Recruitment, Retention, and Engagement Strategies for Exercise Interventions with Rural Antenatal Adolescents: Qualitative Interviews with WIC Providers

Abstract

Public health stakeholder engagement is integral to developing effective public health interventions. The perspectives of women enrolled in the Supplemental Nutritional Program for Women, Infants and Children (WIC) have often been sought when designing WIC-based interventions; however, the perspectives of WIC providers are underrepresented. The goal of this investigation was to explore the experiences of WIC providers who counsel adolescent clients and to identify strategies for recruitment, retention, and engagement of adolescents in an antenatal exercise intervention. Qualitative interviews were conducted with WIC providers (N=9) in the Mississippi Delta; a rural, predominantly African American region in northwest Mississippi. From our data emerged four themes and four hypothesized strategies for recruitment, retention and engagement of adolescent WIC clients and their parents in a future antenatal exercise intervention that will be implemented through WIC. Engaging the perspectives of WIC providers was a critical first step in understanding the context for this intervention.

Introduction:

Adolescent pregnancy (<20 years) among low-income and racial/ethnic minority populations exacerbates the risk of maternal and child obesity.¹ Normal pubertal growth is associated with increased weight and when adolescent pregnancy occurs, maternal obesity risk is exacerbated¹ and offspring are impacted directly through maternal weight on fetal origins and indirectly through mother-to-child interactions.² The Special Supplemental Nutritional Program for Women, Infants, and Children (WIC) is a long-standing public health program whose goal is to protect the health of low-income women, infants, and children (<5 years) at nutritional risk.² WIC has the capacity to help prevent obesity in low-income populations through provision of ancillary healthy foods and nutritional counseling; however, WIC-based intervention studies have minimally focused on exercise, and adolescent mothers have been underrepresented. The American College of Obstetrics and Gynecology recommends 20–30 minutes of moderate-intensity exercise per day on most, if not all days per week for healthy women during pregnancy.³ Antenatal exercise promotes healthy gestational weight gain³, which mitigates the risk of maternal and child obesity in subsequent stages of life.⁴ Despite these recommendations and the protective health benefits, few pregnant women exercise.⁵ Given the extant gap in the literature, study of antenatal exercise interventions tailored for low-income and racial/ethnic minority adolescents is needed.

Historically, formative research guiding the development of WIC-based interventions has sought the perspectives of WIC mothers6–8, yet few studies have included the perspectives of WIC providers.⁹ Public health stakeholder engagement is integral to developing public health interventions.¹⁰ Therefore, we conducted qualitative interviews with WIC providers to explore the context of counseling adolescent clients and to identify strategies for recruitment, retention, and engagement of adolescents in a WIC-based antenatal exercise intervention. We targeted providers serving the Mississippi Delta, a rural region in northwest Mississippi that is predominantly African American (70.4%) and bears a disproportionate burden of adverse health outcomes compared to the rest of the state.

Methods:

Study site and participants.

Mississippi has persistently high rates of adolescent pregnancy (43.7 per 1,000)¹¹, physical inactivity (32.9%)¹², and adult (37.3%) and youth (37%) obesity.¹³ The Delta is a geographically and culturally distinct 18-county region of Mississippi that is plagued by decades of persistent poverty and population decline, making the achievement of optimal health a challenge for most residents. Persistent population decline has also resulted in the majority of county health departments operating on a limited schedule. Thus, full-time WIC providers service multiple part-time locales. Our data represent the perspectives of nine WIC providers with a range of three-to-15 years of experience serving clients across 13 of the 18 Delta Counties. Our sample represents approximately one-third (32.1%) of all WIC providers across these 13 Counties. Mississippi WIC providers are college-degreed professionals who certify eligible persons for WIC and deliver nutritional counseling and education to enrollees. Four WIC Regional Supervisors aided in provider recruitment, which began using our a priori research plan targeting 6 Delta Counties. Upon learning that WIC providers delivered services to health departments across multiple counties, it was decided a posteriori to expand our catchment area to 13 counties. Recruitment concluded once the data reached saturation.

Data collection and analysis.

