Special populations recruitment for the Women's Health Initiative: successes and limitations

Racial disparities in stroke incidence in the Women's Health Initiative: Exploring biological, behavioral, psychosocial, and social risk factors

Background

- Disparities in incident stroke risk among women by race and ethnicity persist. Few studies report the distribution and association of stroke risk factors by age group among a diverse sample of women.

Methods

- Data from the Women's Health Initiative (WHI) Observational Study collected between 1993 and 2010 were used to calculate cumulative stroke incidence and incidence rates among non-Hispanic African American (NHAA), non-Hispanic white (NHW), and Hispanic white or African American (HWAA) women by age group in participants aged ≥50 years at baseline (N = 77,247). Hazard ratios (HRs) and 95% CIs for biological, behavioral, psychosocial, and socioeconomic factors overall and by race or ethnicity were estimated using sequential Cox proportional hazard regression models.

Results

- Average follow-up time was 11.52 (SD, 3.48) years. The incident stroke rate was higher among NHAA (306 per 100,000 person-years) compared to NHW (279/100,000py) and HWAA women (147/100,000py) overall and in each age group. The disparity was largest at ages >75 years. The association between stroke risk factors (e.g., smoking, BMI, physical activity) and incident stroke varied across race and ethnicity groups. Higher social support was significantly associated with decreased stroke risk overall (HR:0.84, 95% CI, 0.76, 0.93); the degree of protection varied across race and ethnicity groups. Socioeconomic factors did not contribute additional stroke risk beyond risk conferred by traditional and psychosocial factors.

Conclusions

- The distribution and association of stroke risk factors differed between NHAA and NHW women. There is a clear need for stroke prevention strategies that address factors driving racial disparities in stroke risk.

HFSA Position Statement The Impact of Healthcare Disparities on Patients with Heart Failure

Heart Failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from Stage A to Stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known healthcare disparities that exist in the care of patients with HF, and to provide a context for how clinicians and researchers should assess both biologic and social determinants of HF risk in vulnerable populations. Furthermore, this document will provide a framework for future steps that can be utilized to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help reduce disparities within HF care.

Taking action to advance the study of race and ethnicity: the Women's Health Initiative (WHI)

“Race” and “ethnicity” are socially constructed terms, not based on biology - in contrast to biologic ancestry and genetic admixture - and are flexible, contested, and unstable concepts, often driven by power. Although individuals may self-identify with a given race and ethnic group, as multidimensional beings exposed to differential life influencing factors that contribute to disease risk, additional social determinants of health (SDOH) should be explored to understand the relationship of race or ethnicity to health. Potential health effects of structural racism, defined as “the structures, policies, practices, and norms resulting in differential access to goods, services, and opportunities of society by “race,” have been largely ignored in medical research. The Women’s Health Initiative (WHI) was expected to enroll a racially and ethnically diverse cohort of older women at 40 U.S. clinical centers between 1993 and 1998; yet, key information on the racial and ethnic make-up of the WHI cohort of 161,808 women was limited until a 2020–2021 Task Force was charged by the WHI Steering Committee to better characterize the WHI cohort and develop recommendations for WHI investigators who want to include “race” and/or “ethnicity” in papers and presentations. As the lessons learned are of relevance to most cohorts, the essence of the WHI Race and Ethnicity Language and Data Interpretation Guide is presented in this paper. Recommendations from the WHI Race and Ethnicity Language and Data Interpretation Guide include: Studies should be designed to include all populations and researchers should actively, purposefully and with cultural-relevance, commit to recruiting a diverse sample; Researchers should collect robust data on race, ethnicity and SDOH variables that may intersect with participant identities, such as immigration status, country of origin, acculturation, current residence and neighborhood, religion; Authors should use appropriate terminology, based on a participant’s self-identified “race” and “ethnicity”, and provide clear rationale, including a conceptual framework, for including race and ethnicity in the analytic plan; Researchers should employ appropriate analytical methods, including mixed-methods, to study the relationship of these sociocultural variables to health; Authors should address how representative study participants are of the population to which results might apply, such as by age, race and ethnicity.

