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Metrics details. The current study builds on existing literature by examining barriers and facilitators of retaining a street-based cohort of cisgender female sex workers recruited in a mobile setting in Baltimore, Maryland who participated in the SAPPHIRE study. Participants completed interviews and sexual health testing at baseline, 3- 6- 9- and months.

Retention strategies are described and discussed in light of their sapphire sex and challenges. Strategies included collecting several forms of participant contact information, maintaining an extensive field presence by data collectors, conducting social media outreach and public record searches, and providing cash and non-cash incentives.

We also calculated raw and adjusted retention proportions at each follow-up period. Although there were drawbacks to each retention strategy, each method was useful in tandem in achieving a successful follow-up sapphire sex. While direct forms of contact such as phone calls, social media outreach, and were useful for retaining more stable participants, less stable participants required extensive field-based efforts such as home and site visits that increase the likelihood of random encounters.

Participants who were younger, recently experienced homelessness, and injected drugs daily were less likely to have completed all or most follow-up visits. Retention of street-based female sex workers required the simultaneous use of diverse retention strategies that were tailored to participant characteristics.

With familiarity of the dynamic nature of the study population characteristics, resources can be appropriately allocated to strategies most likely to result in successful retention. Peer Review reports. While conventional methods of recruitment in research studies may not be practical for hard-to-reach populations, structural vulnerabilities can also challenge their retention in longitudinal research studies.

These biases can lead to a lack of understanding of hard-to-reach populations who are often in the greatest need. Given the importance of their inclusion, researchers have examined the barriers and facilitators associated with retaining these populations [ 9 ]. Maintaining contact with participants has consistently been identified as a primary barrier, necessitating multiple strategies to bolster retention. Strategies include: building rapport through a range of mechanisms; offering incentives cash and non-cash or gifts for study participation; distributing transportation vouchers; branded study items; obtaining several sapphire sex of contact e.

Although a ificant body of research exists, literature on retaining hard-to-reach populations is limited with most studies focusing on fixed locations or utilizing postal or web-based participation, while also omitting high risk populations such as FSW [ 9 ]. Retention of participants recruited in a mobile setting presents unique challenges due to the absence of a permanent location for them to contact or visit without prompting. Fixed-sites have several advantages, primary of which being travel to such a location is somewhat of an initial screener, increasing the likelihood that those who come to the site return for future visits.

The most vulnerable are also less likely to be able to travel to fixed-sites, resulting in further underrepresentation in fixed-site studies.

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Currently, the few studies examining retention techniques targeting sex workers generally focus on broad sex worker samples e. Sex worker characteristics and experiences vary widely by venue of employment e. Depending on the setting, beneficial methods of retention may differ widely. While retaining venue-based sex workers may only require phone calls or occasional site visits, retaining more transient street-based populations can necessitate costly, extensive field-based outreach.

Street-based cisgender FSW CSFW in the US are often impacted by several overlapping and reinforcing structural vulnerabilities such as homelessness, incarceration, and a history of injection drug use that in the context of research, challenge retention techniques given lack of stable housing and reliable forms of contact [ 31323334 ]. Their under representation in research can have a real impact on receipt of funding and relevant programs targeted to their unique health needs.

The current study examines barriers and facilitators to retaining a street-based CFSW cohort recruited in a mobile setting in Baltimore, Maryland. Specifically, we aim to provide a detailed description and discussion of the follow-up strategies used to retain street-based CFSW as well as analyze follow-up rates and demographic differences between study sapphire sex who were and were not lost to follow-up.

We conclude with a discussion of the successes and shortcomings of our strategies in relation to the broader retention literature to provide suggestions for future research. From April to AugustCFSW were recruited through targeted sampling from 11 street-based locations sapphire sex Baltimore using a mobile research van.

The sampling methods have been ly detailed elsewhere [ 35 ]. The mobile research van used was a ft-long recreational vehicle RV configured with two private interview booths and a restroom for participants to self-collect biological specimens. Exclusion criterion were: 1 identifying as male or a man 2 ; being unwilling or unable to provide contact information to be reached for future visits.

Written consent was obtained from all interested and eligible participants. Participants who were under the age of 18 received individualized health counseling with study supervisors, which included having a detailed conversation on service needs and referrals to known providers. Participants who relocated more than 1 h away from Baltimore were permitted to complete interviews by phone; however, no biological specimens were collected.

