CLINICAL SCHOLARSHIP
Lessons Learned From Adolescent Mothers: Advice on Recruitment M. Cynthia Logsdon, PhD, WHNP-BC, FAAN1 , Vicki Hines Martin, PhD, FAAN2 , Reetta Stikes, MSN, RNC-NIC, CLC3 , Deborah Davis, PhD4 , Lesa Ryan, BA5 , Iren Yang, PhD, RN6 , Jean Edward, PhD, RN, CHPE7 , & Jeff Rushton, BA, MBA8 1 Professor, School of Nursing, University of Louisville, and Associate Chief of Nursing for Research, University of Louisville Hospital, Kentucky One Health, Louisville, KY, USA 2 Professor, School of Nursing, University of Louisville, Louisville, KY, USA 3 Professor, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY, USA 4 Advanced Practice Educator, University of Louisville Hospital, Kentucky One Health, Louisville, KY, USA 5 Research Assistant, School of Nursing, University of Louisville, Louisville, KY, USA 6 Postdoctoral Fellow, Nell Hodgson Woodruff School of Nursing School of Nursing, Emory University, Atlanta, GA, USA 7 Assistant Professor, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA 8 Director of Digital Media, University of Louisville, Louisville, KY, USA
Key words Adolescent, depression, research recruitment Correspondence Dr. M. Cynthia Logsdon, University of Louisville School of Nursing, 555 South Floyd Street, Louisville, KY 40202. E-mail: [email protected] Accepted: April 15, 2015 doi: 10.1111/jnu.12142
Abstract Purpose: Adolescent mothers have high rates of depressive symptoms and inadequate rates of depression evaluation and treatment. The purpose of this qualitative study was to identify characteristics of effective recruitment ads for an Internet-based depression intervention for pregnant and parenting adolescents. Methods: Using focus group methods, participants (N = 35) were recruited and enrolled at a teen parent program, part of the public school system. Focus group sessions were analyzed for participant preferences, rationale for choices, key words, and the frequency of words within the videotapes and audiotapes. Results: Findings indicated that adolescent mothers preferred pictures in which everyone looked happy, narrative that clearly indicated cost and eligibility, and words that they would use in conversation. Clinical Relevance: The study filled an important gap in the literature by soliciting from pregnant and parenting adolescents their preferences regarding visual appeal, content adequacy, and message clarity of advertisements that would motivate them to visit an Internet intervention for depression. Results could be extrapolated to education of pregnant and parenting adolescents in clinical settings.
National experts agree that adolescent mothers have high rates of depressive symptoms and inadequate rates of depression evaluation and treatment (Substance Abuse and Mental Health Services Administration, 2005; Williams, O’Connor, Eder, & Whitlock, 2009; Yozwiak, 2010). Internet-based interventions for depression have been successful in overcoming barriers to treatment in adolescents (Christiansen, Griffiths, & Jorm, 2004; O’Kearney, Kang, Christensen, & Griffiths, 2009). However, the best ways to recruit adolescent mothers for an Internet-based intervention for depression are not known. The purpose 294
of this study was to identify characteristics of effective recruitment ads from the perspective of adolescents for an Internet-based depression intervention for adolescent mothers.
Background Successful and cost-effective recruitment is one of the greatest challenges for researchers, particularly in underserved and minority populations (Logsdon & Gohmann, 2008; Pinto-Foltz, Logsdon, & Derrick, 2011). Difficulty Journal of Nursing Scholarship, 2015; 47:4, 294–299. C 2015 Sigma Theta Tau International
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with recruitment is often cited as the reason for failure to reach an estimated sample size, resulting in underpowered studies and serving as a barrier to using research in practice. Strategies to improve research recruitment have been disseminated by the Cochrane Library (Treweek et al., 2010) as well as by noted researchers (Nguyen et al., 2012), but challenges remain. Recently, researchers have begun to use the Internet for research recruitment and interventions (Fenner et al., 2012; Morgan, Jorm, & McKinnon, 2013; Smith, Wilde, & Brasch, 2012). In a recent systematic review, Park and Calamaro (2013) noted the potential of social media for research study recruitment with adolescents and young adults. For example, Facebook has been successfully used to recruit young adults for studies of young adult smokers (Ramo & Prochaska, 2012) and Google ads have been successfully employed to recruit adults to health research websites (Gross, Liv, Contreras, Munoz, & Leykin, 2014). However, the effective characteristics and qualities of the recruitment ads were not discussed, leading to the need for this study.