Recruiting racially and ethnically diverse smokers seeking treatment: Lessons learned from a smoking cessation randomized clinical trial

INTRODUCTION

Recruiting racial/ethnic minorities in smoking cessation trials is a priority. This study described lessons learned from recruiting a diverse sample of African American, White, and Hispanic/Latinx smokers in a smoking cessation trial.

METHODS

We implemented a 42-month recruitment campaign utilizing reactive (e.g., word-of-mouth, newspaper, radio, online ads, flyers, community partnerships) and proactive (e.g., direct invitations) strategies. We included 821 participants in the analysis. We described our recruitment strategies' implementation, their enrollment yield and rate (number enrolled/number screened) by race/ethnicity, and direct cost-per-participant (CPP: total cost/number of enrolled) for paid strategies.

RESULTS

Enrollment yields were higher using reactive strategies than proactive strategies (94.3% vs. 5.7%). The top source of enrollment was word-of-mouth among African Americans (36%) and Whites (44%), and flyers among Hispanics/Latinxs (34%). Proactive recruitment, word-of-mouth, and flyers were more successful among African Americans than other groups. Newspaper and online ads were more successful among Hispanics/Latinxs than other groups (P < .05). Word-of-mouth was cost-free and yielded 23.1% of enrollment. The most economic method among paid strategies was flyer distribution (CPP = $47.6; yield 17.5%), followed by newspaper ($194.7; 23.7%) and online advertisements ($264.6; 24.0%). Radio and television ads were the most expensive and produced the least participant yield ($4,755.6; 0.8%).

CONCLUSION

Recruiting racially/ethnically diverse samples into smoking cessation clinical trials requires implementing multiple strategies and adjusting these strategies based on their enrollment yield and cost. Word-of-mouth, flyers, and newspaper and online ads were more successful among racial/ethnic minorities. Flyers and newspaper ads were the most economic methods for recruitment.

Recruitment and enrollment of African Americans into health promoting programs: the effects of health promoting programs on cardiovascular disease risk study

Objectives: Randomized controlled trials (RCT) often employ multiple recruitment methods to attract participants, however, special care must be taken to be inclusive of under-represented populations. We examine how recruiting from an existing observational study affected the recruitment of African Americans into a RCT that included yoga-based interventions. In particular, we report the recruitment success of The Effects of Health Promoting Programs (HPP) on Cardiovascular Disease Risk (NCT02019953), the first yoga-based clinical trial to focus only on African Americans. Design: To recruit participants, a multifaceted recruitment strategy was implemented exclusively in the Jackson Heart Study (JHS) cohort. The HPP recruited from the JHS cohort using direct mailings, signs and flyers placed around JHS study facilities, and through JHS annual follow-up interviews. Results: Enrollment into HPP was open to all active JHS participants that were eligible to return for the third clinic exam (n = 4644). The target sample size was 375 JHS participants over a 24 month recruitment and enrollment period. From the active members of the JHS cohort, 503 were pre-screened for eligibility in HPP. More than 90% of those pre-screened were provisionally eligible for the study. The enrollment goal of 375 was completed after a 16-month enrollment period with over 25% (n = 97) of the required sample size enrolling during the second month of recruitment. Conclusions: The findings show that participants in observational studies can be successfully recruited into RCT. Observational studies provide researchers with a well-defined population that may be of interest when designing clinical trials. This is particularly useful in the recruitment of a high-risk, traditionally underrepresented populations for non-pharmacological clinical trials where traditional recruitment methods may prolong enrollment periods and extend study budgets.

Mobile Mammography Screening as an Opportunity to Increase Access of Rural Women to Breast Cancer Research Studies

Objectives

Rural women are underrepresented in cancer research. We hypothesized that providing access to a research study to rural, medically underserved women who were receiving their breast cancer screening using a mobile mammography unit would increase the representation of rural women in a cancer cohort study.

