowledge on infant feeding and the app did not provide further information, or experienced technological issues including app dysfunction due to system upgrades. Conclusions/Implications: This study demonstrated a novel approach to comprehensively analyse engagement in an mHealth intervention through quantitative (Engagement Index) and qualitative (interviews) methods. It provides an insight on maximizing data collected from these programs for measuring effectiveness and to understand users of various engagement levels interaction with program features. Measuring this can determine efficacy and refine programs to meet user requirements.

The Food4toddlers study - study protocol for a web-based intervention to promote healthy diets for toddlers: a randomized controlled trial

BACKGROUND

Eating habits are established during childhood and track into adolescence and later in life. Given that these habits have a large public health impact and influence the increasing rates of childhood obesity worldwide, there is a need for effective, evidence-based prevention trials promoting healthy eating habits in the first 2 years of life. The aim of this study was to develop and evaluate the effect of an eHealth intervention called Food4toddlers, aiming to promote healthy dietary habits in toddlers by targeting parents' awareness of their child's food environment (i.e., how food is provided or presented) and eating environment (e.g., feeding practices and social interaction). This paper describes the rationale, development, and evaluation design of this project.

METHODS/DESIGN

We developed a 6-month eHealth intervention, with the extensive user involvement of health care nurses and parents of toddlers. This intervention is in line with the social cognitive theory, targeting the interwoven relationship between the person, behavior, and environment, with an emphasis on environmental factors. The intervention website includes recipes, information, activities, and collaboration opportunities. The Food4toddlers website can be used as a mobile application. To evaluate the intervention, a two-armed pre-post-follow-up randomized controlled trial is presently being conducted in Norway. Parents of toddlers (n = 404) were recruited via social media (Facebook) and 298 provided baseline data of their toddlers at age 12 months. After baseline measurements, participants were randomly allocated to an intervention group or control group. Primary outcomes are the child's diet quality and food variety. All participants will be followed up at age 18 months, 2 years, and 4 years.

DISCUSSION

The results of this trial will provide evidence to increase knowledge about the effectiveness of an eHealth intervention targeting parents and their toddler's dietary habits.

TRIAL REGISTRATION

ISRCTN92980420 . Registered 13 September 2017. Retrospectively registered.

Consumer Engagement in Mobile Application (App) Interventions Focused on Supporting Infant Feeding Practices for Early Prevention of Childhood Obesity

Background and Aims: There has been increasing interest in using mobile applications ("apps") for innovative health service delivery and public health interventions. This paper describes two independent studies investigating mothers' or pregnant women's perceptions of, interest in and experiences with technological devices, apps and websites about infant feeding practices. Methods: Study 1 was a cross-sectional survey conducted with 107 pregnant women in their third trimester in late 2016 and early 2017. Multiple logistic regression analyses were conducted to examine factors associated with their app usage. The second was a qualitative study of 29 mothers of infants aged <1 year conducted in 2014. Thematic network analysis was used to explore the themes from the transcribed interviews. Results: Study 1 found that the use of apps was common among the pregnant women, with 100% having previously downloaded an app on their phone either free or paid. About 60% had used an app for health purposes. The majority reported that they were likely to use an app promoting healthy infant feeding practices, including 30% extremely likely and 53% very likely. Women with university or other tertiary level of education were more likely to use an app for promoting healthy infant feeding practices than those with other levels of education (adjusted odds ratio 3.22, 95% confidence interval 1.28-8.13). The qualitative interviews found that all the mothers were interested in a mobile program to support them with infant feeding practices. Participants felt they would benefit from individualized messages although did not want them to be sent too frequently. Further, participants also expressed the importance of having non-judgmental information and they were interested in receiving information using different modes such as videos, SMS or an app. Conclusions: Both studies suggest that using apps for promoting healthy infant feeding practices is acceptable from the perspective of mothers. There is great potential for health promotion practitioners to be engaged in app development for the purpose of promoting health in early years and health promotion in general.

A Practical Do-It-Yourself Recruitment Framework for Concurrent eHealth Clinical Trials: Simple Architecture (Part 1)

Background

The ability to identify, screen, and enroll potential research participants in an efficient and timely manner is crucial to the success of clinical trials. In the age of the internet, researchers can be confronted with large numbers of people contacting the program, overwhelming study staff and frustrating potential participants.

