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Prevention of Attrition Keys to Successful Cohort Maintenance Patricia B. Crawford, DrPH, RD Adjunct Professor Co-Director, Center for Weight and Health.

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Presentation on theme: "Prevention of Attrition Keys to Successful Cohort Maintenance Patricia B. Crawford, DrPH, RD Adjunct Professor Co-Director, Center for Weight and Health."— Presentation transcript:

1 Prevention of Attrition Keys to Successful Cohort Maintenance Patricia B. Crawford, DrPH, RD Adjunct Professor Co-Director, Center for Weight and Health University of California, Berkeley

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3 Mission Provide leadership for the development of interdisciplinary, science-based solutions to body weight- and health-related problems, with a current focus on the prevention of pediatric overweight University of California, Berkeley

4 Literature reviews and synthesis School-based intervention studies Resources and materials for communities Conducting and translating epidemiologic studies Community-based intervention studies University of California, Berkeley

5 Berkeley University of California, Berkeley San Francisco

6 Berkeley Longitudinal Nutrition Study (BLNS) Aim: To examine the development of childhood obesity from birth to 5 years Design: Longitudinal study Measurements: Anthropometry, food and activity records and interviews, lipid profiles, underwater weighing. University of California, Berkeley

7 Berkeley Longitudinal Nutrition Study Retention YearVisitParticipants (n) months year years years years years years180 University of California, Berkeley

8 1980’s Overweight among black women was significantly higher than among white women and they experienced higher CVD mortality rates. University of California, Berkeley

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10 NHLBI Growth & Health Study (NGHS) (funded by National Institute of Heart, Lung & Blood, NIH) Aim: to track the development of obesity and other cardiovascular risk factors and to identify biological, social and psychological correlates of these risk factors. Measurements: diet, physical activity, anthropometry, self esteem and other psychosocial factors, blood pressure, lipids, glucose, insulin, health beliefs and attitudes, and family environment measures University of California, Berkeley

11 General Description of NGHS Design: –Prospective multi-site biracial cohort study Subjects: 2379 girls –1213 black –1166 white Ages: 9-10 years at baseline University of California, Berkeley

12 Locations Richmond, California Cincinnati, Ohio Washington, DC area University of California, Berkeley

13 Berkeley University of California, Berkeley San Francisco Richmond

14 Richmond, California* Population: ~100,000 16% of the population below poverty line High unemployment approaching 10% Over 1,000 violent crimes/year *statistics from University of California, Berkeley

15 Recruitment Strategies Richmond: census sample of girls enrolled in schools encompassed by Richmond Unified School District Cincinnati: Sampled at school level Washington, DC area: random sampling of HMO members with a few added volunteers.

16 YearAge Retention Rate (%) Richmond (n=887) Cincinnati (n=871) Wash. DC (n=621) Total (n=2379) 19 to to to to to to NGHS Retention Rates by site University of California, Berkeley

17 RichmondCincinnatiWash. DC Refused Not responsive Not located Distance Other Total not seen Percentage of girls not seen by reason by site University of California, Berkeley

18 Minimizing Attrition External validity Internal validity Statistical power

19 Prevention of Attrition Recruitment strategies Traditional retention strategies Key to success: enhanced strategies

20 Traditional Strategies – to Prevent Attrition Communication (7) Phone calls; directory assistance Letter; mail forwarding or certified mail Family and friend contacts Tracking (5) Private investigators, police department, social services, post office, driver's licenses, employment records, job, school, hospital and online databases Incentives (4) Cash, gifts, lottery, raffles Special Methods (1) Send birthday cards, check in often, organize events for participants Educate participants Provide transportation Staff Characteristics (1) Health promotion skills and knowledge and continuity of staff Refs: Aylward 1985; Goldman 1982; Gwadz 1992; Katz 2001; Lloyd 1999; Orr 1992; Pirie 1989; Psaty 1994; Senturia 1998 University of California, Berkeley

21 Communication Incentives Special Methods Staff Characteristics Tracking Traditional Strategies to Prevent Attrition University of California, Berkeley

22 IncentivesCommunication Special Methods Staff Characteristics Tracking Develop refusal conversion system Pilot test Communicate values, expectations, plans, etc. Develop comprehensive tracking system Keys to Success Hire culturally sensitive, respectful, flexible staff University of California, Berkeley

23 1. Staff Hiring Culturally sensitive Flexible Respectful “Customer” is always right University of California, Berkeley

