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

Clinical research nurses' perceptions of the unique needs of people of color for successful recruitment to cancer clinical trials

BACKGROUND

Clinical trials (CTs) test new medical products for safety and effectiveness. Despite federal policy aimed at generating greater inclusivity of people of color (POC) in CTs, disparity in (CT) enrollment persists. Non-Hispanic White patients comprise the majority of CT participants while Black and Hispanic patient participation has declined over the past decade. The scope of Clinical Research Nurses (CRNs) includes recruitment of participants for CTs. The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting POC cancer patients to participate in CTs. The first paper for this study identified three major themes regarding how CRNs view their role in caring for POC considering or enrolling onto cancer clinical trials (CCTs): CRNs act as advocates, care coordinators and educators. This paper focuses on two additional major themes regarding how CRNs view the unique needs of POC in clinical research: establishing and maintaining trusting relationships and recruitment infrastructure.

METHODS

Nineteen nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method.

RESULTS

CRNs described a history of past research injustices, disparate access to care, inadequate cultural training, a physician-driven recruitment structure and provider-based implicit biases that hinder POC enrollment in CTs.

CONCLUSION

Diversity in CCT enrollment requires CRNs to establish trust with POC, advocate for POC when implicit biases are observed and become competent practitioners of culturally sensitive care. Further, meaningful policy change at both federal and organizational levels must occur to ensure equitable access to novel cancer therapies.

Improving diversity in study participation: Patient perspectives on barriers, racial differences and the role of communities

INTRODUCTION

The lack of racial/ethnic diversity in research potentially limits the generalizability of findings to a broader population, highlighting the need for greater diversity and inclusion in clinical research. Qualitative research (i.e., focus groups) was conducted to identify (i) the potential motivators and barriers to study participation across different races and ethnicities; (ii) preferred delivery of education and information to support healthcare decision-making and the role of the community.

METHODS

Patient focus groups were conducted with 26 participants from the sponsor's Patient Engagement Research Councils selected through subjective sampling. Recruitment prioritized adequate representation across different race/ethnic groups. Participation was voluntary and participants underwent a confidential interview process before selection. Narrative analysis was used to identify themes and draw insights from interactions. Experienced research specialists identified emerging concepts, and these were tested against new observations. The frequency of each concept was examined to understand its importance.

RESULTS

Based on self-selected race/ethnicity, participants were divided into five focus groups (Groups: African American/Black: 2; Hispanic/Latino, Asian American, and white: 1 each) and were asked to share their experiences/opinions regarding the stated objectives. Barriers to study participation included: limited awareness of opportunities to participate in research, fears about changes in standard therapy, breaking cultural norms/stigma, religion-related concerns and mistrust of clinical research. Participants identified the importance of transparency by pharmaceutical companies and other entities to build trust and partnership and cited key roles that communities can play. The perceptions of the African American group regarding diversity/inclusion in research studies appeared to be different from other groups; a lack of trust in healthcare providers, concerns about historical instances of research abuse and the importance of prayer were cited.

CONCLUSION

This study provided insights into barriers to study participation, and also highlighted the need for pharmaceutical companies and other entities to authentically engage in strategies that build trust within communities to enhance recruitment among diverse populations.

PATIENT OR PUBLIC CONTRIBUTION

The data collected in the present study was provided by the participants in the focus groups.

Understanding Willingness to Participate in Cancer Clinical Trials Among Patients and Caregivers Attending a Minority-Serving Academic Cancer Center

Advances in cancer treatment are impeded by low accrual rates of patients to cancer clinical trials (CCTs). The national rates of recruitment of underserved groups, including racial/ethnic minorities, are limiting the generalizability of research findings and are likely to enhance inequities in cancer outcomes. The goal of this study was to examine willingness to participate (WTP) in CCTs and factors associated with this willingness among patients and caregivers attending a minority-serving university cancer center in the Southwest. A cross-sectional survey design was utilized (n = 236, 135 patients and 101 caregivers). Fear was the strongest predictor of WTP in CCTs. The only ethnic differences observed related to Spanish-speaking patients exhibiting increased WTP in CCTs, and Spanish-speaking caregivers' decreased WTP, compared to others. These results underscore the importance of future interventions to reduce CCT-related fear among patients and caregivers, with particular need for family-focused tailored interventions designed to meet the needs of Spanish-speaking patients and caregivers.

Limited English Proficiency and Disparities in Health Care Engagement Among Patients With Breast Cancer

PURPOSE

Race and ethnicity have been shown to affect quality of cancer care, and patients with low English proficiency (LEP) have increased risk for serious adverse events. We sought to assess the impact of primary language on health care engagement as indicated by clinical trial screening and engagement, use of genetic counseling, and communication via an electronic patient portal.

METHODS

Clinical and demographic data on patients with breast cancer diagnosed and treated from 2013 to 2018 within the Stanford University Health Care system were compiled via linkage of electronic health records, an internal clinical trial database, and the California Cancer Registry. Logistic and linear regression models were used to evaluate for association of clinical trial engagement and patient portal message rates with primary language group.

RESULTS

Patients with LEP had significantly lower rates of clinical trial engagement compared with their English-speaking counterparts (adjusted odds ratio [OR], 0.29; 95% CI, 0.16 to 0.51). Use of genetic counseling was similar between language groups. Rates of patient portal messaging did not differ between English-speaking and LEP groups on multivariable analysis; however, patients with LEP were less likely to have a portal account (adjusted OR, 0.89; 95% CI, 0.83 to 0.96). Among LEP subgroups, Spanish speakers were significantly less likely to engage with the patient portal compared with English speakers (estimated difference in monthly rate: OR, 0.43; 95% CI, 0.24 to 0.77).

CONCLUSION

We found that patients with LEP had lower rates of clinical trial engagement and odds of electronic patient portal enrollment. Interventions designed to overcome language and cultural barriers are essential to optimize the experience of patients with LEP.

Effectiveness of Recruitment Strategies of Latino Smokers: Secondary Analysis of an mHealth Smoking Cessation Randomized Clinical Trial (Preprint)

Background

Latinos remain disproportionately underrepresented in clinical trials, comprising only 2%-3% of research participants. In order to address health disparities, it is critically important to increase enrollment of Latino smokers in smoking cessation trials. There is limited research examining effective recruitment strategies for this population.

Objective

The purpose of this study was to compare the effectiveness of direct versus mass and high- versus low-effort recruitment strategies on recruitment and retention of Latino smokers to a randomized smoking cessation trial. We also examine how the type of recruitment might have influenced the characteristics of enrolled participants.