Objective

This paper describes a “do-it-yourself” recruitment support framework (DIY-RSF) that uses tools readily available in many academic research settings to support remote participant recruitment, prescreening, enrollment, and management across multiple concurrent eHealth clinical trials.

Methods

This work was conducted in an academic research center focused on developing and evaluating behavioral intervention technologies. A needs assessment consisting of unstructured individual and group interviews was conducted to identify barriers to recruitment and important features for the new system.

Results

We describe a practical and adaptable recruitment management architecture that used readily available software, such as REDCap (Research Electronic Data Capture) and standard statistical software (eg, SAS, R), to create an automated recruitment framework that supported prescreening potential participants, consent to join a research registry, triaging for management of multiple trials, capture of eligibility information for each phase of a recruitment pipeline, and staff management tools including monitoring of participant flow and task assignment/reassignment features. The DIY-RSF was launched in July 2015. As of July 2017, the DIY-RSF has supported the successful recruitment efforts for eight trials, producing 14,557 participant records in the referral tracking database and 5337 participants in the center research registry. The DIY-RSF has allowed for more efficient use of staff time and more rapid processing of potential applicants.

Conclusions

Using tools already supported at many academic institutions, we describe the architecture and utilization of an adaptable referral management framework to support recruitment for multiple concurrent clinical trials. The DIY-RSF can serve as a guide for leveraging common technologies to improve clinical trial recruitment procedures.

Facilitators and challenges in recruiting pregnant women to an infant obesity prevention programme delivered via telephone calls or text messages

Background

Recruitment of pregnant women into trials is a challenge exacerbated by a number of factors, including strict eligibility criteria. There has been little in-depth examination of the recruitment process to trials involving pregnant women. This paper presents the findings of a study conducted to identify facilitators and challenges in recruiting pregnant women to the Communicating Healthy Beginnings Advice by Telephone (CHAT) randomised controlled trial, which aims to reduce the prevalence of infant and childhood obesity.

Methods

Data were collected from (1) administration of a short questionnaire to women at the time of recruitment exploring women’s reasons for consent and non-consent; (2) interviews with recruiters to capture recruiters’ experiences of the recruitment process; and (3) analysis of field notes taken by recruiters on the number of women approached/recruited and reasons as to why they did not consent to participate. Data obtained were triangulated to gain insights into the process of recruiting pregnant women.

Results

A total of 1155 pregnant women (mean gestational age 31.5 weeks) were enrolled over 5 months. The main reasons for women consenting to participate in the study were convenience in programme delivery mode via telephone calls or text messages, altruism and because the programme was free of charge. The main reasons for women not consenting were lack of interest, language challenges/difficulty speaking English and some felt they did not need information and support due to prior experience as a mother. Facilitators included organisational support, rapport with recruiters and some women with no other children who needed advice. Despite the challenges, the mode of delivery of intervention via telephone calls or text messages, the minimal effort required of women to participate, organisational support from the lead site and recruiters’ knowledge of and commitment towards the trial contributed towards successful recruitment.

Conclusion

Despite some challenges in recruiting pregnant women to an infant obesity prevention programme, some of the facilitators in recruitment included mode of delivery of the intervention programme via telephone calls or text messages, the minimal effort required for women to participate, organisational support from the lead site, and recruiters’ knowledge of and commitment towards the trial.

Trial registration

The CHAT RCT is registered with the Australian Clinical Trial Registry (ACTRN12616001470482p); Ethics Review Committee of Sydney Local Health District (Protocol No. X16–0360 & LNR/16/RPAH/495).

Participant Recruitment and Retention in Remote eHealth Intervention Trials: Methods and Lessons Learned From a Large Randomized Controlled Trial of Two Web-Based Smoking Interventions

BACKGROUND

Despite having many advantages, online eHealth trials are not without challenges-notably, participant recruitment, and outcome data retention. Moreover, publications from these trials rarely provide detailed information on the methods used for recruitment and retention or discuss implications of the methods for future studies.

OBJECTIVE

To address this need for empirical guidance regarding recruitment and outcome data retention planning, we aim to describe the methods and lessons learned from the recruitment and retention procedures used in a large randomized trial of 2 Web-based smoking cessation interventions.

