Participation of minorities in cancer research: the influence of structural, cultural, and linguistic factors

Music therapy in an integrated pediatric palliative care program

National experts have recommended that children with life-limiting illnesses receive integrated palliative and medical care. These programs offer a variety of services, including music therapy. Using survey data from parents whose were enrolled in Florida's Partners in Care: Together for Kids (PIC:TFK) program, this study investigates parents' experiences with music therapy. About 44% of children with life-limiting illnesses and 17% of their siblings used music therapy. For children who used music therapy, multivariate results suggest that their parents were 23 times as likely to report satisfaction with the overall PIC:TFK program (P < .05) versus parents whose children did not use music therapy. Pediatric palliative care programs should include music therapy, although recruiting licensed music therapists may be challenging.

Mexican immigrant male knowledge and support toward breast and cervical cancer screening

BACKGROUND

We conducted a focus group study to assess the influence of partner communication on breast and cervical cancer screening and the perceived existing and potential support from male partners in participating in cancer screening. Secondarily, Mexican male and female views on health care and cancer were explored.

METHODS

Seven focus groups (two female-only, three male-only, and two couples) were conducted in Spanish.

RESULTS

Findings suggest that knowledge about cervical cancer was significantly less than knowledge about breast cancer among both men and women. Barriers to cancer screening included language barriers, lack of health insurance, and lack of awareness of the need for screening. Male partners expressed willingness to support their female partners in cancer screening activities.

CONCLUSION

Cervical cancer education is desperately needed, including education on the availability of free and low cost screening services. Education efforts should include the male community members, especially as the males perceive themselves as responsible for the financial burden of care.

Analysis of Maryland cancer patient participation in National Cancer Institute-supported cancer treatment clinical trials

PURPOSE

We examined the relationship of sociodemographic factors, urban/rural residence, and county-level socioeconomic factors on accrual of Maryland patients with cancer to National Cancer Institute (NCI)-sponsored cancer treatment clinical trials.

PATIENTS AND METHODS

Data were analyzed for the period 1999 to 2002 for 2240 Maryland patients with cancer accrued onto NCI-sponsored treatment trials. The extent to which Maryland patients with cancer and patients residing in lower socioeconomic and/or rural areas were accrued to cancer trials and were representative of all patients with cancer in Maryland was determined. Data were obtained from several sources, including NCI's Cancer Therapy Evaluation Program for Maryland patients with cancer in Cooperative Group therapeutic trials, Maryland Cancer Registry data on cancer incidence, and United States Census and the Department of Agriculture.

RESULTS

For Maryland patients with cancer accrued onto NCI-sponsored treatment trials between 1999 and 2002, subgroups accrued at a higher rate included pediatric and adolescent age groups, white patients, female patients (for sex-specific tumors), patients with private health insurance, and patients residing in the Maryland National Capitol region. Moreover, between 1999 and 2002, there was an estimated annual decline (8.9% per year; P < .05) in the percentage of black patients accrued onto cancer treatment trials. Logistic regression models uncovered different patterns of accrual for female patients and male patients on county-level socioeconomic factors.

CONCLUSION

Results highlight disparities in the accrual of Maryland patients with cancer onto NCI-sponsored treatment trials based on patient age, race/ethnicity, geography of residence, and county-level socioeconomic factors. Findings provide the basis for development of innovative tailored and targeted educational efforts to improve trial accrual, particularly for the underserved.

Diversity of participants in clinical trials in an academic medical center: the role of the 'Good Study Patient?'

BACKGROUND

Only 2.5% of adults and even fewer minorities participate in cancer therapeutic trials. Researchers have concluded that many barriers to participation stem from how recruitment is performed by clinician investigators. The objective of the current research was to document specifically how these barriers impede recruitment in the clinical setting.

METHODS

The authors conducted a case study of recruitment in an academic medical center using ethnographic research methods (direct observation of provider-patient interactions and in-depth interviews with providers) to collect data. Qualitative data analysis was used to identify themes related to the provider's role in the recruitment processes.

RESULTS

In the clinics that were studied, the authors observed that providers subjectively assessed which patients seemed to be 'good study patients' to target for recruitment. 'Good study patients' were identified as those who were able to adhere to complex trial protocols, thus helping clinician researchers to complete studies in a timely and efficient manner. These patients were perceived as meticulous, proactive, and compliant; they were considered good communicators; and they were embedded in the kinds of strong social support networks that facilitated their trials participation.

CONCLUSIONS

The providers that were studied sought 'good study patients' for therapeutic trials because they wanted to perform studies in a timely and efficient manner. Future research should examine whether providers in other settings also target their recruitment efforts for this or other reasons. Further research also should consider whether differentially recruiting 'good patients' can impact the ethnic/racial diversity or other characteristics of trial participants in ways that may bias the outcomes or conclusions of therapeutic trials.

Cancer epidemiology in the United States: racial, social, and economic factors

It is widely accepted that there is a differential burden of cancer in certain populations, including racial/ ethnic minorities, the medically underserved, and older adults. Differences in survival, stage at diagnosis, and risk of death have been identified in these populations for cancers of the lung, colon and rectum, prostate, and female breast. The factors that drive these disparities are not uniformly understood. Addressing the unique issue of racial differences in cancer epidemiology necessitates a discussion of the definitions of "race" and "ethniCity," and an analysis of the validity of these concepts within the context of scientific study. Poor cancer-related health outcomes in groups of low socioeconomic status highlight issues of access to care and preventive care use. There is a scant amount of data on cancer in the elderly, and the special considerations that this group faces. A unique challenge facing cancer epidemiologists is suboptimal recruitment of members of these groups into clinical studies, which precludes a robust understanding of the existing disparities. It is critical to appreciate the overlap that exists between these populations, because this may complicate data interpretation. Legislative efforts that have, in part, been driven by the National Center on Minority Health and Health Disparities and by the Department of Health and Human Services, will continue to play an instrumental role in the identification and resolution of cancer disparities in these groups.

An educational video to increase clinical trials enrollment among breast cancer patients

Only 3% of women with breast cancer participate in cancer clinical trials nationwide. The lack of awareness about clinical trials is a significant barrier towards clinical trials participation. A study was conducted at a large urban Comprehensive Cancer Center to test (1) the effectiveness of an 18-min educational video on improving attitudes toward clinical trials and trials enrollment among new breast cancer patients seen at the Karmanos Cancer Institute, and (2) to assess racial differences in attitudes regarding clinical trials. Participants were randomized to either the educational intervention prior to their first oncology clinic appointment or to standard care. A baseline and 2-week post-intervention survey to assess attitudes toward clinical trials participation was completed by participants. Of 218 subjects recruited, 196 (55% white vs. 45% African American (AA)) eligible patients were included in the analysis. A small increase in therapeutic clinical trial enrollment was observed in the intervention arm but was not statistically significant (10.4% vs. 6.1%; P = 0.277). The intervention also did not result in a clear improvement in patients' attitudes toward clinical trials at posttest. However, a lower enrollment rate for the AA women was noted after adjusting for stage (OR = 0.282, P = 0.049). Significantly more negative scores were noted in 3 out of the 5 baseline attitudinal scales for AA women. The educational video did not significantly increase enrollment in breast cancer clinical trials. The findings that AA women had significantly more negative attitudes toward clinical trials than white women may partially explain the racial disparity in enrollment. An educational video remains a simple and cost-effective way to educate patients. Future studies should focus on designing a new educational video to specifically target cultural and attitudinal barriers in the AA population to more effectively change attitudes and increase trial enrollment.