Methods

Latino smokers were enrolled into Decídetexto from 4 states—New Jersey, Kansas, Missouri, and New York. Participants were recruited from August 2018 until March 2021. Mass recruitment strategies included English and Spanish advertisements to the Latino community via flyers, Facebook ads, newspapers, television, radio, church bulletins, and our Decídetexto website. Direct, high-effort strategies included referrals from clinics or community-based organizations with whom we partnered, in-person community outreach, and patient registry calls. Direct, low-effort strategies included texting or emailing pre-existing lists of patients who smoked. A team of trained bilingual (English and Spanish) recruiters from 9 different Spanish-speaking countries of origin conducted recruitment, assessed eligibility, and enrolled participants into the trial.

Results

Of 1112 individuals who were screened, 895 (80.5%) met eligibility criteria, and 457 (457/895, 51.1%) enrolled in the trial. Within the pool of screened individuals, those recruited by low-effort recruitment strategies (both mass and direct) were significantly more likely to be eligible (odds ratio [OR] 1.67, 95% CI 1.01-2.76 and OR 1.70, 95% CI 0.98-2.96, respectively) and enrolled in the trial (OR 2.60, 95% CI 1.81-3.73 and OR 3.02, 95% CI 2.03-4.51, respectively) compared with those enrolled by direct, high-effort strategies. Among participants enrolled, the retention rates at 3 months and 6 months among participants recruited via low-effort strategies (both mass and direct) were similar to participants recruited via direct, high-effort methods. Compared with enrolled participants recruited via direct (high- and low-effort) strategies, participants recruited via mass strategies were less likely to have health insurance (44.0% vs 71.2% and 71.7%, respectively; P<.001), lived fewer years in the United States (22.4 years vs 32.4 years and 30.3 years, respectively; P<.001), more likely to be 1st generation (92.7% vs 76.5% and 77.5%, respectively; P=.007), more likely to primarily speak Spanish (89.3% vs 65.8% and 66.3%, respectively), and more likely to be at high risk for alcohol abuse (5.8 mean score vs 3.8 mean score and 3.9 mean score, respectively; P<.001).

Conclusions

Although most participants were recruited via direct, high-effort strategies, direct low-effort recruitment strategies yielded a screening pool more likely to be eligible for the trial. Mass recruitment strategies were associated with fewer acculturated enrollees with lower access to health services—groups who might benefit a great deal from the intervention.

Trial Registration

ClinicalTrials.gov identifier: NCT03586596; https://clinicaltrials.gov/ct2/show/NCT03586596

International Registered Report Identifier (IRRID)

RR2-DOI: 10.1016/j.cct.2020.106188

Feasibility and Effectiveness of Recruiting Latinos in Decídetexto-A Smoking Cessation Clinical Trial from an Emergency Department Patient Registry

There is an underrepresentation of Latinos in smoking cessation clinical trials. This study describes the feasibility and effectiveness of recruiting Latino smokers in the U.S. from an emergency department (ED) patient registry into a randomized smoking cessation clinical trial. Recruitment occurred from the Hackensack University Medical Center ED. Potential participants were contacted from a patient registry. The primary outcome was whether the participant responded to a call or text. Secondary outcomes included the best day of the week, week of the month, and time of day to obtain a response. Of the 1680 potential participants, 1132 were called (67.5%), while 548 (32.5%) were texted. For calls, response rate was higher compared to text (26.4% vs 6.4%; p < 0.001). More participants were interested in the study when contacted by calls compared to text (11.4% vs. 1.8%) and more participants were enrolled in the study when contacted by calls compared to text (1.1% vs. 0.2%). Regression models showed that ethnicity, age, time of day, and week of the month were not significantly associated with response rates. Recruitment of Latinos from an ED patient registry into a smoking cessation clinical trial is feasible using call and text, although enrollment may be low.

Facilitators, Challenges, and Messaging Strategies for Hispanic/Latino Populations Participating in Alzheimer's Disease and Related Dementias Clinical Research: A Literature Review

Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) disproportionally affect Hispanic and Latino populations, yet Hispanics/Latinos are substantially underrepresented in AD/ADRD clinical research. Diverse inclusion in trials is an ethical and scientific imperative, as underrepresentation reduces the ability to generalize study findings and treatments across populations most affected by a disease. This paper presents findings from a narrative literature review (N = 210) of the current landscape of Hispanic/Latino participation in clinical research, including the challenges, facilitators, and communication channels to conduct culturally appropriate outreach efforts to increase awareness and participation of Hispanics/Latinos in AD/ADRD clinical research studies. Many challenges identified were systemic in nature: lack of culturally relevant resources; staffing that does not represent participants' cultures/language; eligibility criteria that disproportionately excludes Hispanics/Latinos; and too few studies available in Hispanic/Latino communities. The paper also details facilitators and messaging strategies to improve engagement and interest among Hispanics/Latinos in AD/ADRD research, starting with approaches that recognize and address the heterogeneity of the Hispanic/Latino ethnicity, and then, tailor outreach activities and programs to address their diverse needs and circumstances. The needs identified in this article represent longstanding failures to improve engagement and interest among Hispanics/Latinos in AD/ADRD research; we discuss how the field can move forward learning from the experiences of the COVID-19 pandemic.

Transparency, trust and minimizing burden to increase recruitment and retention in trials: a systematic review

OBJECTIVE

To describe patient perspectives on recruitment and retention in clinical trials.

STUDY DESIGN AND SETTING

Systematic review of qualitative studies that reported the perspective of adult patients with any health condition who accepted or declined to participate in clinical trials.

RESULTS

Sixty-three articles involving 1681 adult patients were included. Six themes were identified. Four themes reflected barriers: ambiguity of context and benefit - patients were unaware of the research question and felt pressured in making decisions; lacking awareness of opportunities - some believed health professionals obscured trials opportunities, or felt confused because of language barriers; wary of added burden - patients were without capacity because of sickness or competing priorities; and skepticism, fear and mistrust - patients feared loss of privacy, were suspicious of doctor's motivation, afraid of being a guinea pig, and disengaged from not knowing outcomes. Two themes captured facilitators: building confidence - patients hoped for better treatment, were supported from family members and trusted medical staff; and social gains and belonging to the community - altruism, a sense of belonging and peer encouragement motivated participation in trials.

CONCLUSION

Improving the visibility and transparency of trials, supporting informed decision making, minimizing burden, and ensuring confidence and trust may improve patient participation in trials.

Deciding to Enrol in a Cancer Trial: A Systematic Review of Qualitative Studies

Background

Clinical trials are essential for the advancement of cancer treatments; however, participation by patients is suboptimal. Currently, there is a lack of synthesized qualitative review evidence on the patient experience of trial entry from which to further develop decision support. The aim of this review is to synthesise literature reporting experiences of participants when deciding to enrol in a cancer clinical trial in order to inform practice.