The qualitative interview is a robust method for accessing the lived world of participants, who, in their own words describe their experiences and opinions.¹⁴ Brief, in-person qualitative interviews (~30 minutes) were conducted between January and February 2018 by one investigator (AG) with over a decade of qualitative research experience with educators, public health professionals, and residents in the Delta. The interview guide was developed using the Interview Protocol Refinement Framework¹⁵, consisting of open-ended questions to explore providers’ interactions with adolescent clients and to solicit their perspectives on an antenatal exercise intervention (Supplemental Digital Table). Interviews were audio-recorded, transcribed verbatim, and verified. All procedures were approved by the Institutional Review Boards of both the University of Mississippi Medical Center and the Mississippi State Department of Health.

Data analysis was guided by a qualitative descriptive approach¹⁴ and was conducted in three stages. First, three investigators (AG, MMS, KLC) independently reviewed the transcripts and assigned descriptive and in vivo codes using Microsoft Word®. Next, the first set of codes were compiled and combined into nine hierarchical categories, eliminating duplicates and merging those with similarities. Lastly, categories were distilled into relevant themes representing the interview contents. Audio recordings and transcripts were revisited to confirm the presence and prevalence of these themes, and investigators engaged in dialogue to ensure our presentation of analysis appropriately reflected the data provided by our participants. Investigators retained independent electronic files at each stage in order to enhance the trustworthiness and credibility of our analysis.

Results:

The four themes described below emerged as a result of our analysis. Participant quotes representing each theme are presented in the Table.

Table.

WIC Practitioner Quotes Related to Each Theme

Theme 1: Early recruitment and retention through WIC are possible
Adolescents enroll in WIC early and are retained into postpartum
White; 42-y.o.	“I would say a lot of them [adolescent WIC clients] are probably in their first trimester. As soon as they find out that they’re pregnant, they usually come in and try to get their WIC benefits started.”
White; 33-y.o.	“No [we do not lose teen moms], because they come in to get the baby and so we automatically –unless they just refuse to get on the program, we automatically put them back on as a postpartum. It’s a joint thing when they come in and that guarantees them three months’ worth of slips and then we touch base with them at the next three which also continues the baby’s formula. It’s kind of hand in hand, we kind of do that step. It kind of guarantees that we are going to continue to have them coming in.”
Theme 2: Family involvement and compensation may bolster participation in a WIC-based intervention.
A family-based intervention approach was described as the best approach.
White; 54-y.o.	“Family involvement, especially in the Delta area, is a big, big thing. I mean, you have in the houses, you have mama, grandmama, child, grandchild. I mean, you can have three or four generations in one house here. And so, if you’re telling the teenager something that the mama and grandmama don’t agree with, it ain’t gonna happen. So, getting them involved and explaining to grandmother, and mama, and everybody getting on the same page. It’s very important. Around here family is the big thing in the Delta area.”
Black; 28-y.o.	“I give the teen the information, but more than likely the mom is really, really paying attention and she’s locking it in and saying, okay, well, I know this is what I need to do to make sure that she’s doing what she needs to do.”
Challenges faced when parents accompany adolescents to WIC appointments.
Black; 26-y.o.	“They [parent] kind of take over. Yeah, they kind of take over like with answering questions. I don’t know. It’s kind of like the teen mom is in the place of a child, even though she’s about to have a child. That’s what happens.”
Black; 26-y.o.	“I think, first of all, it’s still the shock of being a teen mom. Then they don’t even know what they don’t know. You don’t know what to ask. But then Mom is there, so you’re already ashamed. You don’t want to talk in front of Mom.”
Compensating families with items related to infant care would encourage participation.
White; 54-y.o.	“Strollers would be a big perk. Because like I said, a lot of them walk to different places. I have a lot of them that walk over here for their WIC and stuff. So a stroller would be nice for them to have for the little ones.”
Black; 32-y.o.	“I think if they knew that the baby was going be getting these things, I kind of think that would be enough. I really think that that would be a big thing, that because that’s what they’re on, “Is there a program where I can get these?” That’s the biggest question that we have. Who can help with diapers? Who can help with wipes? Because that’s a major problem for them, how to get that.”
Theme 3: Transportation and misperceptions about exercise may be barriers to engaging in a WIC-implemented intervention.
Transportation challenges to receiving WIC benefits.
White; 54-y.o.	“I think especially in this area transportation is difficult, especially if their parents work. They may not have transportation to get to where they need to go. A lot of them just miss their doctor’s appointments because they can’t get a ride. They don’t come here part of the time. They come late. They may have an appointment, but they may show up a couple weeks later because that’s when they could get a ride. Especially in this clinic we make appointments, but we see more walk-ins than we see appointments, generally. Because people come when they have transportation. And we’re kind of adapted to that here. I may have 20 people one day, and the next week I may have 5 or 10. So it just depends – like last week, a lot of them called in to reschedule because they didn’t have transportation in the morning, but everybody in the afternoon was able to get here.”
White; 57-y.o.	“You’d be surprised. I mean even if a family member, a relative is bringing them, a lot of times they have to give them, like, $5.00 gas money. So yeah, it’s an issue.”
Misperceptions about and a lack of exercise.
White; 42-y.o.	“I don’t think that these teens do very much exercise at all. A lot of people, and not just teens, what they consider to be exercise is, “I walk on my job.” Very few of them, it seems like, play any sports. I think there’s a lack of physical activity, period. When you say something to them about, ‘If it’s cold outside, go to Wal-Mart and just walk around in the store or something like that. That would be okay.’ They just kind of look at you like you’re crazy, like, ‘Why would I want to do that?’ It’s a very much sedentary lifestyle for a lot of people, young people and old. I think that’s a common factor right there. Nobody gets enough exercise.”
Theme 4: Approaches to intervention delivery and messaging.
Mobile technology used by WIC has been well received by adolescent clients.
Black; 28-y.o.	“They do [have cell phones]. And I’ve grown to realize they – well, with our system now, when we’re doing our appointments and things of that nature, they will ask, “Well, can you text my appointment to my phone?” We have that now where we can type in their cell phone number and right before their appointment is about to happen, you send a reminder about that appointment. So yeah, and that costs less on paper because we normally will mail out the appointments but now we have in the system where you can use the cell phone.”
A mobile intervention would be accessible to adolescents.
White; 42-y.o.	“That is a big factor. Yes, most of them – all have cell phones. It’s not using the little prepaid phones either. That’s a big monthly bill, but they all have cell phones. It’s not just the teens either.”
Social media platforms are important.
Black; 26-y.o.	“I think they would [respond positively to social media-based intervention]. I think there are a lot of moms that want to be better moms that just need the information, because you learn so much just scrolling through. The social media app, that’s a great idea. You’re on the Internet anyway. Even when you get on the Internet, I’m sure you learn something new. That would be a great resource for them.”
Mobile-only versus mobile and in-person intervention delivery.
Black; 28-y.o.	“I think the website and the app would be better [than in-person classes] because, like I said earlier, technology has taken over.”
Brief and encouraging text messages.
Black; 26-y.o.	“They don’t like anything that’s too time consuming. I think every mom is like that, but they don’t like things that are long. Yeah, short and sweet. They would like that. I think they would be more willing to participate.”
White; 45-y.o.	“It does help to have an upbeat attitude about it, not that we would ever down them in any way, but just to have a good attitude about it, make it a happy time.”

