Article Text
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Abstract
Objectives Researchers face numerous challenges when recruiting participants for health and social care research. This study reports on the challenges faced recruiting older adults for Being Your Best, a co-designed holistic intervention to manage and reduce frailty, and highlights lessons learnt amidst the COVID-19 pandemic.
Design A qualitative study design was used. Referrer interviews were conducted to explore the recruitment challenges faced by the frontline workers. An audit of the research participant (aged ≥65) database was also undertaken to evaluate the reasons for refusal to participate and withdrawal from the study.
Setting Hospital emergency departments (EDs) and a home care provider in Melbourne, Australia.
Participants Frontline workers and older adults.
Results From May 2022 to June 2023, 71 referrals were received. Of those referrals, only 13 (18.3%) agreed to participate. Three participants withdrew immediately after baseline data collection, and the remaining 10 continued to participate in the programme. Reasons for older adult non-participation were (1) health issues (25.3%), (2) ineligibility (18.3%), (3) lack of interest (15.5%), (4) perceptions of being ‘too old’ (11.2%) and (5) perceptions of being too busy (5.6%). Of those participating, five were female and five were male. Eleven referrer interviews were conducted to explore challenges with recruitment, and three themes were generated after thematic analysis: (1) challenges arising from the COVID-19 pandemic, (2) characteristics of the programme and (3) health of older adults.
Conclusion Despite using multiple strategies, recruitment was much lower than anticipated. The ED staff were at capacity associated with pandemic-related activities. While EDs are important sources of participants for research, they were not suitable recruitment sites at the time of this study, due to COVID-19-related challenges. Programme screening characteristics and researchers’ inability to develop rapport with potential participants also contributed to low recruitment numbers.
Trial registration number ACTRN12620000533998; Pre-results.
- geriatric medicine
- health services for the aged
- aged
- qualitative research
- frailty
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Challenges recruiting older adults were evaluated from the perspective of referrers from recruitment sites.
The timing of this study unfortunately coincided with the COVID-19 pandemic, so it was concluded early due to recruitment challenges.
A limitation of this study was that older adults who withdrew or refused to participate were not interviewed.
Introduction
Research plays a vital role in advancing health and social care, and recruiting suitable participants is a critical step in conducting successful research to generate evidence on the effectiveness of innovative programmes and interventions.1 However, challenges pertaining to participant recruitment are often underestimated and can significantly impact the study validity.2
One of the most common recruitment challenges in research is the limited pool of potential participants.3 Finding the right individuals who meet specific inclusion criteria can be time-consuming and frustrating.4 Additionally, studies focusing on sensitive topics,5 such as frailty,6 may deter potential participants from participation due to the stigma associated with the word ‘frailty’.6 Recruiting participants is the initial challenge, but ensuring their retention and sustained involvement throughout the project is even more challenging.7 Factors such as time constraints, personal circumstances or lack of motivation can lead to dropout, jeopardising study findings.7 Lack of a prior relationship between researchers and potential participants can also act as a barrier to recruitment.8 To support recruitment, researchers often rely on health and social care providers to overcome potential participants’ wariness of research and potential mistrust. However, health and social care providers may have competing priorities, such as a focus on routine clinical tasks.9 Attitudes of health and social care providers toward research could also inadvertently influence the willingness of potential participants.10 This may include a perception that there is little immediate or short-term benefit of the research for participants or themselves,11 viewing the research as inconsistent with the philosophy or goals of their organisation, or having commitments to other studies that are recruiting from the same pool of potential participants.12
Engaging research participants in emergency departments (EDs) can have more challenges than other settings particularly for studies that rely on interested parties responding to a flyer or notice. A more proactive approach including building legitimacy or trust, framing risks and benefits, and reducing financial, time and social barriers is required for recruitment and retention of participants in the ED.
