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

Factors affecting participation in a breast cancer risk reduction telephone survey among women from four racial/ethnic groups

BACKGROUND

Little is known about the participation of minorities in health behavior research. This manuscript assesses factors associated with participation among women in four racial/ethnic groups.

METHODS

A total of 2800 Asian/Pacific Islander (API), Black, Latina, and non-Latina White women recruited through the San Francisco Mammography Registry was invited in 2002 and 2003 to participate in a telephone survey about breast cancer prevention.

RESULTS

Minorities participated at lower rates (49% for APIs, 60% for Latinas, and 64% for Blacks) than Whites (77%). Increased participation was associated with younger age for Latinas (OR = 1.90, 95% CI 1.05-3.44) and Whites (OR = 1.77, CI 1.08-2.91), and with a family history of breast cancer for APIs (OR = 2.09, CI 1.24-3.52). Decreased participation was associated with having less than a high school education for APIs (OR = 0.47, CI 0.26-0.86), Blacks (OR = 0.29, CI 0.11-0.78), and Latinas (OR = 0.51, CI 0.28-0.94).

CONCLUSIONS

Results suggest minorities' participation in health behavior research does not match Whites' and should be enhanced.

Strategies to recruit and retain older Filipino-American immigrants for a cancer screening study

Recruitment and retention of subjects in cancer prevention, screening, and treatment trials is challenging, especially if subjects are low-income, from minority groups or immigrants with limited English fluency. This article describes our experiences in recruiting 530 female Filipino-American immigrants at community based organizations and churches for a randomized trial that assessed the effect of a small group educational session on breast and cervical cancer screening. We found that a personal invitation from either a female project liaison, a friend, or the Filipino project director were all successful strategies that resulted in over 80% attendance at an educational session that was offered as part of the study. Although non-attendees did not differ from attendees in demographic characteristics, they expressed significantly more barriers to participating in a health study. Attendance at the group session was a significant predictor of retention in the study. We were able to conduct telephone follow-up surveys among 88% of enrollees at 12 month follow-up and 76% at 24 month follow-up. Results and implications are discussed in the hope that they may facilitate future participation of Filipinos and other Asian immigrants in research.

Looking into the institutional review board: observations from both sides of the table

Institutional review board (IRB) reviews offer the benefit of perspective afforded by the board's distance from the research and the research subjects. At the same time, distance from research subjects that is geographic, socioeconomic, cognitive, linguistic, and cultural can undermine the positive role of perspective. In addition, distance between IRB and investigators, largely a result of attitudes and communication, can prolong the review process and can obscure its message. The tension that often characterizes IRB-investigator relationships is due, in part, to variability in the application of federal regulations by IRBs across institutions and, on the part of investigators, inexperience, communication problems, and difficulties in anticipating the needs of their subjects. Contributing to the variability are the demographics and the culture of the IRB, attitudes that influence IRB-investigator relationships, and the adequacy of support from the institution. The effects of these factors on review decisions and on the performance of the human subjects protection system are largely unstudied. The movement for IRB accreditation is causing institutions to examine their overall research protection system and promises a more collaborative approach, where IRB and investigators accept their common charge to meet the needs of subjects and to improve the quality of research.

Ethical issues in identifying and recruiting participants for familial genetic research

Family-based research is essential to understanding the genetic and environmental etiology of human disease. The success of family-based research often depends on investigators' ability to identify, recruit, and achieve a high participation rate among eligible family members. However, recruitment of family members raises ethical concerns due to the tension between protecting participants' privacy and promoting research quality, and guidelines for these activities are not well established. The Cancer Genetics Network Bioethics Committee assembled a multidisciplinary group to explore the scientific and ethical issues that arise in the process of family-based recruitment. The group used a literature review as well as expert opinion to develop recommendations about appropriate approaches to identifying, contacting, and recruiting family members. We conclude that there is no single correct approach, but recommend a balanced approach that takes into account the nature of the particular study as well as its recruitment goals. Recruitment of family members should be viewed as part of the research protocol and should require appropriate informed consent of the already-enrolled participant. Investigators should inform prospective participants why they are being contacted, how information about them was obtained, and what will happen to that information if they decide not to participate. The recruitment process should also be sensitive to the fact that some individuals from families at increased genetic risk will have no prior knowledge of their risk status. These recommendations are put forward to promote further discussion about the advantages and disadvantages of various approaches to family-based recruitment. They suggest a framework for considering alternative recruitment strategies and their implications, as well as highlight areas in need of further empirical research.

Randomized trial of a low-intensity dietary intervention in rural residents: the Rural Physician Cancer Prevention Project

BACKGROUND

Dietary behavior, specifically a low-fat, high-fiber diet, plays a role in the primary prevention of chronic diseases including cancer.