Methods Sample Participants were recruited and enrolled at two locations of a teen parent program, which is part of the public school system. The study was approved by the institutional review boards of the university and the site. Eligibility criteria included (a) currently pregnant or adolescent mother who is 13 to 18 years of age; and (b) child lives with adolescent mother. Three groups of adolescent mothers (total N = 35) participated in the study. Attendance at each focus group was as follows: focus group 1, n = 12; focus group 2, n = 8; and focus group 3, n = 15. The race or ethnicity of participants was as follows: Caucasian (n = 21), African American (n = 13), and Hispanic (n = 2). No other identifying information was collected. Only focus group members and study personnel were present during the sessions. Four researchers were present at each focus group session, including the focus group leader, videographer, note taker and audiotaper, and a researcher that administered research stipends. Focus groups were held in the school library during the student lunch period. Lunch was provided, and each participant received a $15 retail gift card as a stipend.
Procedure Trained study personnel led each of the focus group sessions using a semistructured interview guide developed for the study (Table 1). Focus groups sessions were Journal of Nursing Scholarship, 2015; 47:4, 294–299. C 2015 Sigma Theta Tau International
Table 1. Interview Guide Questions related to pictures Which pictures look most pleasing and catch your eye? Probe: How did you make that choice? What were you feeling? Questions related to messages What do you think about the amount of information that ads include? Probe: Is the amount of information enough? Is the amount of information too much? Which ads give the correct amount of information? Rating of pictures and text Which ad do you like the best? Probe: Is the content clear? Which ad has the clearest message? Which ad is the most confusing? Additional comments What might motivate you to go to this website to get additional information? Is there anything else that you think might be helpful to us?
recorded using videotape and audiotape. In addition, notes were taken by the research team during and subsequent to each of the focus group sessions. The notes taken by study personnel identified participant characteristics and key concepts resulting from the discussion and documented methodological considerations. Each group session adhered to the following process. First, pictures of three racially and ethnically diverse adolescent mothers and babies were taped onto a blackboard. The group members were invited to walk to the blackboard and place numbers on each picture that corresponded to their preferences, using numerals 1 through 3 (most preferred to least preferred). The group discussed their perceptions and selection decisions after this activity. After discussion, this procedure was repeated for text selections, and finally for combinations of pictures and text (Figure 1). Specifically, participants were asked to respond to visual appeal (preference and emotional response), content adequacy (knowledge), and clarity of message (cognitive response).
Data Analysis A qualitative content analysis approach was used for this study. Content analysis is a research method that involves analyzing written, verbal, or visual communication messages as a means of describing critical elements and processes of a phenomenon with the purpose of generating knowledge, new understanding, a representation of phenomena concepts, and an evidence-based guide to action (Cole, 1988; Downe-Wamboldt, 1992; Elo & Kyngas, 2008; Krippendorf, 1980; Sandelowski, 1995). For this study, an inductive approach (qualitative) was selected because little is known about online messaging aimed to recruit adolescent mothers for research about depression. Both words (manifest content) and nonverbal communication such as silence, sighs, laughter, 295
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Figure 1. Combination of pictures and text.
posture, movement, etc. (latent content) were a part of the analysis (Burns & Grove, 2005; Catanzaro, 1988; Morse, 1994; Robson, 1993). All videotapes of focus group sessions were reviewed simultaneously in their entirety by the study team in a series of team meetings during which each study team member individually identified and coded participant preferences, rationale for choices, key words, and the frequency with which those words appeared within the videotapes and audiotapes (Carley, 1990; Carney, 1972; Downe-Wamboldt, 1992; Duncan, 1989; Elo & ¨ 2008; Krippendorf, 1980; Weber, 1990). In Kyngas, addition, nonverbal behaviors were identified, discussed, and validated by personnel consensus and interpreted within the context of the video interaction. This stage 1 analysis involved categorization according to those concepts on which the study semistructured interview guide was developed: visual appeal (preference and emotion), content adequacy (knowledge), and message clarity (cognitive response). The research team examined both the presence and frequency of perceptions, actions, or words presented within, and across, each of the focus groups and the relationship and context of those perceptions, actions, or words to determine what meaning emerged from those data. Notes were taken by each member and subsequently discussed within the group. Coding issues, questions,
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and concerns were addressed within the research team meetings as part of the first stage of data analysis. Intercoder concordance checks were performed during these sessions through reviewing tapes and discussion of team interpretations. Key elements derived (words, preferences, questions, and observations) from this team process served as tentative coding categories and the foundation for subsequent individual analysis by the coinvestigators. In stage 2, two co-investigators (one with expertise in post-partum depression in adolescents and one with expertise in qualitative research methods) individually reviewed the findings from the team sessions, reexamined the data, refined categories, identified exemplars using direct quotes from the sessions, and formulated conceptual relationships among the data to come to conclusions resulting in stage 2 analyses. Category integrity was supported through the following process. Co-investigators met for a final time to compare their individual analysis and study methodological notes about refined categories, conclusions, and chosen exemplars for concordance in interpretation. Lack of concordance in any aspect of the analysis resulted in additional discussion between the coinvestigators. Inability to resolve discrepancies in the individual analyses resulted in content that was eliminated from stage 2 analysis at this time and was not included in study findings.