Characteristics of particular cohorts, such as community-dwelling older adults, also pose additional challenges to research recruitment. Older adults may face mobility and transportation issues, which can hinder their ability to participate in research.13 Moreover, health-related issues, such as chronic conditions, may impact older adults’ ability to participate. For example, cognitive impairment, frailty and dementia can affect older adults’ ability to comprehend study requirements and provide informed consent. More recently, older adults have been observed as less willing to participate in community activities and research while coronavirus (SARS-CoV-2) is still present, due to fear of contracting the virus.14
What is frailty and the Being Your Best study?
Frailty is a complex geriatric syndrome and one of the most challenging aspects of ageing.15 Frailty refers to increased vulnerability to stressors and decreased resilience with multiple causes and contributors, including physical, psychological, social or a combination of factors.16 Individuals with frailty often have reduced functional capacity and physical activity levels.
Frailty can be of many types, ranging from physical and nutritional frailty to cognitive and social frailty. Some of these factors, such as physical and social frailty, have a strong reciprocal relationship that can influence each other and lead to poor health outcomes.17 Frailty can also lead to reduced energy levels, cognitive impairment, and susceptibility to ill health or stressors that otherwise could be well tolerated.18
Frailty mostly affects older adults and makes them vulnerable to adverse health outcomes alongside increased use of community and aged care services and hospitalisations.19 20 The prevalence of frailty has been estimated to be between 12% and 24%, and pre-frailty from 46%–49%.21 This means that at a minimum, over half of older Australians, aged 65 years or more, meet the criteria of being either prefrail or frail; that is, approximately 2.1 million people.22
While frailty mostly occurs later in life, it is not an inevitable part of ageing.23 With the help of validated tools, frailty can be identified early and managed with holistic interventions to slow or stop the trajectory of further decline.24
To better support older Australians with frailty, Being Your Best, a holistic programme was developed to enable integrated care transitions across hospital and community settings.25 26 A pragmatic mixed-methods design was used consisting of a codesign phase (phase 1), followed by an intervention phase (phase 2) to test the feasibility and effectiveness of the programme. It was a 6-month programme that aimed to provide referral and linkage with existing community-based services comprising a choice of four modules to prevent or mitigate symptoms of physical, nutritional, cognitive and social frailty.25 26 Community-dwelling older adults aged 65 or over who had a recent hospital admission were planned to be recruited from four sites across the Greater Melbourne Area, three hospital EDs and a home care provider.
The co-design of the Being Your Best programme was completed in January 2020, but the planned implementation was delayed due to COVID-19-related restrictions. Following the end of restrictions and reopening of community services and activities, the research team re-engaged with research partners to commence recruitment in May 2022. However, the fear of contracting the virus was still present in the community due to ongoing cases and COVID-19-related deaths being reported in media.27 The highest number of deaths were observed in Australian older adults, and Victoria, where the study was implemented, had the second highest number of cases and highest number of deaths in the country.28–32
This study reports on the challenges of recruiting community-dwelling older adults for the Being Your Best25 26 study, from the perspective of frontline workers, and highlights our real-world experience amidst the COVID-19 pandemic.
Methods
This is an end-of-study analysis of Being Your Best, a holistic co-designed intervention to manage and reduce frailty (ACTRN12620000533998), concluded due to recruitment challenges. The study received approval from Monash Health and Bolton Clarke Human Research Ethics Committee (RES-19–0000904 L and No. 210002, respectively) with the study methods published previously.26
Study design, data collection and sources
Given the phase 2 of the Being Your Best study was concluded due to recruitment challenges, a qualitative study was conducted to explore the challenges of recruitment from the perspective of referrers. An audit of the research participant database was undertaken to evaluate the reason for refusal to participate and for withdrawal from the study. This information was triangulated with referrer interviews, which explored the recruitment challenges faced by the frontline workers. For the phase 2, the researchers received recruitment referrals from two hospital EDs and one home care provider from May 2022 to June 2023. The fourth site (a hospital ED) was unable to participate in the recruitment due to severe pandemic-related staff shortages. To track participant recruitment, retention and withdrawal, a database of research participants was developed and maintained by the research team. Referrer interviews were conducted from March to May 2023 to explore awareness of the programme, the referral process and experience with the programme. Seventeen referrers were invited to participate in an interview. Referrers were also asked about their experiences with older adult referrals (please see the Interview Schedule in Appendix 1). The average interview time was 15 min, ranging from 9 to 24 min. Referrer interviews were conducted online using Teams (version 1.6.00.11166, Microsoft, USA). Real-time interview transcripts were generated using Teams, which were critically reviewed by the research team member to rectify transcription errors and to ensure the software did not alter the wording or context of conversation. Data saturation was achieved at the eighth interview; however, three more interviews were conducted to ensure no new codes or themes emerged, which confirmed data saturation.