Abbreviation: y.o., years-old

Theme 1: Early recruitment and retention through WIC are possible.

Overall, providers demonstrated support for a WIC-based exercise intervention. The importance of exercise, along with healthy diet and appropriate gestational weight gain was recognized as critical to achieving optimal maternal and fetal health outcomes. Most adolescents reportedly enrolled in WIC within their first trimester of pregnancy and were adherent to their face-to-face appointments once every three months, which are required for WIC enrollment. Appointments were viewed as opportunities for recruitment and to augment nutritional counseling with individually-tailored support for other health behaviors, such as exercise.

Theme 2: Family involvement and compensation may bolster participation in a WIC-based intervention.

The presence and engagement of family members (adolescent’s mother or grandmother) during WIC appointments had important implications for counseling. On the one hand, family members were sometimes perceived as dominating the conversation, which may have prevented adolescents from speaking candidly or for themselves. On the other hand, providers recognized familial engagement as an opportunity for behavioral reinforcement outside of WIC. A family-based approach was recommended as the best approach for intervening with adolescents.

Compensating family research participation was also encouraged. WIC clients reportedly inquired about no-cost assistance programs offering diapers, wipes, Pack-n-Plays, car seats and strollers. From the perspectives of WIC providers, clients viewed these items as minimally essential to caring for an infant and were often forgone due to limited monetary resources, with the exception of diapers and wipes. Therefore, compensating families with items related to caring safely for an infant was encouraged to bolster family recruitment and retention.

Theme 3: Transportation and misperceptions about exercise may be barriers to engaging in a WIC-based intervention.

