recruitment and retention of high-risk families into a preventive parent training intervention

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The Journal of Primary Prevention, Vol. 18, No. 1, 1997 Recruitment and Retention of High-Risk Families into a Preventive Parent Training Intervention Larry E. Dumka,1,4 Camille A. Garza,2 Mark W. Roosa, 1 and Heather D. Stoerzinger 3 This article describes the process of developing, implementing, and evaluating recruitment and retention strategies for an eight session preventive parenting program designed for high-risk minority parents from low-income inner-city communities. The program was offered in both Spanish and English to a sample of 142 one- and two-parent families (78% Mexican immigrant or Mexican American, 15% African American, and 9% Anglo, Native American, and other). Recruitment and retention strategies resulted in a 70% participation rate with 48% of the families attending 5-8 sessions and 22% attending 1-4 sessions. Attendance rates were higher for married and cohabiting mothers than for single mothers and for Spanish speaking mothers compared to English-speaking Latino mothers. New categories are presented to improve future reporting of recruitment and retention data. INTRODUCTION Successful recruitment and retention of participants is an essential component of prevention program effectiveness (Mrazek & Haggerty, 1994). Preventive interventions are of little value if they are not used by those for whom they were designed (Gensheimer, Roosa, & Ayers, 1990). Insufficient recruitment and retention also can severely limit program developers' ability to evaluate interventions and to apply results to other settings. For example, 1Department of Family Resources and Human Development and Program for Prevention Research, Arizona State University. 2Department of Psychology, Arizona State University. 3Department of Family Resources and Human Development, Arizona State University. 4Address correspondence to Larry Dumka, Program for Prevention Research, Arizona State University, Box 871108, Tempe, AZ 85287-1108. KEY WORDS: recruitment; retention; parenting programs; high-risk families; minority families. 25 c 1997 Human Sciences Press, Inc.

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The Journal of Primary Prevention, Vol. 18, No. 1, 1997

Recruitment and Retention of High-Risk Familiesinto a Preventive Parent Training Intervention

Larry E. Dumka,1,4 Camille A. Garza,2 Mark W. Roosa,1and Heather D. Stoerzinger3

This article describes the process of developing, implementing, and evaluatingrecruitment and retention strategies for an eight session preventive parenting programdesigned for high-risk minority parents from low-income inner-city communities. Theprogram was offered in both Spanish and English to a sample of 142 one- andtwo-parent families (78% Mexican immigrant or Mexican American, 15% AfricanAmerican, and 9% Anglo, Native American, and other). Recruitment and retentionstrategies resulted in a 70% participation rate with 48% of the families attending5-8 sessions and 22% attending 1-4 sessions. Attendance rates were higher formarried and cohabiting mothers than for single mothers and for Spanish speakingmothers compared to English-speaking Latino mothers. New categories are presentedto improve future reporting of recruitment and retention data.

INTRODUCTION

Successful recruitment and retention of participants is an essentialcomponent of prevention program effectiveness (Mrazek & Haggerty, 1994).Preventive interventions are of little value if they are not used by those forwhom they were designed (Gensheimer, Roosa, & Ayers, 1990). Insufficientrecruitment and retention also can severely limit program developers' abilityto evaluate interventions and to apply results to other settings. For example,

1Department of Family Resources and Human Development and Program for PreventionResearch, Arizona State University.

2Department of Psychology, Arizona State University.3Department of Family Resources and Human Development, Arizona State University.4Address correspondence to Larry Dumka, Program for Prevention Research, Arizona StateUniversity, Box 871108, Tempe, AZ 85287-1108.

KEY WORDS: recruitment; retention; parenting programs; high-risk families; minority families.

25

c 1997 Human Sciences Press, Inc.

inadequate retention can distort the process of interventions (e.g., the lead-ers' ability to conduct some instructional activities) and bias outcome results(e.g., through insufficient exposure to the intervention or exclusion of datafrom dropouts).

Recruitment rates for all types of prevention programs are typically low(Braver, 1989). A key reason is that prevention programs, by definition, servethose who are not currently experiencing the problem for which they are at risk.Without an obvious current problem (e.g., a severely acting out child), targetedindividuals need a high level of motivation to outweigh the perceived costs ofparticipating (e.g., time, effort, self-consciousness, possible shame).

