Recruiting Children and Their Families for Clinical Trials: A Case Study William M. Vollmer, PhD, Stephanie Hertert, and Michael J. Allison Kaiser Permanente Center for Health Research, Portland, Oregon
ABSTRACT: We describe the recruitment of 226 families for participation in a randomized trial examining the effectiveness of alternative strategies for the management of pediatric asthma. All families were members of a large health maintenance organization. Families of children identified through emergency room and hospital admission records were much more likely to participate in the study than were families of children identified only through outpatient prescription records. Specific details of the recruitment process are described. KEY WORDS: recruitment, children, bronchial asthma, clinical trials INTRODUCTION Patient accrual can be the most difficult a n d labor-intensive part of a study, a n d researchers face an ongoing n e e d to identify recruitment strategies that are efficient and cost-effective [1,2]. In reviewing almost 100 articles, w e f o u n d that few studies provide detail about the overall recruitment process. Most focus o n the o u t c o m e of recruitment a n d on the d e m o g r a p h i c s of w h o is most likely to participate in health research [3-6]. Only a few articles dealt with the recruitment of families with y o u n g children [7-9]. This p a p e r discusses the recruitment strategies u s e d in a r a n d o m i z e d clinical trial that e x a m i n e d alternatives for m a n a g i n g pediatric a s t h m a within a large health maintenance organization. We c o m p a r e recruitment results for children with mild a n d with moderate-severe asthma and discuss recruitment techniques that did and did not work. We also p r e s e n t general r e c o m m e n dations for the recruitment of children.
METHODS Research Setting The C e n t e r for Health Research conducts basic health research using Kaiser P e r m a n e n t e (KP), N o r t h w e s t Region, as its research laboratory. KP is a large, federally qualified g r o u p practice health m a i n t e n a n c e organization, and the
Address reprint requests to: William M. VoUmer, PhD, Kaiser Permanente Center for Health Research, 3800 N. Kaiser Center Drive, Portland OR 97227. Received July 26, 1991; revised February 25, 1992.
ControlledClinicalTrials13:315-320(I992) © ElsevierSciencePublishingCo., Inc. 1992 655 Avenueof the Americas,New York,New York10010
315
0197-2456/92/$5.00
316
W.M. Vollmer et al. majority of participants in center studies are recruited from the health plan membership. The center maintains a core of permanent recruitment staff and trained on-call recruiters. A computerized patient tracking system facilitates the recruitment process.
ASTHMA Study Design The NIH-funded Alternative Strategies to Help Manage Asthma (ASTHMA) study compares the effectiveness of two supplemental approaches to the management of pediatric asthma: an established class-format program for parents and children and 24-hour access to a specially trained asthma advice nurse. A usual-care-only arm is also included. The study design includes a baseline interview and annual follow-up interviews for 2 years. A brief followup questionnaire is sent out every 4 months. No clinical measurements are involved. Thus the study makes modest demands on the families and involves no adverse risks. All English-speaking children, aged 4-14, who had been KP members for at least a year, whose parents were not planning to move out of the KP service area within the next 2 years, and who had active, doctor-diagnosed asthma were eligible to participate. The only exclusion criterion was cystic fibrosis. No screening visits were required. We gave priority to children in three categories: those hospitalized or seen in the emergency room or urgency care clinic for asthma during the 2 years prior to randomization; those referred by physicians as being particularly difficult to manage; and those taking steroids for their asthma. We refer to these children as the "moderate-severe" group. Additional children identified through pharmacy records are termed the "mild" group.