Data analysis
Descriptive statistics were used as there was insufficient data to apply inferential statistics. Qualitative responses recorded in the database from potential research participants and interviewer notes were analysed to report reasons for withdrawal or refusal to participate. Referrer interviews were thematically analysed.33 A subjectivist inductive approach was used to identify patterns within data to generate codes and themes.33 To ensure rigour and trustworthiness of the qualitative synthesis, two researchers independently read the interview transcripts, coded the data, derived themes, and reached consensus through discussion.
Research team and reflexivity
Research participant and referrer interviews were conducted by two research team members. One of the interviewers (AS) was male with experience as a pharmacist and with qualitative and quantitative research. The other interviewer (AA) was female with experience in workplace culture and qualitative research. Both interviewers worked closely with the participants and referrers, so we acknowledge this as a potentially inherent bias. The referrers were engaged by the research team and were aware of the aims and objectives of this component of the Being Your Best study.
Patient and public involvement
Being Your Best was developed in consultation with older people with lived experience as well as healthcare professionals and aims to mitigate the effects of frailty. Co-design sessions were conducted with 23 healthcare consumers and 17 healthcare professionals. Detailed patient and public involvement statement and codesign methods have been provided elsewhere.25 26
Results
Being Your Best participants
From May 2022 to June 2023, 71 referrals were received from three recruitment sites (two hospital EDs and one home care provider). Half (50.7%) of the referrals came from the home care provider. Of those referrals, only 13 (18.2%) agreed to participate. Three research participants withdrew immediately after baseline data collection and the remaining 10 continued to participate in the programme. Of those participating, five were female and five were male. Reasons for non-participation in the programme were (1) health issues preventing participation (25.3%); (2) not eligible for the study based on age, cognitive impairment, not frail or did not speak English (18.3%); (3) not interested in participating (15.5%), (4) perceptions of being ‘too old’ to benefit from the programme (11.2%); (5) perceptions of having too much on to be involved in the project (5.6%); (6) referrals were unreachable (4.2%) and (7) the programme did not fit current needs (1.4%; table 1).
Participant characteristics
Referrers
To further explore challenges with recruitment, we conducted interviews with referrers across three sites. Seventeen referrers, comprising nurses, clinical team managers, a medical physician and allied health professionals, were invited, of whom 11 participated in an interview.
Table 1 summarises the characteristics of community-dwelling older adults referred to the programme, and referrer characteristics.
Three themes and 12 sub-themes were generated after analysing the verbatim transcripts of referrer interviews (table 2): (1) challenges arising from the COVID-19 pandemic, (2) characteristics of the programme and (3) health of older adults.
Themes and subthemes from referrer interviews
Theme 1: Challenges arising from the COVID-19 pandemic
Lack of time due to shortage of clinicians and burnout
Frontline staff shortages arising from the pandemic were highlighted as a big challenge. Staff shortages meant that frontline workers were already overburdened, and any additional task would put them in a difficult situation.
Look, I understand why the emergency department was chosen, but I think, you know, we're very busy department, especially considering the size of the department and the resources we have. We see quite a lot of patients and I guess asking the nursing staff to complete another task is just another burden. (Site 2, Nursing Unit Manager, 008)
Consistent with the theme of staff shortages, frontline workers did not have the time to spend on study recruitment in addition to their usual patient load and clinical tasks.