Recruitment rates for high-risk populations seem to be particularlylow (Coie et al., 1993). For example, Myers et al. (1992) recruited familiesof first and second graders from seven schools in low-income communitiesinto a culturally adapted parenting program for African Americans. In theirfirst cohort, 25% of available subjects said they would participate, but only14% did so; in the second cohort, 13% agreed to participate but only 6%actually did. Thus, despite systematic recruitment efforts, they recruitedonly a small portion of their target population.

We define retention as sustaining target individuals' attendance for theduration of an intervention. Retention of low-income families is mitigated by anumber of factors. These families are often subject to higher levels of negativeand unpredictable life events (McLoyd, 1990; Syme & Berkman, 1976) and havefewer resources to compensate for emergencies (e.g., car, telephone, sufficientcash). Also, frequent moving makes it more difficult to maintain contact withlow-income families and complicates transportation arrangements.

Improvement of recruitment and retention of high-risk families hasbeen hampered by the fact that many of the lessons learned in implement-ing prevention programs have not been systematically passed along to oth-ers in the field. Most program reports provide only sketchy descriptions ofrecruitment strategies (e.g., Birkel & Reppucci, 1983; Mischley, Stacy, Mis-chley, & Dush, 1985; Myers et al., 1992; Powell, 1987). Recruitment andretention rates have been reported even less often than recruitment strate-gies. When rates have been reported, rarely is there information about thecriteria for calculating these rates or an accounting of all the ways in whichparticipants were gained and lost.

Our aim was to address these shortcomings in the literature. First,we describe in some detail the recruitment and retention strategies thatsuccessfully involved high-risk participants (primarily minority group par-ents from low-income, inner-city communities) in a preventive parent train-ing intervention called the Raising Successful Children Program. Second,we introduce new categories for reporting recruitment and retention ratesaimed at strengthening research in this area.

26 Dumka, Garza, Roosa, and Stoerzinger

METHODS

The recruitment and retention strategies employed in this study aresummarized in Table 1 and described in detail below.

Pre Program Design Stage

Identifying and assessing accessibility to the targeted risk group. Children fromfamilies in low-income communities are known to be at. particularly high-riskfor experiencing mental health problems (Costello, 1989; Huston, 1991). Oneadvantage of targeting this population for a preventive intervention is that low-income families can be identified in most urban areas by geographic area. Withinlow-income communities, school boundaries can be used to further circumscribean appropriate population. To arrange access to the target population, we ne-gotiated cooperative agreements with two community schools.

Consulting the target population. Consulting the target group appears tobe a key factor in program success (Powell, 1988). Consultation permits pro-gram developers to fashion intervention content and processes (including re-cruitment and retention strategies) that address the needs, values, and conditionsof the local community. To this end, we conducted focus groups with subgroupsof our target population to identify sources of motivation and barriers to par-ticipating in the proposed intervention (Lengua et al., 1991).

First, we asked parents about problems facing children in the communityand what programs might be able to do to help families. The results showedinteresting differences in responses among the subgroups. Mothers expressedgreater interest in parent training programs while fathers were more concernedwith external influences on their children (e.g., police protection). Mothers intwo-parent families emphasized the skills training aspect of a parenting programwhereas mothers in single parent families focused on the social support that aparenting program might provide. Parents from the lowest socio-economic group,primarily single mothers, felt that they had little influence on their children'sfutures. These mothers seemed least interested in parent training programs andmost interested in programs that would ease their child care burdens.

We then asked parents what might increase the likelihood of parents intheir community attending such programs. Parents suggested that we shouldcontact families face-to-face, include children and parents together wheneverpossible, provide refreshments, incorporate community issues into the parentingcurricula (e.g., drug use, gang involvement), and encourage social support amongthe parents. Other suggestions had to do with removing potential barriers toattendance such as holding meetings close to home, having meetings no moreoften than once a week, and providing child care for younger children.

