Reconnecting with urban youth enrolled in a randomized controlled trial and overdue for a 12-month follow-up survey.

BACKGROUND: Retention of study participants in randomized controlled trials (RCTs) is crucial to study validity. PURPOSE: We analyzed the results of four retention strategies used to reconnect with urban teens enrolled in a school-based RCT and overdue for a 12-month follow-up survey. METHODS: Traditional retention strategies used to reconnect with teens categorized as 'unable to contact' were weekly redials of nonworking telephone numbers and mailings to the student's home. Nontraditional retention strategies were obtaining assistance from school administration and performing outreach on Facebook. RESULTS: Of the 422 students enrolled, 125 (29.5%) were overdue for a 12-month follow-up survey, but had no working telephone number (unable to contact). We made 196 attempts to contact these 125 students, of which 82 attempts (41.8%) were successful in 'reconnecting' with the student. Using 'mailed reminder letters' as the referent category, odds ratios (95% confidence intervals) for the association between the strategy used and reconnecting were 4.60 (1.8-11.8), 1.94 (1.01-3.73), and 2.91 (0.58-14.50), respectively, for telephone number redials, Facebook outreach, and school administration assistance. Of the 422 students, 380 (90%) ultimately completed the 12-month follow-up survey. LIMITATIONS: Retention strategies were not applied hierarchically or systematically. We were unable to determine student preference for a particular strategy. Findings are likely only applicable to similar study populations. CONCLUSION: A mix of traditional retention strategies and more contemporary methods was effective in reconnecting with urban teenagers enrolled in a school-based RCT and in controlling attrition during the 12-month follow-up survey period.

Exploring the impact of elevated depressive symptoms on the ability of a tailored asthma intervention to improve medication adherence among urban adolescents with asthma.

BACKGROUND: In patients with asthma, medication adherence is a voluntary behavior that can be affected by numerous factors. Depression is an important co-morbidity in adolescents with asthma that may significantly impact their controller medication adherence and other asthma-related outcomes. The modifying effect of depressive symptoms on an asthma intervention's ability to improve asthma controller medication adherence among urban adolescents with asthma has not yet been reported. OBJECTIVE: To assess self-reported symptoms of depression as an effect modifier of the relationship between randomization group and controller medication adherence at 6-month follow-up. METHODS: These analyses use data from a randomized controlled trial (RCT) conducted in Detroit high schools to evaluate a tailored asthma management program. The intervention included referrals to school or community resources for students reporting symptoms of depression and other issues. "Elevated depressive symptoms" was defined as a positive answer to ≥ 5 of 7 questions from a validated tool included on the baseline questionnaire. Self-reported adherence to controller medication was collected at intervention onset (session 1) and at 6-month follow up. Analyses were restricted to students with report of a controller medication at baseline. Logistic regression was used to assess elevated depressive symptoms as an effect modifier of the relationship between randomization group and 6-month adherence. RESULTS: Of the 422 students enrolled in the RCT, a controller medication was reported at intervention onset by n = 123 adolescents (29%). Analyzing this group, we observed an interaction between elevated depressive symptoms and adherence (p = 0.073). Stratified analysis showed better adherence in treatment group adolescents meeting criteria for elevated depressive symptoms at baseline as compared to the control group (adjusted Odds Ratio [aOR] = 9.50; p = 0.024). For adolescents without elevated depressive symptoms at baseline, differences in adherence by group assignment did not reach statistical significance (aOR 1.40, p = 0.49). CONCLUSIONS: In this sample of students reporting controller medications at baseline, report of elevated depressive symptoms at baseline and randomization to the intervention group was associated with significantly better adherence at 6-month follow up when compared to that of a control group. Larger studies are needed to evaluate the impact of depression on the relationship between adherence and asthma intervention effectiveness.

Comparison of early-, late-, and non-participants in a school-based asthma management program for urban high school students.

BACKGROUND: To assess bias and generalizability of results in randomized controlled trials (RCT), investigators compare participants to non-participants or early- to late-participants. Comparisons can also inform the recruitment approach, especially when working with challenging populations, such as urban adolescents. In this paper, we describe characteristics by participant status of urban teens eligible to participate in a RCT of a school-based, web-based asthma management program. METHODS: The denominator for this analysis was all students found to be eligible to participate in the RCT. Data were analyzed for participants and non-participants of the RCT, as well as for students that enrolled during the initially scheduled recruitment period (early-participants) and persons that delayed enrollment until the following fall when recruitment was re-opened to increase sample size (late-participants). Full Time Equivalents (FTEs) of staff associated with recruitment were estimated. RESULTS: Of 1668 teens eligible for the RCT, 386 enrolled early, and 36 enrolled late, leaving 1246 non-participants. Participants were younger (p < 0.01), more likely to be diagnosed, use asthma medication, and have moderate-to-severe disease than non-participants, odds ratios (95% Confidence Intervals) = 2.1(1.7-2.8), 1.7(1.3-2.1), 1.4(1.0-1.8), respectively. ORs were elevated for the association of late-participation with Medicaid enrollment, 1.9(0.7-5.1) and extrinsic motivation to enroll, 1.7(0.6-5.0). Late-participation was inversely related to study compliance for teens and caregivers, ORs ranging from 0.1 to 0.3 (all p-values < 0.01). Early- and late-participants required 0.45 FTEs/100 and 3.3 FTEs/100, respectively. CONCLUSIONS: Recruitment messages attracted youth with moderate-to-severe asthma, but extending enrollment was costly, resulting in potentially less motivated, and certainly less compliant, participants. Investigators must balance internal versus external validity in the decision to extend recruitment. Gains in sample size and external validity may be offset by the cost of additional staff time and the threat to internal validity caused by lower participant follow-up. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00201058.

Applying epidemiologic concepts of primary, secondary, and tertiary prevention to the elimination of racial disparities in asthma.

Despite medical and scientific advances, racial and ethnic disparities persist in US asthma morbidity and mortality rates. Progress in the elimination of these disparities will involve disentangling the contribution of social constructs, such as race, socioeconomic status, and culture, from that of the physical environment and genetic susceptibility. One approach to reducing asthma disparities is through the traditional disease prevention stages of intervention. As such, primary prevention targets reductions in asthma incidence; secondary prevention is the mitigation of established disease and involves disease detection, management, and control; and tertiary prevention is the reduction of complications caused by severe disease. Once causative factors at each level of disease prevention are understood, this knowledge can be translated into clinical practice and public health policy.