Design

This study is a cross-sectional study using a cohort of women who have been recruited to a breast cancer study in Arkansas.

Setting

Recruiters accompanied a mobile mammography unit, the MammoVan, to implement a novel method for reaching and recruiting underrepresented rural Arkansas women into the study. Participants include 5850 women recruited from 2010 through 2012 as part of the Arkansas Rural Community Health (ARCH) study.

Results

Participants recruited during their mammography screening on the MammoVan tended to be more rural, less educated, and more likely to be non-Hispanic than those recruited in other venues. A significant difference was not noted for race or age.

Conclusion

Collaboration with the MammoVan greatly aided the recruitment of rural participants. These strategies can facilitate the representation of this historically underserved and understudied rural population in future research studies.

Comparison of internet and mailing methods to recruit couples into research on unaided smoking cessation

In smoking cessation studies with restrictive criteria (e.g., single-smoker couples), thousands of potential participants might need to be screened to obtain a reasonable sample size. Consideration of recruitment methodology is critical because recruitment methods influence both the success and cost effectiveness of recruitment. Although traditional recruitment methods are often used to recruit participants into smoking cessation research, newer technologies, such as paid Facebook advertising, might offer more cost-effective alternatives for recruitment. The current analysis compares two versions of paid Facebook advertising and a specialized mass mailing method used to recruit single-smoker couples into an intensive three-week study of unaided smoking cessation. The three methods are compared in terms of demographic characteristics, eligibility, and cost-effectiveness. Although Facebook's "Promote Your Page" mechanism achieved the fastest recruitment rate (2.75 couples per month; 498 USD per couple), Facebook's "Send People to Your Website" mechanism was the least expensive and provided the most demographically diverse sample (1.64 couples per month; 181 USD per couple). The specialized mailing method was not productive or cost-effective (0.80 couples per month; 454 USD per couple). Paid Facebook advertising fared better as a recruitment method than a specialized mailing method often used in survey research. Studies that have less restrictive eligibility criteria, that draw from a larger local population, or that recruit for a less intense study might find paid Facebook advertising to be quite feasible.

Recruiting and Assessing Recent Young Adult Latina Immigrants in Health Disparities Research

The authors interviewed 4 researchers to identify facilitators in recruiting and assessing Latina immigrants. The 4 researchers recruited 530 recent Latina immigrants (ages 18-23 years) for a study of social and cultural determinants of health. Consensual qualitative research methods revealed that respondent-driven sampling was an effective recruitment method. Fear of deportation was a barrier. Stigma about sensitive topics (e.g., sex, drug use) did not affect participation. Findings can help counselors conduct health disparities research.

Association of Race, Ethnicity and Language with Participation in Mental Health Research Among Adult Patients in Primary Care

Racial and ethnic minorities remain underrepresented in clinical psychiatric research, but the reasons are not fully understood and may vary widely between minority groups. We used the Z-test of independent proportions and binary logistic regression to examine the relationship between race, ethnicity or primary language and participation in screening as well as interest in further research participation among primary care patients being screened for a depression study. Minorities were less likely than non-Hispanic Whites to complete the initial screening survey. Latinos and Blacks were more likely to agree to be contacted for research than non-Hispanic Whites. Among Latinos, primary language was associated with willingness to be contacted for research. Associations between research participation and race, ethnicity and language are complex and vary across different enrollment steps. Future research should consider stages of the research enrollment process separately to better understand barriers and identify targets for intervention.