Recruitment and retention of older adults in aging research

Older adults continue to be underrepresented in clinical research despite their burgeoning population in the United States and worldwide. Physicians often propose treatment plans for older adults based on data from studies involving primarily younger, more-functional, healthier participants. Major barriers to recruitment of older adults in aging research relate to their substantial health problems, social and cultural barriers, and potentially impaired capacity to provide informed consent. Institutionalized older adults offer another layer of complexity that requires cooperation from the institutions to participate in research activities. This paper provides study recruitment and retention techniques and strategies to address concerns and overcome barriers to older adult participation in clinical research. Key approaches include early in-depth planning; minimizing exclusion criteria; securing cooperation from all interested parties; using advisory boards, timely screening, identification, and approach of eligible patients; carefully reviewing the benefit:risk ratio to be sure it is appropriate; and employing strategies to ensure successful retention across the continuum of care. Targeting specific strategies to the condition, site, and population of interest and anticipating potential problems and promptly employing predeveloped contingency plans are keys to effective recruitment and retention.

Making diabetes self-management education culturally relevant for Filipino Americans in Hawaii

PURPOSE

The purpose of this study was to identify the cultural values, traditions, and perceptions of diabetes risk and self-care among Filipino Americans in Hawaii with type 2 diabetes that facilitate or impede engagement in diabetes self-management behaviors and education classes.

METHODS

This qualitative study used 2 rounds of semistructured focus groups and interviews. Participants included 15 patients with type 2 diabetes recruited from a large health-maintenance organization in Hawaii and 7 health care and cultural experts recruited from the community. The taped and transcribed focus groups and interviews were coded thematically. Participants evaluated example materials for diabetes self-management education (DSME) with Filipino Americans.

RESULTS

Several aspects of Filipino American culture were identified as central to understanding the challenges of engaging in self-management behaviors and DSME: (1) undertaking self-management while prioritizing the family and maintaining social relationships, (2) modifying diet while upholding valued symbolic and social meanings of food, (3) participating in storytelling in the face of stigma associated with diabetes, and (4) reconciling spiritual and biomedical interpretations of disease causality and its management. Respondents also emphasized the role of several qualitative aspects of perceived risk (eg, dread, control) in moderating their behaviors. Participants suggested ways to make DSME culturally relevant.

CONCLUSIONS

Awareness of cultural values and qualitative aspects of perceived risk that influence Filipino Americans' engagement in diabetes self-care behaviors and classes may help to improve teaching methods, materials, and recruitment strategies.

Latina recruitment for cancer prevention education via Community Based Participatory Research strategies

Increasing minority participation in cancer research is an ethical and statistical necessity for gaining population-specific knowledge of cancer prevention, screening, and treatment. Locating and recruiting eligible and willing minority participants presents unique structural and cultural/linguistic challenges. Community Based Participatory Research provides a viable set of principles for facilitating recruitment in hard-to-recruit communities. We focus on the specific challenge of recruiting and engaging low-income and underinsured Latina women in cancer prevention education research, and present community-based strategies used to recruit women into a recently completed study in Arizona, Juntos en la Salud (Together in Health). Community representatives and promotoras' (Latino community health educators) involvement in site identification, individual recruitment, and development of strategies and materials for the interventions built engagement and trust. These strategies resulted in enrollment of an especially low-income, underinsured population. To emphasize the degree to which a particularly underserved population was recruited, we present data comparing demographic and screening profiles of enrollees to the general population of Latinos in Arizona.

Recruitment in the prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial: the first phase of recruitment at Henry Ford Health System

OBJECTIVE

Recruitment of healthy subjects to long-term randomized controlled trials (RCTs) of cancer prevention or early detection has proven to be a difficult task. To quantify recruitment yield as well as characteristics of successfully recruited participants, we examined recruitment outcomes at 1 of the 10 centers participating in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, a National Cancer Institute-funded RCT of cancer screening modalities.

MATERIALS AND METHODS

During the early recruitment phase of PLCO (1993-1997), data on recruitment outcome were collected at the Henry Ford Health System (HFHS) in Detroit, Michigan. In this phase, HFHS identified potential participants using patient databases. Records were used to assess recruitment success by age, sex, race, household income (using area-based U.S. Census data), and preexisting morbidity. Logistic regression was used to assess whether enrollment success differed significantly according to these factors.

RESULTS

Of 74,139 persons ages 55 to 74 invited by HFHS to participate, 8,250 (11%) ;enrolled. In multivariate analyses, the odds of enrolling were modestly but significantly higher for women, Caucasians, persons in their 60's, and persons living in census blocks with higher median household income. Persons with two or more preexisting morbidities had significantly lower odds of enrolling compared to those with one or no preexisting morbidities.

CONCLUSIONS

These data suggest that only a small fraction of persons invited to enroll in long-term RCTs of cancer screening modalities actually do so. In this urban, Midwestern setting, certain characteristics including age, race, and income influenced recruitment success, albeit modestly.

Analysis of Maryland cancer patient participation in national cancer institute-supported cancer treatment clinical trials

PURPOSE

We examined the relationship of sociodemographic factors, urban/rural residence, and county-level socioeconomic factors on accrual of Maryland patients with cancer to National Cancer Institute (NCI) -sponsored cancer treatment clinical trials.

PATIENTS AND METHODS

Data were analyzed for the period 1999 to 2002 for 2,240 Maryland patients with cancer accrued onto NCI-sponsored treatment trials. The extent to which Maryland patients with cancer and patients residing in lower socioeconomic and/or rural areas were accrued to cancer trials and were representative of all patients with cancer in Maryland was determined. Data were obtained from several sources, including NCI's Cancer Therapy Evaluation Program for Maryland patients with cancer in Cooperative Group therapeutic trials, Maryland Cancer Registry data on cancer incidence, and United States Census and the Department of Agriculture.

RESULTS

For Maryland patients with cancer accrued onto NCI-sponsored treatment trials between 1999 and 2002, subgroups accrued at a higher rate included pediatric and adolescent age groups, white patients, female patients (for sex-specific tumors), patients with private health insurance, and patients residing in the Maryland National Capitol region. Moreover, between 1999 and 2002, there was an estimated annual decline (8.9% per year; P < .05) in the percentage of black patients accrued onto cancer treatment trials. Logistic regression models uncovered different patterns of accrual for female patients and male patients on county-level socioeconomic factors.

CONCLUSION

Results highlight disparities in the accrual of Maryland patients with cancer onto NCI-sponsored treatment trials based on patient age, race/ethnicity, geography of residence, and county-level socioeconomic factors. Findings provide the basis for development of innovative tailored and targeted educational efforts to improve trial accrual, particularly for the underserved.