Recruitment and Retention 27

Table 1. Recruitment and Retention Strategies for the Raising Successful Children Program

Preprogram Design StageIdentified and located target populationAssessed accessibility

Established agreements with sponsoring agencyConsulted with the target population

Assessed perceived needsIdentified incentives and barriers to attendance

Decided on program selectiveness

Program Design ElementsFramed program goal as helping children be successfulOffered program in Spanish and EnglishAddressed expressed needsEmphasized consistent discipline before warm nurturanceBuilt in anticipation for completionIncluded opportunity to customize a discipline planIncreased probability of immediate changeEnhanced peer connection and supportProvided consistent encouragement

Staff CharacteristicsFluent in participants' preferred languageShowed consistent respectShared demographic characteristicsHired promoters from the local communityPromoted cultural sensitivity and shared missionProvided preservice and ongoing training/coordination

Reducing Barriers to AttendanceScheduled at convenient timesProvided transportationProvided mealsProvided child care that was attractive to children

Early General Recruitment Procedures (Beginning 9 months prior to program start)Promoted program at school parent-teacher meetingsConducted recruitment/information meetings for target groupSent periodic newsletters to target families

Immediate Preprogram Recruitment Procedures (Beginning 1 month in advance)Made initial recruitment home visitConducted intake assessment interviews (parents paid)Made home visit to schedule program attendance

Monitoring and Referral proceduresMade between session contacts with attendersMade between session home visits to nonattendersAssessed possible barriers to attendance; made referrals for social servicesMade reminder calls

28 Dumka, Garza, Roosa, and Stoerzinger

Deciding on the sekctiveness of the program. A precondition for measuringthe success of recruitment and retention methods is specification of the selec-tiveness of the prevention program (Gordon, 1987; Mrazek & Haggerty, 1994).For example, a universal program seeks to involve all members of a target popu-lation (e.g., all parents). However, universal programs involving psychoeduca-tional interventions can be very expensive and many members of the targetpopulation may not be at higher risk or may already be doing what the inter-vention is trying to produce. A selective intervention targets families who areat higher risk for negative outcomes and, thus, more likely to benefit from aprevention program. An indicated intervention is reserved for members of thepopulation who are currently showing early signs of the negative outcome. Al-though selective and indicated interventions can be more cost effective, theyrequire valid and efficient methods of identifying appropriate participants.These identification methods may unintentionally stigmatize people and includesome whose needs are beyond the scope of a prevention program.

We decided on a selective approach and targeted all parents of fourthgrade children served by two inner-city public elementary schools in Phoenix,Arizona. We based our decision on several factors. First, we were confidentthat virtually all of the families in the area were low-income and subject tomultiple risk factors based on census tract data and previous research inthe community (Michaels, Roosa, & Gensheimer, 1992). Second, we did nothave an empirically validated method to identify people for an indicatedintervention. Even if we had a valid screening method, it was unlikely thecommunities would support an indicated intervention because of the per-ception of unequal treatment of members of the community and the poten-tial for stigmatization of those who would be screened in.

The two selected schools were fairly representative of the school districtwhich was composed of about 77% Mexican immigrants or Mexican Americans,9% African Americans, 8% Anglos, and 6% others. Most of the families livedbelow the poverty level, about 50% were single parent families (U.S. CensusBureau, 1993), and over 90% of the children qualified for free lunch programs.

Program Design Elements

Attracting people to a program and keeping them coming back requiresthat individuals see their participation as important and personally worthwhile.The advertising, content, and processes of the intervention were designed withthis goal in mind. It was crucial to avoid presenting the goal of the programas that of rectifying parenting deficits. Therefore, we framed the interventionin terms of parents' helping their children be successful in life. The result wasthe 8-week Raising Successful Children Program (RSCP; Dumka, 1994) offeredin both Spanish and English.

Recruitment and Retention 29

We endeavored to base the content of the RSCP on the needs, values,and beliefs of the target population as revealed in our focus groups. Be-cause of the high incidence of single mother headed families in the com-munity and the probability that only mothers in two parent householdswould likely attend, we decided to focus on mothers' concerns. Accordingly,the program's supportive parenting and consistent discipline skills, identi-fied by our own (Roosa, Tein, Groppenbacher, Michaels, & Dumka, 1993)and others' research (e.g., Baumrind, 1991) as mediators of child mentalhealth, were presented as powerful ways parents could help their childrenavoid drug and gang involvement. Other studies had shown that low-incomeAfrican American and Hispanic American parents tended to value chil-dren's obedience, getting along with others, and education (Julian,McKenry, & McKelvey, 1994; Powell, Zambrana, & Silva-Palacios, 1990).Thus, we decided to order program content so that the consistent disciplineskills were emphasized at the beginning and then supportive parenting skillswere gradually introduced. Throughout the program, we related these par-enting skills to children's educational success.