The Role of Clinical Trial Participation in Cancer Research: Barriers, Evidence, and Strategies

Fewer than one in 20 adult patients with cancer enroll in cancer clinical trials. Although barriers to trial participation have been the subject of frequent study, the rate of trial participation has not changed substantially over time. Barriers to trial participation are structural, clinical, and attitudinal, and they differ according to demographic and socioeconomic factors. In this article, we characterize the nature of cancer clinical trial barriers, and we consider global and local strategies for reducing barriers. We also consider the specific case of adolescents with cancer and show that the low rate of trial enrollment in this age group strongly correlates with limited improvements in cancer population outcomes compared with other age groups. Our analysis suggests that a clinical trial system that enrolls patients at a higher rate produces treatment advances at a faster rate and corresponding improvements in cancer population outcomes. Viewed in this light, the issue of clinical trial enrollment is foundational, lying at the heart of the cancer clinical trial endeavor. Fewer barriers to trial participation would enable trials to be completed more quickly and would improve the generalizability of trial results. Moreover, increased accrual to trials is important for patients, because trials provide patients the opportunity to receive the newest treatments. In an era of increasing emphasis on a treatment decision-making process that incorporates the patient perspective, the opportunity for patients to choose trial participation for their care is vital.

Recruitment of older adults with type 2 diabetes into a community-based exercise and nutrition randomised controlled trial

BACKGROUND

Recruitment of participants into long-term community-based lifestyle intervention trials, particularly adults with a chronic disease, is often slow and challenging. Currently there is limited data on successful recruitment strategies suitable for older adults with type 2 diabetes into community-based exercise and nutrition programs, and no information on cost estimates associated with such recruitment. The aim of this report is to describe the recruitment strategies used and the success of each approach in recruiting older adults with type 2 diabetes into a 6-month community-based exercise and nutritional supplementation randomised controlled trial (RCT). A secondary aim is to assess the costs associated with the recruitment methods used.

METHODS

The Resistance Exercise, Vitamin D and Muscle Protein Intervention Trial (REVAMP-IT) for type 2 diabetes is a 24-week RCT targeting 202 adults with type 2 diabetes which is designed to evaluate whether post-exercise ingestion of a whey- protein and vitamin D-enriched drink can enhance the effects of progressive resistance training (PRT) on glycaemic control, body composition and cardiometabolic health. Participants in this trial were randomly allocated to either: (1) the Lift for Life® community-based PRT program combined with additional whey protein and vitamin D, or (2) the Lift for Life® PRT program alone. Recruitment strategies included state and local newspaper and radio advertisements, targeted mail-outs, doctor and allied health referrals, community presentations, web-based media and word of mouth. The number of expressions of interest, participants screened and included in the trial, and how they first heard about the study were recorded by research staff during the screening process. Reasons for ineligibility or non-participation in the trial were also recorded as was the cost of each recruitment method used.

RESULTS

A total of 1157 expressions of interest were received over a 21-month recruitment period. Overall 959 (83 %) individuals were screened and found to be ineligible for the trial or chose not to participate or could not be contacted further following their initial enquiry. As a result, 198 participants were randomised to the 24-week intervention. The most effective recruitment strategies were targeted mass mail-outs (39 % of the total participant sample), state (27 %) and local (14 %) print media. In total recruitment expenditure was AUD$40,421, which equated to AUD$35 per enquiry and AUD$204 per eligible participant. Targeted mail-outs and state print media were the most expensive strategies each accounting for 38 % of total expenditure.

CONCLUSIONS

To recruit around 200 older adults with type 2 diabetes into a community-based lifestyle intervention trial in a timely manner, it is important to ensure that an adequate budget is allocated to recruitment as targeted mail-outs and state/local print media were the most costly but effective strategies.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry reference ACTRN12613000592741 . Registered on 27 May 2013.

Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials

PURPOSE

Less than 10% of patients enrolled in clinical trials are minorities. The patient navigation model has been used to improve access to medical care but has not been evaluated as a tool to increase the participation of minorities in clinical trials. The Increasing Minority Participation in Clinical Trials project used patient navigators (PNs) to enhance the recruitment of African Americans for and their retention in therapeutic cancer clinical trials in a National Cancer Institute-designated comprehensive cancer center.

METHODS

Lay individuals were hired and trained to serve as PNs for clinical trials. African American patients potentially eligible for clinical trials were identified through chart review or referrals by clinic nurses, physicians, and social workers. PNs provided two levels of services: education about clinical trials and tailored support for patients who enrolled in clinical trials.

