Table 2.

Challenges, strategies and lessons learned during engagement, recruitment and retention in a multi-level, community research study

Challenge	Strategy	Lessons learned
Head Start (HS) Centers
1. High staff turnover	Increased number of site visits to intervention communities	HS staff turnover necessitated frequent site visits for planning and training and to ensure fidelity
2. Reduced engagement among comparison sites	Increased number of site visits to comparison communities	Extra visits to comparison sites were necessary to maintain their engagement in the research.
3. Inconsistent implementation	Provided process data to intervention sites on a quarterly basis instead of annually	More frequent feedback to sites increased engagement and participation at the HS intervention sites HS administrators used process data to evaluate their site’s performance and make changes
4. Barriers to implementation	Integrated participant feedback into the intervention on an on- going basis where possible without sacrificing fidelity	Incorporating HS staff suggestions throughout the study improved implementation Participants should be encouraged to make recommendations even when it was not feasible to incorporate all of them
Children
1. Confusion around eligibility limited recruitment	Used formative assessment results to determine target populations for recruitment	Formative assessment was invaluable in determining the recruitment strategy
2. Permission forms turned in after baseline data collection	Changed permission forms to allow for retro-active abstraction and use of data	Using permission forms that allowed for retro-active abstraction and use of data increased the amount of data available for analysis
3. Participants could be lost to follow-up	Created permission forms that remained in effect for the duration of the study	Obtaining permission for children to participate for the duration of the study negated the need to re-enroll each year
4. History of distrust of researchers	Provided and participated in community events in addition to orientation/recruitment activities	Actively engaging children and families at events that were not strictly for recruitment or research demonstrated respect and built trust
5. Low enrollment	Developed additional strategies for enrolling participants	Using multiple recruitment strategies increased enrollment and participation.
Parents
1. Participants failed to show for interviews	Over-scheduled participant interviews	Over-scheduling by 50 % increased participation and made effective use of research staff time when traveling long distances to a research site
2. Participants failed to show for interviews	Changed interview process to include reminder calls	Reminder calls to participants the day before their interviews reduced the number of parents that failed to show
3. Schedulers and interviewers were not proactively contacting a sufficient number of participants	Revised protocol to emphasize the need to actively pursue an interview goal for each site	Protocols for schedulers and interviewers needed to focus on the importance of contacting and following-up with a specific number of participants
4. Participation by CHILE championsa waned over the course of the school year	Revised payment schedule for CHILE champions	Stipends paid in two installments (one at the beginning of the school year and one at the end) encouraged more active participation throughout the year
5. Lack of repeated measures for Parent Interviews	Offer greater incentives for follow-up interviews (not done during this study)	Increasing incentives for parents returning for follow-up interviews would reflect the importance of repeat interviews and may have increased the number of return visits
Grocery Stores
Grocery store personnel had limited time to devote to the project	Project staff ensured that intervention materials were properly stocked and displayed	Stores vary in the amount of support for an intervention. Projects need to be flexible, and not expect stores to dedicate employee time to intervention efforts
Lack of understanding of the intervention by employees led to removal of intervention materials	Increased frequency of store visits and engagement with employees	Information about the intervention was not necessarily transmitted from the store owners and managers to other employees. Project staff needed to do this.
Healthcare Providers
1. Limited response by healthcare providers	Recruited physician to physician	Using an enthusiastic physician to contact and interact with healthcare providers improved access and engagement
2. Limited healthcare provider time	Met over lunch and provided lunch	With limited time, the most effective strategy for respecting healthcare provider time constraints was to meet over lunch and provide the food
3. Limited healthcare provider engagement	Maintain regular contact and provide reminders	While healthcare providers are interested in participating, time constraints make it difficult. Building a relationship with participating providers over time helped retain their interest and keep them involved

^aCHILE champions were community members that served as the primary contact for each Head Start center, advocated for CHILE at the Head Start center and within the community, and assisted with logistics for recruitment and data collection