We also tried to enhance retention by fostering participants' sense ofanticipation, progress, and achievement. To this end, the RSCP was organ-ized around the Parents' Road to Successful Children, a cumulative step-by-step skill development framework. Parents were presented withhandouts each session that accumulated toward a complete parents' hand-book. Also introduced at the outset was the prospect of a 'graduation' cere-mony and a completion certificate at the end of the program.

We enhanced the relevance of the program to each parent by pro-viding an opportunity to design and implement a customized discipline plantargeting a child behavior chosen by the parent. We expected that notice-able child behavior change early in the program would reinforce continuedparent attendance. Consequently, we chose a social learning based skilltraining approach to facilitate rapid child behavior change (Martin, 1981).Steps in this approach included: trainers describing and modeling the skill,having parents practice the skill under nondemanding conditions, providinghelpful feedback on performance, and having parents apply the skill athome and report on their experience the next session.

We included process elements in the RSCP aimed at fostering a senseof belonging to the group. Pre-session meal times provided an opportunityfor parents to eat and socialize with group leaders and each other. (Mealsalso served as an incentive for timely arrival.) Sessions began with a warm-up activity in which parents paired up and shared their responses to mildself-disclosure questions. Group leaders were trained to emphasize positivefeedback regarding parents' role-played practice of new skills in session

30 Dumka, Garza, Roosa, and Stoerzinger

and parents' home practice implementation and to encourage the sharingof positive feedback among parents. Finally, each session ended with a rit-ual closing in which parents read together a list of parenting affirmations.

Staff Characteristics and Training

An often overlooked contributor to successful recruitment and re-tention is staff selection, training, and supervision. In addition to com-petency and motivation, a key criterion for our staff was the desire andability to consistently show respect for target parents and their children.We also anticipated that potential participants would feel more comfort-able if staff members shared some of their socio-demographic charac-teristics and were familiar with their beliefs, values, and customs.Additionally, in a bilingual community, it was critical that most of thestaff were fluently bilingual.

The parent training group leaders were the central staff positions asthey set the tone for the intervention. We selected two fluently bilingualMexican American women to form a group leadership team. Both leadershad previous experience working with low-income Mexican American andAfrican American families in urban settings. In addition, three female com-munity aides were hired from the target community (2 bilingual MexicanAmerican and 1 African American). These women conducted much of theinitial recruitment, virtually all of the retention contacts, helped with pro-gram setup and logistical arrangements, and participated in instructionalrole plays during program sessions. Child care workers also were hired fromthe community.

Many low-income communities have ethnic, language, or other demo-graphic characteristics that separate groups and foster the development ofstereotypes and prejudice. Accordingly, a mandatory part of training forall staff members, including the research staff, was participation in a half-day cultural sensitivity workshop. The goal of this workshop was for staffmembers to become aware of their own biases and to clearly communicateour expectation that staff members would treat each other and participatingfamilies with respect. We were also aware that successful recruitment andretention would require high levels of participant monitoring and staff co-ordination. Thus, all staff received extensive pre-service training and weeklysupervision (descriptions of the training and supervision are included inStoerzinger, Dumka, & Roosa, 1994). In addition, the child care aides weretrained to use the communication, encouragement, and disciplinary tech-niques taught in the RSCP curriculum in the child care setting.

Recruitment and Retention 31

Reducing Barriers to Attendance

Other retention strategies were aimed at reducing barriers to atten-dance. Program sessions were scheduled at the schools at times designatedby parents as most convenient. Although most families lived within a mileof the target schools, we provided transportation to families needing it (dueto handicaps or having several young children). All participants were of-fered a ride home from evening sessions to allay safety concerns. Mealswere provided for all family members to free parents from this task. Childcare was provided not just to permit parents to participate fully but alsoto be stimulating and attractive so that the children might encourage theparents to make the effort to attend.

Early General Recruitment Procedures

Nine months prior to program commencement, project staff beganattending Parent Teacher Organization meetings at the target schools topublicize the RSCP. In March and April, we held special recruitment meet-ings for targeted parents. Bilingual invitations to these meetings were senthome with students with a prize for the class who got the most parentsout to the meeting. At the recruitment meetings we asked parents abouttheir goals for their children, the barriers to achieving these goals, and af-firmed parents' instrumental role in their children's success. We also pre-sented the general aims and time frame of the RSCP and announced thatthe RSCP would provide meals for attending parents and their children,child care, and transportation. Following these recruitment meetings, weobtained parents' addresses from school rosters and sent them bilingualnewsletters containing cartoons, recipes, and news about the progress ofthe RSCP at 6 week intervals.