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Figure 2. The most commonly chosen picture and text combination.
Results Visual Appeal All participants focused most heavily on the visual impact of the message options, and a significant amount of discussion resulted. Participant perceptions were influenced by subtle changes in images, including placement of the child in relation to the teen mother and whether the mother figure was or was not smiling. There were also variations in the responses to the picture choices based on whether the picture displayed a mother and child or a pregnant teen, and those differences appeared to be related to whether the participant was already a mom or pregnant at the time of the focus group session (see Figure 1). Participant 1 stated that “the choice [with] hands on her belly . . . because I am pregnant I can identify.” The majority of participants indicated that “even if you are not happy, you [participant] would like to see a happy face on the ad” and “sad is not appealing.” Participants were also influenced by the similarity between how they viewed themselves and if the image choice reflected that perception. For example, participant 2 stated, “the picture was happy . . . looks professional, looks young—I can relate.” The most commonly chosen picture was one of a Caucasian teen mom and her child (Figure 2).
Content Adequacy The wording of the three sample advertisements ranged from general to specific. The message choice that participants perceived as best for any planned website for this population focused on healthy mother–child interventions. The message would have to be brief but have Journal of Nursing Scholarship, 2015; 47:4, 294–299. C 2015 Sigma Theta Tau International
sufficient content so that online users could decide if the advertised site was suitable to their needs. The first choice identified by participants within each of the focus groups was the phrase “get the support you need” with the word support being the key element in the phrase. Participant 3 stated that the phrase indicated that it would assist the user in identifying “how we gonna make it” through the process of becoming a teen mother. There was discussion of phrase choices, with an overall emphasis on nonexclusion. Participant 4 stated, “the message on teen moms is too specific. It might exclude others.” Several participants suggested that the phrase “get the support you need to make it through your pregnancy and beyond” provided enough content for users to make informed or knowledgeable choices about, and be motivated to visit, the website (see Figure 1). There was much discussion about being sure the web message did not sound like one of the many sales pitches that populated social media.
Message Clarity Message clarity was a concept that interrelated closely with visual appeal and content adequacy. During focus group discussions about the overall appeal of the various narrative and visual messages, the participants identified that the chosen language was at times poorly matched with the speaking style or language these participants would use or prefer, identifying that the “words are too sophisticated” and, therefore, negatively affected the clarity of the message. However, participants consistently indicated that the appropriate picture along with the preferred content and use of language would result in a clear message that was both informative and appealing. 297
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Other Findings Within each group there were participants who provided their views using nonverbal communication. If one of the more vocal participants identified a point on which others agreed, the videotape was useful in making inferences about their agreement with a given statement through observations of affirmative head nods, smiles, and increased attention toward the speaker. Conversely, if a statement was not compatible with the views of other participants, facial expressions and head movements indicated disagreement. Disagreement among group participants more commonly led to additional discussion within groups. Discussion identified the areas of disagreement and the rationale for their difference in perception. In one instance, a Caucasian teen mom expressed concern that the most commonly identified picture was that of a Caucasian mother and child and that this choice “left out the African American mother and child” (see Figure 2).