Another demand … they probably just don't have the nursing staff… probably just struggled to find the time to do that. So, there’s a lot to take on during the day. (Site 2, Nursing Unit Manager, 008)
My team at the moment, we are three staff members under. So, they're all carrying that workload among them. So, anything extra, even if it’s small and is not essential is probably not going to get done. (Site 1, Clinical Team Manager, 004)
The pandemic also impacted the frontline workforce, with many people leaving their job due to workload and burnout. Referrers reported that the healthcare system is finally healing and slowly coming out of the impact of pandemic. Therefore, asking frontline staff to do anything extra, given that they were already burnt out, might not have been appropriate at the time of the project and may put an additional burden on them.
And the actual team themselves, they became depleted as well because of illness and they just because it was just bare necessities in the end in ED particularly. So that was a barrier. (Site 2, District Liaison Nurse; 002)
Coming off the back of COVID, I think asking nurses to do anything extra unfortunately, as we know throughout the world optimal best practice has gone straight down the drain and it’s going to take a while for things to improve just to the level that they were before. Not better, just clawing back to where we were at. (Site 1, Clinical Nurse Consultant, 007)
Moreover, to ensure continuity of care, many novice nurses were appointed who needed additional support and training from senior nurses. So, that was an additional responsibility for senior staff, affecting their ability to recruit participants.
And that’s because you're probably aware of the massive brain drain - that all the experienced nurses have left, and we have a huge intake of inexperienced nurses who require a lot of talking and demonstration from experienced nurses, who also then have their own workloads. And then if you add a script (information) for what they've got to, you know, do, it’s. Unfortunately, it’s just not the right timing. (Site 1, Clinical Nurse Consultant, 007)
Lack of consistent clinician champions at recruitment sites
Having a lack of consistent champions within the hospital ED due to the frontline staff shortage arising from pandemic-related stresses was reported as a barrier to recruitment. All referring sites were facing staff shortages, and many frontline workers were working across multiple sites, so it was difficult for them to promote the programme. They also might have missed people who might have been eligible for the programme.
And for us as care coordinators, we’re quite a small team. There’s only one of us on site per day. And also, we rotate across sites. So, we're on a rostered system where it’s a different person every day. And the other thing is that we a lot of us are part timers. So, we you're not gonna get one consistent person to sort of drive the programme. (Site 3, Clinical Team Manager, 006)
Referrers from the community home care service provider also reported that frontline workers were not aware of the programme. Some older adults enquired about the programme following a recruitment phone call to them, but their visiting frontline staff were not aware of the programme. This might have been due to staffing changes and the lack of champions who might have otherwise driven awareness of the programme.
I had a couple of clients that would ask the staff member about the project and they're like, well, we're unaware of it. We don't know about the project; this was in the beginning. (Site 1, Enrolled Nurse, 001)
Lack of face-to-face researcher-clinician referrer contact
Lack of face-to-face contact due to ongoing measures following the pandemic meant that hospital liaison nurses in the community home care organisation could not build the necessary rapport for study recruitment. The use of personal protective equipment also precluded effective rapport building and thus study recruitment.
The biggest challenge I personally had was that I'm not actually meeting with these clients face to face. I think they're old school and prefer to have the face-to-face conversation. (Site 1, Enrolled Nurse, 001)
You're not getting that bedside. Capacity to see people, so definitely that’s a was a major barrier. (Site 2, District Liaison Nurse; 002)
Rapport is built with the referrer, not with the researcher
Frontline workers were the initial point of contact to identify and refer older adults to the programme. The lack of established link with the researcher and an expectation of continuity of care from frontline workers may also have affected the recruitment.
Something like connection with the initial referrer sometimes doesn't transfer or translate to other people that one-on-one rapport building, yeah, can potentially be something that people just feel familiar with and want to follow through on. (Site 2, District Liaison Nurse; 002)
Older adult resistance to reintegrating with the community
Referrers felt the pandemic had a significant impact on recruitment. They explained that community members had faced several challenges, including recurrent lockdowns and fear of contracting the virus. Referrers believed that if there was no pandemic, participants might not have been as cautious about participating in community activities.