Identification of Subjects Since we needed to recruit 216 families over 4 months, we focused recruitment efforts on those children known to have asthma, particularly the moderate-severe group. We used a variety of sources to identify these subjects, including hard-copy urgency care and emergency room (ER) logs from the two KP hospitals, computerized inpatient records, computerized outpatient pharmacy records, and physician referral. Initial review of urgency care/ER logs identified 496 age-eligible children. Further review during recruitment yielded an additional 56 not previously identified moderate-severe subjects. The pharmacy database yielded a further 51 children who received steroids commonly used in the treatment of asthma, and chart review confirmed that 26 of these 51 had asthma. A final 27 children were identified through the inpatient database, physician referral, or call-in. Excluding 12 children whose physicians requested that they not participate and 61 families for w h o m we had no working phone numbers, these efforts resulted in a total of 532 children in the moderate-severe group. Subjects in the "mild" asthma group were identified from the pharmacy database as having filled a prescription for metaproterenol (Alupent), albuterol (Ventolin, Proventil), or theophylline (Theo-Dur, Slo-Bid). During pilot testing we discovered that more than 40% of these children did not have
317
Recruiting Children for Clinical Trials
asthma, and so reviewed the charts of the remaining children in this group before sending them the initial mailing. This review confirmed the diagnosis in 586 out of 1047 children. Excluding 64 children with no phone number resulted in a total of 522 children in the mild group. None of the pilot families was invited to participate in the full trial.
Recruitment Procedures
The actual recruitment process consisted of an initial postcard announcing the pending arrival of the invitation letter, a fact sheet and invitation letter mailed 2 days later, and a follow-up call to screen the participant and, if eligible, to schedule an appointment for a baseline visit. A key component of our initial recruitment strategy was to have each child's physician sign the invitation letter. We felt this would help ensure physician support and enhance recruitment rates. A physician coinvestigator signed the invitation letters for families in the moderate-severe group whose child did not have a personal physician listed in our records. Since this latter approach appeared to produce results comparable to those for other moderatesevere families, we adopted it for all subjects midway through the study in order to facilitate trial logistics. We felt comfortable making this change because of the near unanimous physician support for the study. Toward the end of the study the invitation letters to 63 mild asthma subjects were signed by the principal investigator, who was not a physician. This also did not appear to influence subject participation. For the full trial we mailed to subjects in cohorts and tracked the outcomes for each cohort separately. Cohorts were defined as groups of families that we attempted to contact beginning on a certain date. This facilitated recruitment planning and monitoring, since we could distinguish the final recruitment rates in our early cohorts from the more tentative recruitment rates of cohorts still being worked.
RESULTS Table 1 summarizes the recruitment results for the full trial. Data are presented separately for the moderate-severe and mild groups. In all, we attempted to recruit 1054 age-eligible children known to have asthma. Some Table 1
Comparison of Recruitment Outcomes for Mild and ModerateSevere Subjects
Severity Moderate-severe Mild Significanceb
No. Subjects Contacted
No. Scheduled for Visit
No. Randomizeda
532 522
257 (48%) 125 (24%) P .~ .0001
175 (68%) 69 (55%) P = .019
aRandomizationpercentages computed relative to number scheduled. bTwo-tailed significancelevels based on corrected~ statisticfor comparingmoderate-severeand mild groups.
318
W.M. Vollmer et al. turned out to be siblings, but our recruitment data do not allow us to make this distinction. We do know, however, that the 244 children w h o were ultimately randomized came from a total of 226 families. We scheduled randomization visits for 257 (48%) of the moderate-severe children and for 125 (24%) of the mild group children (corrected ×2 = 66.6, P < .0001). Of these 382 subjects, 175 (68%) from the moderate-severe group and 69 (55%) from the mild group ultimately were randomized (corrected ×2 = 5 . 5 1 , P -- .019). Overall, the randomization rate among eligible subjects was 33% for the moderate-severe group and 13% for the mild group. Subjects who did not show up for their first scheduled visit were rescheduled once and, if necessary, a second time. If they still did not show up, they were assumed to have refused. Fifty-five percent (211/382) of the children who were scheduled for randomization visits attended their initial appointment. Of the remaining 171 children, 66 (39%) rescheduled, and the rest refused to be rescheduled. The combined show rate for the 66 first and 27 second rescheduled appointments was 38% (35/93). Although this was significantly lower than the show rate for the initial appointment (corrected ×2 = 8.59, P = .003), it is still a good result. Over 50% (35/66) of the children who were initially rescheduled were ultimately randomized into the study, including 13 of 27 final reschedules. In scheduling clinic visits, late afternoon was better than early afternoon (more people showed up for their appointments). Also, even though Saturday visits were the easiest to schedule, they were the most commonly missed appointments. Availability of Saturday appointments was important and useful for a few participants, but we found it a good idea to screen these people thoroughly to see if they really couldn't come during the week.