METHODS

To ensure a demographically and geographically diverse participant sample, we used the recruitment strategies (1) traditional, (2) Web-based, and (3) online survey panel methods and adaptively modified each in response to recruitment success. At baseline, participants indicated how they heard about the study and answered demographic questions. To maximize trial retention at each of the 3-, 6-, and 12-month assessment points, 4 survey modalities (first Web, followed by phone, mail, and postcard) were sequentially timed over a 30-day period. Participants received US $25 for submitting their responses, regardless of modality, and received an additional US $10 bonus for completing the Web survey within 24h of electronic notification.

RESULTS

We randomized 2637 smokers in 16 months and achieved 88% retention at 12-months. Participants (79.26% female, 72.60% Caucasian) were recruited from all 50 states. The majority of participants were recruited through Facebook (49.43%), followed by the survey panel (20.85%), free internet sources (14.54%), traditional media (11.34%), and Google ads (3.84%). Descriptively, participant demographics varied by recruitment source. Of the completed follow-up surveys, most were completed by Web (92%). Retention rates did not vary by recruitment source.

CONCLUSIONS

Continuous monitoring and refinement of multiple recruitment methods, particularly of online advertising campaigns, allowed us to maximize the effectiveness of recruitment strategies in recruiting a large, diverse sample of smokers. Likewise, offering multiple follow-up survey modalities in sequential order along with time-dependent bonus incentives enabled us to obtain outcome data from a very high level of enrolled participants for the duration of the trial protocol. These strategies may be similarly useful in other trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01812278; https://clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/71gy5GLvO).

Web-Based Recruitment and Survey Methodology to Maximize Response Rates from Followers of Popular Diets: the Adhering to Dietary Approaches for Personal Taste (ADAPT) Feasibility Survey

BACKGROUND

Although there is interest in popular diets such as vegan and vegetarian, Paleo, and other "whole food" diets, existing cohort studies lack data for these subgroups. The use of electronic data capture and Web-based surveys in nutrition research may be valuable for future studies by allowing targeting of specific dietary subgroups.

OBJECTIVE

The aim was to perform a Feasibility Survey (FS) to assess the practicality of Web-based research methods to gather data and to maximize response rates among followers of popular diets.

METHODS

The FS was an open, voluntary, 15-min survey conducted over 8 wk in the summer of 2015. Recruitment targeted self-identified followers of popular diets from a convenience sample, offering no incentives, via social media and e-newsletters shared by recruitment partners. Feasibility was assessed by number of responses, survey completion rate, distribution of diets, geographic location, and willingness to participate in future research.

RESULTS

A total of 14,003 surveys were initiated; 13,787 individuals consented, and 9726 completed the survey (71% of consented). The numbers of unique visitors to the questionnaire site, view rate, and participation rate were not captured. Among respondents with complete demographic data, 83% were female and 93% were white. Diet designations were collapsed into the following groups: whole-food, plant-based (25%); vegan and raw vegan (19%); Paleo (14%); try to eat healthy (11%); vegetarian and pescatarian (9%); whole food (8%); Weston A Price (5%); and low-carbohydrate (low-carb) (4%). Forced-response, multiple-choice questions produced the highest response rates (0-2% selected "prefer not to answer"). The percentage who were willing to complete future online questionnaires was 86%, diet recall was 93%, and food diary was 75%; the percentages willing to provide a finger-stick blood sample, venipuncture blood sample, urine sample, and stool sample were 60%, 44%, 58%, and 42%, respectively.

CONCLUSIONS

This survey suggests that recruiting followers of popular diets is feasible with the use of Web-based methods. The unbalanced sample with respect to sex and race/ethnicity could be corrected with specific recruitment strategies using targeted online marketing techniques.

Guelph Family Health Study: pilot study of a home-based obesity prevention intervention

OBJECTIVE

To examine the feasibility and preliminary impact of a home-based obesity prevention intervention among Canadian families.

METHODS

Families with children 1.5-5 years of age were randomized to one of three groups: (1) four home visits (HV) with a health educator, emails, and mailed incentives (4HV; n = 17); (2) two HV, emails, and mailed incentives (2HV; n = 14); or (3) general health advice through emails (control; n = 13). Parents randomized to the 2HV and 4HV groups completed post-intervention satisfaction surveys. At baseline and post-intervention, parents reported frequency of family meals and their children's fruit, vegetable, and sugar-sweetened beverage (SSB) intake. We assessed the children's physical activity, sedentary behaviour, and sleep using accelerometers and their % fat mass using bioelectrical impedance analysis. Differences in outcomes at post-intervention, controlling for baseline, were examined using generalized estimating equations.