Methods

A systematic review and meta-synthesis of qualitative studies were conducted to describe the experiences of adult cancer patients who decided to enrol in a clinical trial of an anti-cancer treatment.

Results

Forty studies met eligibility criteria for inclusion. Three themes were identified representing the overarching domains of experience when deciding to enrol in a cancer trial: 1) need for trial information; (2) trepidation towards participation; and (3) justifying the decision. The process of deciding to enrol in a clinical trial is one marked by uncertainty, emotional distress and driven by the search for a cure.

Conclusion

Findings from this review show that decision support modelled by shared decision-making and the quality of a shared decision needs to be accompanied by tailored or personalised psychosocial and supportive care. Although the decision process bears similarities to theoretical processes outlined in decision-making frameworks, there are a lack of supportive interventions for cancer patients that are adapted to the clinical trial context. Theory-based interventions are urgently required to support the specific needs of patients deciding whether to participate in cancer trials.

Perceptions of safety monitoring in CF clinical studies and potential impact on future study participation

BACKGROUND

Individuals with CF and their parents cite safety concerns as barriers to participating in clinical studies. We assessed whether a brochure/infographic describing patient safety monitoring processes could reduce knowledge and attitude barriers regarding safety monitoring. We also identified factors associated with likely participation in future CF studies.

METHODS

Respondents from three CF centers in the U.S. were randomly assigned to receive the safety monitoring brochure/infographic or an unrelated brochure. Fifty parents of children with CF <16, 50 adolescents with CF 16-21, and 50 adults with CF ≥22 years old were recruited to complete the study survey. Factors associated with survey responses and with reported likelihood of participating in future studies were assessed.

RESULTS

Overall the safety monitoring brochure/infographic was associated with increased likelihood of future participation in non-drug studies (aOR 2.30, CI₉₅ 1.01-5.28), but not in drug studies. Non-Hispanic respondents reported greater likelihood of participating in a future drug study than Hispanic respondents (aOR 3.18, CI₉₅ 1.30-7.74). Adults with CF (aOR 2.62, CI₉₅ 1.05-6.51) and parents (aOR 4.49, CI₉₅ 1.66-12.15) were more likely than adolescents to report they would ask their care team about clinical trials. Confidence in safety monitoring was associated with reported likelihood of future participation in drug studies.

CONCLUSIONS

Potential future participation in CF drug and/or non-drug studies was associated with respondent age and ethnicity, receiving the safety monitoring brochure/infographic, and confidence in safety monitoring. Our findings underscore the need for education about safety monitoring, with targeted approaches for the Hispanic CF population and adolescents.

Educating Hispanics About Clinical Trials and Biobanking

Hispanics are under-represented in clinical research. To ensure that the Hispanic population benefits from advances in public health and medicine, including personalized medicine, there is a need to increase their participation in clinical trials and biobanking. There is a great need for improving awareness and addressing concerns individuals may have about participation. The purpose of this study was to adapt, implement, and evaluate educational materials about clinical trials and biobanking for Hispanic individuals. We adapted existing materials based on focus group data. We then trained four promotoras de salud to deliver education to Hispanic adults in community settings in Houston, TX. The promotoras educated 101 Hispanic adults, 51 on biobanking and 50 on clinical trials. Study staff administered brief pre- and post-test questionnaires that measured benefits, barriers, norms, self-efficacy, and intention to participate in either clinical trials or biobanking. Our sample was predominately female (83%) and Spanish-speaking (69%) and made less than $25,000 a year (87%). This intervention increased perceived benefits of participating in biobanking and clinical trials, self-efficacy for donating biospecimens, and intention to participate in biobanking if invited. Perceived barriers to participating declined. This study demonstrated that brief education can result in improved perceptions and attitudes related to participation in biobanking and clinical trials, and could increase participation. Researchers and practitioners could use these educational materials to educate Hispanic community members on clinical research potentially increasing participation rates in the future.

Socio-economic differences in patient participation behaviours in doctor-patient interactions-A systematic mapping review of the literature

Background

The degree to which patients participate in their care can have a positive impact on health outcomes. This review aimed to map the current literature on patient participation behaviours in interactions with physicians and the extent to which differences in these behaviours can be explained by socio‐economic status (SES).

Search strategy

Four electronic databases were searched from 1980 onwards using key words related to socio‐economic status and patient participation behaviours.

Study selection

Titles, abstracts and full texts were screened by two reviewers, with the second reviewer screening 20% of all entries.

Data extraction

Data on year of publication, country, patient population, setting, patient participation behaviour studied, and SES measure used were extracted.

Main results

Forty‐nine studies were included in the review. Most studies were conducted in the United States, and the most commonly studied patient participation behaviour was involvement in decision making. Most studies measured SES using education as an indicator, with very few studies using occupation as a measure. Many studies did not report on participants’ medical condition or study setting. Patient participation in their health‐care appointment increased with increasing SES in 24 studies, although in 27 studies no significant association was found.

Discussion and conclusions

Current literature was found to be mainly US‐centric. Many studies did not specify participants’ medical condition or in what setting the study was undertaken. More studies are needed on less commonly studied patient participation behaviours. It would be helpful for further studies to also include a wider range of SES indicators.

Overcoming Barriers to Clinical Trial Enrollment

Clinical trials are imperative for testing novel cancer therapies, advancing the science of cancer care, and determining the best treatment strategies to enhance outcomes for patients with cancer. However, barriers to clinical trial enrollment contribute to low participation in cancer clinical trials. Many factors play a role in the persistently low rates of trial participation, including financial barriers, logistical concerns, and the lack of resources for patients and clinicians to support clinical trial enrollment and retention. Furthermore, restrictive eligibility criteria often result in the exclusion of certain patient populations, which thus adds to the widening disparities seen between patients who enroll in trials and those treated in routine practice. Moreover, additional factors, such as difficulty by patients and clinicians in coping with the uncertainty inherent to clinical trial participation, contribute to low trial enrollment and represent key components of the decision-making process. Specifically, patients and clinicians may struggle to assess the risk-benefit ratio and may incorrectly estimate the probability and severity of challenges associated with clinical trial participation, thus complicating the informed consent process. Importantly, research has increasingly focused on overcoming barriers to clinical trial enrollment. A promising solution involves the use of patient navigators to help enhance clinical trial recruitment, enrollment, and retention. Although clinical trials are essential for improving and prolonging the lives of patients with cancer, barriers exist that can impede trial enrollment; yet, efforts to recognize and address these barriers and enhance trial enrollment are being investigated.