24 2. Development of Tracking Systems Annual update and expansion of contact information Call records Hire a sleuth, problem solving, obsessive- compulsive interviewer University of California, Berkeley

25 _________________________________________________ TRADITIONAL CALL RECORD for Participant 1181 – Luann Stipes _________________________________________________ 1/9/98 — No answer. 1/10/98 —No answer. 1/12/98 —Called parents. No answer. 1/14/98 —Called parents. Wrong number. Called mother-in-law who said Luann has moved back Antioch. Her phone number there is (555) /15/98 —Called Luann. No answer. 1/16/98 — Reached Luann and scheduled her for Saturday, Jan. 27th at 11 am. Need to mail directions and date/time of appointment. University of California, Berkeley

26 CALL RECORD for Alicia Green th St., Richmond, CA (510) /4/98—1:35 pm— is disconnected. Tried father at (510) Left no message on answering machine. 5:40 pm—Called father’s number and reached Alicia’s brother. She does not have a phone, can be reached through this number. He said he’d relay a message. He said she can be reached at this number between 1 and 3 pm. I told him I’d try tomorrow. He said he’d relay the message. 3/5/98—1:00 pm--busy signal 1:20 pm—Reached Alicia. She is living with Dad and about to move into her own house. Seemed pleased to hear from me. Cooperative. busy now, but call next week. 3/12/98—1:30 pm—Answering machine, did not leave message 3/13/98 - 4:00 pm—Reached brother. Alicia has moved to own place. Got her phone number, Number is not in service. 3/14/98—7:00 pm—Tried Alicia’s number again. Still not in service. Called brother; reached father this time. He doesn’t have number for Alicia. Also says he doesn’t have her new address. Says I can call tomorrow morning at 10:00 am. 3/15/98—10:05 am—Reached brother. Alicia does not have a phone. Gave me her address: th Street in Richmond. Sent Alicia a note with my phone number, asking her to call me. 3/29/98—6:00 pm—Went to Alicia’s address. She was home and very happy to hear from us again. Scheduled her for clinic on 4/7 at 11:00 am. She is happy to have her own place, lives with her son. 4/7/98—Alicia came to clinic. Everything went well. Really cute little boy, named DeVonne.

27 University of California, Berkeley 3. Pilot Testing

28 4. Development of a Refusal Conversion System Hire/designate a specialist Use all information from past call records Take participants’ reservations seriously Minimize number of contacts Take the long view on participation Empathize, listen University of California, Berkeley

29 5. Communication Plan for retention, revise as needed Share what works Values, study goals, results High expectations University of California, Berkeley

30 IncentivesCommunication Special Methods Staff Characteristics Tracking Develop refusal conversion system Pilot test Communicate values, expectations, plans, etc. Develop comprehensive tracking system Key to success: leadership Hire culturally sensitive, respectful, flexible staff University of California, Berkeley

31 Study Leadership Plan and budget recruitment, tracking, cohort retention, refusal conversion Hire culturally sensitive interviewers with excellent communication skills Designate (or hire) specialized tracker and refusal converter staff Develop protocols and train staff Communicate with staff your values including respect, flexibility, and high expectations Celebrate every participant victory University of California, Berkeley

32 Using these methods... RaceWhiteBlack NS87%88% SiteRichmondCincinnati Washington DC p<.00193%81%90% Household IncomeLowMiddleUpper p<.0185%89%90% BMIMean for those retained18.58 NSMean for those lost to follow-up18.51 University of California, Berkeley Comparison of subjects retained and lost (Year 10)

33 NGHS Follow-up Studies Follow-up StudySite End Date Original Cohort Follow- up Retention Rate Fibromylagia and TMDBerkeley % Eating DisordersAll sites % PregnancyBerkeley % University of California, Berkeley

34 We streamlined the human subjects protection forms by using handwritten coversheets: Streamline the human subjects protection forms by using handwritten coversheets In order for your child to participate in the Growth and Health Study this year, you must sign the green consent form and return it to your child’s school before Thursday, October 15 th. Thank you, Pat Crawford Project Director University of California, Berkeley

35 Our blooper: Streamline the human subjects protection forms by using handwritten coversheets I order for your child to participate in the Growth and Health Study this year, you must sign the green consent form and return it to your child’s school before Thursday, October 15 th. Thank you, Pat Crawford Project Director University of California, Berkeley

36 Thank you Sheila Stern Sarah Krathwohl Zak Sabry NHLBI and all of the NGHS participants who have given generously of their time for almost 15 years! University of California, Berkeley Visit the Center for Weight and Health at


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