Cited by 132Meta-analysis and systematic reviewsBehavioral Health and InterventionsStatistical Methods in Clinical Trials

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Differential attrition in health behaviour change trials: A systematic review and meta-analysis

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Crutzen, Rik, Viechtbauer, Wolfgang, Spigt, Mark, Kotz, Daniel·2015·Psychology & Health

DOI 10.1080/08870446.2014.953526

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Abstract

OBJECTIVE: Attrition is a common problem in health behaviour change (HBC) trials. When the degree of attrition differs between treatment conditions, then this is called differential attrition and is regarded as a major threat to internal validity. The primary research question of this study was: how often and to what degree does differential attrition occur in HBC trials? DESIGN: A systematic review and meta-analysis of a random selection of HBC trials (k = 60). We meta-analysed the relative attrition rates using a random-effects model and examined the relationship between the relative attrition rates and the potential moderators: the amount of human contact in delivery and the intensity of the intervention/control condition, the type of control condition, and the follow-up intensity and duration. MAIN OUTCOME MEASURES: Relative attrition rates. RESULTS: The average attrition rate was 18% (SD = .15; M = .15) in the intervention and 17% (SD = .13; M = .13) in the control conditions. The estimated average relative attrition rate was 1.10 (95% CI: 1.01-1.20, p = .02), suggesting an overall higher attrition rate of 10% in the intervention conditions. This relative attrition rate was not related to any of the potential moderators. CONCLUSION: There is indication of a slightly higher amount of attrition on average in the intervention conditions of HBC trials.

