Research reported in this presentation was supported by the National Institute On Drug Abuse of the National Institutes of Health under Award Number

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1 Leah Leavitt 1, Jennifer Schindler-Ruwisch 1, Monique Turner 1, Pamela Johnson 2, Ada Obi 2, Jessica Bushar 3, Sean D. Cleary 1, Indira Singh 2 & Lorien Abroms 1 1 The George Washington University 2 Voxiva, Inc. 3 Zero to Three NIDA: R44DA035017

2 Research reported in this presentation was supported by the National Institute On Drug Abuse of the National Institutes of Health under Award Number R44DA The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute Health.

3 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.

4 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)

5 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

6 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)

7 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

8 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

9 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

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

12 Emotionally Framed Messages Test whether emotional appeal messages are likely to encourage responses to join Pride Empathy Free

13 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

14 Time to response to recruitment broadcast 53.12% responded within the first 30 min enrolled Response Time (N=1090) mean 3.5 hrs (SD = 12 hrs) median 23.5 min max 9 days Min

15 Participants Enrolled Attempts to enroll (N=199) Mean: 2.35 (SD=1.67) Range 1 to 8 attempts Attempts 1

16 Recruitment Flowchart N= (45.66%) Unreachable 10,194 text4baby users sent broadcast Oct 15- Feb 16 1,038 (10.18%) Responded "yes" to recruitment text 152 (14.64%) Refused 184 (17.73%) Ineligible 228 (21.97%) Eligible 199 (87.28%) Enrolled

17 O2: How does emotional framing influence recruitment? 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Responded to Text Made contact after initial response Eligible Enrolled 10.37% Fisher s Exact Test P = % Fisher s Exact Test P = % 10.18% Empathy Free Pride Total Message Type

18 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

19 O3: Do other message elements influence recruitment? Adding now Removing Incentive

20 Adding Now Time to Response with now There was no effect when including now in the recruitment message Time to response Response Rate Enrollment Rate

21 O2: How does removing reference to incentive influence recruitment? Responded to Text Made contact after initial response Eligible Enrolled 12.00% 10.97% 10.00% 8.00% 6.00% 6.0% Fisher s Exact Test Fisher s P Exact =.0107 Test Fisher s P =.0023 Exact Test P = % 4.00% 2.00% 2.04% 3.0% 0.69% 0.00% with incentive Message Type without incentive

22 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

23 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

24 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), Head, K.J., Noar, S.M, Iannarino, N.T., Harrington, N.G. (2013). Efficacy of text messaging-based interventions for health promotion: A metaanalysis. Social Science & Medicine, 97, Nabi, R.L. & Prestin, A. (2016). Unrealistic hope and unnecessary fear: Exploring how sensationalistic news stories influence health behavior. Health Communication, 17, Pew Research Center (2015a). Mobile Technology Fact Sheet. Retrieved from: 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, Morbidity and Mortality Weekly Report, 62 (SS06), Retrieved from: Turner, M. M. (2011). Using Emotional Appeals in Health Messages. In Cho, H. (Eds.) Health Communication Message Design: Theory and Practice (pp ). SAGE Publications. Retrieved from: Tverksy, A. & Kahneman, K. (1981). The Framing of Decisions and the Psychology of Choice. Science, 211, 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: 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.

25 Thank you! Any questions?

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27 Discussion Recruitment technique was feasible for this specific population Persistent and frequent follow-up to enroll Framing of initial message is important

28 % Enrolled Enrollment by Week N=204 25% 20% 15% 10% 5% 0% Free Empathy Pride No Incentive Day Broadcast Message was sent

29 Demographics at Q4B Baseline* Mean (SD), Frequency (%) Number of texts/day (SD = ) Cigarettes smoked/day before pregnancy (SD=10.72) Cigarettes smoked/day during pregnancy 7.33 (SD=6.06) Income Up to $15, (56.34%) $15,000-$30, (30.38%) $30,001-$47, (9.46%) $47,100 or more 19 (3.82%) *N=507

30 Recruitment Flowchart N= (14.64%) Refused Empathy: 85 (16.83%) Free: 32 (13.79%) Pride: 35 (11.63%) 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%) 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%)

31 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

32 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