DISCUSSION Recruiting families with young children poses special challenges for the health researcher. At least two individuals (parent and child) must attend the clinic visit, and parents often have to meet competing time demands (sports, music lessons, etc.). Transportation and child care can be complicating factors, especially for single parents. In contrast to previous studies suggesting that participants are likely to be healthier than nonparticipants [4,6], we found that study participation was higher in families of children with more severe asthma. Several factors may account for this finding. First, the studies by Greenlick et al. [4] and Criqui et al. [6] dealt with recruitment of individual adults, whereas our study dealt with children and parents. It may be that parents feel a greater sense of responsibility for their child's health and that individual adults are more apt to engage in self-denial. Second, most of our moderate-severe children had had recent asthma attacks requiring a hospital visit. This can be traumatic for both parent and child, and may have increased the parent's sense of responsibility for the child. Third, the advice nurse intervention offered greater access to the health care system with little effort required by the family. This may have been especially appealing to families of severely asthmatic children. Finally, most of our moderate-severe group families received an invitation letter signed by their child's personal physician, while most of the mild group
Recruiting Children for Clinical Trials
319
families received a letter signed by a study investigator (an allergist). While we feel that this shift did not appreciably affect our recruitment rates (see "Methods"), any effects that did exist will confound the association with severity. Little has been published on the efficacy of specific recruitment strategies. We attempted to increase recruitment rates by targeting high-risk asthmatics and using personalized physician letters. While the yield from the moderatesevere group was better for the mild group, this approach was very laborintensive. A mass mailing to all age-eligible children or to all children taking asthma medications might have been more cost-effective. In a study of dietary intervention in children with high cholesterol, for example, we abandoned prescreening for high-cholesterol children (by identifying their parents) in favor of a mass mailing to all age-eligible children. This proved to be more efficient, since many adults between the ages of 25 and 50 who had high cholesterol (our initial prescreen) did not have children with high cholesterol. Nevertheless, the decision to review emergency room logs was probably appropriate for the ASTHMA study because the study's focus was on the child with moderate-severe asthma; this population was limited in size; and we needed to recruit our sample within a narrow time frame. By contrast, we think our original use of physician letters was complicated and inefficient. Although physicians were cooperative, the technique was not worth the time and effort. An invitation letter from an allergist coinvestigator seemed to produce acceptable recruitment results and was simpler and less time consuming. While we believe that physicians need to be informed about research that affects patient care, they need not be actively involved in the recruitment process. Rather, the main goal should be to enlist their general support for the research. To this end we presented the study to physicians and other staff at a variety of departmental meetings and used our physician coinvestigators to actively promote the study among their colleagues. Our decision to tailor recruitment materials specifically for families of children with asthma was, in hindsight, also a mistake. We did not anticipate the large number of children (43%) who would be taking "asthma" medications for conditions other than asthma.Since the wording of our recruitment letter assumed that the child had asthma, we puzzled and distressed many pilot parents, and were forced to review all of the mild asthma charts by hand to confirm the diagnosis of asthma. A simple change of phrasing ("If your child has a s t h m a . . . ' ) would have prevented this problem and, in fact, we used this approach for our last cohort mailing, bypassing the chart review. Ultimately, it is important to distinguish generalizable findings from studyspecific conclusions. Clearly part of our approach to recruitment takes advantage of our close relationship with Kaiser Permanente. Nonetheless, much of it should apply to other settings. In particular, the recruitment materials must be written in an appealing, easy-to-read style. Our experience from a variety of studies suggests that attractive, brightly colored recruitment materials and "announcement" postcards increase both the number of eventual participants and the show rates for clinic appointments. In addition, the recruitment staff must be available to call when the parents are most likely to be home. Most of our recruitment staff worked from 5 to 9 p.m. Monday through Friday, and from 9 a.m. to 2 p.m. on Saturdays.