RESULTS

Between 2007 and 2014, 424 African American patients with cancer were referred to the Increasing Minority Participation in Clinical Trials project. Of those eligible for a clinical trial (N = 378), 304 (80.4%) enrolled in a trial and 272 (72%) consented to receive patient navigation support. Of those receiving patient navigation support, 74.5% completed the trial, compared with 37.5% of those not receiving patient navigation support. The difference in retention rates between the two groups was statistically significant (P < .001). Participation of African Americans in therapeutic cancer clinical trials increased from 9% to 16%.

CONCLUSION

Patient navigation for clinical trials successfully retained African Americans in therapeutic trials compared with non-patient navigation trial participation. The model holds promise as a strategy to reduce disparities in cancer clinical trial participation. Future studies should evaluate it with racial/ethnic minorities across cancer centers.

Conjugated estrogens and bazedoxifene in minority populations: pooled analysis of four phase 3 trials

OBJECTIVE

The aim of the study was to compare efficacy of conjugated estrogens (CE)/bazedoxifene (BZA) for treatment of menopausal symptoms and prevention of postmenopausal osteoporosis in minorities (black/Hispanic) versus whites.

METHODS

In a post hoc analysis, data were pooled from 3,424 white or minority nonhysterectomized postmenopausal women randomized to CE 0.45 or 0.625 mg/BZA 20 mg or placebo in four double-blind, phase 3 Selective Estrogens, Menopause, and Response to Therapy (SMART) trials. Outcomes included hot flush frequency/severity (daily diary) in women with at least seven moderate-to-severe hot flushes per day (SMART-1, -2), vaginal cytology in women with at most 5% superficial cells (SMART-1, -3), lumbar spine and total hip bone mineral density (BMD) (SMART-1, -5), and the Menopause-Specific Quality of Life (MENQOL) questionnaire (SMART-1, -2, -3, -5).

RESULTS

The analysis included 2,907 white (84.9%), 315 black (9.2%), and 202 Hispanic (5.9%) women. The reduction in hot flush frequency/severity versus placebo (P < 0.05; week 12) was similar in white and minority women. In both populations, both doses significantly (P < 0.05 vs placebo) improved MENQOL vasomotor function, sexual function, and total scores at 3 months; decreased the percentage of parabasal cells at 2 years; and increased the percentage of BMD responders at 12 and 24 months. Significant differential treatment effects by race/ethnicity were observed only for effects on vaginal superficial cells at month 24 and vaginal pH at month 3.

CONCLUSIONS

Notwithstanding a limited sample size, CE/BZA had a similar and beneficial impact on hot flushes, MENQOL, and BMD in minorities and whites.

The Role of Clinical Trial Participation in Cancer Research: Barriers, Evidence, and Strategies

Fewer than one in 20 adult patients with cancer enroll in cancer clinical trials. Although barriers to trial participation have been the subject of frequent study, the rate of trial participation has not changed substantially over time. Barriers to trial participation are structural, clinical, and attitudinal, and they differ according to demographic and socioeconomic factors. In this article, we characterize the nature of cancer clinical trial barriers, and we consider global and local strategies for reducing barriers. We also consider the specific case of adolescents with cancer and show that the low rate of trial enrollment in this age group strongly correlates with limited improvements in cancer population outcomes compared with other age groups. Our analysis suggests that a clinical trial system that enrolls patients at a higher rate produces treatment advances at a faster rate and corresponding improvements in cancer population outcomes. Viewed in this light, the issue of clinical trial enrollment is foundational, lying at the heart of the cancer clinical trial endeavor. Fewer barriers to trial participation would enable trials to be completed more quickly and would improve the generalizability of trial results. Moreover, increased accrual to trials is important for patients, because trials provide patients the opportunity to receive the newest treatments. In an era of increasing emphasis on a treatment decision-making process that incorporates the patient perspective, the opportunity for patients to choose trial participation for their care is vital.

