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Recruitment Strategies for the Princeton (Ohio) City SchoolDistrict Epidemiological StudyAmy Cline, Tara Schafer-Kalkhoff, Elena Strickland, Tara Hamann

Large, school-based, epidemiologic studies representthe cornerstone for obtaining information to under-

stand the natural history of pediatric diseases and the pre-clinical stages of adult pathology. The increasingcomplexity of school-based research studies requiresa clear research strategy. Yet, limited published datadescribe in detail the process and issues that researchteams encounter, as well as the successful and unsuccess-ful strategies used when initiating large, school-basedepidemiologic studies.1 Harrington et al2 identified 4 lev-els of recruitment: district, school, teacher, and student.Several articles discussed recruitment for school-basedresearch on these levels but did not include a descriptionof a research team whose qualifications match the focusof the study.2,3 This article describes the progression fromthe early stages of assembling a research team to recruit-ment of a school district and study population for thePrinceton City (Ohio) School District (PCSD) study.Successes and challenges of the research experience aredetailed.

The population of the PCSD study included adoles-cents, grades 5 to 12 in a large (4,273 students), well-defined (47% female, 53% male), racially integrated(46.7% African American, 47.7% non-Hispanic white),urban-suburban school district containing a range ofsocioeconomic demographics. Approximately 62% ofthe population was recruited for the study.

ASSEMBLING A RESEARCH TEAMThe first step to a successful research study involves

compiling a competent, credible research team. Experi-ence and skills of the team must match the study focus.The PCSD epidemiologic study examined the naturalhistory of obesity, insulin resistance, and diabetes. Theresearch team needed the following experience andskills to succeed: (1) knowledge of normal pediatricdevelopment including puberty, (2) understanding of thepathophysiology of insulin resistance and diabetes, (3)experience with recruitment and retention in longitudi-nal studies, (4) knowledge of Institutional Review Board(IRB) rules and procedures, (5) experience with school

district procedures, (6) ability to perform basic compo-nents of a medical history and physical examination, (7)maturity to deal with adolescents, and (8) experiencewith phlebotomy, sample processing, and data collectionand entry. The fundamental framework of the PCSDteam included a registered nurse overseeing the projectand entry-level research assistants.

The complexity of the study design and study popula-tion required more nursing staff. The team was expandedto include 3 registered nurses, 3 research assistants, anda lab technician/phlebotomist. Professionals comprisingthe research team varied in educational background andexpertise. Registered nurses were selected for collabora-tive skills, problem-solving capabilities, and motivation.Each nurse was knowledgeable and skilled in pediatrics,family dynamics, and disease processes.

One nurse with experience as a school nurse provedinvaluable when maneuvering through the school dis-trict. Two nurses were experienced in conducting epi-demiologic studies and clinical trials. These researchnurses were well versed in IRB submissions and proce-dures, and they understood regulations for human sub-ject research. They exhibited a working knowledge ofthe consent process and a successful record with subjectrecruitment and retention. The lab technician had exten-sive phlebotomy experience in home and clinical care.Research assistants were educated in child development,data collection, and data analysis.

RECRUITING A SCHOOL DISTRICTIn a school-based study, data collection should begin

in the fall at the start of the school year. However, con-tact between key members in the school district andthe research team should begin in the spring prior tothe study. Close contact continues through the summer.Initial contact commences with the school superinten-dent, who presents the research to the school board.With board approval, the next administrative contact isthe district pupil personnel services director, alsoknown as student services director or pupil servicesdirector. The pupil personnel services director ensuresthat students receive the support services and programsto suit individual student needs. Typically, the pupilpersonnel services director serves on the superintend-ent’s cabinet and assists in developing policies and pro-cedures for the district. This partnership is pivotalbecause influential members of the school district inter-act closely with the pupil personnel services director.

Amy Cline, RN, BSN, Research Nurse II, (Amy.cline@cchmc.org);Tara Schafer-Kalkhoff, MA, Clinical Research Coordinator III,(Tara.schafer-kalkhoff@cchmc.org); Elena Strickland, RN, BSN,Research Nurse II, (Elena.strichland@ccmc.org); and Tara Hamann,RN, BA, Research Nurse II, (Tara.hamann@cchmc.org), CincinnatiChildren’s Hospital Medical Center, 3333 Burnet Ave, MLC 10000,Cincinnati, OH 45229-3039. Project supported by funding from theNational Institutes of Health.

