Leah Leavitt1, Jennifer Schindler-Ruwisch1,

Monique Turner1 , Pamela Johnson2, Ada

Obi2, Jessica Bushar3, Sean D. Cleary1,

Indira Singh2 & Lorien Abroms1

1The George Washington University2Voxiva, Inc.3Zero to Three

NIDA: R44DA035017

Research reported in this presentation was supported by the National Institute On Drug Abuse of the National Institutes of Health under Award Number R44DA035017. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute Health.

Conflicts of Interest•Dr. Lorien Abroms has stock options in Voxiva, Inc. and has licensed Quit4Baby and Text2Quit to Voxiva, Inc.

•Dr. Pamela Johnson, Ada Obi & Indira Singh are currently employed by Voxiva, Inc.

•Jessica Bushar is employed by ZERO TO THREE, a partner operating the Text4baby service.

•Jennifer Schindler-Ruwisch, Leah Leavitt, Monique Turner and Sean D. Cleary have no relevant conflicts of interest to disclose.

Smoking during pregnancy

• Smoking during pregnancy leads to: low birth weight, preterm birth, fetal growth restriction, pregnancy complications such as ectopic pregnancies, and morbidities after the child is born (US HHS, 2014)

• 10.7% of women in the US smoked during the third trimester of their pregnancy in 2010 (Tong et al. 2013)

• Difficult to recruit low-income vulnerable populations to research, despite NIH goals to increase representation from these groups and Healthy People 2020 goals to decrease disparities (Barnett et al., 2012).

• A meta-analysis of 95 papers on recruitment/retention of hard to reach participants (Yancey, Ortega & Kumanyika, 2006) and a paper documenting successful recruitment of 941 pregnant/postpartum women in the Bronx, NY with a 98.1% retention rate (Barnett et al., 2012) found that among others, successful recruitment tips include:– Tailoring and targeting of recruitment and intervention materials

– Incentives

– Availability and accessibility

Background

Tailoring and targeting recruitment messages: Importance of framing

• Research suggests that both frame and emotion may be relevant to messages advising pregnant smokers to quit:

– Messages that are framed positively (i.e. a 25% chance of winning) are perceived differently than messages that are framed negatively (i.e. a 75% chance of losing) (Tversky & Kahneman, 1981) –but there are different kinds of gains and losses

– Emotion is also a well-studied area of health communication that suggests that different emotional appeals have differential impacts on health behaviors (Turner, 2011).

– In fact, looking to emotional appeals, we can frame gains in emotional terms (Nabi& Prestin, 2016)

Advantages of SMS enrollment• 90% of US adults own a cell phone, making mhealth is a promising

avenue to expand health care reach (Pew Research Center, 2015; WHO, 2011)

• Currently available smoking cessation texting programs have been found efficacious, more so for smoking than many other health behaviors (Head, Noar, Iannarino & Harrington, 2013).

• Advantages of using SMS for recruitment purposes:– Efficient/accessible/few barriers to reply

– Proactive messages interrupt you in the moment

– Quick turn-around

– Already interested/like text messaging medium

– Can reach stigmatized and hard to reach populations

Objectives

1. To determine the feasibility and effectiveness of recruitment through SMS

2. To understand if emotional framing influences recruitment

3. To understand if other message elements influence recruitment

Text4baby• Send free text-messages to

pregnant users (3x/week), timed around due date on a variety of pregnancy related health and development topics– 987,000 pregnant women

have been enrolled to date

Quit4baby• Provides free automated,

bidirectional text-messages with advice on quitting smoking tailored for pregnant women around due date and quit date– Offered to a select group of

Text4baby users

How can we best recruit pregnant smokers to join the Quit4baby study?

Emotionally Framed Messages• Test whether emotional appeal messages are likely to encourage responses to

join

Pride Empathy Free

O1: Feasibility and effectiveness of recruitment through SMS

Broadcast sent to new Text4Baby users on Tuesdays

Export phone numbers 1 hr., 4 hrs., 1 day & 3 days

post broadcast

Attempt via phone call within 1 hr. after export

Attempt via phone/text at least 4 times

within the first week of

initial response

0

20

40

60

80

100

120

140

160

180

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29Min

Time to response to recruitment broadcast53.12% responded within the first 30 min

enrolled

Response Time (N=1090)mean 3.5 hrs (SD = 12 hrs)median 23.5 minmax 9 days

Mean: 2.35 (SD=1.67)

Range 1 to 8 attempts

Attempts to enroll (N=199)95

33

20 21 21

4 4 10

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8

Participants Enrolled

Attempts

Recruitment Flowchart N=199

10,194 text4Baby users sent broadcast

Oct ‘15- Feb ‘16

1,038 (10.18%) Responded "yes" to

recruitment text

474 (45.66%) Unreachable

152 (14.64%) Refused

184 (17.73%) Ineligible

228 (21.97%) Eligible

199 (87.28%) Enrolled

O2: How does emotional framing influence recruitment?

10.37%8.99%

10.97%10.18%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Empathy Free Pride Total

Message Type

Responded to Text Made contact after initial response Eligible Enrolled

Fisher’s Exact Test P = .02

Fisher’s Exact Test P = .06

Eligibility and Refusal Rates

• Ineligibility among respondents was significantly different across messages

– Pride (22.26%) > Empathy (16.04%), p = .0306

• Refusal and enrollment rates did not significantly differ between groups

O3: Do other message elements influence recruitment?

Adding “now” Removing Incentive

Adding “Now”

There was no effect when including “now” in the recruitment message• Time to response• Response Rate• Enrollment Rate

Time to Response with “now”

O2: How does removing reference to incentive influence recruitment?