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Background
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Sundström, C., Schell, C., Wardell, J. D., Godinho, A., & Cunningham, J. A. (2020) · Substance Use & Misuse · doi:10.1080/10826084.2020.1788087 · Cited by 10
“Although attrition was high in the trial, it did not differ between the two groups, which under the circumstances can be seen as a strength, since differential attrition is considered a major threat to internal validity (Crutzen et al., 2015).”
How Education and Metacognitive Training May Ameliorate Religious Prejudices: A Randomized Controlled Trial
Moritz, S., Ahmed, K., Krott, N., Ohls, I., & Reininger, K. (2020) · International Journal for the Psychology of Religion · doi:10.1080/10508619.2020.1815994 · Cited by 10
“Better adherence in the intervention conditions (here: metacognitive conditions) is an unusual finding and speaks for the feasibility of the approach (Crutzen et al., 2015).”
Background
Missing, Presumed different: Quantifying the risk of Attrition Bias in Education Evaluations
Weidmann, B., & Miratrix, L. W. (2021) · Journal of the Royal Statistical Society Series A (Statistics in Society) · doi:10.1111/rssa.12677 · Cited by 10
“%) and is only marginally higher than samples of RCTs in public health interventions (Crutzen et al., 2015, n = 60 studies, median attrition = 14%), and economics (Hirshleifer et al., 2019, n = 90 studies, mean attrition = 15%).”
Background
Evaluation of the effectiveness of a 7-week minimal guided and unguided cognitive behavioral therapy-based stress-management APP for students
Weiss, E. M., Harder, M., Staggl, S., Holzner, B., Dresen, V., & Canazei, M. (2025) · BMC Public Health · doi:10.1186/s12889-025-23399-4 · Cited by 11
Adolescents' self‐reported experiences following a person‐centred, theory‐based educational intervention versus conventional education for improved oral hygiene: Analysis of secondary outcomes of a randomized field study
Dimenäs, S. L., Andersson, J. S., Jönsson, B., Lundgren, J., Petzold, M., Östberg, A., & Abrahamsson, K. H. (2023) · Journal Of Clinical Periodontology · doi:10.1111/jcpe.13883 · Cited by 9
Personalized feedback intervention for individuals with low distress tolerance who smoke cigarettes: A randomized controlled trial of a digital intervention
Redmond, B. Y., Salwa, A., Bricker, J. B., Buckner, J. D., Garey, L., & Zvolensky, M. J. (2023) · Journal of Substance Use and Addiction Treatment · doi:10.1016/j.josat.2023.209163 · Cited by 8
PRIORITY Trial: Results from a feasibility randomised controlled trial of a psychoeducational intervention for parents to prevent disordered eating in children and young people with type 1 diabetes
Jones, C. J., Read, R. K., O’Donnell, N., Wakelin, K., John, M., Skene, S. S., Stewart, R., Hale, L. S., Cooke, D. D., Kanumakala, S., et al. (2023) · Diabetic Medicine · doi:10.1111/dme.15263 · Cited by 8
Differential attrition and engagement in randomized controlled trials of occupational mental health interventions in person and online: A systematic review and meta-analysis
de Miquel, C., Haro, J. M., Feltz-Cornelis, C. M. V. D., Ortiz-Tallo, A., Chen, T., Sinokki, M., Naumanen, P., Olaya, B., & Lima, R. A. (2024) · Scandinavian Journal of Work Environment & Health · doi:10.5271/sjweh.4173 · Cited by 8
“These results line up with previous meta-analysis on differential attrition in behavioral and clinical interventions (18, 19).”
Influential
Why and how we should care about the General Data Protection RegulationPreprint
Crutzen, R., Peters, G.-J., & Mondschein, C. F. (2018) · doi:10.31234/osf.io/5gybt · Cited by 8
Attrition and discontinuation in amyotrophic lateral sclerosis clinical trials: a meta-analysis
van Eijk, R. P. A., van Loon, F. T., van Unnik, J. W. J., Weemering, D. N., Seitidis, G., Mavridis, D., van den Berg, L. H., & Nikolakopoulos, S. (2024) · Journal of Neurology · doi:10.1007/s00415-024-12813-3 · Cited by 7
“Studies with no discontinuations in either the intervention or the placebo arm were handled by adding 0.50 to each cell in the 2 by 2 table [4, 5].”
Influential
Interventions to promote home radon testing: A randomized clinical trial of a smartphone app vs. printed brochures
Kim, S., Chiu, T. H., Klug, M. G., Schmitz, D. F., & Schwartz, G. G. (2022) · Cancer Medicine · doi:10.1002/cam4.4988 · Cited by 7
Comparing Communication Methods to Increase Radon Knowledge and Home Testing: A Randomized Controlled Trial in a High-Radon City
Kim, S. G., Scheffer-Wentz, H., Klug, M. G., & Schwartz, G. G. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20095634 · Cited by 7
A feasibility randomised controlled trial of a Fibromyalgia Self-management Programme for adults in a community setting with a nested qualitative study (FALCON)
Pearson, J., Coggins, J., Derham, S., Russell, J., Walsh, N. E., Lenguerrand, E., Palmer, S., & Cramp, F. L. (2022) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-022-05529-w · Cited by 7
“A systematic literature review and meta-analysis showed there was, on average, slightly higher attrition in intervention arms of health behaviour change trials [62].”
Background
Effect of Eyeglasses on Student Academic Performance: What Matters? Evidence from a Randomized Controlled Trial in China
Du, K., Wang, H., Ma, Y., Guan, H., & Rozelle, S. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191710923 · Cited by 7
“The attrition rate of our study was low, according to relevant RCT literature [23].”
Background
Twelve Month Efficacy of Computer-Tailored Communication in Boosting Fruit and Vegetable Consumption Among Adults Aged Forty and over: A Three-Level Meta-Analysis and Systematic Review of Randomized Controlled Trials
Misir, A., Viechtbauer, W., de Vries, H., & Mesters, I. (2023) · Advances in Nutrition · doi:10.1016/j.advnut.2023.100150 · Cited by 7
“In addition, Crutzen et al. (2013) [80] claim that there is an indication that slightly higher attrition rates are often seen in intervention groups compared with control, which attenuates the observed effect.”
Result
The Self-as-Doer Identity and Physical Activity: The Mediating Effect of Self-Efficacy for Managing Physical Activity Barriers
Brouwer, A. M. (2019) · Identity · doi:10.1080/15283488.2019.1697272 · Cited by 6
Participant and trial characteristics reported in predictive analyses of trial attrition: an umbrella review of systematic reviews of randomised controlled trials across multiple conditions
McChrystal, R., Lees, J. S., Gillies, K., McAllister, D., & Hanlon, P. (2025) · Trials · doi:10.1186/s13063-025-08794-x · Cited by 5
Impact of trial attrition rates on treatment effect estimates in chronic inflammatory diseases: A meta‐epidemiological study
Overgaard, S. H., Moos, C. M., Ioannidis, J. P. A., Luta, G., Berg, J., Nielsen, S. M., Andersen, V. C., & Christensen, R. (2024) · Research Synthesis Methods · doi:10.1002/jrsm.1708 · Cited by 5
“For example, studies with anti-depressant drug interventions 17 or health behaviour change interventions 18 observed more attrition in the experimental intervention groups than in the con-trol comparator groups.”