A lot of elderly people that I know have become more housebound, they just don't want to be involved because they're too scared. They’re scared because it’s even though it’s not talked about as much (COVID-19) is still out there. (Site 1, Enrolled Nurse, 001)
Difficulty to build rapport over the telephone
Frontline workers described older adults hesitation with telephone communication as one of the challenges towards rapport building with the research team and subsequent recruitment. It appeared that older adults were hesitant to answer calls from unknown telephone numbers. Fear of scammers also meant that older adults hesitated to share information with unknown callers.
The biggest challenge though, I personally had with that (client referral). Because I'm not actually meeting with these clients face to face. They won't answer a private number. And we're unable to unblock our number. So, when if you're ringing on their mobile phone, which a lot of them have got mobile phones now. Alright, you're ringing. It comes up with this private number. A lot of them won't answer it. Yeah, yeah, sorry, which is, which is really unfortunate. (Site 1, Enrolled Nurse, 001)
Theme 2: Characteristics of the program
Broad nature of the program
Frontline workers believed the programme was quite generalised with a broad remit, which may have confused older adults and carers about the programme and the potential benefits. It was noted that older adults and carers often wanted immediate results, which can be challenging to achieve with frailty.
Umm, it’s quite a general programme, so people don't necessarily know what they're gonna get out of it because people want stuff, you know, so to say so as clinicians and also as patients, I think it’s hard to know sort of the outcome and that’s potentially what has been the barrier. (Site 03, Clinical Team Manager, 006)
Competing information with staff
Referrers, as part of their usual roles, had much information to pass on to frontline staff but did not have a central repository to access that information.
Conflict with competing information. So, it’s very, you know, there’s a lot of information that we're trying to pass on to staff, and so it’s very difficult to get a specific place of information to. (Site 2, Nursing Unit Manager, 008)
Information overload in older adults
Some referrers were concerned that older adults might have felt overwhelmed with the amount of information they received about the programme. They were particularly concerned about the screening questions because they were too long for older adults, and many might have felt exhausted responding to them.
So, I think (name of a person) would be the client feeling overwhelmed with the information and amount of things they need to be involved in and the staff having to sort of explain that, you know, they're conscious that might impact their relationship with the client because their main job is to provide, go and do nursing care. (Site 1, Clinical Team Manager, 003)
Moreover, older adults often required support and care services from multiple health service providers, with further information potentially confusing and overwhelming.
Sometimes older clients, they can feel like overwhelmed with the information that they receive over the phone. (Site 1, Clinical Team Manager, 003)
Research limited to English-speaking older adults
Frontline workers reported that the programme was only designed for older adults who could communicate in English. This was a barrier given the large numbers of people from culturally and linguistically diverse backgrounds in the recruitment catchment areas.
So that itself will actually present a barrier to find even that suitable client. So, you need to tell one or over the age of 65 can speak English well. You needed people who can comprehend and follow through instructions and participate in activities. So, our main clientele might not, unfortunately fit into that so. (Site 1, Clinical Team Manager, 003)
Theme 3: Health of older adults
Complexity of older adults
Frontline workers reported that older adults often had multiple health issues and complex needs, which made it difficult for them to refer older adults. For example, many older adults had cognitive impairment, a study exclusion criterion, making referral to the programme challenging. They reported that older adults are usually busy managing complex health problems, so they did not want to put any extra burden on them; therefore, they felt they needed to carefully consider and refer only those older adults who they believed might benefit from the programme.
And you know, our clientele also is quite complex. It’s not every day that we do have these suitable clients who meet the criteria. You know, we in the community look after a particular cohort of clients who are actually quite complex. (Site 1, Clinical Team Manager, 003)
I think the issue is that with my clients, they're so complex, that I see the complex people. So, to get clients from me, they're probably gonna be more busy and more complicated than maybe other people who provide candidates. (Site 1, Clinical Nurse Consultant, 007)
Health following ED discharge
The health of older adults immediately following ED discharge may not have been optimal, as they were still focused on their immediate health issues and, therefore, unwilling to address other needs through engagement with the community.
