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

Health Disparities: Interventions for Pulmonary Disease - A Narrative Review

There is expansive literature documenting the presence of health disparities, but there are disproportionately few studies describing interventions to reduce disparity. In this narrative review, we categorize interventions to reduce health disparity in pulmonary disease within the US health care system to support future initiatives to reduce disparity. We identified 211 articles describing interventions to reduce disparity in pulmonary disease related to race, income, or sex. We grouped the studies into the following four categories: biologic, educational, behavioral, and structural. We identified the following five main themes: (1) there were few interventional trials compared with the breadth of studies describing health disparities, and trials involving patients with asthma who were Black, low income, and living in an urban setting were overrepresented; (2) race or socioeconomic status was not an effective marker of individual pharmacologic treatment response; (3) telehealth enabled scaling of care, but more work is needed to understand how to leverage telehealth to improve outcomes in marginalized communities; (4) future interventions must explicitly target societal drivers of disparity, rather than focusing on individual behavior alone; and (5) individual interventions will only be maximally effective when specifically tailored to local needs. Much work has been done to catalog health disparities in pulmonary disease. Notable gaps in the identified literature include few interventional trials, the need for research in diseases outside of asthma, the need for high quality effectiveness trials, and an understanding of how to implement proven interventions balancing fidelity to the original protocol and the need to adapt to local barriers to care.

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.

The role of clinical research nurses in minority recruitment to cancer clinical trials

Clinical trials (CTs) are the established research mechanism designed to examine how new medical therapies are tested for safety and effectiveness. Specifically, non-Hispanic White patients still account for most CT participants and Black patient participation has declined over the past decade. Clinical Research Nurses (CRNs) whose scope of practice includes the recruitment of participants for CTs, have the potential to significantly increase minority patients participation in cancer clinical trials (CCTs). The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting minority cancer patients to participate in CTs. A total of 19 nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method. The role of CRNs was described as advocates who coordinate care, establish trust, and provide education for CT patients within physician-driven recruitment structures. The CRN's role was also described as self-taught or learn on the go with no formalized recruitment training and lack of robust cultural training. To achieve diverse patient enrollment in CCTs, CRNs and study staff need to receive training on culturally competent clinical research care and the diversity of CRNs and study teams must be increased. Further, meaningful federal and hospital policy change must occur so that minority patients have equitable access to novel cancer therapies and the role of the CRN is delineated from other healthcare staff to optimize research patient care.

Organized Lung Cancer Screening Pilot: Informing a Province-Wide Program in Ontario, Canada

BACKGROUND

Lung cancer is the leading cause of cancer deaths in Ontario. The National Lung Screening Trial demonstrated that screening with low-dose computed tomography (LDCT) reduces lung cancer mortality.

METHODS

In June 2017, Ontario Health (Cancer Care Ontario) initiated a pilot for lung cancer screening to inform implementation of a province-wide initiative. The screening pathway includes targeted recruitment strategies, the Tammemägi risk prediction model (PLCOm2012) to determine eligibility, opt-out smoking cessation services for all current smokers, use of the Lung-RADS scoring system to guide abnormal results management, and screening navigators providing end-to-end support. Referral criteria include being 55 years of age to 74 years of age and a current or former daily cigarette smoker for greater than or equal to 20 years, while the screening eligibility criterion is a PLCOm2012 risk greater than or equal to 2% in 6 years. Selected results of the interim pilot evaluation are presented. Four hospitals contributed data in the first year of the pilot.

RESULTS

During 2017 to 2018, 4205 Ontarians were recruited, 3234 risk assessments were conducted, and 2151 (66.5%) individuals were eligible for screening. Baseline LDCT scans were performed in 1624 (50.2%) individuals. Diagnostic evaluation in 120 (7.4%) individuals identified 28 (1.7%) with lung cancer, and proportions of stage I to II and stage III to IV were 71% and 29%, respectively. Of those recruited, 1443 (34.3%) individuals were smokers and 1326 (91.9%) accepted smoking cessation services.

CONCLUSIONS

The pilot is the largest in Canada and aligns with International Agency for Research on Cancer standards for population-based, organized cancer screening. Recruitment of high-risk individuals, high rates of smoking cessation program acceptance, and detection of early-stage cancers are demonstrated.

Patient Perceptions of CT Imaging in a Diverse Patient Sample

OBJECTIVE

To describe patient perceptions related to CT and evaluate variation related to patient sociodemographic characteristics.

