Table 3.

Strategies to address multiple-level barriers to recruitment and retention of individuals with SMI and DM in a behavioral RCT

Barrier by Level	Procedural/methodological strategies	Personnel strategies
Macro Level
Weather	Re-schedule assessments, postpone group sessions until most severe weather passed.
Providers not referring patients	Study presented annually to new medical trainees, and to faculty at regular meetings	Primary care provider co-investigators served as “Recruitment Champions” to promote referrals
Potential subjects unaware of study	Flyers at community mental health centers and throughout community	CTSA Community Outreach
Mediator Level
Transportation difficulty	Provided roundtrip bus tickets, validated parking, Scheduled assessments on days that participants had existing clinic appointment
Stigma	Letters mailed to individuals referred to a study of DM, with no mention of SMI	Discuss SMI as a chronic disease similar to DM
Micro-level
Phone disconnected	Use EHR to update contact information, repeated call attempts, contact authorized secondary contact person, mail letters to participants requesting that they contact the study staff
Chronic physical health problem	Scheduled assessments around participants existing clinic appointments, flexible scheduling of assessments, telephone assessments if needed, assessment scheduling window of +/− 2 weeks of target date
Schedule conflicts	Flexible appointment times to accommodate participant's schedule, scheduled assessment around participants existing clinic appointments, scheduling window allowing +/− 2 weeks of target date for assessment.
Acute health issues	Reschedule assessment
Mental health issues	Refer to a mental health provider, If necessary, conduct assessment by phone;	Continuity of experienced, dedicated, empathetic and encouraging study staff
Disagreed with SMI diagnosis	Explanation of SMI and DM as chronic illnesses, did not focus on specifics of mental health diagnosis	Social support from study team members
Financial	$25.00 stipend for assessment visits, round trip bus pass or parking validation, flexible scheduling for assessments to allow for jobs, provided diabetic-appropriate snacks which participants may not have been able to afford at assessment visits and TTIM sessions
Stigma	For those attending the TTIM intervention, hearing PEs and participants discuss SMI helped those who were initially reluctant to join the discussions
Stress from family or living circumstance	Flexible scheduling	Social support from study team members; Problem identification and solving skills and practice for TTIM intervention participants.
Cultural or language barrier	Encourage questions, PEs were of diverse backgrounds	Bi-lingual Spanish/English research assistant for participants more comfortable conversing in Spanish.* Project staff were trained and had on-going discussions with the team regarding cultural competency and awareness.

^*Ability to speak and understand English was an inclusion requirement because the TTIM intervention was only available in English