Empowering Latina breast cancer patients to make informed decisions about clinical trials: a pilot study

Minority representation in clinical trials is vital for researchers to assess differential effects in outcomes of therapies on biological and genetic characteristics among groups. This study assessed the effect of Choices, a bilingual multi-component intervention, on perceived understanding of clinical trials, agreement with stages of decision readiness and consideration of clinical trials as a treatment option, among Latina breast cancer patients. This randomized controlled pilot study compared Choices with a control condition providing general clinical trial information to eligible patients. Seventy-seven Latina breast cancer patients were randomly assigned to either Choices (n = 38) or the control (n = 39). Choices included three components: an educational interactive video, a low-literacy booklet, and care coordination by patient navigation (i.e., educational and psychosocial support, coordinating appointments, translating, interacting with the medical team). Choices was more effective than the control in improving perceived understanding of clinical trials (p = .033) and increasing consideration of clinical trials as a treatment option (p = .008). Additionally, intervention participants showed significant changes between baseline and post-intervention on agreement with stages of decision readiness statements (p < .002) than control participants (p > .05); the percentage of intervention women in agreement with preparation to action statements increased from 52.8% at baseline to 86.1% at post-intervention, and those in agreement with ready to action stages rose from 50.0% to 88.9%. Computer-based videos and care coordination provided by patient navigation-specifically tailored to Latinos-are effective strategies to successfully address awareness, and improved decision-making skills to make informed decisions about clinical trial participation.

Bridging the Gap: Racial concordance as a strategy to increase African American participation in breast cancer research

Lack of African American females in breast cancer research has been receiving substantial attention. This study seeks to identify research perceptions and motivating factors needed to increase racial/ethnic minority participation in breast cancer research. A total of 57 African American women (Σ = 47.8 years), from Rhode Island and Texas, completed a questionnaire and focus group. While many participants were not breast cancer survivors, they reported knowledge of their racial group’s risk for breast cancer. One major finding that could be seen as both a facilitator and barrier is racial concordance between participant and researcher. Cultural sensitivity and trust building is recommended to increase minority participation.

Factors associated with willingness to participate in a vaccine clinical trial among elderly Hispanic patients

A population specific understanding of barriers and facilitators to participation in clinical trials could improve recruitment of elderly and minority populations. We investigated how prior exposure to clinical trials and incentives were associated with likelihood of participation in a vaccine clinical trial through a questionnaire administered to 200 elderly patients in an academic general internal medicine clinic. Wilcoxon signed rank sum test compared likelihood of participation with and without monetary incentives. Logistic regression evaluated characteristics associated with intent to participate in an influenza vaccine trial, adjusted for age, gender, language, and education history. When asked about likelihood of participation if there was monetary compensation, there was a 12.2% absolute increase in those reporting that they would not participate, with a significant difference in the distribution of likelihood before and after mentioning a monetary incentive (Wilcoxon signed rank test, p = 0.001). Those with previous knowledge of clinical trials (54.4%) were more likely to report they would participate vs. those without prior knowledge (OR 2.5, 95% CI [1.2, 5.2]). The study highlights the importance of pre-testing recruitment materials and incentives in key group populations prior to implementing clinical trials.

Development and Validation of the Biomedical Research Trust Scale (BRTS) in English and Spanish

This study developed and validated the Biomedical Research Trust Scale (BRTS), a 10-item measure of global trust in biomedical research, in English and Spanish (BRTS-SP). In total, 85 English- and 85 Spanish-speaking participants completed the BRTS or BRTS-SP, as well as measures of biobanking attitudes, self-efficacy, receptivity, and intentions to donate blood or urine. Results indicated the BRTS and BRTS-SP showed adequate internal consistency in both English and Spanish. In addition, greater levels of trust in biomedical research were significantly associated with greater self-efficacy, receptivity, attitudes, and intentions to donate blood and urine in English-speaking participants, and self-efficacy and intention to donate urine in Spanish-speaking participants. These results support the use of the BRTS and BRTS-SP among English- and Spanish-speaking community members.

Culturally sensitive approaches to recruitment and retention of Hispanics in the national lung screening trial

Hispanics are underrepresented in medical research. At the National Lung Screening Trial's University of Colorado Denver screening center, traditional recruitment methods resulted in enrollment of few Hispanics. In response, the center adopted culturally sensitive recruitment techniques, including use of carefully-crafted bilingual materials. Bilingual interviewers were hired, and persons familiar with culture and language of groups of different Hispanic origin were consulted. Representation of Hispanics among participants enrolled at the Colorado center increased nearly threefold, from 3.3 to 9.4 %, after adoption of these methods. In this manuscript, we report on the specialized recruitment methods that were developed and how they were used to address known barriers to Hispanic recruitment.

Mexican-American perspectives on participation in clinical trials: A qualitative study

Clinical trials are essential to advancing knowledge to reduce disease morbidity and mortality; however, ethnic and racial minorities remain under-represented in those studies. We explored knowledge and perceptions of clinical trials among Mexican-Americans in Texas. We conducted focus groups (N = 128) stratified by gender, language preference, and geographical location. This paper presents four emergent, primary themes: 1) knowledge and understanding of clinical trials, 2) fears and concerns about participating, 3) perceived benefits of participating, and 4) incentives to participate. Results suggest that lack of knowledge and understanding of clinical trials leads to misunderstanding about research, including fears and lack of trust. Participants indicated that fears related to perceived experimentation, harm, immigration status, and lack of clinical trial opportunities within their communities were barriers to participation. On the other hand, free healthcare access, helping family members in the future, and monetary incentives could facilitate participation. We also found differences across themes by language, gender, and place of residence. Findings from our study could inform the development of interventions to enhance recruitment of Mexican-American participants into clinical trials.

Considerations of Methodological Approaches in the Recruitment and Retention of Immigrant Participants

OBJECTIVE

This study aims to identify effective strategies related to recruitment and retention of immigrant survey participants.

METHODOLOGY

The study used a multi-mode approach in, first, conducting a literature review of recent articles on surveys that either targeted immigrants or included large numbers of immigrants in their samples. Next, six surveys were reviewed that either targeted or included large numbers of immigrants. Finally, expert opinions on immigration were gathered regarding recruitment and retention of immigrant survey participants.

RESULTS

Although immigrants may be difficult to recruit due to limited English proficiency, mistrust of strangers, and/or high mobility, many of these challenges can be overcome by adopting the same strategies used when surveying ethnically diverse populations (e.g., snowballing versus advertisement, establishing a personal connection with data collectors). Nonetheless, a few practices were identified as most relevant for recruitment and retention of immigrant populations, including involving local community organizations relevant to immigrants, translation of materials tailored to the vernacular language of the various ethnicities, and customizing non-monetary incentives to the specific ethnicity.