Clinical trials attitudes and practices of Latino physicians

BACKGROUND

Ethnic differences in physicians' attitudes and behaviors related to clinical trials might partially account for disparities in clinical trial participation among Latino patients. Literature regarding Latino physicians' clinical trials attitudes and practices, in comparison to White physicians, was lacking.

METHODS

Cross-sectional data from randomly selected physicians (N=695), stratified by ethnicity, were analyzed to test associations of ethnicity with physicians' participation in and attitudes toward referral of patients to clinical trials.

RESULTS

Chi-square analyses showed significant (p<0.05) associations of physician race/ethnicity and clinical trials involvement, type of trial for which the physician is likely to recommend a patient, belief in scientific value, and factors that would influence recommendation for a patient to participate. Multivariate analyses resulted in several significant (p<0.05) predictors of clinical trials outcomes, including physician race/ethnicity.

CONCLUSIONS

Latino physicians were significantly less involved in clinical trials than White physicians and found less scientific value in them, highlighting areas for future education and intervention.

Influence of clinical communication on patients' decision making on participation in clinical trials

PURPOSE

To investigate how communication among physicians, patients, and family/companions influences patients' decision making about participation in clinical trials.

PATIENTS AND METHODS

We video recorded 235 outpatient interactions occurring among oncologists, patients, and family/companions (if present) at two comprehensive cancer centers. We combined interaction analysis of the real-time video-recorded observations (collected at Time 1) with patient self-reports (Time 2) to determine how communication about trial offers influenced accrual decisions.

RESULTS

Clinical trials were explicitly offered in 20% of the interactions. When offers were made and patients perceived they were offered a trial, 75% of patients assented. Observed messages (at Time 1) directly related to patients' self-reports regarding their decisions (2 weeks later), and how they felt about their decisions and their physicians. Specifically, messages that help build a sense of an alliance (among all parties, including the family/companions), provide support (tangible assistance and reassurance about managing adverse effects), and provide medical content in language that patients and family/companions understand are associated with the patient's decision and decision-making process.

CONCLUSION

In two urban, National Cancer Institute-designated comprehensive cancer centers, a large percentage of patients are not offered trials. When offered a trial, most patients enroll. The quality and quantity of communication occurring among the oncologist, patient, and family/companion when trials are discussed matter in the patient's decision-making process. These findings can help increase physician awareness of the ways that messages and communication behaviors can be observed and evaluated to improve clinical practice and research.

Barriers to recruiting urban African American women into research studies in community settings

This qualitative study identified barriers to African American women's participation in a community-based behavioral intervention trial to increase mammography screening. Four themes emerged from focus group discussions with community agency providers and research team members. These themes were (1) going to the gatekeepers; (2) knowing the culture; (3) location is everything; and (4) protocols, policies, and possibilities. A checklist of actions that nurse researchers could consider to increase African American women's participation in community trials is provided.

Latino recruitment to cancer prevention/screening trials in the Southwest: setting a research agenda

Examples of cancer prevention and screening trials in the Southwest are reviewed as a platform for highlighting gaps in research on Latino recruitment. Three trials are described, using "message/source/channel" categories as a framework. Each trial engaged community members to facilitate recruitment and developed tailored strategies to meet challenges emerging after recruitment began. Although we affirm that culturally relevant messages, community member referral networks, and adjustment to community realities seem important to Latino recruitment, current anecdotal and research findings do not allow evidence-based recommendations to be made. We suggest a research agenda to further illuminate critical factors for successful Latino recruitment.

Enrollment of racial and ethnic minorities in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

BACKGROUND

Minority populations in the United States, especially blacks and Hispanics, are generally underrepresented among participants in clinical trials. Here, we report the experience of enrolling ethnic minorities in a large cancer screening trial.

METHODS

The Prostate, Colorectal, Lung and Ovarian (PLCO) Cancer Screening Trial is a multicenter randomized trial designed to evaluate the effectiveness of screening for the PLCO cancers. Subjects were recruited at 10 U.S. centers between 1993 and 2001. One screening center had a major special recruitment effort for blacks and another center had a major special recruitment effort for Hispanics.

RESULTS

Among almost 155,000 subjects enrolled in PLCO, minority enrollment was as follows: black (5.0%), Hispanic (1.8%) and Asian (3.6%). This compares to an age-eligible population in the combined catchment areas of the PLCO centers that was 14.0% black, 2.9% Hispanic and 5.4% Asian, and an age-eligible population across the U.S. that was 9.5% black, 6.5% Hispanic and 3.0% Asian. About half (45%) of Hispanics were recruited at the center with the special Hispanic recruitment effort. Seventy percent of blacks were recruited at two centers; the one with the major special recruitment effort and a center in Detroit whose catchment area was 20% black among age-eligibles. Blacks, Hispanics and (non-Hispanic) whites were all more highly educated, less likely to currently smoke and more likely to get regular exercise than their counterparts in the general population.

CONCLUSION

Significant efforts were made to recruit racial/ ethnic minorities into PLCO, and these efforts resulted in enrollment levels that were comparable to those seen in many recent cancer screening or prevention trials. Blacks and Hispanics were nonetheless underrepresented in PLCO compared to their levels among age-eligibles in the overall U.S. population or in the aggregate PLCO catchment areas.

Challenges and strategies in recruitment of ethnically diverse populations for cancer nursing research

PURPOSE/OBJECTIVES

To describe common barriers, identify challenges for researchers, and provide strategies for recruitment and retention of ethnic minority groups for cancer nursing research.

DATA SOURCES

Computerized search of databases, published articles, abstracts, master's theses, and doctoral dissertations.

DATA SYNTHESIS

Social, economic, and cultural factors present challenges to recruitment of minorities into research. Knowing the culture of the target population, developing trust, engaging the community, and using tailored materials are strategies for recruitment and retention of minorities.

CONCLUSIONS

Knowledge of potential barriers and challenges to research with diverse populations provides the foundation for the development of strategies for successful recruitment of minorities in cancer nursing research.

IMPLICATIONS FOR NURSING

Increasing ethnic minorities in research will generate knowledge that will contribute to culturally competent cancer care.

Early participant attrition from clinical trials: role of trial design and logistics

BACKGROUND

Participant attrition from randomized controlled trials reduces the statistical power of the study and can potentially introduce bias. Early identification of potential causes of attrition can help reduce patient attrition. We performed secondary analyses of two trials involving cancer patients.

PURPOSE

To identify predictors of attrition during two early phases, i.e., from consent to screening (Phase-1), and from screening to intake interview (Phase-2) in two clinical trials.

METHODS

Cancer patients undergoing chemotherapy were asked to enroll in one of two clinical trials. In each trial the benefits of a cognitive behavioral intervention were compared with a psycho-educational intervention to assist patients to manage cancer and treatment-related symptoms. Following consent patients were screened for their symptoms' severity to determine their eligibility.