DESIGN

A community-based randomized trial to assess the impact of a low-intensity, physician-endorsed, self-help dietary intervention that provided tailored dietary feedback, and was designed to promote improved fat and fiber behavior in a rural, low-education/low-literacy, partly minority population. The data were collected from 1999 to 2003.

SETTING/PARTICIPANTS

A total of 754 patients from three physician practices in rural Virginia completed a baseline telephone survey assessing dietary and psychosocial information, and were then randomly assigned to the intervention or control condition. Follow-up telephone evaluation was based on 522 participants at 1 month, 470 at 6 months, and 516 participants at 12 months.

INTERVENTION

A series of tailored feedback, followed by brief telephone counseling and theory-based nutritional education booklets, provided by staggered delivery to the home.

MAIN OUTCOME MEASURES

Dietary fat and fiber behavior, dietary intentions to change, self-efficacy for dietary change, and fat and fiber knowledge.

RESULTS

The intervention group demonstrated significant improvement in dietary fat and fiber behaviors and intentions to change fat and fiber intake (p <0.05) at 1, 6, and 12 months.

CONCLUSIONS

The Rural Physician Cancer Prevention Project provides an effective model for achieving public health-level dietary health behavior changes among a rural, minority, and low-literacy/low-education population.

Variations among Institutional Review Board reviews in a multisite health services research study

OBJECTIVE

To document the Institutional Review Board (IRB) review process and to explore the impact of different patient notification procedures.

DATA SOURCES/STUDY SETTING

Review of IRB application and correspondence records prospectively collected during a multisite study of health care quality involving telephone interviews of 3,000 participants across 15 primary care sites.

STUDY DESIGN

Records were reviewed to ascertain: (1) the type of IRB review conducted, (2) the number of days from submission to approval of the IRB application, (3) whether the IRB required patient notification and/or consent prior to the release of names, and (4) patient participation rates.

DATA COLLECTION/EXTRACTION METHODS

The study coordinating center prepared a common study protocol for IRB submission and assisted sites with submission. The application, correspondence with the IRB, consent script, and patient letters were collected, reviewed, coded, and analyzed.

PRINCIPAL FINDINGS

IRBs at the 15 sites and survey center varied in the type of IRB required and the number of days from submission to approval (range of 5-172 days). Four sites required patient notification in advance of the study; 2-11 percent of patients refused in opt-out sites and 37 percent in the single opt-in site. Participation among contacted patients did not appear to be related to patient notification procedures.

CONCLUSIONS

Variations in IRB requirements can affect response rates and sample generalizability.

Investigation of Ethnic Differences in Willingness to Enroll in a Rehabilitation Research Registry

OBJECTIVE

To investigate differences between African American and white respondents in willingness to enroll in a rehabilitation research registry for future research and to determine if reasons for consenting and refusing to enroll differ by ethnicity.

DESIGN

Inpatient recruitment results from 739 African American and white respondents in which patients were admitted to a rehabilitation hospital with a diagnosis of stroke or traumatic brain injury.

RESULTS

A similar proportion of African American and white respondents (both patients and surrogates) consented to enroll in the registry (72% of all African American respondents vs. 68% of all white respondents). African Americans and whites provided similar reasons for consenting and refusing to enroll. Demographic variables associated with consent were: higher education, younger age, and facility. The odds of consenting to enroll in the registry were 5 times as high for those who thought they had a great deal to gain from enrollment compared with those who thought they had less to gain and were nearly 2 times as high for those who reported little concern about privacy compared with those who were more concerned about privacy.

CONCLUSIONS

Ethnicity was not found to be a predictor of willingness to enroll in a study registry. A greater belief of gain and less concern over privacy were associated with willingness to enroll, even after controlling for age, education, facility, and ethnic group.

Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: dismantling the effects of amount of content versus contact

Relapse prevention remains a major challenge to smoking cessation efforts. T. H. Brandon, B. N. Collins, L. M. Juliano, and A. B. Lazev (2000) found that a series of 8 empirically based relapse-prevention booklets mailed to ex-smokers over 1 year significantly reduced relapse. This study dismantled 2 components of that intervention: the amount of content (number of booklets) and the frequency of contact. Content and contact were crossed in a 2 X 2 factorial design. The criteria of at least 1 week of abstinence at baseline was met by 431 participants, 75%-85% of whom returned 12-, 18-, and 24-month follow-up questionnaires. Eight booklets produced consistently higher point-prevalence abstinence rates than did a single booklet, but frequency of contact did not affect outcome. Moreover, the high-content interventions were highly cost-effective.

Recruitment and retention strategies for longitudinal African American caregiving research: the Family Caregiving Project

OBJECTIVE

This article provides a detailed discussion, guided by a culturally competent approach, on recruitment and retention strategies used to study caregiving to older dependent elders in African American families.