Immediate Preprogram Recruitment Procedures

At the beginning of the next school year, community aides and groupleaders made home visits to all eligible families. The home visitors de-scribed the RSCP, the incentives for participating, and the rationale andprocedures for the intake interviews. The home visitors also ascertainedwhen parents could attend the program meetings. Next, a team of profes-sional bilingual interviewers visited the family to conduct intake interviewswith the parent(s) and the 4th grade child. The purpose of these interviewswas to collect demographic data and assess other variables thought to be

32 Dumka, Garza, Roosa, and Stoerzinger

related to program outcome. Families were paid $25 or $35 for these pre-program interviews (which took about 2 hours) depending on whether oneor two parents participated. Payment was given to the parents immediatelyafter the interview and was not contingent on parents attending the pro-gram. After the interviews and within a week of the program beginning,community aides revisited parents at home to confirm their language pref-erence and availability, determine transportation needs, and remind themabout the child care and meals that would be provided.

Monitoring and Referral Procedures

Another critical retention strategy was persistent monitoring. Betweenprogram sessions, community aides contacted parents who attended the ses-sion. Aides asked parents about their reactions to the session and told par-ents they looked forward to seeing them next week. For parents who misseda session, the aides made home visits to deliver session handouts face toface and briefly explain them and to identify and help alleviate potentialbarriers to attending the next session. In addition, families with phonesreceived a reminder call the day before the session. We wanted to com-municate to parents that they were an important part of the RSCP andthat they would be missed if they did not attend.

Finally, staff periodically became aware of some families' pressingneeds for food, housing, or health care. Whenever possible and appropriatewe made referrals to community agencies who might be able to meet theseneeds. Meeting these needs often was critical to the parents being able tocontinue attending the program.

RESULTS

Accurate assessment of recruitment and retention for prevention pro-grams requires that researchers be able to enumerate the target populationand specify a set of categories that accounts for all circumstances affectingattendance. In reporting our results, we propose some new terminology tospecify categories relevant to our project (these are summarized in Table 2).For example, the target population consisted of all parents of fourth gradersenrolled in the two targeted elementary schools. Access to the officiallydocumented cases of the target population was through school rosters intwo consecutive years, 1992-93 and 1993-94. All reported numbers are cu-mulative over the two years of the project.

Recruitment and Retention 33

Table 2. Recruitment and Retention Categories and Enumeration for the Raising SuccessfulChildren Program

Target Population: All Parents of 4th Graders in Two Schools

Officially documented cases of target population (from school rosters) 189 students

Plus undocumented cases (students not on school rosters)

Minus redundant cases (families with 2 children in 4th grade)

Equals targetable cases

Minus not beatable cases

Equals contacted cases

Minus interim emigrated/lost cases

Equals recruitable cases

Minus refusing cases

Minus unsuccessfully recruited cases

Equals total recruited cases (Attended at least 1 session)

Low retention cases (Attended 1-4 sessions)

High retention cases (Attended 5-8 sessions)

6 students

7 students

188 families

23 families

165 families

9 families

156 families

14 families

32 families

110 families

35 families

75 families

9%

21%

70%

22%

48%

Fall school rosters showed a total of 189 fourth graders. In addition,two families with fourth grade children not appearing on the school rosterscontacted us. Checking with 4th grade teachers directly netted an additionalfour students. These additional 6 cases (undocumented cases of the targetpopulation) brought the total targetable cases to 195. However, seven fami-lies had two children in fourth grade. We called these redundant cases andthey reduced the number of targetable cases to 188. Twenty-three of thesefamilies were not beatable despite extensive effort (due to recent movesor bad, possibly false, addresses), leaving 165 families that were contactedand invited to participate in the intake interview and the RSCP (contactedcases). Of these 165 contacted families, eight moved out of the area be-tween the time of the initial contact and the beginning date of the RSCP.Furthermore, one mother was hospitalized throughout the recruitment pe-riod. We called these 9 cases interim emigrated/lost cases. This left 156 re-cruitable cases at the time the RSCP was to begin.