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A community advisory board CAB comprised of current and former FSW provided insight and suggestions for all study procedures. Data are unavailable due to privacy concerns for participants. The sample was characterized by several structural vulnerabilities. We employed several population-specific strategies to maximize the potential for follow-up encounters through the duration of the study.

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Study management prioritized collecting several forms of participant contact information, maintaining an extensive field presence by data collectors, conducting social media outreach and public record searches, and providing cash and non-cash incentives. At each study visit, participants completed a standard locator form.

Locator form fields included: participant name; physical description; primary phone ; and social media s; addresses; three locations frequented by participants; and phone s and addresses of two stable contacts. Participants were required to provide either one direct form of contact e. If participants were unable to provide a direct form of contact, then two stable contacts were required. Participants who were unable to provide either one direct form of contact and a stable contact or two stable contacts were prohibited from enrolling in the study.

Given the high prevalence of injection drug use among our study population [ 383940 ], study staff also recorded whether participants attended the Baltimore Syringe Services Program SSP and if so, which SSP locations they visited. A study phone and laptop were kept in the study office and on the study van for staff use. As follow-up van shifts approached, in-office study staff continued contact attempts. Locations were chosen based on the greatest of eligible participants.

Since recruitment and follow-up occurred simultaneously, 1—2 shifts a week were deated for follow-up interviews to ensure that there was available space on the van to accommodate all study participants. Once the entire cohort had been recruited, 3—5 follow-up shifts were scheduled per week, depending on the of eligible participants. Van shift times varied based on the initial targeted sampling framework [ 35 ]. When the van arrived at a zone, staff canvassed the area to locate study participants.

If someone encountered was thought to be a participant, they were brought to the van to check their enrollment and follow-up window. If an individual was enrolled, eligible for follow-up, and interested in completing their interview, study staff would complete a new contact form and continue with the remainder of the follow-up visit. Staff also updated contact information if sapphire sex were not eligible.

After surveying the area for potential participants, staff returned to the van to contact all eligible participants recruited from that zone. As many participants reported drug injection, tracking staff also visited Baltimore SSP locations during the times participants provided on their locator form. Like van shifts, if participants were not eligible, the tracking team updated contact information in REDCap. Staff also used a public web-based database, Maryland Judiciary Case Search Case Search [ 43 ], to learn whether participants were currently sapphire sex and therefore not available for follow-up.

Case Search provided information on all civil, traffic, and criminal cases. Listed information included defendant name, address, casedate of birth, trial date, charge, case disposition, and sentencing information. Study staff used listed information to determine participant availability for follow-up and to verify addresses for tracking. Study staff also distributed non-monetary incentives including condoms, naloxone, lip balm, hand sanitizer, and cleansing wipes. Study management ensured tracking teams and the study van were fully stocked with supplies, beverages, and candy.

With input from the CAB, study management chose these specific non-cash incentives due to their practicality with the target population e. Participants were provided with non-monetary incentives at each encounter regardless of eligibility.

Study management held routine meetings with field staff to obtain feedback on study protocols. Study management hosted several staff trainings to ensure staff operated in a manner that made participants feel safe, comfortable, and at ease during all study procedures and interactions.

Prepared with this understanding and a diverse set of life experiences, staff established trust and ongoing relationships with study participants. When possible, the same staff were ased to track participants at subsequent visits to further contribute to rapport building. The in-person interview format used in this study often led to larger conversations between participants and interviewers outside of the specific survey questions. Extensive neighborhood and need-specific e.

At the request of participants, staff assisted in linking them to qualified organizations to ensure that the needs of the sapphire sex were met. Retention rates sapphire sex analyzed to understand the impact of the range of strategies that were sapphire sex. Retention was defined as having successfully completed a follow-up visit within the two-month window.

For study staff retention efforts, we calculated a raw retention proportion and an adjusted retention proportion, removing participants who missed a follow-up visit for any of the following reasons during the study: incarceration, death, relocation from Baltimore, enrollment in in-patient drug treatment, refusal to participate in the study, and removal from the study.

Both raw and adjusted retention proportions were calculated at each follow-up period. Calculations were based on the of participants that completed their follow-up study visit at each period divided by the total study sample, minus those who met one of the six above listed circumstances in the adjusted retention proportion calculations.