10.97%

7.18%

6.0%

3.0%2.04%

0.69%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

with incentive without incentiveMessage Type

Responded to Text Made contact after initial response Eligible Enrolled

Fisher’s Exact Test P = .0023

Fisher’s Exact Test P = .0107

Fisher’s Exact Test P = .0011

Results

• O1: Recruitment through Text4baby was feasible and effective– Most people responded within minutes

– Interest via SMS did not necessarily translate to enrollment

• O2: Emotional framing influences recruitment– Significantly more interest to emotional recruitment messages

– But study enrollment rate did not significantly differ between messages

• O3: Other message elements influence on recruitment– Adding urgency to SMS response doesn’t matter

– Removing incentive does matter

Future Direction

• Assess potential confounding factors systematically

• Test other emotion appeals

• Impact on cancellation rate from existing program

• Translation to program recruitment versus study recruitment

References• Barnett, J., Aguilar, S., Brittner, M., Bonuck, K. (2012). Recruiting and retaining low-income, multi-ethnic women into randomized controlled trials:

Successful strategies and staffing. Contemporary Clinical Trials, 33(5), 925-932.

• Head, K.J., Noar, S.M, Iannarino, N.T., Harrington, N.G. (2013). Efficacy of text messaging-based interventions for health promotion: A meta-analysis. Social Science & Medicine, 97, 41-48.

• Nabi, R.L. & Prestin, A. (2016). Unrealistic hope and unnecessary fear: Exploring how sensationalistic news stories influence health behavior. Health Communication, 17, 1-12.

• Pew Research Center (2015a). Mobile Technology Fact Sheet. Retrieved from: http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/

• Tong, V.T., Dietz, P.M., Morrow, B., D’Angelo, D.V., Farr, S.L…England, L.J. (2013). Trends in Smoking Before, During and After Pregnancy –Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, 2000-2010. Morbidity and Mortality Weekly Report, 62 (SS06), 1-19. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6206a1.htm?s_cid%3Dss6206a1_x#Tab2

• Turner, M. M. (2011). Using Emotional Appeals in Health Messages. In Cho, H. (Eds.) Health Communication Message Design: Theory and Practice(pp. 59-69). SAGE Publications. Retrieved from: https://books.google.com/books?id=MACkkuKWEqEC

• Tverksy, A. & Kahneman, K. (1981). The Framing of Decisions and the Psychology of Choice. Science, 211, 453-458.• U.S. Department of Health and Human Services (2014). The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Chapter 9: Reproductive Outcomes. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. • World Health Organization (2011). Mhealth: New horizons for health through mobile technologies. Retrieved from:

http://www.who.int/goe/publications/goe_mhealth_web.pdf

• Yancey, A.K., Ortega, A.N. & Kumanyika, S.K. (2006). Effective Recruitment and Retention of Minority Research Participants. Annual Review of Public Health, 27, 1-28.

Thank you! Any questions?

Leah_leavitt@gwmail.gwu.edu

jschindler@gwmail.gwu.edu

Discussion

• Recruitment technique was feasible for this specific population

• Persistent and frequent follow-up to enroll

• Framing of initial message is important

Enrollment by Week N=204

14 24 17 21 16

15

2518 16 16

17

5

0%5%

10%15%20%25%

% E

nro

lled

Day Broadcast Message was sent

Free Empathy Pride No Incentive

Demographics at Q4B Baseline* Mean (SD), Frequency (%)

Number of texts/day 91.08 (SD = 287.15)

Cigarettes smoked/day before pregnancy 16.70 (SD=10.72)

Cigarettes smoked/day during pregnancy 7.33 (SD=6.06)

Income

Up to $15,000 280 (56.34%)

$15,000-$30,000 151 (30.38%)

$30,001-$47,099 47 (9.46%)

$47,100 or more 19 (3.82%)

*N=507

Recruitment Flowchart N=199

10,194 text4Baby users received

broadcast

Empathy: 4,871

Free: 2,580

Pride: 2,743

1,038 (10.18%) Responded "yes" to

recruitment text

Empathy: 505 (10.37%)

Free: 232(8.99%)

Pride: 301 (10.97%)

152 (14.64%) Refused

Empathy: 85 (16.83%)

Free: 32 (13.79%)

Pride: 35 (11.63%)

184 (17.73%) Ineligible

Empathy: 81 (16.04%)

Free: 36 (15.52%)

Pride: 67 (22.26%)

228 (21.97%) Eligible

Empathy: 113 (22.38%)

Free: 52 (22.41%)

Pride: 63 (20.93%)

199 (87.28%) Enrolled

Empathy: 97 (85.84%)

Free: 46 (88.46%)

Pride: 56 (88.89%)

Demographics at Q4B Baseline* Mean (SD), Frequency (%)

Marital Status

Single 200 (39.53%)

Single/cohabitating (living with partner) 165 (32.61%)

Married 97 (19.17%)

Divorced/Separated 39 (7.17%)

Widowed 5 (0.99%)

Education

Did not graduate HS 138 (27.22%)

HS Graduate/GED or equivalent 164 (32.3%)

Some College/Associates Degree 185 (36.5%)

Bachelors Degree/Masters or Professional 20 (3.94%)

*N=507

Demographics at Q4B Baseline* Mean (SD), Frequency (%)

Employment

Part-time 86 (17.06%)

Full-time 79 (15.67%)

Unemployed 339 (67.26%)

Ethnicity

Hispanic or Latino 41 (8.17%)

Race

White 350 (67.18%)

Black/African American 130 (24.95%)

Other 41 (7.87%)

Phone type

Smartphone 436 (86.00%)

*N=507