34 Dumka, Garza, Roosa, and Stoerzinger

Of these 156 recruitable cases, 14 (9%) refused to be interviewed orparticipate in the RSCP (refusing cases). Of the 142 families who completedthe intake assessment interviews, data were available to conduct analyseson the demographic characteristics of 137 mothers (in three cases motherswere not available for intake interviews; in two other cases mothers' datawere considered unreliable). Of these 137 mothers, 107 (78%) were Mexi-can immigrants or Mexican Americans, 21 (15%) were African American,and 9 (7%) were other (Anglo, Native, American, Other); 80 of the moth-ers (58%) were married or cohabiting, Spanish was the preferred languagefor 82 of the 107 Mexican immigrant/Mexican American mothers (77%).Of the 61 fathers or male partners who consented to be interviewed, 56(92%) were Mexican immigrants or Mexican American.

In 32 (21%) of the remaining 142 recruitable cases that completedthe intake interviews, neither the mother nor the father attended anysessions (unsuccessfully recruited cases); in 35 cases (22%), at least oneparent attended 1-4 sessions (low retention cases); and in 75 cases (48%),at least one parent attended 5-8 sessions (high retention cases). Of the61 fathers/male partners interviewed, 35 (57%) attended no sessions; 17(28%) were low retention; and 9 (15%) were high retention. Moreover,of the 32 unsuccessfully recruited cases, we were not able to personallyre-contact the parents in four families after the intake interview. In sixfamilies, the mothers cited work commitments that consistently conflictedwith program times. In two families, the mothers suffered from severehealth problems.

There was a relationship between attendance and marital status [x2

(2df) = 7.67, p < .05]. A higher proportion of married or cohabiting moth-ers (i.e., mothers in two-parent households) were high retention cases(63%) compared to single mothers (40%) and a lower proportion of thesemothers from two-parent households were unsuccessfully recruited cases(15%) compared to single mothers (32%). Among the Mexican immi-grant/Mexican American mothers, there was a relationship between atten-dance and language of preference [x2 (2df) = 12.3, p < .01] with Spanishspeaking mothers comprising a higher proportion of high retention cases(65% compared to 28% of English speaking mothers) and a lower propor-tion of unsuccessfully recruited cases (15% compared to 44% for Englishspeaking mothers). There were no differences in attendance attributableto sex of the target child, number of children in the household, or mothers'education level.

Debriefing interviews were conducted with attenders and non-atten-ders of two waves of the program (Fall, 1992; Spring, 1994). Written com-ments were solicited from both low and high retention parents. The main

Recruitment and Retention 35

goal of these evaluations was to assess how our strategies for increasing pro-gram attractiveness and reducing barriers to attendance were being received.Responses from attenders revealed uniform highly positive evaluations ofthe program with compliments centering on the competency and caring ofthe group leaders and community aides, the opportunity for parents to talkwith each other, and the presentation of different ways of handling parentingdifficulties. The principal recommendations for improvement were extendingthe program's length, getting more parents to participate actively, offeringthe program to parents earlier in their parenting careers, and having vide-otapes of skill demonstrations instead of role played demonstrations. Atten-ders' most frequent reasons for missing sessions were work commitments,personal health problems, sick family members, other negative life events(e.g., court dates), or transportation mixups. Attending parents expressedappreciation for the meals, were very complimentary of the child care, andhad mixed reactions to transportation arrangements (e.g., taxis not coming).Nonattenders identified health and personal problems (e.g., substance abuse,relationship problems, incarceration), work conflicts, or other higher priori-ties as the main reasons for non-participation.

DISCUSSION

Our recruitment and retention rates appear to be significantly higherthan those typically reported, indicating that with sufficient effort a majorityof high-risk low-income mothers can be recruited and retained in preven-tive parent training interventions. Comparisons are difficult however be-cause most reporters do not clearly specify their recruitment or retentioncategories, procedures, or calculation methods. Our study reveals the com-plexity of assessing recruitment and retention and proposes methods forgreater specification of these elements in order to improve research andpractice.

Because we did not experimentally evaluate our recruitment and re-tention strategies, we cannot be sure that other methods would not haveworked as well. Nor can we identify which recruitment and retention strate-gies, alone or in combination, may have been responsible for the relativelyhigh turnout and retention numbers. The costs of evaluating even a smallnumber of the strategies would be substantial. However, if those imple-menting programs carefully describe their recruitment and retention effortsand results, over time we can learn a great deal about what works withspecific high-risk groups.