And one of the other major things, especially coming out of ED … very so focused on what was still wrong with them physically. So the fact that they had presented to ED, there was this quite massive thing wrong with them that they had to go home for anyways and potentially still were suffering at home but recovering. So I felt the immediacy of the study to start directly after the ED presentation in hindsight, could have been that we should reach out 2 weeks down the track, when they've had time to recover. (Site 2, District Liaison Nurse; 002)
Discussion
This study has demonstrated that recruiting older adults for the Being Your Best programme amidst the pandemic was challenging. A surprisingly low number of referrals were received across the 13 months of active recruitment. Prior studies have demonstrated that multidimensional partnerships that include a familiar third party could be of benefit to all stakeholders.34 We attempted to use familiar third parties (such as through community liaison nurses, allied health professionals, ED nursing staff and doctors), but unfortunately, none were effective in providing more referrals. The desire for in-person and face-to-face engagement from participants was apparent, but in some cases, face-to-face engagement was not possible due to pandemic-related staff shortages in Australian hospitals and healthcare settings. On further exploring the challenges of recruitment with referrers, three main themes were identified: (1) challenges arising from the COVID-19 pandemic, (2) characteristics of the programme and (3) health of older adults.
Challenges arising from the pandemic have been identified as a major barrier to participant recruitment. A key lesson learnt was that multidimensional partnerships, including a familiar third party,34 were of no additional benefit due to staffing shortages as a result of the pandemic. The initial plan was for ED nurses to act as clinician champions.25 26 However, this was not possible due to pandemic-related workforce shortages, so this strategy was not successful. Many of the frontline workers in EDs were working across multiple sites, and this resulted in increased workload and burnout. Hence, EDs were not suitable recruitment sites at the time of this study. A systematic review identified that nearly half of the healthcare workers experienced burnout during the pandemic.35 This shortage of staff also meant there was a lack of consistent clinician champions at recruitment sites who could play a vital role in driving awareness of the programme and participant recruitment,36 thus contributing to research programme failure. While EDs are an important source of participants for research, the logistics for recruitment including consistent staffing and champions should be considered. Implementing study processes that does not rely on a busy overwhelmed workforce with many immediate demands is important for success.
During the pandemic, the lack of access to hospital EDs by researchers and other recruitment personnel was another key reason for low referrals and participation in this programme. Community liaison nurses from the home care organisation were precluded from face-to-face interaction with older adults in the ED due to ongoing pandemic-related government restrictions in hospital EDs, impacting their ability to build the necessary rapport for study recruitment. Older adults are known to be a hard-to-reach group for community-based research programmes.14 34 37 Frontline workers noted resistance in older adults to reintegrating with the community due to fear of contracting the virus. As suggested in the literature, older adults’ patterns of physical activity, social interaction and community participation changed following the pandemic and its associated restrictions,37 38 and this may explain older adults’ unwillingness to participate in the Being Your Best programme (specifically aimed at linking people with existing community-based services).
Programme characteristics, another known influence on recruitment,39 may have affected participant recruitment in this study. For example, some referrers believed the programme had a broad focus and might not have been suitable for the older adults to whom they provided care services, and this could have impacted recruitment. This indicates that the frontline workers and perhaps older adults might not have understood the programme, and instead, they focused on immediate clinical benefits. There is a possibility that frailty may not have been considered as much of a pressing clinical issue, as it is considered a broader, conceptual issue to address and over time. It might have been difficult to promote this to potential participants, especially if the training clinical staff were less enthusiastic or time poor in their introduction to the programme. Participants and referrers often need a more detailed understanding of the potential benefits of research programmes, but typically, they do not approach researchers to acquire more information.3 Identifying and addressing the knowledge gap by providing sufficient information to participants and referrers is essential to overcoming this recruitment challenge.