METHODS

The study (lasting from 1995 through 2000) included collecting three waves of data, 9 months apart, among 202 caregiving units (containing a maximum of three caregivers per unit).

RESULTS

Four key strategies were identified as useful in recruiting and retaining the sample: (a) assigning the same interviewers to communicate with and interview study participants for each wave of data collection, (b) ensuring that all interviewers are knowledgeable of possible family dynamics and social issues within the African American community (e.g., access to health care, income and education issues, and discrimination), (c) providing a mechanism by way of a toll-free number for all participants to contact the project staff at the participant's convenience, and (d) allowing flexibility in scheduling and rescheduling interviews at the participant's convenience.

DISCUSSION

Researchers need to acquire knowledge and develop skills that will foster culturally competent approaches when studying diverse cultural groups, which involves incorporating the beliefs, values, and attitudes of a cultural group in every phase of the research project, from conceptualization to interpretation of findings. Additionally, a genuine interest in, knowledge of, and respect for the population are necessary to help improve participant involvement in longitudinal research among African American caregivers.

Ethnic minority older adults participating in clinical research: developing trust

OBJECTIVE

African American, Latino, and American Indian older adults are underrepresented in clinical research studies. A significant barrier to participation in research is mistrust of the scientific community and institutions. The aims of this article are to discuss the lack of representation of ethnic minorities in clinical research.

METHODS

This article presents a review of the literature regarding medical research mistrust. Also described are the trust-building activities of the Resource Centers on Minority Aging Research (RCMAR), federally funded centers focused on research and aging in communities of color.

DISCUSSION

The RCMAR centers are building trust with the communities they serve, resulting in the recruitment and retention of ethnic minority older adults in clinical research studies and health promotion projects. Implications are discussed for other researchers toward building trust with ethnic minority elders to increase their participation in research.

Factors associated with attrition of African Americans during the recruitment phase of a clinical trial examining adherence among individuals with rheumatoid arthritis

OBJECTIVE

To examine factors contributing to the loss of potential minority participants in a study of medication adherence among rheumatoid arthritis patients.

METHODS

Chi-square statistics were used to test for differences in refusal/ineligibility by race and site at 4 screening points (initial eligibility review, initial patient contact, adherence screening, and informed consent). Differences in criteria-specific risks for exclusion at initial eligibility review were examined across 4 sites by race. Odds ratios (95% confidence intervals) were estimated if differences were significant. Multivariate logistic regression was used to examine sociodemographic factors associated with the probability for ineligibility at the initial eligibility review. Stated reasons for refusal were qualitatively quantified.

RESULTS

A greater percentage of African Americans were lost at every screening point when compared with whites, but only the difference at the initial eligibility review was statistically significant.

CONCLUSION

Factors associated with attrition included selection of area medical sites, research design issues, comorbid conditions, alcohol abuse, and being younger, unmarried, African American, and male.

Minority Recruitment in Hereditary Breast Cancer Research

Although recruitment of ethnic and racial minorities in medical research has been evaluated in several studies, much less is known about the methods used to recruit these populations to participate in cancer genetics research. This report reviews the resources that have been used to identify and recruit ethnic and racial minorities to participate in hereditary breast cancer research. Overall, hospital-based resources were used most often to identify potential subjects, and active recruitment methods were used most frequently to enroll eligible subjects. This review suggests that there appears to be a finite number of resources and strategies to identify and recruit potential subjects to participate in cancer genetics research; however, options for improving awareness about cancer genetics research among ethnic and racial minorities have not been extensively evaluated. To study ethnic and racial minority participation in cancer genetics research, stronger evaluation components will need to be integrated into research methods. Both observational and experimental studies are needed to determine resources that are most effective for identifying potential subjects who are ethnic and racial minorities and to evaluate the effects of different recruitment strategies on enrollment decisions among these populations.

Factors associated with colorectal cancer screening among the US urban Japanese population

OBJECTIVES

The author examined the prevalence and predictors of colorectal cancer screening among the urban Japanese population of the United States.

METHODS

A sample of Japanese residents of major US metropolitan areas completed a self-administered mailed survey.

RESULTS

Physician recommendation, acculturation, and perceived psychological costs were consistent predictors of screening for colorectal cancer. Gender and marital status were related to screening via fecal occult blood testing; age, susceptibility, and health insurance were related to sigmoidoscopy/colonoscopy screening.

CONCLUSIONS

Colorectal cancer screening among the urban Japanese population could be increased with interventions seeking to promote physician recommendations for screening, alleviate perceived psychological costs among patients, and improve physician-patient communication.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Are minority children under- or overrepresented in pediatric research?