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In the PCSD, the pupil services director facilitateda meeting with the district data manager. This integratedeffort helped provide the research group with a copy ofthe school database, which contains demographic infor-mation on all students in the district. In a site-basedmanagement district such as PCSD, school principalsmake the decision regarding studies conducted in theirbuildings. Site-based management reflects the conceptsof empowerment and shared decision making.4 Theshared decision-making model involves various stake-holders and facilitative leadership at the school level.5

School nurses and teaching staff play a collaborativerole in a school-based study. The timing and order ofcontact with administrators in the district are essential toensure a successful study kickoff.

Recruitment of district administrators is multilayeredand follows this sequence: superintendent to schoolboard to pupil services director/data manager to highschool principal to district school nurses to teachers.

RECRUITING SUBJECTSRecruitment strategies should include both parents

and students. Initial contact must begin with parents/guardians. Recruitment starts with an introduction letterto families of students attending the collaboratingschool. The letter describes the purpose and key playersin the study, and it should be signed by the district super-intendent and the principal investigator. Several weekslater, the families received a packet containing a detaileddescription of the study, informed consent, medical his-tory form, and a postage-paid return envelope. Signa-tures of school administrators signify the collaborationbetween the school district and the institution.

The research team should attend open houses at eachschool in the district at the start of the school year andpresent information about the study to parents. This pro-vides parents the opportunity to meet the research staff,ask questions, and enroll their children. School adminis-trators may offer the research staff an opportunity tobriefly describe the purpose of the study. Attending openhouses makes the team visible to parents and faculty.

Student outreach campaigns begin in the classroom.(1) Approximately 1 week before the subject visits areset to begin, team up with the teachers. (2) Obtain per-mission from administration to go door-to-door in theclassrooms explaining the study to students and offeringopportunity to participate. (3) Distribute a sign-up sheetin the class. Interested students receive consent packetsand are asked to take them home and return completedpackets. (4) Make phone contact with parents of stu-dents who express interest on the sign-up sheets.

Recruitment must be supported by teachers andschool faculty to succeed. Educate staff on the impor-tance of the research and its positive impact on students.Find ways to spark student, teacher, and faculty aware-ness and support. There are many creative avenues forachieving this goal such as collaborating with the pro-duction teachers and crew at the school to make a videofor morning announcements with student actors, offer-ing to have a registered nurse teach a health class on thestudy topic, providing staff appreciation luncheons, orenlisting student helpers to distribute study materials.

When recruiting subjects from a school-based popu-lation, recruitment strategies must be age appropriate.Approaches used for recruiting teens are much differ-ent from those for elementary students.

LESSONS LEARNEDThe PCSD study used many recruitment strategies

to reach the recruitment goal: 80% of the eligible stu-dent body, grades 5 to 12. Subjects in the PCSD studywere recruited to participate in a 4-year study withcross-sectional and longitudinal aims to examine thenatural history of the development of obesity, insulinresistance, and diabetes in an adolescent population.Subject recruitment was multilayered to accommodatethe target population.

The most successful recruitment strategy in thePCSD study was door-to-door contact in each class-room. The visit was prearranged with the classroominstructor and usually took place during a homeroomstudy period. The purpose of classroom recruitmentwas to interface with staff and students while attempt-ing not to interfere with instruction time. Students andteachers were able to directly communicate with theresearch staff.

At the elementary schools, a nurse from theresearch staff presented information about diabetes ina classroom setting. All students were encouraged toask questions. The enthusiasm of staff and the non-threatening, professional approach, helped establishtrust between study staff and the students and teachersinvolved. Student face-to-face interaction with thePCSD study staff allowed for open discussion aboutdiabetes.

Subjects were offered incentives to participate,which were valuable for recruiting purposes. Incentivesincluded a $20 gift certificate to a local mall, anexcused absence from a class, and breakfast. Subjectsfelt that they were getting something in return for theirefforts as a participant. Baxter et al6 noted that studiesoffering incentives showed higher participation ratesthan studies with no incentives. Study budgets shouldinclude room for incentives.