RESULTS

Of the 885 consenters 785 completed screening and of the 782 eligible for participation, 713 completed intake interview. In the first phase, longer delays between consent and first contact attempt, lower levels of patient education, minority race, and prolonged duration of screening increased the likelihood of dropping out with a significantly stronger effect on minorities than white patients. In the second phase, low education, being a minority, longer screening delays, and impact of symptom severity on enjoyment of life significantly increased probability of attrition.

LIMITATIONS

Participant reported causes of attrition were not modeled; however, exclusion of patients who died during the time period of this research meant that most patients leaving the study made a conscious decision to do so.

CONCLUSIONS

To assure preservation of external validity, the time between consent and randomization into the arms of a trial must be held to a minimum. Delays between contacts and run in time, that may include screening patients to assure they will benefit from a trial, must be balanced against rates of attrition. Compressing intervals between contacts is particularly important to retain minorities.

An educational video to increase clinical trials enrollment among lung cancer patients

INTRODUCTION

Only 3 to 5% of new adult cancer patients participate in clinical trials nationwide. The lack of knowledge and awareness about clinical trials is a significant barrier to clinical trials participation. A randomized trial was conducted to test the effect of an educational video on positively changing patients' knowledge and attitudes regarding clinical trials and thereby increasing enrollment rates.

METHODS

Lung cancer patients were randomized to viewing either an 18-minute video about clinical trials before first clinic appointment or to standard care. Participants completed a baseline and 2-week postintervention survey to assess their knowledge and attitudes toward trials participation. Fisher's exact test tests, t tests, and regression were used to compare patient characteristics and outcomes between arms.

RESULTS

Of 145 subjects randomized, 126 (63/arm) satisfied all inclusion criteria and were included in the analysis. A linear regression showed that the video intervention was significantly associated with patients' self-assessed likelihood to enroll score measured at 2-week follow-up (p = 0.019). Although statistically insignificant, enrollment rates were found to be higher in the intervention arm for therapeutic trials alone (17.5% versus 11.1%) and for therapeutic and nontherapeutic trials combined (25.4% versus 15.9%).

CONCLUSIONS

The brief educational video seems to be effective in positively changing lung cancer patients' attitudes about participation in clinical trials. Higher enrollment rates were also observed in the intervention group but the differences did not reach statistical significance. These findings suggest a potential impact of the educational video on clinical trial enrollment; however, larger studies are needed to confirm these findings.

An examination of community members', researchers' and health professionals' perceptions of barriers to minority participation in medical research: an application of concept mapping

OBJECTIVE

Some of the most promising medical treatments are currently being developed and used in clinical trials. In the US, rates of chronic disease among racial/ethnic minorities are disproportionately high. Unfortunately, the rates of minority participation in medical research are low, and the reasons are unclear. This study seeks to contribute to the body of knowledge that is currently available relating to the specific barriers to racial/ethnic minority participation in medical research through the conceptualization and measurement of these barriers.

DESIGN

Study participants included a convenience sample obtained from the National Cancer Institute's Special Populations Networks, and consisted of practitioners, researchers and community members who specialize in research related to the treatment and prevention of cancer. A structured form of concept mapping (Trochim 1989) was the methodology used in this study. The concept mapping process has three specific phases: (1) project planning - development of project focus statements and sample selection (2) idea generation and structuring and (3) analysis and interpretation. This method is analogous to a more formalized and structured focus group approach, and involved the gathering of 149 ideas and the sorting of 70 statements. Comparisons across participant demographics were conducted and are presented in the form of pattern matches.

RESULTS

The findings of this study suggest that there are two specific areas where barriers to minority participation may be addressed. The first area is the research system, specifically, the manner in which research studies are designed and implemented, including referral, recruitment and retention of racial/ethnic minorities. The data suggest that recruitment and retention will be aided by addressing patient concerns regarding the research process, and assuaging fears about clinical trials. The second area pertains to minority perceptions of the research process based on history and personal experiences.

CONCLUSION

There appears to be a difference in the barriers to participation as defined by community members themselves, and health professionals' perceptions of these barriers. Increased inclusion of minorities in the design, management, and implementation of medical research studies would help mitigate negative perceptions of the research process, and serve to increase participation among racial/ethnic minorities.

Recruiting low-income healthy women to research: an exploratory study

OBJECTIVE

The study goals were (1) to assess the feasibility of using an existing telephone health information and referral service for low-income, ethnically diverse women to recruit women for research participation; (2) to assess the feasibility of recruiting low-income, African American and Latino men into health research through the women callers to the telephone service; and (3) to describe the challenges women face and the strategies they use when talking to men about the men's health and research participation.

DESIGN

We recruited women for individual semi-structured qualitative interviews via the Every Woman Counts (EWC) telephone information and referral service, a California Department of Health Services Cancer Detection Program. This paper describes our eligibility and recruitment assessment, and our qualitative data from 23 interviews with low-income African American and Latino women who called EWC.

RESULTS

We found that it was feasible to recruit women, but not to recruit men through women who call this telephone service. Almost 50% (113) of women demographically eligible for recruitment, completed our screening questionnaire, despite calling EWC for a different purpose. Some 48% (54) of those women were eligible for an interview. Of interview-eligible women, 58% (10) of African Americans and 35% (13) of Latinos completed an interview. Only 17% (4) of women referred a man for participation in an interview for our study. Several themes emerged from our analysis of interview data: (1) women's role in men's health can be significant but is often uneasy; (2) challenges when talking to men about their health include health access, gender dynamics, and men's fear of health care; (3) women's understanding of research may be limited; (4) women use a range of strategies to address and overcome men's resistance to taking care of their health and participating in research.

CONCLUSIONS

The challenges women face when talking with men about their health affect their ability to effectively speak to men about research participation. However, EWC and similar telephone health services may be an effective means for recruiting low-income women to chemoprevention and other studies requiring healthy participants.

The impact of HIPAA authorization on willingness to participate in clinical research

PURPOSE

This study systematically examined the impact of inclusion of Health Insurance Portability and Accountability Act (HIPAA) authorization on the willingness of African Americans of diverse sociodemographic characteristics to participate in a clinical research study and explored reasons for nonparticipation.

METHODS

For a purposive sample of 384 African American outpatients at four metropolitan primary care clinics from August 2005 through May 2006, willingness to participate in a hypothetic clinical research study of an antihypertensive medication under one of two experimental conditions was compared. Interviewees were randomly assigned to undergo informed consent alone (control group) or informed consent with HIPAA authorization (HIPAA group). They were asked whether they would participate and reasons for their decisions.

RESULTS

A smaller proportion of interviewees in the HIPAA group were willing to enroll in the study (27% vs. 39%; p = 0.02), with an adjusted odds ratio of 0.56 (95% confidence interval = 0.36-0.91). Those in the HIPAA group were more likely to give reasons related to privacy (p < 0.001), poor understanding of the form (p = 0.01), and mistrust or fear of research (p = 0.04) for nonparticipation.

CONCLUSIONS

The inclusion of HIPAA authorization within the informed consent process may adversely affect the willingness of African Americans to participate in clinical research and may raise concerns about privacy, understanding the forms, and mistrust or fear of research.