OBJECTIVES

There is extensive documentation that minority adults are underrepresented in medical research, but there are scant data regarding minority children and their parents.

METHODS

All full-length articles published in the paper edition of 3 general pediatric journals between July 1999 and June 2000 were collected and reviewed. Articles were excluded when they did not include at least 1 US researcher, all subjects at US institutions, parents or children as subjects, some prospective data collection, or between 8 and 10 000 subjects. We recorded the number and race/ethnicity (R/E) of all subjects, the type of research, and the type of data collected. Corresponding authors were surveyed to clarify R/E data.

RESULTS

A total of 192 studies qualified. R/E data were reported in 114 (59%) studies, and survey data provided additional or new information in 25 studies resulting in R/E data in 128 (67%) articles accounting for 75% of the subjects. R/E was described by >10 different labels. There was an overrepresentation of black subjects and an underrepresentation of white and Hispanic subjects compared with the census data. When compared with research participation of child subjects, generally, black children were overrepresented and Hispanic children were underrepresented in clinical trials, and both were underrepresented in therapeutic research. Black and Hispanic children were overrepresented in potentially stigmatizing research.

CONCLUSIONS

Overall, we found an overrepresentation of black subjects and an underrepresentation of white and Hispanic subjects with significant variations depending on the type of research.

Who gets the information about genetic testing for cancer risk? The role of race/ethnicity, immigration status, and primary care clinicians

This study identified factors associated with awareness of genetic testing for cancer risk in the US general population. Multiple logistic regression analysis was used to analyze data from the 2000 National Health Interview Survey. The strong predictors were education, race/ethnicity, immigration status, health status, interaction with health professionals, controlling for socioeconomic status, cancer diagnosis, family history of cancer, and perceived personal cancer risk. The substantial lack of awareness of genetic testing among immigrant and ethnic populations warrants further research and tailored educational interventions. Ways to improve quality of patient interactions with non-genetic clinicians in promoting public knowledge of genetic testing for cancer risk are also worthy of further exploration.

Central challenges facing the national clinical research enterprise

Medical scientists and public health policy makers are increasingly concerned that the scientific discoveries of the past generation are failing to be translated efficiently into tangible human benefit. This concern has generated several initiatives, including the Clinical Research Roundtable at the Institute of Medicine, which first convened in June 2000. Representatives from a diverse group of stakeholders in the nation's clinical research enterprise have collaborated to address the issues it faces. The context of clinical research is increasingly encumbered by high costs, slow results, lack of funding, regulatory burdens, fragmented infrastructure, incompatible databases, and a shortage of qualified investigators and willing participants. These factors have contributed to 2 major obstacles, or translational blocks: impeding the translation of basic science discoveries into clinical studies and of clinical studies into medical practice and health decision making in systems of care. Considering data from across the entire health care system, it has become clear that these 2 translational blocks can be removed only by the collaborative efforts of multiple system stakeholders. The goal of this article is to articulate the 4 central challenges facing clinical research at present--public participation, information systems, workforce training, and funding; to make recommendations about how they might be addressed by particular stakeholders; and to invite a broader, participatory dialogue with a view to improving the overall performance of the US clinical research enterprise.

Supports and obstacles to cancer survival for Hawaii's native people

PURPOSE

Investigators have suggested that high cancer mortality rates among Native Hawaiians are due to fatalistic attitudes toward the disease, poor access to care, and lack of consideration of Native Hawaiian cultural values in Western approaches to healthcare. This study used qualitative methods to examine these factors in Native Hawaiian cancer survivors.

METHODS

Eight focus groups were held on five islands, attracting 45 Native Hawaiian cancer survivors from both rural and urban locales. The focus groups explored survivors' experiences with cancer diagnosis, treatment, and recovery. Participatory research methods were used, with researchers gaining community input on study design, incorporating appropriate Native Hawaiian cultural protocols into the focus groups, and engaging participants in the interpretation of the data.

RESULTS

Similar to cancer survivors of other ethnicities, these individuals demonstrated the following: success in accessing healthcare information, professionals, facilities, and insurance; the ability to overcome the barriers confronted; and proactive health behaviors regarding screening, diagnosis, and treatment. They also demonstrated ways in which they were sustained through the cancer experience by Native Hawaiian traditions, such as helping others, gaining strength from Hawaiian spiritual beliefs, and relying on family for personal support. Participants did not respond passively to their cancer diagnoses, and they expressed few fatalistic attitudes. Participants did give numerous examples of other Native Hawaiians who did not seek screening or treatment for cancer because they lacked insurance, had poor access to care, or felt alienated by Western healthcare.

CLINICAL IMPLICATIONS

The findings suggest that improving access to care and incorporating cultural values in health education and services can enhance survivorship and quality of life for Native Hawaiians with cancer. These themes may have applications for other minority groups.