Lack of rapport with researchers was also an apparent barrier to recruitment. Frontline workers reported that participants might have expected continuity of care for recruitment and eligibility screening from the same frontline worker. However, frontline workers could not provide such continuity of care through the research programme due to staffing shortages and clinical priorities. Consequently, participants were referred to the research team for eligibility screening and recruitment, but lack of prior contact with the researcher might have made recruitment screening over the phone challenging. Lack of trust and information overload during phone screening may also have been a barrier to recruitment.40 Recruiting from locations that can provide continuity of care might be the way forward to recruit and retain older adults. Moreover, the programme was designed for testing within English-speaking populations, while the catchment area had a high proportion of people from culturally and linguistically diverse backgrounds. This is a clear limitation of our programme, which could not be rectified within the resource constraints of the project.
A large proportion of potential participants declined to participate mainly due to reported health issues, lack of interest and perceptions of being too old, all of which are well-known recruitment challenges.41 Poor health and perceptions of being too old particularly indicate self-directed ageism and a lack of awareness of frailty and how it could contribute to further decline in their health and well-being. A growing body of evidence suggests an association between ageism, health and frailty,42 43 indicating a need to improve awareness of frailty and ageism in older adults to motivate them to understand and tackle frailty proactively. Referrers also reported the health of older adults as a challenge for recruitment, which coincided with the self-reported reasons from some participants we contacted. Frontline workers reported that older adults often have multiple health issues and complex needs, complicating the referral of the target cohort. For example, older adults’ health may not be optimal after discharge from ED. Older adults with poor health may also have mobility issues that limit their ability to drive to participate in community-based programmes. Previous studies have shown that older adults try to live healthily, often facilitated by others, yet sometimes are restricted by poor health.44 There could be several reasons for their lack of participation; older adults with mobility issues have reported a reluctance to undertake health promotion activities, conveyed apathy and reported little social interaction.44 Involving and educating caregivers,45 and developing strategies at the study conception stage to overcome minor and major health issues may maximise participation.46 Offering transportation services or conducting home visits for those with limited mobility may broaden the pool of participants. Incentivising research participation by reimbursing participation costs may also improve recruitment of older adults.47
Lastly, the timing of the Being Your Best project, which coincided with the COVID-19 pandemic, was unfortunate. The programme was co-designed prior to the pandemic, yet it was implemented 2 years after, impacting the ability of staff to act as champions, in line with previously discussed workforce shortages, and subsequent pandemic-related altered models of ED care. This has clearly shown that co-design sessions are vital to current understanding of the context and environment in which the research will be conducted and, in hindsight, should have been conducted shortly before commencing study recruitment. A limitation of this study is that the conclusions were drawn based on interviews with frontline worker and not older adults.
Conclusion and recommendations
Recruiting older adults for a holistic frailty intervention during the COVID-19 pandemic was challenging, and despite using multiple strategies, the recruitment rate was much lower than anticipated. Very few referrals were received from hospital EDs, likely due to the pandemic impact on the workforce and altered models of care post-pandemic. Therefore, EDs might not have been suitable recruitment sites at the time of this study. Programme screening characteristics and researchers’ inability to develop rapport with potential participants also contributed to low recruitment numbers. In addition, older adults’ reported lack of interest may indicate poor awareness and understanding of frailty and the benefits of intervention. We anticipate that more timely co-design sessions to account for pandemic-related healthcare changes, workforce shortages and altered attitudes of older adults towards a community-based frailty intervention would have been beneficial.
Supplemental material
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Monash Health and Bolton Clarke Human Research Ethics Committee (RES-19-0000904L and No. 210002, respectively). Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors JAL, CM, AA and AS: conception and substantial contributions to the design of this qualitative component of the Being Your Best study; AS and AA: participant interviews and data analysis; AS: drafting and revising the manuscript; JAL, CM, AA, DVS, FS, LB, MR, FOK, AM and AH: reviewing the manuscript; JAL: guarantor, final approval and responsibility for the version to be published.
Funding This work is supported by Monash Partners Medical Research Future Fund (MRFF) Rapid Applied Research Translation (Award number M15001 3272941).
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.