Participation in research studies: factors associated with failing to meet minority recruitment goals

PURPOSE

To determine the recruitment goals that investigators set for racial/ethnic minorities and the factors associated with failure to meet those goals.

METHODS

Four hundred forty principal investigators (PIs) conducting clinical research funded by the National Heart, Lung, and Blood Institute (NHLBI) in 2001 completed a mailed survey providing their minority recruitment goals and enrollment data for their most recent NHLBI-funded study.

RESULTS

Ninety-two percent of PIs set goals for African Americans, 68% for Hispanics, 55% for Asian Americans, 35% for Native Hawaiians/Pacific Islanders, and 23% of PIs set recruitment goals for American Indians/Native Alaskans. Among those PIs who did set minority recruitment goals, the mean goal for the recruitment of African Americans was 31%, 16% for Hispanics, and 9% for Asian Americans. Twenty-seven percent of PIs failed to meet their recruitment goals for African Americans, 23% for Asian Americans, and 23% for Hispanics. After adjusting for multiple investigator and trial characteristics, the type of study (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.2, 3.4 for observational vs. phase III trial) completion of study enrollment (OR 2.0; 95% CI 1.2, 3.4), and PI identification of a larger number of major barriers to participation (OR 1.8; 95% CI 1.1, 3.0) were all associated with failure to meet recruitment goals for African Americans. However, no factors were consistently associated with failure to meet recruitment goals across different racial/ethnic groups.

CONCLUSIONS

Investigators often do not set recruitment goals for some racial/ethnic groups. Factors associated with failure to meet recruitment goals vary in the recruitment of different minority groups.

Attitudes toward participation in breast cancer randomized clinical trials in the African American community: a focus group study

Participation of African Americans in research trials is low. Understanding the perspectives of African American patients toward participation in clinical trials is essential to understanding the disparities in participation rates compared with whites. A qualitative study was conducted to discover attitudes of the African American community regarding willingness to participate in breast cancer screening and randomized clinical trials. Six focus groups consisting of 8 to 11 African American women (N = 58), aged 30 to 65, were recruited from local churches. Focus group sessions involved a 2-hour audio-taped discussion facilitated by 2 moderators. A breast cancer randomized clinical trial involving an experimental breast cancer treatment was discussed to identify the issues related to willingness to participate in such research studies. Six themes surrounding willingness to participate in randomized clinical trials were identified: (1) Significance of the research topic to the individual and/or community; (2) level of trust in the system; (3) understanding of the elements of the trial; (4) preference for "natural treatments" or "religious intervention" over medical care; (5) cost-benefit analysis of incentives and barriers; and (6) openness to risk versus a preference for proven treatments. The majority (80%) expressed willingness or open-mindedness to the idea of participating in the hypothetical trial. Lessons learned from this study support the selection of a culturally diverse research staff and can guide the development of research protocols, recruitment efforts, and clinical procedures that are culturally sensitive and relevant.

American Academy of Nursing Expert Panel report: developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations

The members of the Expert Panel on Cultural Competence of the American Academy of Nursing (AAN) envisioned this article to serve as a catalyst to action by the Academy to take the lead in ensuring that measurable outcomes be achieved that reduce or eliminate health disparities commonly found among racial, ethnic, uninsured, underserved, and underrepresented populations residing throughout the United States. The purposes of this article are to (a) assess current issues related to closing the gap in health disparities and achieving cultural competence, (b) discuss a beginning plan of action from the Expert Panel on Cultural Competence for future endeavors and continued work in these areas beyond the 2002 annual conference on Closing the Gap in Health Disparities, and (c) provide clearly delineated recommendations to assist the Academy to plan strategies and to step forward in taking the lead in reshaping health care policies to eliminate health care and health disparities.

Improving treatment of depression among low-income patients with cancer: the design of the ADAPt-C study

OBJECTIVE

This article describes the randomized clinical trial methodology for a population-based study of oncology patients receiving cancer care in a public sector medical center. The primary goal is to test the effectiveness of socioculturally tailored collaborative care intervention in improving depression and quality of life outcomes among low-income ethnic minority patients with major depression and cancer.

METHODS

The Patient Health Questionnaire (PHQ-9) depression scale was used to identify patients meeting criteria for major depression (one cardinal depression symptom plus a PHQ-9 score of > or =10). Study-eligible patients were >/=90 days from cancer diagnosis who were receiving acute cancer treatment or follow-up care in oncology clinics. Patients with advanced disease limiting life expectancy to <6 months, acutely suicidal or on antipsychotic medication were excluded. Allowing for attrition due to death or loss to follow-up, the study was powered at the 80% level to detect a 20% difference between study arms in the proportion of patients with >/=50% reduction in PHQ-9 symptoms at 12 months.

RESULTS

Of 2330 patients screened, 23.2% met criteria. An 82.4% enrollment rate resulted in 446 primarily women being recruited and randomized to intervention or usual care.

CONCLUSION

The study applies methods used in primary care depression trials with adaptations for oncology care clinics and for low-income minority patients.

HIV vaccine trial preparedness among Spanish-speaking Latinos in the US

Latinos are under-represented in HIV/AIDS medical research in the US. Although they are disproportionately impacted by HIV/AIDS, Latinos may be reluctant to participate in HIV vaccine trials. Three focus groups were conducted with 32 Spanish-speaking Latinos recruited from two community-based healthcare organizations in Los Angeles, California. A qualitative focus group interview guide was developed to explore concerns, motivators and intentions in regard to participation in HIV vaccine trials. Mistrust and fear of government emerged as important themes related to reluctance to participate in an HIV vaccine trial. Specific concerns regarding trial participation included: (1) fear of vaccine-induced HIV infection, (2) physical side effects, (3) stigma and (4) false-induced HIV-positive test results and their social repercussions. Motivators for enrolling in an HIV vaccine trial included: (1) incentives, (2) convenience of participating in a study, (3) sufficient and appropriate study information, (4) personal benefits and (5) altruism. Interventions to facilitate participation by Latinos in HIV vaccine trials should address mistrust and fear of government-sponsored HIV/AIDS medical research, increase access to and convenience of clinical trials, address fear of vaccine-induced infection, combat HIV/AIDS stigma and raise awareness of the relevance of HIV/AIDS to Latino communities.

Research partnership with underserved African-American communities to improve the health of older persons with disability: a pilot qualitative study

BACKGROUND AND AIMS

Underserved ethnic minorities are often under-represented in clinical investigations, often in the context of poor relationships between academic institutions and their minority communities. The aim of this study was to investigate an African-American community's perceptions about the barriers that hinder participation in research studies and, more broadly, on the status of institution/community relationships.

METHODS

We conducted a pilot qualitative study, based on semi- structured interviews of leaders of African-American communities in Winston-Salem, North Carolina. Relevant themes were abstracted from the interviews by a standardized iterative process.