36 Dumka, Garza, Roosa, and Stoerzinger

Categorization of the recruitable cases into unsuccessfully recruited,low retention, and high retention groups permitted analyses of differencesamong these groups. For example, our methods appear to have been par-ticularly effective with Mexican immigrant parents, many of whom wererelatively recent immigrants. One reason for this might be that this groupof parents, having undertaken the challenges of emigration in hopes ofmaking a better life for themselves, were highly allied with the expressedpurpose of the program, that is, raising children who would be successfulin their adopted country. Other likely contributors to high attendance bythis group were the enthusiastic response to the program being availablein Spanish and the respect we endeavored to show these parents.

The greater likelihood of married or cohabiting mothers to be highattenders is also noteworthy. Perhaps, mothers in two-parent families, beingless likely to be sole providers for their family, were more able to considertheir role in guiding children towards success. It is also possible that thesemothers were more likely to have help which made it easier to fit the pro-gram into their schedules. At the same time, it appears that several malepartners discouraged mothers from attending.

The low attendance rate for fathers and male partners was likely dueto a number of factors. In the less acculturated Mexican immigrant andMexican American families, many of the fathers may have viewed childrearing as primarily the domain of women and thus not directly relevantto them. In addition, most of the recruiters and all of the group leadersand community aides were women. Fathers may have perceived thesewomen as less authoritative. Most of the attending men were low attenders,participating in only one or several sessions, perhaps to find out what theirwives were doing, and once convinced of the program's nonthreatening na-ture, discontinued attending. Also, after attending one or more times andseeing that the group was comprised almost entirely of women, some fa-thers may have felt out of place or unwelcome.

A limitation of our study was that we did not systematically interviewnonattending fathers to find out their reasons for attending and not at-tending and their thoughts on what would have made their attendancemore likely. We oriented the RSCP primarily around the expressed con-cerns of mothers. However, from a health promotion perspective, an im-portant factor in eliciting and maintaining behavior change is fosteringsocial support for the change. If more fathers could be recruited and re-tained then social support for both parents' behavior change likely wouldbe enhanced and these changes would likely be more resilient. Methodsfor increasing fathers' participation in parenting interventions representsan important challenge in prevention research.

Recruitment and Retention 37

There is also a need for more information on refusing cases. Althoughadditional persuasion tactics may enhance recruitment and retention ratessomewhat (Cialdini, 1993), results of our qualitative enquiries of attendersand nonattenders suggested that there may be upper thresholds to recruit-ment and retention for prevention programs. Prevention programs like theRSCP cannot address all parents' particular needs, accommodate all workschedules, change negative life events, prevent sickness, stop moves, keepparents out of jail, alter travel plans, resolve substance abuse or relationshipproblems, or reorder parents' priorities. Even with huge expenditures ofresources, some people are not recruitable. What this pilot study demon-strated is that a sizeable majority of our selected population was recruitablegiven a certain amount of effort. A logical next step is an analysis of thecost/benefit ratio of this effort. The cost/benefit question can only be an-swered through large scale experimental field trials that include longitudi-nal follow-up of participants. Continued systematic investigation intorecruitment and retention has the potential to contribute significantly tothe science of prevention.

ACKNOWLEDGMENTS

Work on this study was funded in part by the National Institute forMental Health Grant 2-P50-MH39246-06 to support a Preventive Interven-tion Research Center and the Ruth and Ray Cowden Fellowship. Theauthors gratefully acknowledge contributions to the study made by PeggyPena.

REFERENCES

Baumrind, D. (1991). Parenting styles and adolescent development. In J. Brooks-Gunn, R.Lerner, & A.C. Peteisen (Eds.), The encyclopedia on adolescence (pp. 758-772). NewYork: Garland.

Birkel, R. C, & Reppucci, N. D. (1983). Social networks, information-seeking, and theutilization of services. American Journal of Community Psychology, 11, 185-205.

Braver, S. L. (1989). Selection issues in children of divorce interventions. In I. N. Sandier,M. W. Roosa, S. A. Wolchick, S. G. West, & S. L. Braver, Center for the Prevention ofChild and Family Stress (pp. 112-129). NIMH Grant Proposal Number MH39246.