Discussion There is a growing body of literature suggesting that Internet interventions may be effective for various health concerns. Few data were available on the best ways to recruit individuals to participate in such interventions, especially in relation to depression in pregnant and parenting adolescents. The current qualitative study filled an important gap in the literature by soliciting from pregnant and parenting adolescent girls their opinions and preferences regarding visual appeal, content adequacy, and message clarity of advertisements that would direct them to participate in online interventions for depression. Pictures were a powerful tool in evoking responses from adolescent mothers as we were developing recruitment ads. Photos have been used in other populations as an aspect of a text message intervention (Buchholz, Ingram, Wilbur, & Pelt, 2013). The most commonly chosen picture was one of a Caucasian adolescent mother and her child. Responses to the picture did not vary by the participants’ race. Adolescent mothers responded that they preferred positive messages with words that they would use in conversation. Thus, research teams that focus on adolescent populations would be well-served by advisory groups of adolescents in order to create effective messaging and recruitment. The results of the qualitative content analysis allow generalization of study findings only to similar populations. The aim of this study did not focus on characteristics of recruitment ads that would be effective in a sample with specific demographics, but future researchers could choose this focus if appropriate for their purposes. 298
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Adolescents are an underserved population with many unmet health needs, particularly in regard to health promotion, early intervention, and treatment for mental health problems. Developing effective recruitment ads for an Internet-based depression intervention addresses national health priorities of “adopting, adapting, and generating new technologies for better health care,” as well as health promotion and health disparities. Ongoing input is needed from those individuals being targeting by the intervention to ensure that the messages are tailored for the specific population rather than using a single message and method for all. In summary, in terms of recruitment ads, adolescent mothers preferred pictures in which everyone looked happy, even if the ad was for depression intervention. They liked pictures that looked real and not posed and narrative that clearly indicated parameters of cost and eligibility, with words that they would use in conversation. Adolescent mothers would be motivated to respond to an ad and use an Internet intervention if they felt that the picture and message came from someone like them. Results could be extrapolated to education of pregnant and parenting adolescents in clinical settings. Our previous work has indicated that adolescent mothers are already using the Internet to obtain health information (Logsdon, Crutzen, et al., 2014; Logsdon, Mittelberg, & Myers, 2014), so information about their preferences related to words and pictures could be incorporated into this information.
Clinical Resource
r
The Cochrane Library: http://www.thecochranelibrary.com
References Buchholz, S. W., Ingram, D., Wilbur, J., & Pelt, P. (2013). Using photos to develop text messages to promote walking. Journal of Nursing Scholarship, 45, 380–387. doi: 10.1111/jnu.12043 Burns, N., & Grove, S. K. (2005). The practice of nursing research: Conduct, critique & utilization. St. Louis, MO: Elsevier Saunders. Carley, K. (1990). Content analysis. In R. E. Asher (Ed.), The encyclopedia of language and linguistics. Edinburgh, UK: Pergamon Press. Carney, T. F. (1972). Content analysis: A technique for systematic inference from communications. Winnipeg, Manitoba, Canada: University of Manitoba Press.
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Catanzaro M. (1988). Using qualitative analytical techniques. In P. Woods & M. Catanzaro (Eds.), Nursing research; theory and practice (pp. 437–456). New York, NY: Mosby. Christiansen, H., Griffiths, K., & Jorm, A. (2004). Delivering interventions for depression by using the Internet: Randomized controlled trial. British Medical Journal, 328: 265. doi: 10.1136/bmj.37945.566632.EE Cole, F. L. (1988). Content analysis: Process and application. Clinical Nurse Specialist, 2(1), 53–77. doi: 10.1097/00002800-198800210-00025 Downe-Wamboldt, B. (1992). Content analysis: Method, application, and issues. Health Care for Women International, 13(3), 313–321. doi: 10.1080/07399339209516006 Duncan, D. F. (1989). Content analysis in health education research: An introduction to purposes and methods. Health Education, 20(7), 27–31. ¨ H. (2008). The qualitative content analysis Elo, S., & Kyngas, process. Journal of Advanced Nursing, 62(1), 107–115. doi: 10.1111/j.1365-2648.2007.04569.x Fenner, Y., Garland, S., Moore, E., Jayasinghe, Y., Fletcher, A., Tabrizi, S., . . . Wark, J. (2012). Web based recruiting for health research using a social networking site: An exploratory study. Journal of Medical Internet Research, 14(1), e20. doi: 10.2196/jmir.1978 Gross, M., Liv, N., Contreras, O., Munoz, R., & Leykin, Y. (2014). Using Google ad words for international multilingual recruitment to health research websites. Journal of Medical Internet Research, 16(1): e18. doi: 10.2196/jmir.2986. Krippendorf, K. (1980). Content analysis: An introduction to its methodology. Beverly Hills, CA: Sage Publications. Logsdon, M. C., Crutzen, R., Martin, L., Eckert, D., Robertson, A., Myers, J., . . . Flamini, L. (2014). Preferred health resources and use of social media to obtain health information by adolescent mothers. Journal of Child & Adolescent Psychiatric Nursing, 27, 163–168. doi: 10.1111/jcap.12083 Logsdon, M. C., & Gohmann, S. (2008). Challenges and costs related to recruitment of female adolescents for clinical research. Journal of Pediatric Nursing, 23, 331–336. doi: 10.1016/j.pedn.2007.10.006 Logsdon, M. C., Mittelberg, M., & Myers, J. (2014). Use of social media and Internet to obtain health information by rural adolescent mothers. Applied Nursing Research. Published online June 7, 2014. doi: 10.1016/j.apnr.2014.14.006 Morgan, A., Jorm, A., & MacKinnon, A. (2013). Internet based recruitment to a depression prevention intervention: Lessons learned from the mood memos study. Journal of Medical Internet Research, 15(2), e31. doi: 10.2196/jmir.2262 Morse, J. M. (1994). Critical issues in qualitative research methods. London, UK: Sage Publications.