Effectiveness of an LGBTQ+ E-Learning Module for Social Workers: A Randomized Controlled Trial
Schaub, J., Keemink, J. R., Stander, W. J., & Montgomery, P. (2023) · Research on Social Work Practice · doi:10.1177/10497315231208199 · Cited by 4
“%) as is typical in trials such as this one (Crutzen et al., 2015).”
Development and assessment of a self-management intervention for urinary incontinence among patients with prostate cancer: protocol for a randomized feasibility study
Chien, C., Liu, K., Wu, C., Chuang, C., Yu, K., Lin, P., Huang, X., & Pang, S. (2023) · BMC Urology · doi:10.1186/s12894-023-01367-7 · Cited by 4
“Based on this information and considering a study discontinuation rate of 17–18% [67], we plan to include a total of 86 patients (43 per group) in this study.”
Method
Family structure and delinquency: Antisocial cognition as a mediating mechanism
Walters, G. D., Runell, L., & Kremser, J. (2022) · Journal of Adolescence · doi:10.1002/jad.12063 · Cited by 4
‘Relearning how to think’: A brief online intervention to modify biased interpretations in emotional disorders—study protocol for a randomised controlled trial
Nieto, I., & Vázquez, C. (2021) · Trials · doi:10.1186/s13063-021-05459-3 · Cited by 6
Adherence to Behavioral Weight Management: A Scoping Review of Definitions, Measurement, and Components
Wang, D., Rojo‐Tirado, M. Á., Benito, P. J., Rubio‐Arias, J. Á., Ramos‐Campo, D. J., & Marques, M. M. (2025) · Obesity Reviews · doi:10.1111/obr.70066 · Cited by 4
Randomized Trial of Self-Guided, Internet-Based, Cognitive Behavior Therapies for Migraine
Huguet, A., Rozario, S., Chaplin, W., McDonald, M., Wozney, L., Lagman‐Bartolome, A. M., Kronish, I. M., Purdy, A., Stinson, J., & McGrath, P. J. (2024) · Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques · doi:10.1017/cjn.2024.287 · Cited by 3
“44 Differential attrition could be because of the greater effort required to participate in the treatment arms.”
Feasibility, acceptability and preliminary effectiveness of a manualized lay-led food literacy intervention for women in a community setting
Greenberg, K. L., Bar‐Zeev, Y., Donchin, M., Karjawally, M., Sneineh, S. A., Husseini, M. N., & Zwas, D. R. (2025) · Appetite · doi:10.1016/j.appet.2025.107885 · Cited by 3
Efficacy of Occupation-Based Intervention in Promoting Well-Being Among Occupational Therapy Graduate Students
Espiritu, E., Chang, P.-F., Evetts, C., & Adams, J. (2024) · OTJR: Occupation, Participation and Health · doi:10.1177/15394492241287712 · Cited by 4
Submitting the original participant information letter as supplementary material of a trial report is useful and can be easily implemented
Kotz, D., Viechtbauer, W., Spigt, M., & Crutzen, R. (2019) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2019.09.013 · Cited by 3
“This differential attrition is a common problem in, for example, health behavior change trials [4].”
Background
Palliative Care Interventions Among Adolescents and Young Adults With Serious Illness: A Scoping Review
Newman, A. R., Kenney, A. E., Witkowski, E., Karst, J. S., Lerret, S. M., Davies, W. H., & Rothschild, C. B. (2023) · Clinical Practice in Pediatric Psychology · doi:10.1037/cpp0000486 · Cited by 3
“Attrition from behavioral health interventions is common (Crutzen et al., 2015).”
Revitalizing wellbeing: App design for stress reduction through artificial intelligence and persuasive technology
Orji, J., Chan, G., & Orji, R. (2025) · International Journal of Human-Computer Studies · doi:10.1016/j.ijhcs.2025.103600 · Cited by 3
Dietary E‐Health Interventions for Adults With Severe Mental Illness: A Systematic Review
Holmes, K., Heaney, S. E., Smith, A., Skinner, J. A., & Burrows, T. L. (2025) · Journal of Human Nutrition and Dietetics · doi:10.1111/jhn.70112 · Cited by 2
The great live and move challenge and the promotion of physical activity in children: results from a two-school-year cluster-randomized trial
Gourlan, M., Lambert, C., Fregeac, B., Mora, L., Jeanleboeuf, F., Minotte, A., Coste, O., Pereira, B., & Cousson‐Gélie, F. (2025) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-025-01849-x · Cited by 3
“…had a significantly higher attrition rate than the control group, and attrition was associated with older age, which, while common in health trials [100, 101], may have reduced the representativeness of the retained sample and thereby threatened the study’s internal validity [102] and limited the…”
Study Design Complexity and Participant Completion in Dietary Trials for Inflammatory Bowel Disease: A Systematic Review and Metaresearch Study
Gregersen, L., Moos, C. M., Hikmat, Z., Rasmussen, N. F., Petersen, S. R., Heitmann, B. L., Halldorsson, T. I., Andersen, V. C., & Christensen, R. (2026) · Advances in Nutrition · doi:10.1016/j.advnut.2026.100614 · Cited by 2
“…collect information on the number of outcomes reported by the trials, the intensity of intervention delivery, the motivation incentives, or the degree of control over energy intake, which could have provided more nuanced perspectives on trial completion as also indicated by previous reviews [1,96].”
Influential
Recruitment and Retention of Social Workers as Research Participants: Lessons from a Randomized Controlled Trial
Keemink, J. R., Stander, W. J., Montgomery, P., & Schaub, J. (2025) · Social Work Research · doi:10.1093/swr/svaf002 · Cited by 2
From Trials to Practice: Implementing a Clinical Intervention in Community Settings
Vaughan, E. M., Yu, X., Cardenas, V. J., Johnston, C. A., Virani, S. S., Balasubramanyam, A., Ballantyne, C. M., & Naik, A. D. (2025) · Journal of Primary Care & Community Health · doi:10.1177/21501319251339190 · Cited by 2
Combination Therapy of Resilience Intervention with Biologics in Crohn's Disease (CATHARSIS): Study protocol for a randomized controlled trial
Keefer, L., Ungaro, R. C., Lewis, A. E., Lee, J., de Amorrortu, C., Lores, T. J., Siganporia, T., Mehandru, S., Petralia, F., & Colombel, J. (2025) · Contemporary Clinical Trials · doi:10.1016/j.cct.2025.108151 · Cited by 2
5-Year Follow-Up of a Telephone Intervention to Increase Fruit and Vegetable Consumption in Preschoolers: The ‘Healthy Habits’ Cluster Randomised Trial
Wyse, R., Stacey, F. G., Campbell, L., Yoong, S. L., Lecathelinais, C., Wiggers, J. H., Campbell, K. J., & Wolfenden, L. (2020) · Nutrients · doi:10.3390/nu12123702 · Cited by 2
“effectiveness, and if their expectations are not met they drop out of follow-up [44].”
BackgroundResult
Development of a Mobile App to Monitor the Effectiveness of a Hydrolyzed Cartilage Matrix Supplement on Joint Discomfort: Real-World Study
Newman, C., Adriaens, E., Virgilio, N., Vleminckx, S., Pelsmaeker, S. D., Prawitt, J., & Silva, C. I. F. (2023) · JMIR Formative Research · doi:10.2196/42967 · Cited by 2
“Although dropouts are a common issue in controlled trials [42-44], the dropout rates in this study were relatively low (3% for the HCM group, 19% for the placebo group), especially given the fact that this study was run at distance.”
Result