CONCLUSIONS

Based on the reviews and expert interviews, multiple strategies have been shown to be effective in recruiting and retaining immigrant participants.

Characteristics of clinical trials that require participants to be fluent in English

BACKGROUND/AIMS

Diverse samples in clinical trials can make findings more generalizable. We sought to characterize the prevalence of clinical trials in the United States that required English fluency for participants to enroll in the trial.

METHODS

We randomly chose over 10,000 clinical trial protocols registered with ClinicalTrials.gov and examined the inclusion and exclusion criteria of the trials. We compared the relationship of clinical trial characteristics with English fluency inclusion requirements. We merged the ClinicalTrials.gov data with US Census and American Community Survey data to investigate the association of English-language restrictions with ZIP-code-level demographic characteristics of participating institutions. We used Chi-squared tests, t-tests, and logistic regression models for analyses.

RESULTS

English fluency requirements have been increasing over time, from 1.7% of trials having such requirements before 2000 to 9.0% after 2010 (p < 0.001 from Chi-squared test). Industry-sponsored trials had low rates of English fluency requirements (1.8%), while behavioral trials had high rates (28.4%). Trials opening in the Northeast of the United States had the highest regional English requirement rates (10.7%), while trials opening in more than one region had the lowest (3.3%, p<0.001). Since 1995, trials opening in ZIP codes with larger Hispanic populations were less likely to have English fluency requirements (odds ratio=0.92 for each 10% increase in proportion of Hispanics, 95% confidence interval=0.86-0.98, p=0.013). Trials opening in ZIP codes with more residents self-identifying as Black/African American (odds ratio=1.87, 95% confidence interval=1.36-2.58, p<0.001 for restricted cubic spline term) or Asian (odds ratio=1.16 for linear term, 95% confidence interval=1.07-1.25, p<0.001) were more likely to have English fluency requirements. ZIP codes with higher poverty rates had trials with more English-language restrictions (odds ratio=1.06 for a 10% poverty rate increase, 95% confidence interval=1.001-1.11, p=0.045). There was a statistically significant interaction between year and intervention type, such that the increase in English fluency requirements was more common for some interventions than for others.

CONCLUSION

The proportion of clinical trials registered with ClinicalTrials.gov that have English fluency requirements for study inclusion has been increasing over time. English-language restrictions are associated with a number of characteristics, including the demographic characteristics of communities in which the sponsoring institutions are located.

African Americans' and Hispanics' information needs about cancer care

Few studies have reported on African American and Hispanic (AA and H) populations' informational needs when seeking cancer care at an institution that offers clinical trials. Moffitt Cancer Center (MCC) sought to identify and examine the decision making process, the perceptions, and the preferred channels of communication about cancer care services for AA and H communities in order to develop a list of marketing recommendations. Five focus groups (N = 45) consisting of two AA and three H were conducted in four counties of the MCC catchment area in Tampa, FL. Participants were asked about their perceptions, knowledge, attitudes, and beliefs about cancer care and MCC. Focus groups were audio-recorded and verbatim transcripts were analyzed using content analysis. Similarities in responses were found between AA and H participants. Participants received general health and cancer information from media sources and word of mouth and preferred to hear patient testimonials. There were concerns about costs, insurance coverage, and the actual geographic location of the cancer center. In general, H participants were not opposed to participating in cancer clinical trials/research, whereas, AA participants were more hesitant. A majority of participants highly favored an institution that offered standard care and clinical trials. AA and H participants shared similar concerns and preferences in communication channels, but each group had specific informational needs. The perceptions and preferences of AA and H must be explored in order to successfully and efficiently increase cancer clinical trial participation.

Motivators and barriers to Latinas' participation in clinical trials: the role of contextual factors

OBJECTIVE

Latinas are underrepresented in clinical trials despite the rise in Hispanic population. This study examines the factors associated with Latinas' willingness to participate in preventive breast cancer randomized clinical trials (RCTs).

METHODS

Women self-identifying as Latina, over age 40, with no prior history of breast cancer were eligible. Using the Behavior Model for Vulnerable Populations, we administered a survey (n=168) to assess predisposing (e.g., knowledge), enabling (e.g., trust) and need factors (e.g., risk perception). Intention to participate was defined using a lenient (maybe, probably or definitely) and a stringent criterion (probably and definitely). Chi-square tests and logistic regression models examined the associations of predisposing, enabling, and need factors with women's intentions to participate in RCTs.

RESULTS

Most participants (74.9%) were monolingual Spanish-speaking immigrants. Most (83.9%) reported willing to participate in clinical trials using the lenient definition (vs. 43.1% under the stringent definition). Using the lenient definition, the odds of willing to participate in RCTs were significantly lower for unmarried women (OR=.25, 95% CI=.08-.79) and those with lower cancer risk perceptions (OR=.20, 95% CI=.06-.63), while being significantly higher for women with lower language acculturation (OR=6.2, 95% CI=1.8-20.9). Using the stringent definition, women who did not endorse a motivation to enroll to help family members (if they had cancer) had significantly lower odds to report intent (OR=.33, 95% CI=.13-.86).

CONCLUSION

Many RCTs may have limited generalizability due to the low representation of minorities. Culturally targeted interventions that address the importance of family for Latinos may ultimately increase their participation in RCTs.

Enhancing Hispanic participation in mental health clinical research: development of a Spanish-speaking depression research site

BACKGROUND

Hispanics, particularly those with limited English proficiency, are underrepresented in psychiatric clinical research studies. We developed a bilingual and bicultural research clinic dedicated to the recruitment and treatment of Spanish-speaking subjects in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study, a large clinical trial of treatment-naïve subjects with major depressive disorder (MDD).

METHODS

Demographic and clinical data derived from screening evaluations of the first 1,174 subjects presenting for participation were compared between the Spanish-speaking site (N = 275) and the primary English-speaking site (N = 899). Reasons for ineligibility (N = 888) for the PReDICT study were tallied for each site.

RESULTS

Compared to English speakers, Spanish speakers had a lower level of education and were more likely to be female, uninsured, and have uncontrolled medical conditions. Clinically, Spanish speakers demonstrated greater depression severity, with higher mean symptom severity scores, and a greater number of previous suicide attempts. Among the subjects who were not randomized into the PReDICT study, Spanish-speaking subjects were more likely to have an uncontrolled medical condition or refuse participation, whereas English-speaking subjects were more likely to have bipolar disorder or a non-MDD depressive disorder.

CONCLUSION

Recruitment of Hispanic subjects with MDD is feasible and may enhance efforts at signal detection, given the higher severity of depression among Spanish-speaking participants presenting for clinical trials. Specific approaches for the recruitment and retention of Spanish-speaking participants are required.