RESULTS

Of the 44 families enrolled, 42 (96%) had 6-month outcome data. Satisfaction with the intervention was high; 80% were "very satisfied" and 20% were "satisfied." At post-intervention, children randomized to the 4HV and 2HV groups had significantly higher fruit intake and children randomized to the 2HV group had significantly lower percentage of fat mass, as compared to the control. No significant intervention effect was found for frequency of family meals, the children's vegetable or SSB intake, physical activity, sedentary behaviour, or sleep.

CONCLUSIONS

Our results suggest that the delivery of a home-based intervention is feasible among Canadian families and may lead to improved diet and weight outcomes among children. A full-scale trial is needed to test the effectiveness of this home-based intervention.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02223234.

Impact of the Growing Healthy mHealth Program on Maternal Feeding Practices, Infant Food Preferences, and Satiety Responsiveness: Quasi-Experimental Study

Background

Infancy is an important life stage for obesity prevention efforts. Parents’ infant feeding practices influence the development of infants’ food preferences and eating behaviors and subsequently diet and weight. Mobile health (mHealth) may provide a feasible medium through which to deliver programs to promote healthy infant feeding as it allows low cost and easy access to tailored content.

Objective

The objective of this study was to describe the effects of an mHealth intervention on parental feeding practices, infant food preferences, and infant satiety responsiveness.

Methods

A quasi-experimental study was conducted with an mHealth intervention group (Growing Healthy) and a nonrandomized comparison group (“Baby's First Food"). The intervention group received access to a free app with age-appropriate push notifications, a website, and an online forum that provided them with evidence-based advice on infant feeding for healthy growth from birth until 9 months of age. Behavior change techniques were selected using the Behaviour Change Wheel framework. Participants in both groups completed three Web-based surveys, first when their infants were less than 3 months old (baseline, T1), then at 6 months (time 2, T2), and 9 months of age (time 3, T3). Surveys included questions on infant feeding practices and beliefs (Infant Feeding Questionnaire, IFQ), satiety responsiveness (Baby Eating Behaviour Questionnaire), and infant’s food exposure and liking. Multivariate linear regression models, estimated using maximum likelihood with bootstrapped standard errors, were fitted to compare continuous outcomes between the intervention groups, with adjustment for relevant covariates. Multivariate logistic regression adjusting for the same covariates was performed for categorical outcomes.

Results

A total of 645 parents (Growing Healthy: n=301, Baby's First Food: n=344) met the eligibility criteria and were included in the study, reducing to a sample size of 546 (Growing Healthy: n=234, Baby's First Food: n=312) at T2 and a sample size of 518 (Growing Healthy: n=225, Baby's First Food: n=293) at T3. There were approximately equal numbers of boy and girl infants, and infants were aged less than 3 months at baseline (Growing Healthy: mean 7.0, SD 3.7 weeks; Baby's First Food: mean 7.9, SD 3.8 weeks), with Growing Healthy infants being slightly younger than Baby's First Food infants (P=.001). All but one (IFQ subscale “concerns about infant overeating or becoming overweight” at T2) of the measured outcomes did not differ between Growing Healthy and Baby's First Food.

Conclusions

Although mHealth can be effective in promoting some health behaviors and offers many advantages in health promotion, the results of this study suggest that design and delivery characteristics needed to maximize the impact of mHealth interventions on infant feeding are uncertain. The sensitivity of available measurement tools and differences in baseline characteristics of participants may have also affected the results.

Lessons From the Dot Contraceptive Efficacy Study: Analysis of the Use of Agile Development to Improve Recruitment and Enrollment for mHealth Research

Background

Smartphone apps that provide women with information about their daily fertility status during their menstrual cycles can contribute to the contraceptive method mix. However, if these apps claim to help a user prevent pregnancy, they must undergo similar rigorous research required for other contraceptive methods. Georgetown University’s Institute for Reproductive Health is conducting a prospective longitudinal efficacy trial on Dot (Dynamic Optimal Timing), an algorithm-based fertility app designed to help women prevent pregnancy.