The adjusted retention proportion helped guide and motivate study staff efforts because these situations circumstantially prevented participants from being located or interviewed, and thus, attention was shifted to participants who could possibly be reached to complete their next survey. Participants could miss individual study visits and remain in the study, reentering at any future follow-up time point.

A secondary outcome was the total of visits participants completed out of the five study visits. To be considered as a completed study visit, the study visit had to have been completed within the allotted two-month eligibility window. The possible range for of completed visits was 1 to 5.

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Age was retained as a continuous covariate. We explored: relationship status single vs. We also asked about substance use, dichotomizing into daily or less than daily non-injection or injection drug use. Marijuana use was not considered for the daily non-injection drug use variable. The sample was comprised of CFSW. Women were recruited and retained through the methods described above. Routine weekly SAPPHIRE team meetings provided an outlet for field staff to discuss the successes and challenges of follow-up data collection with study management.

With this information, study management could alter staff makeup, protocols, and the allocation of resources toward beneficial methods of follow-up. Key insights from these retention strategies are presented below. Detailed and accurate locator forms were essential for successful completion of follow-up visits. In addition to participant name and birthdate, the most beneficial pieces of information included: primary phone s ; participant physical description; address; social media s; and phone s and addresses of stable contacts.

Detailed physical descriptions of participants helped field team members in identifying participants during data collection. Contacting participants through primary phone s emerged as a low-cost method of communicating with a large portion of participants. and social media also served as critical no cost resources that improved the likelihood of locating a participant with minimal staff effort.

These communication platforms are accessible on a variety of devices and allowed participants to engage with study staff whenever they could access their s. Participants with limited phone sapphire sex, unreliable internet capability, and those with the propensity to change cell phones could and often did contact study staff using social media. Participants frequently visited fast food establishments with free Wi-Fi or hotels and libraries with computers to check their online s for messages.

One of the greatest benefits of social media and communication was that conversation histories were retained irrespective of duration since last contact or device used. Participants could see prior messages from study staff regardless of the time since the original contact attempts.

This feature also allowed study staff to review prior conversations, setup subsequent interview sessions, and update locator information in REDCap based on past contact. Furthermore, social media photos supported pre-existing physical descriptions recorded on locator forms, which allowed study staff to more easily identify participants sapphire sex data collection. One challenge of using social media to locate participants was the occasional difficulty in locating s due to duplicate profiles or profiles created using a different name.

Additionally, messages sent to study participants occasionally went to spam or junk folders and never reached participants. Sapphire sex participants could not be reached directly, stable contacts provided information regarding participant whereabouts and updated phone s and addresses.

Many participants listed parents, relatives, or romantic partners as stable contacts, some of which proved to be more useful than others. When making outreach calls or home visits, it was not uncommon to learn that the stable contact listed had not seen or communicated with the participant for an extended period of time. Once this issue became apparent, interviewers also encouraged participants to list other women enrolled in the study as stable contacts to create a network of women who were able to convey messages and locate each other for follow-up visits.

The one item on the locator form that was not useful for retention was the list of three locations frequented by participants. In practice, most participants listed the same convenience stores or prominent sex work areas within a recruitment zone.

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The likelihood of encountering a participant at one of these convenience stores was minimal, and staff were already spending time in these areas during van and tracking shifts. Study management implemented the use of a participant database in REDCap after the start of 6-month follow-up interviews that allowed all staff to access locator forms, determine participant eligibility, and view sapphire sex attempts. REDCap also improved communication between field staff and reduced the time spent calling or visiting non-viable contacts.

REDCap allowed study staff to remove incorrect participant information efficiently. Having a central participant database also allowed study management to audit sapphire sex contact history to ensure all possible methods had been attempted. Branded with the study logo, the study RV was recognizable and quickly became well-known among our target population. CFSW with no viable contact information frequented the van for outreach materials, to inquire about follow-up visits, and to seek refuge from inclement weather. The van provided a safe and private space for staff to speak with participants, update locator information, and complete follow-up interviews.

In addition to being recognizable, the study van could accommodate simultaneous interviews, affording staff the capacity to complete up to eight interviews during a typical four-hour data collection shift. There were also several disadvantages to using the van as a follow-up resource.

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Van shifts also required ificant staffing resources. Due to the interview capacity of the van, the unpredictability of the of interviews per shift, and the need for staff to sometimes canvas areas on foot, three staff members were needed during all van shifts.

For many shifts, staff costs were incurred even though no interviews were obtained.

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