320
W.M. Vollmer et al. While m a n y lessons from s u r v e y research m a y a p p l y to recruitment, ind e p e n d e n t research o n recruitment m e t h o d o l o g y is also n e e d e d , especially for the "nuts-and-bolts" aspects. The research c o m m u n i t y has yet to acknowledge that good recruitment requires serious planning, evaluation, a n d revision. Typically, while time and m o n e y are allocated to planning, evaluating, and revising the clinical aspect of trials, the same is not true for the recruitment component. The authors gratefully acknowledge the editorial assistance of Mr. David Porter. Funding provided through NIH grant no. HL41964.
REFERENCES
1. Agras WS, Bradford RH: Recruitment: An introduction. Circulation 66(6FF2):lV2W5, 1982 2. Agras WS, Marshall GD, Kraemer HC" Planning recruitment. Circulation 66(6PT2):W54-IV58, 1982 3. Atkins KJ, Patterson TL, Roppe BE: Recruitment issues, health habits, and the decision to participate in a health promotion program. Am J Prev Med 3(2):87-94, 1987 4. Greenlick MR, Bailey JW, Wild J, Grover J: Characteristics of men most likely to respond to an invitation to be screened. Am J Public Health 69:1011-1015, 1979 5. Weintraub J, Leske GS, Ripa LW, Levinson A: Recruitment of a clinical field trial population: Reasons for nonparticipation. J Public Health Dept 40:141-143, 1980 6. Criqui MH, Barett-Conner E, Austin M: Differences between respondents and nonrespondents in a population-based cardiovascular disease study. Am J Epidemiol 108(5):367-372, 1978 7. Croft JB: Recruitment and participation of children in a long-term study of cardiovascular disease: The Bogalusa Heart Study, 1973-1982. Am J Epidemiol 120:436448, 1984 8. Nader PR, Sallis JF: The San Diego Family Health Project: Reaching families through the schools. J School Health (V56, N6), August 1986 9. Hooks PC, Tsong Y: Recruitment strategies for multiethnic family and community health research. Family Community Health 11(1):48-59, 1988
ABSTRACT: We describe the recruitment of 226 families for participation in a randomized trial examining the effectiveness of alternative strategies for the management of pediatric asthma. All families were members of a large health maintenance organization. Families of children identified through emergency room and hospital admission records were much more likely to participate in the study than were families of children identified only through outpatient prescription records. Specific details of the recruitment process are described. KEY WORDS: recruitment, children, bronchial asthma, clinical trials INTRODUCTION Patient accrual can be the most difficult a n d labor-intensive part of a study, a n d researchers face an ongoing n e e d to identify recruitment strategies that are efficient and cost-effective [1,2]. In reviewing almost 100 articles, w e f o u n d that few studies provide detail about the overall recruitment process. Most focus o n the o u t c o m e of recruitment a n d on the d e m o g r a p h i c s of w h o is most likely to participate in health research [3-6]. Only a few articles dealt with the recruitment of families with y o u n g children [7-9]. This p a p e r discusses the recruitment strategies u s e d in a r a n d o m i z e d clinical trial that e x a m i n e d alternatives for m a n a g i n g pediatric a s t h m a within a large health maintenance organization. We c o m p a r e recruitment results for children with mild a n d with moderate-severe asthma and discuss recruitment techniques that did and did not work. We also p r e s e n t general r e c o m m e n dations for the recruitment of children.
METHODS Research Setting The C e n t e r for Health Research conducts basic health research using Kaiser P e r m a n e n t e (KP), N o r t h w e s t Region, as its research laboratory. KP is a large, federally qualified g r o u p practice health m a i n t e n a n c e organization, and the
Address reprint requests to: William M. VoUmer, PhD, Kaiser Permanente Center for Health Research, 3800 N. Kaiser Center Drive, Portland OR 97227. Received July 26, 1991; revised February 25, 1992.