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Nguyen, B., McGregor, K., O’Connor, J., Shrewsbury, V., Lee, A., Steinbeck, K., . . . Baur, L. (2012). Recruitment challenges and recommendations for adolescent obesity trials. Paediatrics and Child Health, 48, 38–43. doi: 10.1111/j.1440-1754.2011.02183.x O’Kearney, R., Kang, K., Christensen, H., & Griffiths, K. (2009). A controlled trial of a school-based internet program for reducing depressive symptoms in adolescent girls. Depression and Anxiety, 26, 65–72. doi: 10.1002/da.20507 Park, B. K., & Calamaro, C. (2013). A systematic review of social networking sites: Innovative platforms for health research targeting adolescents and young adults. Journal of Nursing Scholarship, 45, 256–264. doi: 10.1111/jnu.12032 Pinto-Foltz, M. D., Logsdon, M. C., & Derrick, A. (2011). Engaging adolescents in longitudinal mental health intervention study: Challenges and lessons learned. Issues in Mental Health Nursing, 32, 214–219. doi: 10.3109/01612840.2010.544841. Ramo, D., & Prochaska, J. (2012). Broad reach and targeted recruitment using Facebook for an online survey of young adult substance use. Journal of Medical Internet Research, 14(1), e28. doi: 10.2196/jmir.1878 Robson, C. (1993). Real world research: A resource for social scientists and practitioner–researchers. Oxford, UK: Blackwell Publishers. Sandelowski, M. (1995). Qualitative analysis: What it is and how to begin? Research in Nursing & Health, 18, 371–375. doi: 10.1002/nur.4770180411 Smith, J., Wilde, M., & Brasch, J. (2012). Internet recruitment and retention for a 6 months’ longitudinal study. Journal of Nursing Scholarship, 44, 165–170. doi: 10.1111/j.1547-5069.2012.01446.x Substance Abuse and Mental Health Services Administration. (2005). Depression among adolescents. Retrieved from http://www.samhsa.gov/data/2k5/youthDepression/ youthDepression.pdf Treweek, S., Mitchell, E., Pitkethly, M., Cook, J., Kjeldstrom, M., Taskila, T., . . . Jones, R. (2010). Strategies to improve recruitment to randomized controlled trials. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.MR000013.pub4 Weber, R. P. (1990). Basic content analysis (2nd ed). Newbury Park, CA: Sage Publications. Williams, S. B., O’Connor, E. A., Eder, M., & Whitlock, E. P. (2009). Screening for child and adolescent depression in primary care settings: A systematic evidence review for the U.S. Preventive Services Task Force. Pediatrics, 123, e716–e735. doi: 10.1542/peds.2008-2415 Yozwiak, J. A. (2010). Postpartum depression and adolescent mothers: A review of assessment and treatment approaches. Journal of Pediatric & Adolescent Gynecology, 23, 172–178. doi: 10.1016/j.pag.2009.09.003
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Lessons Learned From Adolescent Mothers: Advice on Recruitment M. Cynthia Logsdon, PhD, WHNP-BC, FAAN1 , Vicki Hines Martin, PhD, FAAN2 , Reetta Stikes, MSN, RNC-NIC, CLC3 , Deborah Davis, PhD4 , Lesa Ryan, BA5 , Iren Yang, PhD, RN6 , Jean Edward, PhD, RN, CHPE7 , & Jeff Rushton, BA, MBA8 1 Professor, School of Nursing, University of Louisville, and Associate Chief of Nursing for Research, University of Louisville Hospital, Kentucky One Health, Louisville, KY, USA 2 Professor, School of Nursing, University of Louisville, Louisville, KY, USA 3 Professor, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, KY, USA 4 Advanced Practice Educator, University of Louisville Hospital, Kentucky One Health, Louisville, KY, USA 5 Research Assistant, School of Nursing, University of Louisville, Louisville, KY, USA 6 Postdoctoral Fellow, Nell Hodgson Woodruff School of Nursing School of Nursing, Emory University, Atlanta, GA, USA 7 Assistant Professor, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA 8 Director of Digital Media, University of Louisville, Louisville, KY, USA
Key words Adolescent, depression, research recruitment Correspondence Dr. M. Cynthia Logsdon, University of Louisville School of Nursing, 555 South Floyd Street, Louisville, KY 40202. E-mail: [email protected] Accepted: April 15, 2015 doi: 10.1111/jnu.12142
Abstract Purpose: Adolescent mothers have high rates of depressive symptoms and inadequate rates of depression evaluation and treatment. The purpose of this qualitative study was to identify characteristics of effective recruitment ads for an Internet-based depression intervention for pregnant and parenting adolescents. Methods: Using focus group methods, participants (N = 35) were recruited and enrolled at a teen parent program, part of the public school system. Focus group sessions were analyzed for participant preferences, rationale for choices, key words, and the frequency of words within the videotapes and audiotapes. Results: Findings indicated that adolescent mothers preferred pictures in which everyone looked happy, narrative that clearly indicated cost and eligibility, and words that they would use in conversation. Clinical Relevance: The study filled an important gap in the literature by soliciting from pregnant and parenting adolescents their preferences regarding visual appeal, content adequacy, and message clarity of advertisements that would motivate them to visit an Internet intervention for depression. Results could be extrapolated to education of pregnant and parenting adolescents in clinical settings.