Authors: Crutzen, R., Viechtbauer, W., Spigt, M., & Kotz, D.
Affiliations: Maastricht University (NL)
Cancer Research UK (GB)
Corresponding author: Crutzen, Rik
ORCID: Crutzen, Rik
Viechtbauer, Wolfgang
Spigt, Mark
Kotz, Daniel
Venue: Psychology & Health
Publisher: Informa UK Limited
Published: 2014-12-09
Volume: 30
Issue: 1
Pages: 122-134
ISSN: 0887-0446 (ISSN-L)
1476-8321
DOI: 10.1080/08870446.2014.953526
OpenAlex: W2160645377
Cited by: 132
References: 41
Citations by year: 2026: 8 · 2025: 20 · 2024: 8 · 2023: 13 · 2022: 16 · 2021: 13 · 2020: 11 · 2019: 10 · 2018: 5 · 2017: 10 · 2016: 7 · 2015: 5 · 2014: 6
FWCI: 2.56
Type: journal article
Language: en
Open access: green
cris.maastrichtuniversity.nl
Licence: other-oa
Locations: Psychology and Health (publishedVersion)
PubMed (publishedVersion)
Research Publications (Maastricht University) (publishedVersion, other-oa)
Lirias (submittedVersion)
Research Publications (Maastricht University) (submittedVersion, other-oa)
Topics: Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Clinical Trials
Keywords: differential attrition, health behavior change interventions, attrition rates, internal validity, control conditions, intervention intensity, follow-up intensity
MeSH terms: Humans, Patient Dropouts, Health Behavior, Bias, Randomized Controlled Trials as Topic

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Differential attrition in health behaviour change trials: A systematic review and meta-analysis

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