ControlledClinicalTrials13:315-320(I992) © ElsevierSciencePublishingCo., Inc. 1992 655 Avenueof the Americas,New York,New York10010
315
0197-2456/92/$5.00
316
W.M. Vollmer et al. majority of participants in center studies are recruited from the health plan membership. The center maintains a core of permanent recruitment staff and trained on-call recruiters. A computerized patient tracking system facilitates the recruitment process.
ASTHMA Study Design The NIH-funded Alternative Strategies to Help Manage Asthma (ASTHMA) study compares the effectiveness of two supplemental approaches to the management of pediatric asthma: an established class-format program for parents and children and 24-hour access to a specially trained asthma advice nurse. A usual-care-only arm is also included. The study design includes a baseline interview and annual follow-up interviews for 2 years. A brief followup questionnaire is sent out every 4 months. No clinical measurements are involved. Thus the study makes modest demands on the families and involves no adverse risks. All English-speaking children, aged 4-14, who had been KP members for at least a year, whose parents were not planning to move out of the KP service area within the next 2 years, and who had active, doctor-diagnosed asthma were eligible to participate. The only exclusion criterion was cystic fibrosis. No screening visits were required. We gave priority to children in three categories: those hospitalized or seen in the emergency room or urgency care clinic for asthma during the 2 years prior to randomization; those referred by physicians as being particularly difficult to manage; and those taking steroids for their asthma. We refer to these children as the "moderate-severe" group. Additional children identified through pharmacy records are termed the "mild" group.
Identification of Subjects Since we needed to recruit 216 families over 4 months, we focused recruitment efforts on those children known to have asthma, particularly the moderate-severe group. We used a variety of sources to identify these subjects, including hard-copy urgency care and emergency room (ER) logs from the two KP hospitals, computerized inpatient records, computerized outpatient pharmacy records, and physician referral. Initial review of urgency care/ER logs identified 496 age-eligible children. Further review during recruitment yielded an additional 56 not previously identified moderate-severe subjects. The pharmacy database yielded a further 51 children who received steroids commonly used in the treatment of asthma, and chart review confirmed that 26 of these 51 had asthma. A final 27 children were identified through the inpatient database, physician referral, or call-in. Excluding 12 children whose physicians requested that they not participate and 61 families for w h o m we had no working phone numbers, these efforts resulted in a total of 532 children in the moderate-severe group. Subjects in the "mild" asthma group were identified from the pharmacy database as having filled a prescription for metaproterenol (Alupent), albuterol (Ventolin, Proventil), or theophylline (Theo-Dur, Slo-Bid). During pilot testing we discovered that more than 40% of these children did not have
317
Recruiting Children for Clinical Trials
asthma, and so reviewed the charts of the remaining children in this group before sending them the initial mailing. This review confirmed the diagnosis in 586 out of 1047 children. Excluding 64 children with no phone number resulted in a total of 522 children in the mild group. None of the pilot families was invited to participate in the full trial.
Recruitment Procedures
The actual recruitment process consisted of an initial postcard announcing the pending arrival of the invitation letter, a fact sheet and invitation letter mailed 2 days later, and a follow-up call to screen the participant and, if eligible, to schedule an appointment for a baseline visit. A key component of our initial recruitment strategy was to have each child's physician sign the invitation letter. We felt this would help ensure physician support and enhance recruitment rates. A physician coinvestigator signed the invitation letters for families in the moderate-severe group whose child did not have a personal physician listed in our records. Since this latter approach appeared to produce results comparable to those for other moderatesevere families, we adopted it for all subjects midway through the study in order to facilitate trial logistics. We felt comfortable making this change because of the near unanimous physician support for the study. Toward the end of the study the invitation letters to 63 mild asthma subjects were signed by the principal investigator, who was not a physician. This also did not appear to influence subject participation. For the full trial we mailed to subjects in cohorts and tracked the outcomes for each cohort separately. Cohorts were defined as groups of families that we attempted to contact beginning on a certain date. This facilitated recruitment planning and monitoring, since we could distinguish the final recruitment rates in our early cohorts from the more tentative recruitment rates of cohorts still being worked.