A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders

To assess the experienced or perceived barriers and facilitators to health research participation for major US racial/ethnic minority populations, we conducted a systematic review of qualitative and quantitative studies from a search on PubMed and Web of Science from January 2000 to December 2011. With 44 articles included in the review, we found distinct and shared barriers and facilitators. Despite different expressions of mistrust, all groups represented in these studies were willing to participate for altruistic reasons embedded in cultural and community priorities. Greater comparative understanding of barriers and facilitators to racial/ethnic minorities' research participation can improve population-specific recruitment and retention strategies and could better inform future large-scale prospective quantitative and in-depth ethnographic studies.

An Examination of Factors Associated with Healthcare Discrimination in Latina Immigrants: The Role of Healthcare Relationships and Language

ACKNOWLEDGEMENT

The authors are grateful to all of the women who took time to participate in the study, Dr. Elmer Huerta and members of the Latin American Cancer Research Coalition. Funding for these activities were supported, in part, by ACS grants MRSGT-06-132-01-CPPB (VBS), Herbert W. Nickens, M.D., Junior Faculty Achievement Award, AAMC (VBS), and MRSGT-05-104-01-CPPB (JW), National Cancer Institute grants UO1 CA86114 (EH, JM), U01-CA114593 (JM), and KO5 CA96940 (JM).

BACKGROUND

Understanding factors that are associated with perceived discrimination in Latina immigrants may provide opportunities to improve care for this growing population.

OBJECTIVE

To examine the prevalence of discrimination experiences in urban Latina immigrants and identify socio-cultural and healthcare factors that predict discrimination experiences.

DESIGN

Cross-sectional survey of 166 Latina immigrants.

MEASUREMENTS

Socio-cultural: region of origin, primary language, and education. Healthcare factors: insurance, place of care, patient-provider communication, trust in provider, and satisfaction with care. Multivariable logistic regression was used to examine factors that predicted discrimination.

RESULTS

42% had at least one discrimination experience. Communication with providers was the factor most strongly associated with reporting having a discrimination experience while controlling for other variables (p < 01). Women with good communication with their provider were 71% less likely to report discrimination.

CONCLUSION

Better communication with providers may reduce Latinas' perceptions of discrimination and thereby improve healthcare access and use of services.

Feasibility trial of a Spanish-language multimedia educational intervention

BACKGROUND

Hispanic cancer patients are underrepresented in clinical trials; research suggests lack of knowledge and language barriers contribute to low accrual. Multimedia materials offer advantages to Hispanic populations because they have high acceptability, are easy to disseminate, and can be viewed with family.

PURPOSE

Hispanic cancer patients and caregivers participated in focus groups to aid in developing a Spanish-language multimedia intervention to educate Hispanic cancer patients about clinical trials. We explored the feasibility of delivering the intervention in medical oncology clinics.

METHODS

A total of 35 patients were randomized to either the multimedia intervention group (n = 18) or a control group (n = 17) who were asked to read the National Cancer Institute's Spanish-language clinical trials brochure. Self-reported data on knowledge about and attitudes toward clinical trials, self-efficacy for participating in a clinical trial, intention to participate in a clinical trial if asked, and receptivity to information about a clinical trial were collected at baseline and 10 days later.

RESULTS

Delivery of the multimedia presentation in oncology clinics was feasible. The intervention group had more knowledge about clinical trials at follow-up than the control group; scores for intention to participate in a clinical trial by participants in the intervention group increased from 3.8 to 4.0 of a possible 5, but declined in the control group from 4.5 to 4.1. No statistically significant difference was detected between groups in scores for attitudes or self-efficacy for making a decision to participate in a clinical trial.

LIMITATIONS

Our sample size was inadequate to identify differences between the informational methods. Although all patients were asked about their willingness to participate in a clinical trial, this decision was hypothetical. In addition, the study was conducted with a sample of Spanish-speaking Hispanic cancer patients at a comprehensive cancer center in Florida. Thus, the results may not generalize to other Hispanic populations.

CONCLUSION

In the pilot project, we demonstrated the feasibility of delivering multimedia information to patients in medical oncology clinics. Because delivery in a clinical setting was found to be feasible, a larger study should be conducted to evaluate the efficacy of the multimedia intervention with respect to promoting accrual of Hispanic patients to clinical trials.

Improving awareness of cancer clinical trials among Hispanic patients and families: audience segmentation decisions for a media intervention

Clinical trials hold great promise for cancer treatment; yet, Hispanic cancer patients have low rates of clinical trial participation. Lack of awareness and knowledge of clinical trials and language barriers may account for low participation rates. Patient education through audiovisual materials can improve knowledge of and attitudes toward clinical trials among Hispanic populations. In this study, 36 Hispanic cancer patients/survivors and caregivers in Florida and Puerto Rico participated in focus groups to aid in developing a Spanish-language DVD and booklet intervention designed to increase knowledge about clinical trials. Focus group results showed (a) low levels of knowledge about clinical trials, (b) uncertainty about why a physician would expect a patient to make a choice about treatment, and (c) desire for family participation in decision making. Respondents expressed various preferences for aspects of the DVD such as showing extended family in the DVD and physician explanations about key terms. On the basis of these preferences, the authors developed a creative brief for a DVD. The content of the DVD was reviewed by Hispanic community leaders and key stakeholders. A final DVD was created, in Spanish, using Hispanic patients and physicians, which contained the information deemed important from the focus groups and stakeholder interviews. The DVD is complete with companion booklet and currently undergoing a randomized control trial.

Assessing the awareness of and willingness to participate in cancer clinical trials among immigrant Latinos

Clinical trials are considered the gold standard of evidence about the efficacy of cancer prevention, early detection, and treatment interventions. A paucity of data exists on determinants of clinical trial participation in the growing US Latino population despite poor cancer outcomes in this group. This study seeks to describe correlates of awareness of and willingness to participate in clinical trials among largely Central, North, and South American Latinos using safety-net clinics. Between June 2007 and November 2008, we conducted an interviewer-administered, Spanish-language cross-sectional survey (n = 944). Logistic regression was used to assess effects of health information sources and psychosocial variables on awareness of and intention to participate in clinical trials. Analyses were completed in spring 2010. While only 48% knew what a clinical trial was, when explained, 65% indicated a willingness to participate. Providers were the most common source of health information. Use of Internet for health information, trust in health information, and higher education each independently increased the odds of clinical trial awareness, but obtaining information from providers did not. Contacting the Cancer Information Service and psychosocial factors were each independently associated with intent to join a clinical trial, while demographic factors were not. Information channels such as the Internet may be effective in conveying clinical trial information to Latinos. Providers being cited as the most common source of health information but not being associated with knowledge about or intent to participate in trials suggests a missed opportunity for communication to this population.