Rural transportation was unanimously identified as the primary reason for missed WIC appointments. Although providers explained that these appointments were typically rescheduled and attended in order to maintain WIC enrollment, they believed that transportation would contribute to attrition in a face-to-face intervention and were supportive of a mobile-based intervention to circumvent this barrier.

Misperceptions of what it means to be physically active or to exercise were identified as reasons for an overall lack of physical activity among WIC clients. Providers emphasized the need to educate adolescents and their parents about the importance and safety of exercise during pregnancy, and encouraged frequent dissemination of behavioral prompts matching the adolescents’ stage of pregnancy.

Theme 4: A mobile intervention approach to deliver positive messaging may be effective when intervening with adolescents.

All participants reported adolescent clients having a mobile smartphone, which was potentially their only point of reliable and continuous internet access. Providers perceived a mobile exercise intervention as being easily accessible and frequently utilized by adolescents. Social media applications were also identified as frequented by adolescents when seeking information about pregnancy. Providers emphasized the importance of making pregnancy a “happy time” for adolescents and promoting exercise as a means to improve overall health, rather than focusing on weight and obesity.

Discussion:

Using qualitative interviews, we probed the perspectives of WIC providers to develop testable hypotheses for future study, which are discussed below.

Hypothesis 1: Recruiting adolescents in early pregnancy to participate in a WIC-based exercise intervention study is feasible.

While WIC food packages are designed to supplement the nutritional needs of one-person², entire families often rely on WIC to offset household food insecurity.¹⁶ This may in-part explain adolescents’ consistent early enrollment in WIC, which presents the opportunity for early recruitment within the first trimester of pregnancy.

Hypothesis 2: Supplementing adolescent-focused intervention strategies with an interpersonal parental component supports participant engagement and retention.

Dating back to the Moynihan Report (1965)¹⁷, the structure of African American families living in poverty has been characterized by multigenerational, single parent, female heads-of-household. WIC providers’ descriptions of adolescents and their families reflected this characterization, emphasizing the integral role of the family in the lives of Delta residents, the majority of which are led by older African American women. Thus, a family-based intervention approach may be critical for adolescents’ engagement and retention.

Hypothesis 3: Compensating adolescent-parent-dyads with items related to the shared goal of caring for an infant enhances recruitment and retention.

Altruism and the provision of mild incentives have been reported as significant motivators for African Americans participation in research.¹⁸ Our data indicate that familial altruism will support recruitment and compensating families with items related to the adolescent’s and her mother’s shared goal of caring for an infant will bolster retention. Namely, diapers, wipes, car seats, strollers, and Pack-n-Plays would be particularly valued and beneficial.

Hypothesis 4: A mobile health intervention disseminating brief, positive messages fosters participant engagement and retention.

Participant burden is a barrier contributing to minority underrepresentation in research.¹⁸ Transportation barriers may increase attrition in a face-to-face intervention. Mobile interventions offer convenient and frequent accessibility to users, have demonstrated efficacy for improving health behaviors¹⁹, and racial/ethnic minority youth are the highest users of mobile technology.²⁰ Thus, brief, positive messaging (behavioral prompts and education relating to the overall health benefits of antenatal exercise) delivered frequently via text and social media may foster adolescents’ engagement and retention.

Limitations.

Several limitations should be considered. While the analytic team followed procedures to enhance trustworthiness and credibility of the data, there was the potential for some investigator bias given the investigators a prior perception of the benefit of a WIC-based antenatal exercise intervention. We also focused on a small sample of WIC providers counseling adolescent clients in the Mississippi Delta, limiting our generalizability to populations outside of the Delta.

Conclusion.

Engaging the perspectives of WIC providers was a critical first step in understanding the context for an antenatal exercise intervention that will be delivered through WIC. Investigators ascertained insight from front-line public health practitioners that informed strategies for recruitment, retention, and engagement of antenatal adolescents and their parents. Investigators are currently conducting interviews with adolescent WIC clients and their parents to corroborate these hypotheses and garner further insight for intervention development.

Implications for Policy and Practice.

• Engaging front-line public health practitioners in formative research to understand their lived experiences, opinions and perspectives of the clients they serve offers important and valuable insight when developing and planning for an intervention study.

• Public health entities serving vulnerable populations at high risk for adverse health outcomes may represent ideal settings for the recruitment, retention, and engagement of populations that are underrepresented in health research. Included among these vulnerable populations are low-income families, racial and ethnic minorities, and families in rural settings.