RESULTS Table 1 summarizes the recruitment results for the full trial. Data are presented separately for the moderate-severe and mild groups. In all, we attempted to recruit 1054 age-eligible children known to have asthma. Some Table 1
Comparison of Recruitment Outcomes for Mild and ModerateSevere Subjects
Severity Moderate-severe Mild Significanceb
No. Subjects Contacted
No. Scheduled for Visit
No. Randomizeda
532 522
257 (48%) 125 (24%) P .~ .0001
175 (68%) 69 (55%) P = .019
aRandomizationpercentages computed relative to number scheduled. bTwo-tailed significancelevels based on corrected~ statisticfor comparingmoderate-severeand mild groups.
318
W.M. Vollmer et al. turned out to be siblings, but our recruitment data do not allow us to make this distinction. We do know, however, that the 244 children w h o were ultimately randomized came from a total of 226 families. We scheduled randomization visits for 257 (48%) of the moderate-severe children and for 125 (24%) of the mild group children (corrected ×2 = 66.6, P < .0001). Of these 382 subjects, 175 (68%) from the moderate-severe group and 69 (55%) from the mild group ultimately were randomized (corrected ×2 = 5 . 5 1 , P -- .019). Overall, the randomization rate among eligible subjects was 33% for the moderate-severe group and 13% for the mild group. Subjects who did not show up for their first scheduled visit were rescheduled once and, if necessary, a second time. If they still did not show up, they were assumed to have refused. Fifty-five percent (211/382) of the children who were scheduled for randomization visits attended their initial appointment. Of the remaining 171 children, 66 (39%) rescheduled, and the rest refused to be rescheduled. The combined show rate for the 66 first and 27 second rescheduled appointments was 38% (35/93). Although this was significantly lower than the show rate for the initial appointment (corrected ×2 = 8.59, P = .003), it is still a good result. Over 50% (35/66) of the children who were initially rescheduled were ultimately randomized into the study, including 13 of 27 final reschedules. In scheduling clinic visits, late afternoon was better than early afternoon (more people showed up for their appointments). Also, even though Saturday visits were the easiest to schedule, they were the most commonly missed appointments. Availability of Saturday appointments was important and useful for a few participants, but we found it a good idea to screen these people thoroughly to see if they really couldn't come during the week.
DISCUSSION Recruiting families with young children poses special challenges for the health researcher. At least two individuals (parent and child) must attend the clinic visit, and parents often have to meet competing time demands (sports, music lessons, etc.). Transportation and child care can be complicating factors, especially for single parents. In contrast to previous studies suggesting that participants are likely to be healthier than nonparticipants [4,6], we found that study participation was higher in families of children with more severe asthma. Several factors may account for this finding. First, the studies by Greenlick et al. [4] and Criqui et al. [6] dealt with recruitment of individual adults, whereas our study dealt with children and parents. It may be that parents feel a greater sense of responsibility for their child's health and that individual adults are more apt to engage in self-denial. Second, most of our moderate-severe children had had recent asthma attacks requiring a hospital visit. This can be traumatic for both parent and child, and may have increased the parent's sense of responsibility for the child. Third, the advice nurse intervention offered greater access to the health care system with little effort required by the family. This may have been especially appealing to families of severely asthmatic children. Finally, most of our moderate-severe group families received an invitation letter signed by their child's personal physician, while most of the mild group
Recruiting Children for Clinical Trials
319
families received a letter signed by a study investigator (an allergist). While we feel that this shift did not appreciably affect our recruitment rates (see "Methods"), any effects that did exist will confound the association with severity. Little has been published on the efficacy of specific recruitment strategies. We attempted to increase recruitment rates by targeting high-risk asthmatics and using personalized physician letters. While the yield from the moderatesevere group was better for the mild group, this approach was very laborintensive. A mass mailing to all age-eligible children or to all children taking asthma medications might have been more cost-effective. In a study of dietary intervention in children with high cholesterol, for