Objective

The aim of this paper was to highlight decision points during the recruitment-enrollment process and the effect of modifications on enrollment numbers and demographics. Recruiting eligible research participants for a contraceptive efficacy study and enrolling an adequate number to statistically assess the effectiveness of Dot is critical. Recruiting and enrolling participants for the Dot study involved making decisions based on research and analytic data, constant process modification, and close monitoring and evaluation of the effect of these modifications.

Methods

Originally, the only option for women to enroll in the study was to do so over the phone with a study representative. On noticing low enrollment numbers, we examined the 7 steps from the time a woman received the recruitment message until she completed enrollment and made modifications accordingly. In modification 1, we added call-back and voicemail procedures to increase the number of completed calls. Modification 2 involved using a chat and instant message (IM) features to facilitate study enrollment. In modification 3, the process was fully automated to allow participants to enroll in the study without the aid of study representatives.

Results

After these modifications were implemented, 719 women were enrolled in the study over a 6-month period. The majority of participants (494/719, 68.7%) were enrolled during modification 3, in which they had the option to enroll via phone, chat, or the fully automated process. Overall, 29.2% (210/719) of the participants were enrolled via a phone call, 19.9% (143/719) via chat/IM, and 50.9% (366/719) directly through the fully automated process. With respect to the demographic profile of our study sample, we found a significant statistical difference in education level across all modifications (P<.05) but not in age or race or ethnicity (P>.05).

Conclusions

Our findings show that agile and consistent modifications to the recruitment and enrollment process were necessary to yield an appropriate sample size. An automated process resulted in significantly higher enrollment rates than one that required phone interaction with study representatives. Although there were some differences in demographic characteristics of enrollees as the process was modified, in general, our study population is diverse and reflects the overall United States population in terms of race/ethnicity, age, and education. Additional research is proposed to identify how differences in mode of enrollment and demographic characteristics may affect participants’ performance in the study.

Trial Registration

ClinicalTrials.gov NCT02833922; http://clinicaltrials.gov/ct2/show/NCT02833922 (Archived by WebCite at http://www.webcitation.org/6yj5FHrBh)

Key Lessons and Impact of the Growing Healthy mHealth Program on Milk Feeding, Timing of Introduction of Solids, and Infant Growth: Quasi-Experimental Study

Background

The first year of life is an important window to initiate healthy infant feeding practices to promote healthy growth. Interventions delivered by mobile phone (mHealth) provide a novel approach for reaching parents; however, little is known about the effectiveness of mHealth for child obesity prevention.

Objective

The objective of this study was to determine the feasibility and effectiveness of an mHealth obesity prevention intervention in terms of reach, acceptability, and impact on key infant feeding outcomes.

Methods

A quasi-experimental study was conducted with an mHealth intervention group (Growing healthy) and a nonrandomized comparison group (Baby’s First Food). The intervention group received access to a free app and website containing information on infant feeding, sleep and settling, and general support for parents with infants aged 0 to 9 months. App-generated notifications directed parents to age-and feeding-specific content within the app. Both groups completed Web-based surveys when infants were less than 3 months old (T1), at 6 months of age (T2), and 9 months of age (T3). Survival analysis was used to examine the duration of any breastfeeding and formula introduction, and cox proportional hazard regression was performed to examine the hazard ratio for ceasing breast feeding between the two groups. Multivariate logistic regression with adjustment for a range of child and parental factors was used to compare the exclusive breastfeeding, formula feeding behaviors, and timing of solid introduction between the 2 groups. Mixed effect polynomial regression models were performed to examine the group differences in growth trajectory from birth to T3.

Results

A total of 909 parents initiated the enrollment process, and a final sample of 645 parents (Growing healthy=301, Baby’s First Food=344) met the eligibility criteria. Most mothers were Australian born and just under half had completed a university education. Retention of participants was high (80.3%, 518/645) in both groups. Most parents (226/260, 86.9%) downloaded and used the app; however, usage declined over time. There was a high level of satisfaction with the program, with 86.1% (143/166) reporting that they trusted the information in the app and 84.6% (170/201) claiming that they would recommend it to a friend. However, some technical problems were encountered with just over a quarter of parents reporting that the app failed to work at times. There were no significant differences between groups in any of the target behaviors. Growth trajectories also did not differ between the 2 groups.