RESULTS

Interviewees identified barriers to participation of African- Americans in research, and suggested that existing barriers may be overcome with an innovative model of a community/institution relationship, which would include open communication and cooperation, mutually beneficial programs, holistic approaches to health and disease, participatory and balanced partnerships with communities, and the establishment of multiethnic advisory boards.

CONCLUSIONS

This study suggests strategies that public health researchers should consider to establish effective institution/community relationships, in order to enhance participation of underserved ethnic minorities in research studies, and to improve the health status of their most disabled and demanding seniors.

HIV-infected African Americans are willing to participate in HIV treatment trials

BACKGROUND

Despite the high prevalence rates of HIV infection in the African-American community, African Americans remain underrepresented in HIV treatment trials.

OBJECTIVE

(1) To develop a questionnaire that measures attitudes and concerns about HIV treatment trials among HIV-infected African Americans at a university-based clinic. (2) To determine actual participation rates and willingness to participate in future HIV treatment trials among HIV-infected African Americans at a university-based clinic.

DESIGN

Questionnaire development and cross-sectional survey.

SETTING, PARTICIPANTS, AND MEASUREMENTS

In a sample of 200 HIV-infected African-American adults receiving medical care at the Pittsburgh AIDS Center for Treatment (a university-based ambulatory clinic), we assessed research participation rates and willingness to participate in future HIV treatment trials, trust in the medical profession, sociodemographic characteristics, attitudes, and concerns about HIV treatment trials.

MAIN OUTCOME MEASURES

Research participation rates and willingness to participate in future HIV treatment trials.

RESULTS

Only 57% of survey respondents had ever been asked to participate in an HIV treatment trial but 86% of those asked said yes. Prior research participation was significantly related to willingness to participate in future HIV treatment trials (P = .001). Contrary to previous studies, neither trust/distrust in the medical profession nor beliefs about the dishonesty of researchers was associated with research participation rates or willingness to participate in future HIV treatment trials.

CONCLUSIONS

Having never been asked to participate in research is a major barrier to the participation of HIV-infected African Americans in HIV treatment trials. African Americans who seek medical care for HIV infection should be asked to participate in HIV treatment trials.

Barriers to and Strategies for Recruiting Korean Americans for Community-Partnered Health Promotion Research

While increasing numbers of researchers are targeting ethnic minorities in order to address their health disparities, the unique health needs of Korean Americans are not well known to the mainstream community, and only relatively few systematic research studies have been conducted in this "hard-to reach" population. The purpose of this paper is to describe the barriers to recruiting participants for health promotion research and to identify facilitators in the community that can contribute to this effort. We have analyzed data pertaining to the 14 studies we have conducted since 1998, which included a total sample of about 2,400 Korean Americans. We describe in detail the unique recruitment challenges that we have faced in regard to the culture, language, sociodemographic characteristics of the participants, such as gender and age, and other community level barriers. Multiple strategies at different levels (individual and community) to address these issues are discussed.

African Americans and participation in clinical trials: differences in beliefs and attitudes by gender

OBJECTIVES

To explore gender differences in perceptions of 1) barriers and motivators to participation in clinical trials and perceived need of clinical trials and 2) perceptions of risks and benefits of participation in clinical trials in African American men and women.

METHODS

Focus groups were conducted among African American participants by gender. A total of 67 African American participated in the focus groups. All focus groups were audio-taped and transcribed verbatim. Data analysis was performed by combining the key elements of grounded theory and content analysis with the assistance of the qualitative software ATLAS.ti 5.0.

RESULTS

Different themes emerged for men versus women. The business and economic of research were important to male participants. The researcher-participant relationship emerged as one of the strongest themes related to potential female participation in research.

DISCUSSION

Focus group results indicate that African American men and women present different preferences, beliefs and barriers to participation. Men expressed the desire to know information on funding issues, financial benefit and impact of the research. Women expressed the desire to be treated respectfully and as an individual as opposed to just a study subject. Integrating gender preferences into researcher-participant interactions, advertisement, informed consent delivery and advertisement of research studies may lead to increased participation rates. Discussing and presenting relevant information on clinical research funding mechanisms, and the business of clinical research with potential participants may be helpful in building trust with the researcher and the research team. Creating a process for information exchange and methods to minimize the power imbalance between the researcher and participant may also build trust and help participants feel more comfortable to participate in research.

Factors associated with enrollment in cancer genetics research

Previous studies have identified low patient accrual in large-scale cancer clinical trials, particularly for underrepresented groups, such as ethnic minorities, females, and patients >65 years. As there have been few studies examining participation in cancer genetics epidemiologic research, our objective was to identify clinical and demographic factors predicting enrollment in these studies. A total of 1,111 patients diagnosed with colorectal cancer presenting to a gastrointestinal oncology clinic were approached to enroll in a study investigating the role of the MSH6 gene in familial colorectal cancer. Patient consent was sought for providing a blood specimen for DNA analysis and review of medical records/tumor specimens and contacting family members to confirm the family history of cancer. Seven predictor variables for enrollment (age, sex, ethnicity, family history of colorectal cancer in a first-degree relative, presence of children, insurance type, and type of visit) were analyzed using logistic regression analysis to determine the effect on decision to enroll. Of 1,111 patients approached, 696 (62.6%) enrolled in the study. Of these approached individuals, 4.2% were of nonwhite ethnicity and 33.5% were age > or =65 years. Patients of white ethnicity [odds ratio (OR), 2.10; P = 0.018], males (OR, 1.47; P = 0.002), those ages < or =65 years (OR, 1.42; P = 0.009), and those with a first-degree relative with colorectal cancer (OR, 1.57; P = 0.005) were significantly more likely to enroll. Fewer than 4% of all participants denied permission for the study researchers to access information from medical records or to be recontacted by researchers to discuss the enrollment of additional family members. Our data suggest that, once subjects decided to enroll, the majority (88%) was comfortable with consenting to all study components, including the creation of cell lines and future recontact. Low participation rates for ethnic minorities, females, and elderly patients are similar for both cancer genetics and clinical trial studies.

Cognitive Mediators Linking Social Support Networks to Colorectal Cancer Screening Adherence

This paper argues that normative considerations are more important than attitudinal factors in engaging colorectal cancer screening, and tests a model explaining how unique cultural expressions of social networks influence screening adherence. Structural equation modeling was used to understand colorectal cancer screening in a population-based sample of 341 Japanese Americans aged 50 and over. The model accounted for 25% of the variance in screening adherence. Adherence was most strongly associated with family/friend subjective norms about colorectal cancer screening use. Emotional family support, but not the size of the networks, was indirectly related to adherence via increased family/friend subjective norms, while emotional friend support was directly related to adherence. While usual source of care was directly associated with adherence, better provider-patient communication was directly and indirectly associated with adherence via increased perceived benefits. The findings of this study support strengthening informal support networks to enhance adherence among Japanese Americans at risk.

Attitudes of urban American Indians and Alaska Natives regarding participation in research

OBJECTIVE

To determine what factors influence participation in health research among American Indians and Alaska Natives.