Cialdini, R. B. (1993). Influence: Science and practice (3rd ed.). New York: Harper Collins.Coie, J. D., Watt, N., West, S. G., Hawkins, D., Asarnow, J., Markman, H., Ramey, S., Shure,

M., & Long, B. (1993). The science of prevention: A conceptual framework for and somedirections for a national research program. American Psychologist, 48(10), 1013-1022.

Costello, E. J. (1989). Child psychiatric disorders and their correlates: A primary care sample.Journal of the American Academy of Child and Adolescent Psychiatry, 28, 851-855.

Dumka, L. (1994). Raising Successful Children Program: Group Leader Manual. Program forPrevention Research, Arizona State University, Tempe, Arizona.

38 Dumka, Garza, Roosa, and Stoerzinger

Gensheimer, L.K., Roosa, M.W., & Ayers, T.S. (1990). Children's self-selection into aprevention program for children of alcoholics: Evaluation of an innovative recruitmentstrategy. American Journal of Community Psychology, 18, 707-723.

Gordon, R. (1987). An operational classification of disease prevention. In J. A. Steinberg &M. M. Silverman (Eds.), Preventing mental disorders: A research perspective (pp. 20-26)(DHHS publication No. ADM-87-1492). Washington, DC: U.S. Government PrintingOffice.

Huston, A. (1991). Children in poverty: Developmental and policy issues. In A. Huston (Ed.),Children in poverty: Child development and public policy (1-22). New York: CambridgeUniversity Press.

Julian, T. W., McKenry, P. C., & McKelvey, M. W. (1994). Cultural variations in parenting:Perceptions of Caucasian, African-American, Hispanic, and Asian-American Parents.Family Relations, 43, 30-37.

Lengua, L. J., Roosa, M. W., Shupak-Newberg, E., Michaels, M. L., Berg, C. N., & Weschler,L. F. (1991). Using focus groups to guide the development of a parenting program fordifficult-to-reach, high risk families. Family Relations, 41, 163-168.

Martin, J. (1981). Mastering instruction. New York: Allyn & Bacon.McLoyd, V. C. (1990). Impact of economic hardship on black families and children.

Psychological distress, parenting and socioemotional development. Child Development, 61,311-346.

Michaels, M., Roosa, M. W., & Gensheimer, L. K. (1992). Family characteristics of childrenwho self-select into a prevention program for children of alcoholics. American Journal ofCommunity Psychology, 20, 663-672.

Mischley, M., Stacy, E. W., Mischley, L., & Dush, D. (1985). A parent education project forlow-income families. Prevention in Human Services, 3, 45-57.

Mrazek, P., & Haggerty, R. J. (1994). Reducing risks for mental disorders: Frontiers for preventiveintervention research. Washington, D.C., National Academy Press.

Myers, H. F., Alvy, K. T., Arrington, A., Richardson, M. A., Marigna, M., Huff, R., Main,M., & Newcomb, M. (1992). The impact of a parent training program on inner-cityAfrican-American families. Journal of Community Psychology, 10, 132-147.

Powell, D. R. (1987). A neighborhood approach to parent support groups. Journal ofCommunity Psychology, 15, 51-62.

Powell, D. R. (1988). Emerging directions in parent-child intervention. In D. R. Powell (Ed.),Parent education as early childhood intervention: Emerging directions in theory, research,and practice (pp. 1-22). Norwood, NJ: Ablex Publishing Corporation.

Powell, D., Zambrana, R., & Silva-Palacios, V. (1990). Designing culturally responsive parentprograms: A comparison of low-income Mexican and Mexican-American mothers'preferences. Family Relations, 39, 298-304.

Roosa, M. W., Tein, J., Groppenbacher, N., Michaels, M., & Dumka, L. (1993). Mothers'parenting behavior and child mental health in families with a problem drinking parent.Journal of Marriage and the Family, 55, 107-118.

Stoerzinger, H., Dumka, L., Roosa, M. (1994). Raising Successful Children Program:Implementation Manual. Tempe, AZ: Arizona State University, Program for PreventionResearch.

Syme, S. L., & Berkman, L. F. (1976). Social class, susceptibility, and sickness. AmericanJournal of Epidemiology, 104, 1-8.

U.S. Bureau of the Census (1993). 1990 Census of population and housing. Census tracts.Phoenix, Arizona. Washington, DC: U.S. Government Printing Office.

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