Recruitment strategies and the retention of obese urban racial/ethnic minority adolescents in clinical trials: the FIT families project, Michigan, 2010-2014

Introduction

The successful recruitment and retention of participants is integral to the translation of research findings. We examined the recruitment and retention rates of racial/ethnic minority adolescents at a center involved in the National Institutes of Health Obesity Research for Behavioral Intervention Trials (ORBIT) initiative by the 3 recruitment strategies used: clinic, informatics, and community.

Methods

During the 9-month study, 186 family dyads, each composed of an obese African American adolescent and a caregiver, enrolled in a 6-month weight-loss intervention, a sequential multiple assignment randomized trial. We compared recruitment and retention rates by recruitment strategy and examined whether recruitment strategy was related to dyad baseline characteristics.

Results

Of the 186 enrolled families, 110 (59.1%) were recruited through clinics, 53 (28.5%) through informatics, and 23 (12.4%) through community. Of those recruited through community, 40.4% enrolled in the study, compared with 32.7% through clinics and 8.2% through informatics. Active refusal rate was 3%. Of the 1,036 families identified for the study, 402 passively refused to participate: 290 (45.1%) identified through informatics, 17 (29.8%) through community, and 95 (28.3%) through clinics. Recruitment strategy was not related to the age of the adolescent, adolescent comorbidities, body mass index of the adolescent or caregiver, income or education of the caregiver, or retention rates at 3 months, 7 months, or 9 months. Study retention rate was 87.8%.

Conclusion

Using multiple recruitment strategies is beneficial when working with racial/ethnic minority adolescents, and each strategy can yield good retention. Research affiliated with health care systems would benefit from the continued specification, refinement, and dissemination of these strategies.

Engagement, recruitment, and retention in a trans-community, randomized controlled trial for the prevention of obesity in rural American Indian and Hispanic children

Engagement, recruitment and retention of participants are critical to the success of research studies but specific strategies are rarely elucidated in the literature. The purpose of this paper is to describe the engagement, recruitment and retention process and outcomes in the Child Health Initiative for Lifelong Eating and Exercise (CHILE) study, and to describe lessons learned in the process. CHILE is a multi-level, group randomized controlled trial of a childhood obesity prevention intervention in rural American Indian and predominantly Hispanic Head Start (HS) centers in New Mexico. Barriers to engagement, recruitment and retention included distrust of researchers, long travel distances, and different HS and community structures. CHILE employed multiple strategies from the onset including the use of formative assessment, building on previous relationships, developing Memoranda of Agreement, using a community engagement specialist, and gaining support of a community champion. As a result of lessons learned, additional strategies were employed, including more frequent feedback to intervention sites, revised permission forms, telephone reminders, increased site visits and over-scheduling of interviews. These strategies resulted in the recruitment of 16 HS centers, 1,879 children, 655 parents, 7 grocery stores and 14 healthcare providers, meeting or exceeding recruitment goals. By combining principles of community engagement, a variety of recruitment strategies, and lessons learned, this study obtained a high level of recruitment and retention.

African American women's perceptions and attitudes regarding participation in medical research: the Mayo Clinic/The Links, Incorporated partnership

OBJECTIVE

To examine perceptions and attitudes toward health-related research participation among professional African American women.

METHODS

Participants were members of an African American women's service organization, The Links, Incorporated. Data were collected via self-administered questionnaires at The Links, Incorporated 2012 National Assembly. Sociodemographics, prior research experience, intention to participate (ITP), willingness to participate (WTP) in a variety of research studies and attitudes about research participation were measured.

RESULTS

A total of 381 surveys were analyzed. A majority of respondents were married (66%), employed (69%), and college educated (96%). Median age was 59; 38% reported prior research participation. Overall, 78% agreed with the statement, "Participation in research will mean better care," 24% agreed "Participation in research is risky" and 3% agreed "Scientists cannot be trusted." Fifty-two percent agreed with the statement, "Research conducted in the U.S. is ethical." Mean ITP in research was 4.9±1.7 on a rating scale of 1 ("definitely no") to 7 ("definitely yes"). WTP was highest for an interview study and providing a blood sample, and lowest for clinical trial and medical record review.