Venipuncture was a mandatory procedure for partic-ipation in the study. Pediatric research subjects areoften turned off to study participation due to venipunc-ture. Many subjects fear this procedure. To help allevi-ate fears, a temporary skin refrigerant was sprayed onthe skin prior to venipuncture. It did not ease all thepain, but in some cases, it helped the subject withunderlying fear associated with the procedure. Most ofthe research staff had previous experience in the careof children and adolescents and were able to employdistraction techniques, hand holding, and blood-drawsimulation to ease anxiety.

Staff appreciation breakfast/luncheons were providedat schools. The purpose of these luncheons was 2-fold:recruitment and retention of school staff. Breakfast orboxed lunches were offered to all staff members. Teach-ers, nurses, office workers, custodians, and cafeteriastaff were invited. This gesture also provided an oppor-tunity to request feedback from staff on how to improveupon our procedures at school.

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OBSTACLES ENCOUNTEREDA notable lack of communication existed between

parents and children. Initial mailings or phone callsabout the study were not discussed with children. Par-ents assumed that the children would not be interestedin participation. When classroom recruitment com-menced, many students were not aware of the study.Unknowingly, students acknowledged interest in partic-ipation, although a parent stated that the child was notinterested. This made for a difficult situation. The stu-dent wanted to participate in the study, but the staffdid not want to challenge a parental decision. In thesecases, the student was encouraged to discuss the deci-sion regarding participation with their parents.

Phone calls prior to face-to-face contact were anunsuccessful recruitment strategy. This process met withresistance. Parents did not take calls and messages wentunreturned. Many parents perceived the call as an invasionof privacy. Some were angry and immediately turned offby this cold-calling approach. Eventually, through multi-ple interactions and communications with parents andchildren, trust was established. As a result, phone callsresumed with a much different outcome and proved effi-cacious in recruiting a substantial number of participants.

Employment of a field staff was an unsuccessfulmeans of recruitment. The field staff was hired to can-vass neighborhoods in the district that were perceivedas resistant to enrolling subjects due to racial mistrustand tension in the city. The field staff included AfricanAmerican females from or familiar with the community.Previous studies in this school district found thisapproach rewarding, but a decade later this was not thecase. A person going door-to-door for recruitment pur-poses was not well received by the community. Anotherobstacle identified was the inability of field staff to func-tion without supervision. The futile attempts of fieldstaff were noted within the first few months of recruit-ment. Consequently, this approach was discontinued.

CONCLUSIONSAccording to Frye et al,3 more researchers need to

report their strategies and experiences with recruitmentand agreement to participate in school-based studies.Experiences from the PCSD study serve as a ‘‘presentday’’ guide for navigating the complex layers of a schooldistrict. Assembling a staff capable of meeting the needsof the study and the participants is essential. Frye et alalso stated that specific factors that may influence par-ticipation need investigated and results shared to helpimprove recruitment efforts for future school-basedstudies.3 Sharing of knowledge and experiences withsubject recruitment is beneficial to all research teamsconducting school-based studies. Reporting successesand failures of recruitment allow future research teamsto incorporate proven effective strategies, thereforeadvancing school-based research. j

References1. Lytle LA, Johnson CC, Bachman K, et al. Successful recruit-

ment strategies for school-based health promotion: experiences fromCATCH. J Sch Health. 1994;64:405-409.

2. Harrington KF, Binkley D, Reynolds KD, et al. Recruitmentissues in school-based research: lessons learned from the High 5Alabama Project. J Sch Health. 1997;67:415-421.

3. Frye FHA, Baxter S, Thompson WO, Guinn CH. Influence ofschool, class, ethnicity, and gender on agreement of fourth graders toparticipate in a nutrition study. J Sch Health. 2002;72:115-120.

4. Holloway J. The promise and pitfalls of site-based management.Educ Leadersh. 2000; April:81-82.

5. Levey J, Acker-Hocevar M. Site-based management: retro-spective understandings and future directions. Paper presented at:Annual Meeting of the Mid-South Educational Research Association;November 4-6, 1998; New Orleans, La. ERIC Document ReproductionService No. ED428439.

6. Baxter SD, Thompson WO, Davis HC, Johnson MH. Impact ofgender, ethnicity, meal component, and time interval between eatingand reporting on accuracy of fourth graders’ self-reports of schoollunch. J Am Diet Assoc. 1997;11:1293-1298.

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