Power of an effective clinical conversation: improving accrual onto clinical trials

The National Cancer Institute (NCI) is actively transforming clinical trials to revitalize the clinical trials system and improve patient accrual. For more than 30 years, NCI has provided information and communication resources about cancer clinical trials. The Institute supports a clinical trials Web site (www.cancer.gov/clinicaltrials) that receives nearly a half million page views a month. In addition, NCI's Cancer Information Service (800-4-CANCER, chat and e-mail) responds to 1,750 clinical trial inquiries every month. Although these numbers suggest that a high volume of clinical trial information is being exchanged between NCI, the public, and providers, most patients decide whether to participate in clinical trials during the patient-provider interaction.

The impact of familism on physical and mental health among Hispanics in the United States

The rapidly expanding number of Hispanics living in USA has increased the need for their inclusion in research on physical and mental health. Current studies that have explored health outcomes among Hispanics have often noted an 'epidemiological paradox', in which there is a discrepancy between their minority status and positive health outcomes when compared with other racial/ethnic groups. Certain socio-cultural variables, in particular the value placed on family, have been largely implicated in these findings. This review will provide a summary of the literature exploring familism within the structure of the Hispanic family and its potential impact on health. We will focus on research exploring the plausible impact that family and familism values may have on the physical health (particularly within the HIV, diabetes, and breast cancer literature) and also on health behaviours of Hispanics, as well as its effect on mental health (particularly related to acculturative stress and caregiver stress). Throughout the review, we highlight some of the potential mechanisms by which familism may impact on the health status of Hispanics. We conclude the review by noting some of the clinical and ethical implications of this research, and by offering suggestions for future work in this area.

Exploring decision-making of HIV-infected Hispanics and African Americans participating in clinical trials

Underrepresentation of HIV-infected Hispanics and African Americans in clinical trials seriously limits our understanding of the benefits and risks of treatment in these populations. This qualitative study examined factors that racial/ethnic minority patients consider when making decisions regarding research participation. A total of 35 HIV-infected Hispanic and African American patients enrolled in clinical research protocols at the National Institutes of Health were recruited to participate in focus groups and in-depth interviews. The sample included mostly male participants (n = 22), had a mean age of 45, had nearly equal representation of race/ethnicity, and were diagnosed 2 to 22 years earlier. Baseline questionnaires included demographics and measures of social support and acculturation. Interviewers had similar racial/ethnic, cultural, and linguistic backgrounds as the participants. Four major themes related to the decisions of participants to enroll in clinical trials emerged, which are as follows: enhancers, barriers, beliefs, and psychosocial context. Results may help researchers develop strategies to facilitate inclusion of HIV-infected Hispanics and African Americans into clinical trials.

Cancer-related psychosocial research: what are the perspectives of cancer care centre users on participation?

PURPOSE

To explore the perspectives of cancer care centre users on participation in psychosocial research to inform research design and ethics.

METHODS

The study is based on a qualitative research design. Fourteen semistructured interviews were carried in people diagnosed with cancer and carers. The interview included four main questions about practical barriers to participation, types of research design, motivating factors and the conduct of research in a cancer care support setting. The data were analysed using qualitative content analysis.

RESULTS

Interviewees demonstrated a willingness to participate in psychosocial research within certain circumstances. There were no practical barriers identified, although they considered payment for research-related travel important. The most acceptable research design was the face-to-face interview and the least preferred was the randomised control trial. The factors that motivated participation were altruism, valuing research, and making a contribution to the centre. Interviewees supported the conduct of research in cancer care support centres conditional upon delaying recruitment during the initial months of users' visits and its need to be discreet to avoid deterring visitors from accessing the centre.

CONCLUSIONS

The study concludes that the personal interaction between participants and researchers is the most important feature of decision-making by patients/carers to join studies. Taking into account the perspectives of people affected by cancer during the early stages of research design may enhance recruitment and retention and can contribute to the development of research protocols and ethics.

Effect of directly observed therapy for highly active antiretroviral therapy on virologic, immunologic, and adherence outcomes: a meta-analysis and systematic review

INTRODUCTION

Directly observed therapy of highly active antiretroviral therapy (DOT-HAART) is a feasible adherence intervention. Prospective DOT-HAART studies have shown mixed results, and optimal target groups have yet to be defined. We performed a meta-analysis and systematic review to assess the effect of DOT-HAART on adherence and virologic and immunologic response.

METHODS

We performed a comprehensive search through August 2009 to identify peer-reviewed controlled studies that involved outpatient DOT-HAART among adults and reported at least 1 outcome assessed in this meta-analysis. Random-effects meta-analyses were performed; differences in effect on virologic suppression were examined using stratified meta-analyses and meta-regression on several study characteristics.

RESULTS

Seventeen studies met inclusion criteria. Compared with control groups, DOT-HAART recipients were more likely to achieve an undetectable viral load (random effects risk ratio 1.24, 95% confidence interval (CI): 1.08 to 1.41), a greater increase in CD4 cell count (random effects weighted mean difference 43 cells/microL, 95% CI: 12 to 74 cells/microL), and HAART adherence of > or =95% (random effects risk ratio 1.17, 95% CI: 1.03 to 1.32). Results varied with respect to virologic response. DOT-HAART did not have a significant effect on virologic suppression when restricted to randomized controlled studies. Post-treatment effect was not observed in a limited number of studies.

CONCLUSIONS

DOT-HAART had a significant effect on virologic, immunologic, and adherence outcomes, although its efficacy was not supported when restricting analysis to randomized controlled trials. DOT-HAART shows greatest treatment effect when targeting individuals with greater risk of nonadherence and when delivering the intervention that maximizes participant convenience and provides enhanced adherence support. Further investigation is needed to assess the postintervention effect and cost-effectiveness of DOT-HAART.

What leads Indians to participate in clinical trials? A meta-analysis of qualitative studies

Background

With the globalization of clinical trials, large developing nations have substantially increased their participation in multi-site studies. This participation has raised ethical concerns, among them the fear that local customs, habits and culture are not respected while asking potential participants to take part in study. This knowledge gap is particularly noticeable among Indian subjects, since despite the large number of participants, little is known regarding what factors affect their willingness to participate in clinical trials.

Methods

We conducted a meta-analysis of all studies evaluating the factors and barriers, from the perspective of potential Indian participants, contributing to their participation in clinical trials. We searched both international as well as Indian-specific bibliographic databases, including Pubmed, Cochrane, Openjgate, MedInd, Scirus and Medknow, also performing hand searches and communicating with authors to obtain additional references. We enrolled studies dealing exclusively with the participation of Indians in clinical trials. Data extraction was conducted by three researchers, with disagreement being resolved by consensus.