Conclusions

An mHealth intervention using a smartphone app to promote healthy infant feeding behaviors is a feasible and acceptable mode for delivering obesity prevention intervention to parents; however, app usage declined over time. Learnings from this study will be used to further enhance the program so as to improve its potential for changing infant feeding behaviors.

Enrolling Underserved Women in mHealth Programs: Results From Text4baby Outreach Campaigns

Public health practitioners have increasingly leveraged technology-based communication to get health information into the hands of hard-to-reach populations; however, best practices for outreach and enrollment into mobile health (mHealth) programs are lacking. This article describes enrollment results from campaigns focused on enrolling underserved pregnant women and mothers in Text4baby-a free, mHealth service-to inform outreach strategies for mHealth programs. Text4baby participants receive health and safety information, interactive surveys, alerts, and appointment reminders through at least three weekly texts and a free app-timed to users' due date or babies' birth date. Text4baby worked with partners to implement national, state, and community-based enrollment campaigns. Descriptive statistics were used to compare baseline enrollment prior to a campaign with enrollment during a campaign to generate enrollment estimates. Enrollment rates were calculated for campaigns for which the number targeted/reached was available. National television campaigns resulted in more than 10,000 estimated enrollments. Campaigns that were integrated with an existing program and text-based recruitment had the highest enrollment rates, ranging from 7% to 24%. Facebook advertisements and traditional media targeting providers and consumers were least effective. mHealth programs should consider text-based recruitment and outreach via existing programs; additional research is needed on return on investment for different outreach strategies and on the effectiveness of different outreach strategies at reaching and enrolling specific target populations.

Feasibility and Efficacy of a Parent-Focused, Text Message-Delivered Intervention to Reduce Sedentary Behavior in 2- to 4-Year-Old Children (Mini Movers): Pilot Randomized Controlled Trial

Background

Despite public health guidelines to limit sedentary behavior, many young children spend large amounts of time sedentary (eg, screen and sitting time) during waking hours.

Objective

The objective of this study was to test the feasibility and efficacy of a parent-focused, predominantly text message–delivered intervention to support parents to reduce the amount of time their children spend in sedentary behavior.

Methods

Mini Movers was a pilot randomized controlled trial delivered to parents of 2- to 4-year-old children in Melbourne, Australia. Participants were recruited through playgroups, social media, and snowball sampling. Eligibility criteria were having an ambulatory child (2-4 years), English literacy, and smartphone ownership. Participants were randomized to intervention or wait-list control on a 1:1 ratio after baseline data collection. The 6-week intervention was predominantly delivered via text messages, using a Web-based bulk text message platform managed by the interventionist. Intervention strategies focused on increasing parental knowledge, building self-efficacy, setting goals, and providing reinforcement, and were underpinned by the Coventry, Aberdeen & London-Refined taxonomy of behavior change techniques and social cognitive theory. The primary outcome was intervention feasibility, measured by recruitment, retention, intervention delivery, and fidelity; process evaluation questionnaires; and qualitative interviews with a subsample of participants. Secondary outcomes were children’s screen and restraint time (parent report), sitting time (parent report, activPAL), and potential mediators (parent report). Linear regression models were used to determine intervention effects on secondary outcomes, controlling for the child’s sex and age and clustering by playgroup; effect sizes (Cohen's d) were calculated.

Results

A total of 57 participants (30 intervention; 27 wait-list control) were recruited, and retention was high (93%). Process evaluation results showed that the intervention was highly acceptable to parents. The majority of intervention components were reported to be useful and relevant. Compared with children in the control group, children in the intervention group had significantly less screen time postintervention (adjusted difference [95% CI]=−35.0 [−64.1 to −5.9] min/day; Cohen's d=0.82). All other measures of sedentary behavior were in the expected direction, with small to moderate effect sizes.

Conclusions

Mini Movers was shown to be a feasible, acceptable, and efficacious pilot intervention for parents of young children, warranting a larger-scale randomized control trial.

Trial Registration

Australian New Zealand Clinical Trials registry: ACTRN12616000628448; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?ACTRN=12616000628448p (Archived by WebCite at http://www.webcitation.org/ 6wZcA3cYM)

Factors Influencing Engagement and Behavioral Determinants of Infant Feeding in an mHealth Program: Qualitative Evaluation of the Growing Healthy Program

Background

Infant feeding practices, including breastfeeding and optimal formula feeding practices, can play a role in the prevention of childhood obesity. The ubiquity of smartphone ownership among women of childbearing age provides important opportunities for the delivery of low-cost, broad reach parenting interventions delivered by mobile phone (mHealth or mobile health interventions). Little is known about how parents engage with mHealth programs targeting infant feeding and how such programs might influence infant feeding practices.