METHODS

Institutional review board-approved survey of adult patients undergoing outpatient CT at a large academic hospital administered May 2016 to March 2017. The survey included questions about participant demographic and socioeconomic characteristics as well as scales that addressed five perceptual constructs related to their CT examination: knowledge, benefits, barriers, expectations, and trust. Two of these constructs use the Health Belief Model as a conceptual framework, and questions were adapted from the Benefits and Barriers Scale for Screening Mammography. Descriptive statistics were calculated for all variables. Heterogeneous choice models were used to evaluate associations between participant characteristics and the perceptual constructs.

RESULTS

In all, 302 surveys were completed by a diverse patient sample (33% non-Hispanic white, 29% Hispanic or Latino, 24% black, 8% mixed or other race, 5% Asian or Pacific Islander, 2% American Indian or Alaska Native). A large majority of participants responded positively to CT examination perceptions for each item with: high knowledge (71%-97%), positive expectations (94%-98%), high trust (92%) and benefits (67%-93%), and low barriers (only 9%-17% reported). In addition, 26% of participants reported seeking information about the CT before their appointment, with calling their physician's office the most common approach. The heterogeneous choice models found that responses to nearly all of the scale questions did not vary by sociodemographic characteristics, although in a larger sample some associations may be significant.

CONCLUSIONS

Among a diverse sample of patients, perceptions of CT examination were highly positive and similar according to sociodemographic characteristics.

Impact of patient and public involvement on enrolment and retention in clinical trials: systematic review and meta-analysis

OBJECTIVE

To investigate the impact of patient and public involvement (PPI) on rates of enrolment and retention in clinical trials and explore how this varies with the context and nature of PPI.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ten electronic databases, including Medline, INVOLVE Evidence Library, and clinical trial registries.

ELIGIBILITY CRITERIA

Experimental and observational studies quantitatively evaluating the impact of a PPI intervention, compared with no intervention or non-PPI intervention(s), on participant enrolment and/or retention rates in a clinical trial or trials. PPI interventions could include additional non-PPI components inseparable from the PPI (for example, other stakeholder involvement).

DATA EXTRACTION AND ANALYSIS

Two independent reviewers extracted data on enrolment and retention rates, as well as on the context and characteristics of PPI intervention, and assessed risk of bias. Random effects meta-analyses were used to determine the average effect of PPI interventions on enrolment and retention in clinical trials: main analysis including randomised studies only, secondary analysis adding non-randomised studies, and several exploratory subgroup and sensitivity analyses.

RESULTS

26 studies were included in the review; 19 were eligible for enrolment meta-analysis and five for retention meta-analysis. Various PPI interventions were identified with different degrees of involvement, different numbers and types of people involved, and input at different stages of the trial process. On average, PPI interventions modestly but significantly increased the odds of participant enrolment in the main analysis (odds ratio 1.16, 95% confidence interval and prediction interval 1.01 to 1.34). Non-PPI components of interventions may have contributed to this effect. In exploratory subgroup analyses, the involvement of people with lived experience of the condition under study was significantly associated with improved enrolment (odds ratio 3.14 v 1.07; P=0.02). The findings for retention were inconclusive owing to the paucity of eligible studies (odds ratio 1.16, 95% confidence interval 0.33 to 4.14), for main analysis).

CONCLUSIONS

These findings add weight to the case for PPI in clinical trials by indicating that it is likely to improve enrolment of participants, especially if it includes people with lived experience of the health condition under study. Further research is needed to assess which types of PPI work best in particular contexts, the cost effectiveness of PPI, the impact of PPI at earlier stages of trial design, and the impact of PPI interventions specifically targeting retention.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016043808.

Strategies to improve recruitment to randomised trials

BACKGROUND

Recruiting participants to trials can be extremely difficult. Identifying strategies that improve trial recruitment would benefit both trialists and health research.

OBJECTIVES

To quantify the effects of strategies for improving recruitment of participants to randomised trials. A secondary objective is to assess the evidence for the effect of the research setting (e.g. primary care versus secondary care) on recruitment.

SEARCH METHODS

We searched the Cochrane Methodology Review Group Specialised Register (CMR) in the Cochrane Library (July 2012, searched 11 February 2015); MEDLINE and MEDLINE In Process (OVID) (1946 to 10 February 2015); Embase (OVID) (1996 to 2015 Week 06); Science Citation Index & Social Science Citation Index (ISI) (2009 to 11 February 2015) and ERIC (EBSCO) (2009 to 11 February 2015).

SELECTION CRITERIA

Randomised and quasi-randomised trials of methods to increase recruitment to randomised trials. This includes non-healthcare studies and studies recruiting to hypothetical trials. We excluded studies aiming to increase response rates to questionnaires or trial retention and those evaluating incentives and disincentives for clinicians to recruit participants.