METHODS

Using vignettes that described 3 types of research studies (a behavioral intervention trial, a genetic association study, and a pharmacotherapy trial), we surveyed 319 patients and 101 staff from an urban Indian health care facility to ascertain how study design, institutional sponsorship, community involvement, human subjects' issues, and subject matter influence participation.

RESULTS

Overall response rates were 93% for patients and 75% for staff. Hypothetical participation was highest for the genetic study (patients=64%; staff=48%), followed by the behavioral intervention (patients=46%; staff=42%), and the pharmacotherapy trial (patients=32%; staff=23%). The odds of participation (odds ratio [OR]) were generally increased among patients and staff when the study was conducted by health care providers (OR=1.3 to 2.9) and addressed serious health problems (OR=1.2 to 7.2), but were decreased if the federal government led the study (OR=0.3 to 0.5), confidentiality might be broken (OR=0.1 to 0.3), and compensation was not provided (OR=0.5 to 0.7).

CONCLUSION

Close attention to study type, institutional sponsorship, community involvement, potential risks and benefits, and topic are essential to conceptualizing, designing, and implementing successful health research with American Indian and Alaska Native populations.

Promoting the participation of minorities in research

The current policy of the National Institute of Health designed to increase the participation of women and minorities is radically different from previous policies designed to protect minorities from abuses in research studies. The principal arguments to support this policy are twofold: 1) Increased representation of minorities and women in research would increase the generalizability of research data and allow for valid analyses of differences in subpopulations; and 2) being in a clinical research study is advantageous to participants regardless of the final research study results. It remains unclear whether minorities find these arguments compelling. Instead of telling minorities that participation in research is good for them, the research community should focus on understanding what minority communities want from clinical research and then tailoring the message to meet this need. Persuasive arguments to promote long-term increased representation of minorities in clinical research must come from within minority communities.

EFFECTIVE RECRUITMENT AND RETENTION OF MINORITY RESEARCH PARTICIPANTS

Our ability, as leaders in public health scholarship and practice, to achieve and measure progress in addressing racial/ethnic disparities in health status and health care is severely constrained by low levels of participation of racial/ethnic minority populations in health-related research. Confining our review to those minority groups federally defined as underrepresented (African Americans/blacks, Latinos/Hispanics, and Native Americans/American Indians), we identified 95 studies published between January 1999 and April 2005 describing methods of increasing minority enrollment and retention in research studies, more than three times the average annual output of scholarly work in this area during the prior 15-year period. Ten themes emerged from the 75 studies that were primarily descriptive. The remaining 20 studies, which directly analyzed the efficacy or effectiveness of recruitment/retention strategies, were examined in detail and provided useful insights related to four of the ten factors: sampling approach/identification of targeted participants, community involvement/nature and timing of contact with prospective participants, incentives and logistical issues, and cultural adaptations. We then characterized the current state of this literature, discussing implications for future research needs and directions.

What race and ethnicity measure in pharmacologic research

Advances in genomic technology have put the utility of collecting racial and ethnic data into question. Some researchers are optimistic about the potential of moving toward "personalized medicine" by using a person's genome to administer medications. Genetics will not erase the importance of race and ethnicity because race and ethnicity do not measure genetic composition. Unlike genes, race and ethnicity are social constructs; 2 persons with identical genetic makeup may self-identify as being of different race or ethnic origin. Race and ethnic categories have been subject to change over time; a person's self-identification may vary according to the context, wording, and format of the question asked. Despite the fluid nature of the concept, self-identified race and ethnicity can capture something that genes cannot, namely, aspects of culture, behavior, diet, environment, and features of social status that commonly used measures of socioeconomic status, such as income, education, and occupation, cannot measure.

Recruitment and participation in clinical trials: socio-demographic, rural/urban, and health care access predictors

BACKGROUND

Recruitment and participation in clinical trials by minorities, particularly African Americans and rural underserved populations, are low. This report examines predictors of clinical trial recruitment and participation for adult Marylanders.

METHODS

A cross-sectional design was used to survey 5154 adults (18 years and older) residing in 13 of the 24 jurisdictions in Maryland, including urban Baltimore City, and the rural regions of Western Maryland and the Eastern Shore. The survey, conducted between December 2001 and March 2003, used Computer-Assisted Telephone Interviewing and random-digit dialing procedures. Primary dependent variables included "ever asked to participate" (i.e., recruited) and "participated" in clinical trials.

RESULTS

11.1% of the respondents had been recruited to clinical trials. In addition, 59.4% of the respondents recruited to clinical trials actually participated in a clinical trial. Among respondents recruited to clinical trials, black and middle income respondents were significantly less likely to actually participate in clinical trials; whereas, respondents who received information about clinical trials from their health care provider, who were knowledgeable about clinical trials, and those who had the time commitment were significantly more likely to participate in clinical trials.

CONCLUSIONS

These results suggest serious gaps in efforts to recruit racial/ethnic minorities and residents of rural regions into clinical trials. The findings provide the basis for the development and implementation of community-based educational programs for both the general public and health care professionals, and to enhance availability of community-based clinical trials, especially in the rural areas of the state.

Asian Americans and cancer clinical trials: a mixed-methods approach to understanding awareness and experience

Cancer clinical trials have been based on low accrual rates. Barriers to recruitment of minority populations affect the generalizability and impact of trial findings for those populations. The authors undertook a mixed-methods approach to understanding levels of awareness and experiences with cancer clinical trials. A survey was administered to new cancer patients and their caretakers (family, close friends, or other social support) at outpatient oncology clinics. Field observations of the trial accrual process also were conducted by employing the grounded theory approach in qualitative methods. Comparison of survey results for Asian-American respondents and non-Asian respondents indicated that Asians were less likely to have heard the term "clinical trial" and were more likely to define a clinical trial as "an experiment" or "a test procedure in a clinic" than non-Asians. Asians were more likely to have employer-based insurance and to report understanding issues related to cost reimbursement. Asians were less likely to have been involved in or to know someone in a trial and reported less willingness than white respondents to consider trial participation. Qualitative observations suggested that Asians who presented for a potential trial were interested in the availability of a novel cancer therapy but were not eligible for available trials. Multiple strategies will be necessary to enhance awareness of and experience with accrual to cancer clinical trials for Asians, including richer understanding and increased involvement of Asians in cancer clinical trials and greater attention to the location and diversity of the Asian population in structuring study centers and evaluating trial results.

Assessing the attitudes, knowledge, and awareness of HIV vaccine research among adults in the United States

OBJECTIVES

To assess HIV vaccine research attitudes, awareness, and knowledge among adults in the general US population, African Americans, Hispanics, and men who have sex with men (MSM).

METHODS

Applying results of focus groups and a media content analysis, a survey was designed and conducted to validate key HIV vaccine research themes and messages identified by focus groups and a media content analysis. Between December 2002 and February 2003, 3509 telephone interviews were conducted, including 2008 randomly selected from the general population, and 501 population-specific samples of African Americans and Hispanics, and 500 from MSM.