National experts agree that adolescent mothers have high rates of depressive symptoms and inadequate rates of depression evaluation and treatment (Substance Abuse and Mental Health Services Administration, 2005; Williams, O’Connor, Eder, & Whitlock, 2009; Yozwiak, 2010). Internet-based interventions for depression have been successful in overcoming barriers to treatment in adolescents (Christiansen, Griffiths, & Jorm, 2004; O’Kearney, Kang, Christensen, & Griffiths, 2009). However, the best ways to recruit adolescent mothers for an Internet-based intervention for depression are not known. The purpose 294
of this study was to identify characteristics of effective recruitment ads from the perspective of adolescents for an Internet-based depression intervention for adolescent mothers.
Background Successful and cost-effective recruitment is one of the greatest challenges for researchers, particularly in underserved and minority populations (Logsdon & Gohmann, 2008; Pinto-Foltz, Logsdon, & Derrick, 2011). Difficulty Journal of Nursing Scholarship, 2015; 47:4, 294–299. C 2015 Sigma Theta Tau International
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with recruitment is often cited as the reason for failure to reach an estimated sample size, resulting in underpowered studies and serving as a barrier to using research in practice. Strategies to improve research recruitment have been disseminated by the Cochrane Library (Treweek et al., 2010) as well as by noted researchers (Nguyen et al., 2012), but challenges remain. Recently, researchers have begun to use the Internet for research recruitment and interventions (Fenner et al., 2012; Morgan, Jorm, & McKinnon, 2013; Smith, Wilde, & Brasch, 2012). In a recent systematic review, Park and Calamaro (2013) noted the potential of social media for research study recruitment with adolescents and young adults. For example, Facebook has been successfully used to recruit young adults for studies of young adult smokers (Ramo & Prochaska, 2012) and Google ads have been successfully employed to recruit adults to health research websites (Gross, Liv, Contreras, Munoz, & Leykin, 2014). However, the effective characteristics and qualities of the recruitment ads were not discussed, leading to the need for this study.
Methods Sample Participants were recruited and enrolled at two locations of a teen parent program, which is part of the public school system. The study was approved by the institutional review boards of the university and the site. Eligibility criteria included (a) currently pregnant or adolescent mother who is 13 to 18 years of age; and (b) child lives with adolescent mother. Three groups of adolescent mothers (total N = 35) participated in the study. Attendance at each focus group was as follows: focus group 1, n = 12; focus group 2, n = 8; and focus group 3, n = 15. The race or ethnicity of participants was as follows: Caucasian (n = 21), African American (n = 13), and Hispanic (n = 2). No other identifying information was collected. Only focus group members and study personnel were present during the sessions. Four researchers were present at each focus group session, including the focus group leader, videographer, note taker and audiotaper, and a researcher that administered research stipends. Focus groups were held in the school library during the student lunch period. Lunch was provided, and each participant received a $15 retail gift card as a stipend.