DATA COLLECTION AND ANALYSIS

We extracted data on: the method evaluated; country in which the study was carried out; nature of the population; nature of the study setting; nature of the study to be recruited into; randomisation or quasi-randomisation method; and numbers and proportions in each intervention group. We used a risk difference to estimate the absolute improvement and the 95% confidence interval (CI) to describe the effect in individual trials. We assessed heterogeneity between trial results. We used GRADE to judge the certainty we had in the evidence coming from each comparison.

MAIN RESULTS

We identified 68 eligible trials (24 new to this update) with more than 74,000 participants. There were 63 studies involving interventions aimed directly at trial participants, while five evaluated interventions aimed at people recruiting participants. All studies were in health care.We found 72 comparisons, but just three are supported by high-certainty evidence according to GRADE.1. Open trials rather than blinded, placebo trials. The absolute improvement was 10% (95% CI 7% to 13%).2. Telephone reminders to people who do not respond to a postal invitation. The absolute improvement was 6% (95% CI 3% to 9%). This result applies to trials that have low underlying recruitment. We are less certain for trials that start out with moderately good recruitment (i.e. over 10%).3. Using a particular, bespoke, user-testing approach to develop participant information leaflets. This method involved spending a lot of time working with the target population for recruitment to decide on the content, format and appearance of the participant information leaflet. This made little or no difference to recruitment: absolute improvement was 1% (95% CI -1% to 3%).We had moderate-certainty evidence for eight other comparisons; our confidence was reduced for most of these because the results came from a single study. Three of the methods were changes to trial management, three were changes to how potential participants received information, one was aimed at recruiters, and the last was a test of financial incentives. All of these comparisons would benefit from other researchers replicating the evaluation. There were no evaluations in paediatric trials.We had much less confidence in the other 61 comparisons because the studies had design flaws, were single studies, had very uncertain results or were hypothetical (mock) trials rather than real ones.

AUTHORS' CONCLUSIONS

The literature on interventions to improve recruitment to trials has plenty of variety but little depth. Only 3 of 72 comparisons are supported by high-certainty evidence according to GRADE: having an open trial and using telephone reminders to non-responders to postal interventions both increase recruitment; a specialised way of developing participant information leaflets had little or no effect. The methodology research community should improve the evidence base by replicating evaluations of existing strategies, rather than developing and testing new ones.

Self-reported race and ethnicity of US biobank participants compared to the US Census

Precision medicine envisions a future of effective diagnosis, treatment, and prevention grounded in precise understandings of the genetic and environmental determinants of disease. Given that the original genome-wide association studies represented a predominately European White population, and that diversity in genomic studies must account for genetic variation both within and across racial categories, new research studies are at a heightened risk for inadequate representation. Currently biological samples are being made available for sequencing in biobanks across the USA, but the diversity of those samples is unknown. The aims of this study were to describe the types of recruitment and enrollment materials used by US biobanks and the diversity of the samples contained within their collection. Biobank websites and brochures were evaluated for reading level, health literacy, and factors known to encourage the recruitment of minorities, such as showing pictures of diverse populations. Biobank managers were surveyed by mail on the methods and materials used for enrollment, recruitment, consent, and the self-reported race/ethnicity of biobank participants. From 51 US biobanks (68% response rate), recruitment and enrollment materials were in English only, and most of the websites and brochures exceeded a fifth-grade reading level. When compared to the 2015 US Census, self-reported race/ethnicity of participants was not significantly different for Whites (61%) and blacks (13%). The percentages were significantly lower for Hispanics and Latinos (18 vs. 7%, p = 0.00) and Hawaiian/Pacific Islanders (0.2 vs. 0.01%; p = 0.01) and higher for Asians (13 vs. 5%, p = 0.01). Materials for recruitment predominantly in English may limit participation by underrepresented populations.

Clinical Practice and Knowledge in Caring: Breastfeeding Ties and the Impact on the Health of Latin-American Minor Migrants

In the context of the project "Clinical and social evaluation of medical practices in the treatment of infectious diseases in pediatrics for children of vulnerable population" carried out in 2013 by a multidisciplinary team at the National Institute for Health, Migration and Poverty (NIHMP) in Rome, a study in medical anthropology on the incorporation of illnesses that mothers feel they transmit to their children through breastfeeding was conducted. The results of the anthropological study, that targeted 34 children and adolescents from the age of 3 to the age of 17, all immigrants from Latin America residing in Italy, show that some forms of suffering in minors are described by women as being connected to factors such as susto ("fright"), coraje, muina, enojo ("anger") and mal de ojo ("evil eye"), and are in relation to a specific cultural frame. It is clear that barriers that prevent the access to the healthcare system must be removed, barriers that are accentuated by linguistic and cultural incomprehension, through adequate multidisciplinary healthcare settings such as the one we are presenting, composed of a medical doctor, an anthropologist and a cultural mediator.