RESULTS

Although the majority of each population believes that an HIV preventive vaccine is the best way to control and end the global AIDS epidemic, only 34.9% of African Americans and 28.8% of the general population are supportive of someone they know volunteering for an HIV vaccine trial. The study also found that 47.1% of African Americans, 26.5% of Hispanics, and 13.4% of MSM believed an HIV vaccine already exists and is being kept secret, and 78.0% of African Americans, 57.5% of Hispanics, and 68.0% of MSM did not know or incorrectly believed that the vaccines being tested could cause HIV infection. A subanalysis of the general population also found that women generally had less knowledge of or a decreased awareness about HIV vaccine research.

CONCLUSIONS

Awareness, knowledge, and attitudes toward HIV vaccine research vary by population and these issues must be addressed to ensure an adequate number of volunteers for future domestic HIV preventive vaccine clinical trials. In some populations, barriers such as misinformation and distrust must be targeted to increase support for HIV vaccine research.

Factors that influence Spanish- and English-speaking participants' decision to enroll in cancer randomized clinical trials

Cancer randomized clinical trial (RCT) participation is low, particularly among ethnic and racial minorities. Hispanic enrollment is far below their representation in the US population, yet their cancer burden is higher. Little is known from the patient perspective about factors which influence the decision to enroll in RCTs. We asked Spanish- and English-speaking individuals what factors influence decisions about cancer RCT participation. Eight focus groups were conducted with 55 participants (25 Spanish and 30 English-speaking). The groups were taped, transcribed, and analyzed for themes. Six major themes emerged: patient-provider communication, personal relationship with provider, involvement of significant others in decision making, role of faith, need for information, and impact of discrimination on decision making. Both similarities (e.g. need for comprehensive information) and differences (e.g. need for provider acknowledgement of emotional and spiritual concerns) were found between Spanish- and English-speaking participants. Among Spanish-speaking participants, level of education was differentially related to decision-making themes. Implications for providers are discussed.

Strategies and issues for managing menopause-related symptoms in diverse populations: ethnic and racial diversity

Menopause is a naturally occurring "equal opportunity" event that every woman who lives beyond the age of approximately 52 years will experience. During the next 20 years, approximately 3.5 million African American women, 2 million Latinas, and 1 million Asian American women will enter the menopause. How a woman approaches the menopausal transition depends on a number of factors, from educational level to socioeconomic status; health-related factors, including stress; and marital status. Increasingly, the roles of race and ethnicity, as they relate to menopausal symptoms, are being explored. Understanding similarities and differences among women of color in perceptions, attitudes, and expectations surrounding the menopause can help provide culturally appropriate care and promote lifestyles that may decrease symptoms and increase quality of life. For example, minority women are usually the gatekeepers for healthcare for themselves and their families and have a highly developed social support network, often including extended family, a church community, and involvement in sororal or social organizations. In the future, research on menopausal symptoms among women of different racial/ethnic groups should focus on exploring in greater detail the effect of dietary factors and body mass index, additional evaluation of pituitary sensitivity, and use of complementary and alternative medicines in symptom management, with a better understanding of the risks and benefits of such therapies.

Enrollment of racial/ethnic minorities in NIAID-funded networks of HIV vaccine trials in the United States, 1988 to 2002

OBJECTIVE

The purpose of this study was to analyze enrollment of racial/ethnic minorities in Phase I and Phase II HIV vaccine trials in the U.S. conducted by National Institute of Allergy and Infectious Diseases (NIAID)-funded networks from 1988 to 2002.

METHODS

A centralized database was searched for all NIAID-funded networks of HIV vaccine trial enrollment data in the U.S. from 1988 through 2002. The authors reviewed data from Phase I or Phase II preventive HIV vaccine trials that included HIV-1 uninfected participants at low to moderate or high risk for HIV infection based on self-reported risk behaviors. Of 66 identified trials, 55 (52 Phase I, 3 Phase II) met selection criteria and were used for analyses. Investigators extracted data on participant demographics using statistical software.

RESULTS

A total of 3,731 volunteers enrolled in U.S. NIAID-funded network HIV vaccine trials from 1988 to 2002. Racial/ethnic minority participants represented 17% of the overall enrollment. By pooling data across all NIAID-funded networks from 1988 to 2002, the proportion of racial/ethnic minority participants was significantly greater (Fisher's exact test p-value < 0.001) in Phase II trials (278/1,061 or 26%) than in Phase I trials (347/2,670 or 13%). By generalized estimating equations, the proportion of minorities in Phase I trials increased over time (p = 0.017), indicating a significant increase in racial/ethnic minority participants from 1988 to 2002.

CONCLUSIONS

There has been a gradual increase in racial/ethnic minority participation in NIAID-funded network HIV vaccine trials in the U.S. since 1988. In the light of recent efficacy trial results, it is essential to continue to increase the enrollment of diverse populations in HIV vaccine research.

Strategies for retaining study participants in behavioral intervention trials: retention experiences of the NIH Behavior Change Consortium

Failing to retain an adequate number of study participants in behavioral intervention trials poses a threat to interpretation of study results and its external validity. This qualitative investigation describes the retention strategies promoted by the recruitment and retention committee of the Behavior Change Consortium, a group of 15 university-based sites funded by the National Institutes of Health to implement studies targeted toward disease prevention through behavior change. During biannual meetings, focus groups were conducted with all sites to determine barriers encountered in retaining study participants and strategies employed to address these barriers. All of the retention strategies reported were combined into 8 thematic retention categories. Those categories perceived to be most effective for retaining study participants were summarized and consistencies noted among site populations across the life course (e.g., older adults, adults, children, and adolescents). Further, possible discrepancies between site populations of varying health statuses are discussed, and an ecological framework is proposed for use in future investigations on retention.

Health disparities: a barrier to high-quality care

PURPOSE

Disparities in the treatment of cardiovascular disease, diabetes mellitus, and cancer among the sexes and racial groups and possible interventions are discussed.

SUMMARY

The ongoing process to identify and reduce health disparities has engaged numerous federal agencies as they monitor the nation's progress toward policy-driven and health-related objectives. Cardiovascular disease disproportionately affects minority groups and is the leading cause of death among women in the United States, and both groups receive suboptimal care for the disease. Disparities in the treatment of diabetes mellitus in African Americans, women, patients with less than a high school education, and the elderly have been found. Many minority groups continue to suffer disproportionately from cancer. Racial disparities also exist in cancer screening and treatment. Minorities are underrepresented in clinical trials for multiple reasons, many of which may be related to cultural beliefs. At all levels of coinsurance, the poor are less likely to seek preventive care. Adherence to national screening and treatment guidelines, clinical trial recruitment and participation, addressing language and geographic barriers, and increasing access to insurance are part of the coordinated efforts required to reduce health disparities. Because pharmacists influence patients' health status directly through pharmaceutical care and indirectly by engaging patients in their treatment, it is essential for pharmacists to be able to provide culturally competent care.

CONCLUSION

Despite significant efforts over the past several years, health disparities continue to exist, particularly among minority groups. Interventions aimed at eliminating these disparities should include ensuring cultural competence among health care providers and improving health literacy among patients.