Procedure Trained study personnel led each of the focus group sessions using a semistructured interview guide developed for the study (Table 1). Focus groups sessions were Journal of Nursing Scholarship, 2015; 47:4, 294–299. C 2015 Sigma Theta Tau International
Table 1. Interview Guide Questions related to pictures Which pictures look most pleasing and catch your eye? Probe: How did you make that choice? What were you feeling? Questions related to messages What do you think about the amount of information that ads include? Probe: Is the amount of information enough? Is the amount of information too much? Which ads give the correct amount of information? Rating of pictures and text Which ad do you like the best? Probe: Is the content clear? Which ad has the clearest message? Which ad is the most confusing? Additional comments What might motivate you to go to this website to get additional information? Is there anything else that you think might be helpful to us?
recorded using videotape and audiotape. In addition, notes were taken by the research team during and subsequent to each of the focus group sessions. The notes taken by study personnel identified participant characteristics and key concepts resulting from the discussion and documented methodological considerations. Each group session adhered to the following process. First, pictures of three racially and ethnically diverse adolescent mothers and babies were taped onto a blackboard. The group members were invited to walk to the blackboard and place numbers on each picture that corresponded to their preferences, using numerals 1 through 3 (most preferred to least preferred). The group discussed their perceptions and selection decisions after this activity. After discussion, this procedure was repeated for text selections, and finally for combinations of pictures and text (Figure 1). Specifically, participants were asked to respond to visual appeal (preference and emotional response), content adequacy (knowledge), and clarity of message (cognitive response).
Data Analysis A qualitative content analysis approach was used for this study. Content analysis is a research method that involves analyzing written, verbal, or visual communication messages as a means of describing critical elements and processes of a phenomenon with the purpose of generating knowledge, new understanding, a representation of phenomena concepts, and an evidence-based guide to action (Cole, 1988; Downe-Wamboldt, 1992; Elo & Kyngas, 2008; Krippendorf, 1980; Sandelowski, 1995). For this study, an inductive approach (qualitative) was selected because little is known about online messaging aimed to recruit adolescent mothers for research about depression. Both words (manifest content) and nonverbal communication such as silence, sighs, laughter, 295
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Figure 1. Combination of pictures and text.
posture, movement, etc. (latent content) were a part of the analysis (Burns & Grove, 2005; Catanzaro, 1988; Morse, 1994; Robson, 1993). All videotapes of focus group sessions were reviewed simultaneously in their entirety by the study team in a series of team meetings during which each study team member individually identified and coded participant preferences, rationale for choices, key words, and the frequency with which those words appeared within the videotapes and audiotapes (Carley, 1990; Carney, 1972; Downe-Wamboldt, 1992; Duncan, 1989; Elo & ¨ 2008; Krippendorf, 1980; Weber, 1990). In Kyngas, addition, nonverbal behaviors were identified, discussed, and validated by personnel consensus and interpreted within the context of the video interaction. This stage 1 analysis involved categorization according to those concepts on which the study semistructured interview guide was developed: visual appeal (preference and emotion), content adequacy (knowledge), and message clarity (cognitive response). The research team examined both the presence and frequency of perceptions, actions, or words presented within, and across, each of the focus groups and the relationship and context of those perceptions, actions, or words to determine what meaning emerged from those data. Notes were taken by each member and subsequently discussed within the group. Coding issues, questions,
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and concerns were addressed within the research team meetings as part of the first stage of data analysis. Intercoder concordance checks were performed during these sessions through reviewing tapes and discussion of team interpretations. Key elements derived (words, preferences, questions, and observations) from this team process served as tentative coding categories and the foundation for subsequent individual analysis by the coinvestigators. In stage 2, two co-investigators (one with expertise in post-partum depression in adolescents and one with expertise in qualitative research methods) individually reviewed the findings from the team sessions, reexamined the data, refined categories, identified exemplars using direct quotes from the sessions, and formulated conceptual relationships among the data to come to conclusions resulting in stage 2 analyses. Category integrity was supported through the following process. Co-investigators met for a final time to compare their individual analysis and study methodological notes about refined categories, conclusions, and chosen exemplars for concordance in interpretation. Lack of concordance in any aspect of the analysis resulted in additional discussion between the coinvestigators. Inability to resolve discrepancies in the individual analyses resulted in content that was eliminated from stage 2 analysis at this time and was not included in study findings.
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Figure 2. The most commonly chosen picture and text combination.
Results Visual Appeal All participants focused most heavily on the visual impact of the message options, and a significant amount of discussion resulted. Participant perceptions were influenced by subtle changes in images, including placement of the child in relation to the teen mother and whether the mother figure was or was not smiling. There were also variations in the responses to the picture choices based on whether the picture displayed a mother and child or a pregnant teen, and those differences appeared to be related to whether the participant was already a mom or pregnant at the time of the focus group session (see Figure 1). Participant 1 stated that “the choice [with] hands on her belly . . . because I am pregnant I can identify.” The majority of participants indicated that “even if you are not happy, you [participant] would like to see a happy face on the ad” and “sad is not appealing.” Participants were also influenced by the similarity between how they viewed themselves and if the image choice reflected that perception. For example, participant 2 stated, “the picture was happy . . . looks professional, looks young—I can relate.” The most commonly chosen picture was one of a Caucasian teen mom and her child (Figure 2).