example, we abandoned prescreening for high-cholesterol children (by identifying their parents) in favor of a mass mailing to all age-eligible children. This proved to be more efficient, since many adults between the ages of 25 and 50 who had high cholesterol (our initial prescreen) did not have children with high cholesterol. Nevertheless, the decision to review emergency room logs was probably appropriate for the ASTHMA study because the study's focus was on the child with moderate-severe asthma; this population was limited in size; and we needed to recruit our sample within a narrow time frame. By contrast, we think our original use of physician letters was complicated and inefficient. Although physicians were cooperative, the technique was not worth the time and effort. An invitation letter from an allergist coinvestigator seemed to produce acceptable recruitment results and was simpler and less time consuming. While we believe that physicians need to be informed about research that affects patient care, they need not be actively involved in the recruitment process. Rather, the main goal should be to enlist their general support for the research. To this end we presented the study to physicians and other staff at a variety of departmental meetings and used our physician coinvestigators to actively promote the study among their colleagues. Our decision to tailor recruitment materials specifically for families of children with asthma was, in hindsight, also a mistake. We did not anticipate the large number of children (43%) who would be taking "asthma" medications for conditions other than asthma.Since the wording of our recruitment letter assumed that the child had asthma, we puzzled and distressed many pilot parents, and were forced to review all of the mild asthma charts by hand to confirm the diagnosis of asthma. A simple change of phrasing ("If your child has a s t h m a . . . ' ) would have prevented this problem and, in fact, we used this approach for our last cohort mailing, bypassing the chart review. Ultimately, it is important to distinguish generalizable findings from studyspecific conclusions. Clearly part of our approach to recruitment takes advantage of our close relationship with Kaiser Permanente. Nonetheless, much of it should apply to other settings. In particular, the recruitment materials must be written in an appealing, easy-to-read style. Our experience from a variety of studies suggests that attractive, brightly colored recruitment materials and "announcement" postcards increase both the number of eventual participants and the show rates for clinic appointments. In addition, the recruitment staff must be available to call when the parents are most likely to be home. Most of our recruitment staff worked from 5 to 9 p.m. Monday through Friday, and from 9 a.m. to 2 p.m. on Saturdays.
320
W.M. Vollmer et al. While m a n y lessons from s u r v e y research m a y a p p l y to recruitment, ind e p e n d e n t research o n recruitment m e t h o d o l o g y is also n e e d e d , especially for the "nuts-and-bolts" aspects. The research c o m m u n i t y has yet to acknowledge that good recruitment requires serious planning, evaluation, a n d revision. Typically, while time and m o n e y are allocated to planning, evaluating, and revising the clinical aspect of trials, the same is not true for the recruitment component. The authors gratefully acknowledge the editorial assistance of Mr. David Porter. Funding provided through NIH grant no. HL41964.
REFERENCES
1. Agras WS, Bradford RH: Recruitment: An introduction. Circulation 66(6FF2):lV2W5, 1982 2. Agras WS, Marshall GD, Kraemer HC" Planning recruitment. Circulation 66(6PT2):W54-IV58, 1982 3. Atkins KJ, Patterson TL, Roppe BE: Recruitment issues, health habits, and the decision to participate in a health promotion program. Am J Prev Med 3(2):87-94, 1987 4. Greenlick MR, Bailey JW, Wild J, Grover J: Characteristics of men most likely to respond to an invitation to be screened. Am J Public Health 69:1011-1015, 1979 5. Weintraub J, Leske GS, Ripa LW, Levinson A: Recruitment of a clinical field trial population: Reasons for nonparticipation. J Public Health Dept 40:141-143, 1980 6. Criqui MH, Barett-Conner E, Austin M: Differences between respondents and nonrespondents in a population-based cardiovascular disease study. Am J Epidemiol 108(5):367-372, 1978 7. Croft JB: Recruitment and participation of children in a long-term study of cardiovascular disease: The Bogalusa Heart Study, 1973-1982. Am J Epidemiol 120:436448, 1984 8. Nader PR, Sallis JF: The San Diego Family Health Project: Reaching families through the schools. J School Health (V56, N6), August 1986 9. Hooks PC, Tsong Y: Recruitment strategies for multiethnic family and community health research. Family Community Health 11(1):48-59, 1988
