A Project of Greatest Interest from the 2023 MAFP Innovation & Research Forum
by Joey Dagher, Patrick Van House, Rose Hyson, PhD, Katherine Vickery-Diaz, MD, MSc, and Tyler Winkelman, MD, MSc, Health, Homelessness, and Criminal Justice Lab at the Hennepin Healthcare Research Institute
PROJECT OVERVIEW
Individuals who experience homelessness or incarceration encounter challenges when engaging in health care or health- related research, often related to historical trauma and the ongoing stigma they face in these settings. The Health, Homelessness, and Criminal Justice Lab (HHCJ) at the Hennepin Healthcare Research Institute works to overcome barriers to optimal health and wellness for people experiencing homelessness and criminal justice involvement through research and collaboration.
The lab currently runs two large National Institutes of Health-funded clinical trials designed to support these populations:
- The Diabetes Homeless Medication Support Study (D-HOMES) investigates the effectiveness and acceptability of wellness coaching for individuals with type 2 diabetes who are experiencing housing insecurity.
- The Transitions Clinic Network: Post-Incarceration Addiction Treatment, Healthcare, and Social Support Study (TCN-PATHS) assesses the effectiveness of the Transitions Clinic Network (TCN) for individuals with a history of incarceration and opioid use.
Both studies follow a similar plan, with an initial assessment, randomization into a behavioral intervention or a standard of care control group and follow-up assessments.
Due to inclusion criteria of type 2 diabetes and an eligible lab value, D-HOMES had a low recruitment rate (38 people over 12 months) but high retention rate: 100% retention at 3 months and 94% retention at 6 months. TCN-PATHS has broader inclusion criteria and a higher recruitment rate (68 over 12 months) but lower retention (79%). These studies used different recruitment and retention strategies that impact these rates.
We offer a summary of the methods we’ve used to recruit and retain participants who have competing priorities to research engagement, such as housing, legal support, food and economic insecurity. By reflecting on recruitment and retention strategies within these research studies, health care professionals can consider how to effectively engage with these populations in clinical and preventive health care.
RECRUITMENT & RETENTION STRATEGIES
Community-Engaged Research: D-HOMES is a community-engaged research study that collaborates with the Quorum for Community-Driven Wellness Research, a group of community members who have experienced housing insecurity and/or diabetes, community health workers, researchers and staff from housing organizations. The Quorum advised on all steps of the D-HOMES study and helped our research team design protocols to align with participants’ realities.
Two-Step Enrollment Process: D-HOMES used a two-part enrollment process with an initial assessment that included a hemoglobin A1c blood test, followed by a second visit if study participants met inclusion criteria (A1c at or above 7.5%) when randomization occurred. The two-part enrollment allowed research staff to verify participants’ eligibility and raised the likelihood that potential participants would attend future D-HOMES assessments. This rigorous process contributed to both slower recruitment and very high retention rates.
Institutional Relationships: In TCN-PATHS, participants have experiences with incarceration and opioid use. We refer the treatment group to a multi-disciplinary TCN clinic that centers on coordination efforts of a community health worker with a history of incarceration. The control group is instead referred to a community-standard primary care clinic that offers Suboxone alongside other routine services. TCN-PATHS identifies and enrolls participants rapidly through partnerships with carceral facilities.
Retention Outreach + Material Incentives: Retaining TCN-PATHS participants post-release requires creative methods, including giving material incentives to participants. Our team finds that in-person enrollments in jail or the community are essential for building the rapport necessary to stay connected to participants after they are released.
To re-connect with participants, we use electronic medical records and jail rosters to verify participant contact information and incarceration status. We also call participants or their listed contacts. Once we reach a participant, we schedule an in-person meeting to build rapport, verify preferred contacts and give participants phones and other material incentives to build a stronger relationship. These techniques have led to an improvement in our overall retention for the TCN-PATHS study over time.
Effective Strategies for Study Recruitment & Retention
This table summarizes effective strategies from both studies (D-HOMES and TCN-PATHS):
KEY TAKEAWAYS
Our team uses several methods for recruitment and retention for people experiencing homelessness and incarceration.
The D-HOMES study’s two-step enrollment process and community-engaged research approach contributed to a high retention rate. However, the two-step enrollment process also slowed the pace of participant recruitment in D-HOMES.
Partnerships with carceral facilities contribute to the rapid TCN-PATHS recruitment, and creative retention approaches have led to improvements in participant retention.
In future studies, we intend to combine successful approaches from both studies.
CONCLUSION
Engaging individuals experiencing homelessness or incarceration requires a multifaceted strategy that acknowledges their complex circumstances. D-HOMES and TCN-PATHS provide unique insights for health care, public health professionals and researchers about the value of tailored engagement approaches, strong institutional partnerships and careful study design.
By assimilating these approaches, we can cultivate the trust needed to engage these populations ethically and successfully in health care and health-related research.
Learn more about the Health, Homelessness, and Criminal Justice Lab (HHCJ) at the Hennepin Healthcare Research Institute at www.hhcjlab.org.