Content Adequacy The wording of the three sample advertisements ranged from general to specific. The message choice that participants perceived as best for any planned website for this population focused on healthy mother–child interventions. The message would have to be brief but have Journal of Nursing Scholarship, 2015; 47:4, 294–299. C 2015 Sigma Theta Tau International
sufficient content so that online users could decide if the advertised site was suitable to their needs. The first choice identified by participants within each of the focus groups was the phrase “get the support you need” with the word support being the key element in the phrase. Participant 3 stated that the phrase indicated that it would assist the user in identifying “how we gonna make it” through the process of becoming a teen mother. There was discussion of phrase choices, with an overall emphasis on nonexclusion. Participant 4 stated, “the message on teen moms is too specific. It might exclude others.” Several participants suggested that the phrase “get the support you need to make it through your pregnancy and beyond” provided enough content for users to make informed or knowledgeable choices about, and be motivated to visit, the website (see Figure 1). There was much discussion about being sure the web message did not sound like one of the many sales pitches that populated social media.
Message Clarity Message clarity was a concept that interrelated closely with visual appeal and content adequacy. During focus group discussions about the overall appeal of the various narrative and visual messages, the participants identified that the chosen language was at times poorly matched with the speaking style or language these participants would use or prefer, identifying that the “words are too sophisticated” and, therefore, negatively affected the clarity of the message. However, participants consistently indicated that the appropriate picture along with the preferred content and use of language would result in a clear message that was both informative and appealing. 297
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Other Findings Within each group there were participants who provided their views using nonverbal communication. If one of the more vocal participants identified a point on which others agreed, the videotape was useful in making inferences about their agreement with a given statement through observations of affirmative head nods, smiles, and increased attention toward the speaker. Conversely, if a statement was not compatible with the views of other participants, facial expressions and head movements indicated disagreement. Disagreement among group participants more commonly led to additional discussion within groups. Discussion identified the areas of disagreement and the rationale for their difference in perception. In one instance, a Caucasian teen mom expressed concern that the most commonly identified picture was that of a Caucasian mother and child and that this choice “left out the African American mother and child” (see Figure 2).
Discussion There is a growing body of literature suggesting that Internet interventions may be effective for various health concerns. Few data were available on the best ways to recruit individuals to participate in such interventions, especially in relation to depression in pregnant and parenting adolescents. The current qualitative study filled an important gap in the literature by soliciting from pregnant and parenting adolescent girls their opinions and preferences regarding visual appeal, content adequacy, and message clarity of advertisements that would direct them to participate in online interventions for depression. Pictures were a powerful tool in evoking responses from adolescent mothers as we were developing recruitment ads. Photos have been used in other populations as an aspect of a text message intervention (Buchholz, Ingram, Wilbur, & Pelt, 2013). The most commonly chosen picture was one of a Caucasian adolescent mother and her child. Responses to the picture did not vary by the participants’ race. Adolescent mothers responded that they preferred positive messages with words that they would use in conversation. Thus, research teams that focus on adolescent populations would be well-served by advisory groups of adolescents in order to create effective messaging and recruitment. The results of the qualitative content analysis allow generalization of study findings only to similar populations. The aim of this study did not focus on characteristics of recruitment ads that would be effective in a sample with specific demographics, but future researchers could choose this focus if appropriate for their purposes. 298
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Adolescents are an underserved population with many unmet health needs, particularly in regard to health promotion, early intervention, and treatment for mental health problems. Developing effective recruitment ads for an Internet-based depression intervention addresses national health priorities of “adopting, adapting, and generating new technologies for better health care,” as well as health promotion and health disparities. Ongoing input is needed from those individuals being targeting by the intervention to ensure that the messages are tailored for the specific population rather than using a single message and method for all. In summary, in terms of recruitment ads, adolescent mothers preferred pictures in which everyone looked happy, even if the ad was for depression intervention. They liked pictures that looked real and not posed and narrative that clearly indicated parameters of cost and eligibility, with words that they would use in conversation. Adolescent mothers would be motivated to respond to an ad and use an Internet intervention if they felt that the picture and message came from someone like them. Results could be extrapolated to education of pregnant and parenting adolescents in clinical settings. Our previous work has indicated that adolescent mothers are already using the Internet to obtain health information (Logsdon, Crutzen, et al., 2014; Logsdon, Mittelberg, & Myers, 2014), so information about their preferences related to words and pictures could be incorporated into this information.
Clinical Resource
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The Cochrane Library: http://www.thecochranelibrary.com
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