CONCLUSION

Attitudes toward research participation were generally favorable among professional African American women; many expressed WTP in a variety of research study types.

Volunteer bias in recruitment, retention, and blood sample donation in a randomised controlled trial involving mothers and their children at six months and two years: a longitudinal analysis

BACKGROUND

The vulnerability of clinical trials to volunteer bias is under-reported. Volunteer bias is systematic error due to differences between those who choose to participate in studies and those who do not.

METHODS AND RESULTS

This paper extends the applications of the concept of volunteer bias by using data from a trial of probiotic supplementation for childhood atopy in healthy dyads to explore 1) differences between a) trial participants and aggregated data from publicly available databases b) participants and non-participants as the trial progressed 2) impact on trial findings of weighting data according to deprivation (Townsend) fifths in the sample and target populations. 1) a) Recruits (n = 454) were less deprived than the target population, matched for area of residence and delivery dates (n = 6,893) (mean [SD] deprivation scores 0.09[4.21] and 0.79[4.08], t = 3.44, df = 511, p<0.001). b) i) As the trial progressed, representation of the most deprived decreased. These participants and smokers were less likely to be retained at 6 months (n = 430[95%]) (OR 0.29,0.13-0.67 and 0.20,0.09-0.46), and 2 years (n = 380[84%]) (aOR 0.68,0.50-0.93 and 0.55,0.28-1.09), and consent to infant blood sample donation (n = 220[48%]) (aOR 0.72,0.57-0.92 and 0.43,0.22-0.83). ii) Mothers interested in probiotics or research or reporting infants' adverse events or rashes were more likely to attend research clinics and consent to skin-prick testing. Mothers participating to help children were more likely to consent to infant blood sample donation. 2) In one trial outcome, atopic eczema, the intervention had a positive effect only in the over-represented, least deprived group. Here, data weighting attenuated risk reduction from 6.9%(0.9-13.1%) to 4.6%(-1.4-+10.5%), and OR from 0.40(0.18-0.91) to 0.56(0.26-1.21). Other findings were unchanged.

CONCLUSIONS

Potential for volunteer bias intensified during the trial, due to non-participation of the most deprived and smokers. However, these were not the only predictors of non-participation. Data weighting quantified volunteer bias and modified one important trial outcome.

TRIAL REGISTRATION

This randomised, double blind, parallel group, placebo controlled trial is registered with the International Standard Randomised Controlled Trials Register, Number (ISRCTN) 26287422. Registered title: Probiotics in the prevention of atopy in infants and children.

Attributes of researchers and their strategies to recruit minority populations: results of a national survey

Despite NIH mandates for inclusion, recruiting minorities is challenging for biomedical and public health researchers. Little is known about how attributes of researchers affect their choice of recruitment strategies. The purpose of this study was to address this gap by examining how use of recruitment strategies relates to other researcher characteristics. To do this, we conducted an online survey from May to August 2010 with researchers (principal investigators, research staff, and IRB members) in which we measured the number and types of recruitment strategies utilized, along with other characteristics of the researchers and their research. We identified two clusters of researchers: comprehensive researchers who utilized a greater number and more diverse and active recruitment strategies, and traditional researchers, who utilized fewer and more passive strategies. Additional characteristics that distinguished the two groups were that comprehensive researchers were more likely than traditional researchers to 1) report racial and ethnic differences as one of their specific aims or hypotheses, 2) receive federal (CDC and NIH) funding, 3) conduct behavioral or epidemiological research, and 4) have received training in conducting research with and recruiting minorities. Traditional researchers, on the other hand, were more likely to conduct clinical research and a greater (though non-significant) percentage received funding from pharmaceutical sources. This study provides a novel description of how researcher attributes are related to their recruitment strategies and raises a number of future research questions to further examine the implications of this relationship.