Objective

The objectives of this study were to explore participant views on (1) factors influencing engagement with the Growing healthy program, an mHealth program targeting healthy infant feeding practices from birth to 9 months of age, and (2) the ways in which the program influenced behavioral determinants of capability, opportunity, and motivation for breastfeeding and optimal formula feeding behaviors.

Methods

Semistructured, telephone interviews were conducted with a purposeful sample (n=24) of mothers participating in the Growing healthy program. Interviews explored participants’ views about engagement with the program and its features, and the ways the program influenced determinants of infant feeding behaviors related to breastfeeding and optimal formula feeding. The interview schedule was informed by the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

Results

Participants reported that engagement fluctuated depending on need and the degree to which the program was perceived to fit with existing parenting beliefs and values. Participants identified that the credibility of the program source, the user friendly interface, and tailoring of content and push notifications to baby’s age and key transition points promoted engagement, whereas technical glitches were reported to reduce engagement. Participants discussed that the program increased confidence in feeding decisions. For breastfeeding mothers, this was achieved by helping them to overcome doubts about breast milk supply, whereas mothers using formula reported feeling more confident to feed to hunger and satiety cues rather than encouraging infants to finish the bottle. Participants discussed that the program provided around-the-clock, readily accessible, nonjudgmental information and support on infant feeding and helped to reinforce information received by health professionals or encouraged them to seek additional help if needed. Participants reflected that their plans for feeding were typically made before joining the program, limiting the potential for the program to influence this aspect of motivation. Rather, the program provided emotional reassurance to continue with current feeding plans.

Conclusions

Our findings suggest that engagement with the program was influenced by an interplay between the program features and needs of the user. Participants reported that the program enhanced confidence in feeding decisions by providing a 24/7 accessible, expert, nonjudgmental support for infant feeding that complemented health professional advice. It is likely that interventions need to commence during pregnancy to maximize the impact on breastfeeding intentions and plans.

Facilitator and Participant Use of Facebook in a Community-Based Intervention for Parents: The InFANT Extend Program

BACKGROUND

Social networking sites such as Facebook afford new opportunities for behavior-change interventions. Although often used as a recruitment tool, few studies have reported the use of Facebook as an intervention component to facilitate communication between researchers and participants. The aim of this study was to examine facilitator and participant use of a Facebook component of a community-based intervention for parents.

METHODS

First-time parent groups participating in the intervention arm of the extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) Program were invited to join their own private Facebook group. Facilitators mediated the Facebook groups, using them to share resources with parents, arrange group sessions, and respond to parent queries. Parents completed process evaluation questionnaires reporting on the usefulness of the Facebook groups.

RESULTS

A total of 150 parents (from 27 first-time parent groups) joined their private Facebook group. There were a mean of 36.9 (standard deviation 11.1) posts/group, with the majority being facilitator posts. Facilitator administration posts (e.g., arranging upcoming group sessions) had the highest average comments (4.0), followed by participant health/behavior questions (3.5). The majority of participants reported that they enjoyed being a part of their Facebook group; however, the frequency of logging on to their groups' page declined over the 36 months of the trial, as did their perceived usefulness of the group.

CONCLUSIONS

Facebook appears to be a useful administrative tool in this context. Parents enjoyed being part of their Facebook group, but their reported use of and engagement with Facebook declined over time.

Assessing User Engagement of an mHealth Intervention: Development and Implementation of the Growing Healthy App Engagement Index

BACKGROUND

Childhood obesity is an ongoing problem in developed countries that needs targeted prevention in the youngest age groups. Children in socioeconomically disadvantaged families are most at risk. Mobile health (mHealth) interventions offer a potential route to target these families because of its relatively low cost and high reach. The Growing healthy program was developed to provide evidence-based information on infant feeding from birth to 9 months via app or website. Understanding user engagement with these media is vital to developing successful interventions. Engagement is a complex, multifactorial concept that needs to move beyond simple metrics.

OBJECTIVE

The aim of our study was to describe the development of an engagement index (EI) to monitor participant interaction with the Growing healthy app. The index included a number of subindices and cut-points to categorize engagement.