Results

Six qualitative studies and one survey were found evaluating the main themes affecting the participation of Indian subjects. Themes included Personal health benefits, Altruism, Trust in physicians, Source of extra income, Detailed knowledge, Methods for motivating participants as factors favoring, while Mistrust on trial organizations, Concerns about efficacy and safety of trials, Psychological reasons, Trial burden, Loss of confidentiality, Dependency issues, Language as the barriers.

Conclusion

We identified factors that facilitated and barriers that have negative implications on trial participation decisions in Indian subjects. Due consideration and weightage should be assigned to these factors while planning future trials in India.

Influence of culture and discrimination on care-seeking behavior of elderly African Americans: a qualitative study

In this study, the influence of culture and discrimination on care-seeking behavior of elderly African Americans was explored. This was a qualitative phenomenological study that involved in-depth interviews with 15 African American men and women aged 60 and older in Alabama. The sample size of 15 was adequate for the phenomenological method of this study. While this was a small exploratory study and was not intended for any generalizations, it did provide a unique opportunity to hear the voices, the concerns, and the stories of elderly African Americans, which have often been overlooked in the literature. The following themes emerged from the analysis of data: (1) perception of health as ability to be active, (2) reluctance toward prescription medicine use, (3) lack of trust in doctors, (4) avoidance of bad news, (5) race of doctors, (6) use of home remedies, and (7) importance of God and spirituality on health, illness, and healing.

Design Elements for the Development of Cancer Education Print Materials for a Latina/o Audience

Health educators can help reduce cancer disparities in Latino populations through the creation of effective print materials. In this effort, the National Cancer Institute conducted a comprehensive needs assessment to identify key design elements of cancer education programs and create a cost-effective process that would ensure consistency in the development of materials. This article introduces the Checklist of Design Elements for the Development of Cancer Education Print Materials for Latina/o Audiences (CEMLA ), which includes a total of 10 design elements related to the process of developing materials and content. Using social learning theory as a theoretical framework, design elements are included that reflect cultural sensitivity at the surface and deep structure levels. This is the most comprehensive effort to date to integrate and synthesize theory and application in the design of materials for this audience.

Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review

Racial and ethnic minorities, older adults, rural residents, and individuals of low socioeconomic status are underrepresented among participants in cancer-related trials. The authors conducted a systematic review to determine the barriers to participation of underrepresented populations in cancer-related trials. Their search included English-language publications that reported original data on the recruitment of underrepresented groups to cancer treatment or prevention trials between 1966 and December 2005 in multiple electronic databases. They also hand-searched titles in 34 journals from January 2003 to December 2005 and they examined reference lists for eligible articles. Titles and abstracts were reviewed to identify relevant studies. Data on barriers to participation were synthesized both qualitatively and based on statistically significant associations with trial enrollment. Of 5257 studies that were cited, 65 studies were eligible for inclusion in the current analysis, including 46 studies on recruitment into cancer therapeutic trials, 15 studies on recruitment into prevention trials, and 4 studies on recruitment into both prevention and treatment trials. Numerous factors were reported as barriers to participation in cancer-related trials. However, only 20 of the studies reported statistically significant associations between hypothesized barriers and enrollment. The available evidence had limitations in quality regarding representativeness, justification of study methods, the reliability and validity of data-collection methods, potential for bias, and data analysis. The results indicated that underrepresented populations face numerous barriers to participation in cancer-related trials. The current systematic review highlighting the literature on recruitment of underrepresented populations to cancer trials and may be used as the evidence base toward developing an agenda for etiologic and intervention research to reduce the disparities in participation in cancer-related trials.

Community readiness to promote Latinas' participation in breast cancer prevention clinical trials

The high breast cancer (BC) mortality rates that exist among Hispanic women (Latinas) are a health disparity burden that needs to be addressed. Prevention clinical trials are a burgeoning area of cancer prevention efforts and may serve to promote parity. Unfortunately, Latinas, along with other ethnic minority women, continue to be under-represented in this form of research. Previous studies have examined individual barriers to ethnic minorities' participation, but none have assessed community factors contributing to Latinas' under-representation in these studies. The present study addressed these limitations from a community perspective by exploring which factors might inhibit Latinas' participation in clinical trials, specifically BC prevention trials. Using the Community Readiness Model (CRM), 19 key informants were interviewed in four communities, two rural and two urban, in Colorado, USA. The key informant assessment involved a semistructured interview that measured the level of community readiness to encourage participation in BC prevention activities. The results reflected a community climate that did not recognise BC as a health problem that affected Latinas in participating communities. Compared to other healthcare priorities, participation in BC prevention clinical trials was considered a low priority in these communities. Overall, leadership and community resources were not identified or allocated to encourage the participation of Latinas. The results highlight the lack of awareness regarding clinical trials among both community members and leaders. According to the CRM, strategies to enhance awareness at multiple levels in the community are necessary. This study demonstrates how the CRM can be used to better understand a community's perspective on BC, and specifically, the under-representation of Latinas in clinical trials.

Provider roles in the recruitment of underrepresented populations to cancer clinical trials

BACKGROUND

Providers play a vital role in the successful recruitment of underrepresented patients to cancer clinical trials because they often introduce the opportunity of clinical trials. The purpose of the current systematic review was to describe provider-related factors influencing recruitment of underrepresented populations to cancer clinical trials.

METHODS

To find original studies on the recruitment of underrepresented populations to cancer clinical trials, electronic databases from January 1966 to December 2005 were searched; hand-searched titles in 34 journals from January 2003 to January 2006; and reference lists were examined of eligible articles. Title and abstract reviews were conducted to identify relevant studies. Potential articles were then abstracted using a structured instrument and a serial review process by 2 investigators.

RESULTS

Eighteen studies were eligible for review: 13 targeted healthcare providers, 3 targeted patients/participants, and 2 targeted both providers and patients. The study designs included randomized controlled trial, concurrent controlled trial, case-control, descriptive, and qualitative. A lack of available protocols and/or a lack of provider awareness about clinical trials prevented providers from discussing the opportunity of clinical trials in 2 studies. In 14 studies, patient accrual was affected by provider attitudinal barriers relating to patient adherence to the study protocol, patient mistrust of research, patient costs, data collection costs, and/or patient eligibility. Providers' communication methods were barriers in 5 studies and promoters in 1 study.

CONCLUSIONS

A heterogeneous body of evidence suggests that several provider-related factors influence recruitment of underrepresented groups to clinical trials. Future recruitment efforts should address these factors.