METHODS

The Growing program was a feasibility study in which 300 mother-infant dyads were provided with an app which included 3 push notifications that was sent each week. Growing healthy participants completed surveys at 3 time points: baseline (T1) (infant age ≤3 months), infant aged 6 months (T2), and infant aged 9 months (T3). In addition, app usage data were captured from the app. The EI was adapted from the Web Analytics Demystified visitor EI. Our EI included 5 subindices: (1) click depth, (2) loyalty, (3) interaction, (4) recency, and (5) feedback. The overall EI summarized the subindices from date of registration through to 39 weeks (9 months) from the infant's date of birth. Basic descriptive data analysis was performed on the metrics and components of the EI as well as the final EI score. Group comparisons used t tests, analysis of variance (ANOVA), Mann-Whitney, Kruskal-Wallis, and Spearman correlation tests as appropriate. Consideration of independent variables associated with the EI score were modeled using linear regression models.

RESULTS

The overall EI mean score was 30.0% (SD 11.5%) with a range of 1.8% - 57.6%. The cut-points used for high engagement were scores greater than 37.1% and for poor engagement were scores less than 21.1%. Significant explanatory variables of the EI score included: parity (P=.005), system type including "app only" users or "both" app and email users (P<.001), recruitment method (P=.02), and baby age at recruitment (P=.005).

CONCLUSIONS

The EI provided a comprehensive understanding of participant behavior with the app over the 9-month period of the Growing healthy program. The use of the EI in this study demonstrates that rich and useful data can be collected and used to inform assessments of the strengths and weaknesses of the app and in turn inform future interventions.

mHealth and Application Technology Supporting Clinical Trials: Today's Limitations and Future Perspective of smartRCTs

Nowadays, applications (apps) for smartphones and tablets have become indispensable especially for young generations. The estimated number of mobile devices will exceed 2.16 billion in 2016. Over 2.2 million apps are available in the Google Play store^®, and about 1.8 million apps are available in the Apple App Store^®. Google and Apple distribute nearly 70,000 apps each in the category Health and Fitness, and about 33,000 and 46,000 each in medical apps. It seems like the willingness to use mHealth apps is high and the intention to share data for health research is existing. This leads to one conclusion: the time for app-accompanied clinical trials (smartRCTs) has come. In this perspective article, we would like to point out the stones put in the way while trying to implement apps in clinical research. Further, we try to offer a glimpse of what the future of smartRCT research may hold.

Evaluating and improving recruitment and retention in an mHealth clinical trial: an example of iterating methods during a trial

BACKGROUND

Recruitment and retention strategy investigations in mHealth clinical trials are rare. Technology presents an opportunity to intensely and remotely evaluate recruitment, use of mobile apps, and retention, leading to new insights for continuous improvement of mHealth trials. The objective of this paper is to present a case study in which a trial evaluated and changed strategies during a clinical trial to improve recruitment, adherence to study protocols, and retention in the mHealth trial.

METHODS

In Fall 2015, the NUYou trial enrolled 150 college freshmen in an mHealth protocol. Three months after study initiation, NUYou struggled to meet recruitment goals and maintain anticipated usage levels of the study smartphone application. Two sets of data were collected to improve recruitment and retention: a survey about recruitment was sent to the target population and surveys regarding usability of the app was sent to the study sample. Survey results informed improvements in recruitment strategies, the study retention protocol, and the smartphone application.

RESULTS

Survey results revealed several insights including misunderstanding components of the trial by potential participants, low perceived usefulness of the app, and little recall or impact of the incentive structure. After implementation of user-centered improvements, the second cohort of NUYou recruitment in the fall of 2016 produced an equal sample size in 4 weeks less time. Winter quarter of 2016 compared to 2017 demonstrated an improvement in retention via app use and completion of weekly in-app surveys.

CONCLUSIONS

Recruitment and retention in clinical trials continues to be a critical challenge and mHealth trials may present both unique challenges and opportunities. To our knowledge, this is the first study to describe a systematic evaluation followed by changes and further evaluation to recruitment, use of the mHealth application, adherence to study protocol, and retention during an mHealth clinical trial. Future work should adopt and explicitly study these processes to optimize both enrollment and retention in these types of trials to preserve validity and reliability of research results.