Minority recruitment into clinical trials: experimental findings and practical implications

Racial and ethnic minorities in the US suffer disproportionately from obesity and related comorbidities, yet remain underrepresented in health research. To date, research on practical strategies to improve minority reach and recruitment into clinical trials is primarily descriptive rather than experimental. Within a randomized behavioral weight management trial for obese women, this recruitment experiment examined whether two characteristics of direct mail letters, an ethnically-targeted statement and personalization, increased the response rate among minority women. The ethnically-targeted statement noted ethnic-specific information about health risks of obesity. Personalized letters included recipients' names/addresses in the salutation and a handwritten signature on high-quality letterhead. Of women sent direct mail letters (N=30,000), those sent letters with the ethnically-targeted statement were more likely to respond than women sent letters with the generic statement, 0.8% (n=121) vs. 0.6% (n=90) respectively, p=.03, a 34.4% increase. Women sent personalized letters were no more likely to respond than women sent non-personalized letters, p=.53. In the weight management trial itself, of 267 women randomized into the trial, 33.7% (n=90) were minorities. Of minority women randomized into the trial, 68.9% (n=62) were recruited by direct mail letters: 75.8% (n=47) of those were sent a letter and 24.2% (n=15) were referred by friends/family who were sent a letter. The results indicate that a simple modification to a standard recruitment letter can have a meaningful impact on minority reach and recruitment rates. Practical implications include using ethnically-targeted, non-personalized direct mail letters and recruiting through friends/family at no additional cost.

Adding more muscle and nerve to clinical trials

In this review we illustrate both the fundamentals and challenges of randomized clinical trials in neuromuscular disorders and suggest directions for prospective efforts to improve the design, conduct, rigor, and objectivity of these trials. Current research in clinical trials for neuromuscular disorders and key issues affecting these trials are reviewed. This perspective addresses the planning of clinical research, level of preclinical data needed to justify trials, patient recruitment and retention, and opportunities to access federal funding and infrastructure in support of clinical trials. The need for innovation in trial design and conduct, rigorous standards for the preclinical efficacy and safety data that support trial rationale, novel collaborative paradigms, objective interpretations of outcomes, and sharing of the lessons learned from trials in any one disorder among all neuromuscular trialists are imperative to improving the heretofore limited success in delivering novel, safe, and effective therapies to patients burdened by neuromuscular disorders.

The cross-sectional relationship of hemoglobin levels and functional outcomes in women with self-reported osteoarthritis: results from the Women's Health Initiative

OBJECTIVES

Gastrointestinal blood loss is a recognized complication of the use of nonsteroidal anti-inflammatory drugs (NSAIDS) in patients with arthritis. We examined the cross-sectional relationship of patient-reported outcomes of overall health, physical function, vitality, and quality of life to hemoglobin (hgb) levels in postmenopausal women with self-reported osteoarthritis to determine whether hgb levels as potential markers of chronic blood loss were associated with these functional outcomes.

METHODS

Postmenopausal women (N = 64,850) with self-reported osteoarthritis (srOA) at baseline in the Women's Health Initiative study, excluding participants with chronic or hemolytic diseases associated with anemia, had hgb levels measured and completed Short-Form Health Surveys. General linear models analysis adjusting for potential confounders was performed.

RESULTS

A nonlinear plateauing relationship between hgb levels and functional outcomes was found. Participants with srOA had statistically significantly worse overall health, physical function, and vitality, but not quality of life, for each gram of hgb below 14 g/dL, compared with those with hgb 14 g/dL (P < 0.001). Participants with srOA taking NSAIDS had worse functional outcomes for each level of hgb compared with those not reporting NSAIDS use.

CONCLUSIONS

In cross-sectional analyses of postmenopausal women with srOA, differences in hgb levels are related to differences in functional outcomes of overall health, physical function, and vitality at clinically important levels. Prospective studies evaluating whether changes in hgb levels result in changes in functional outcomes in participants with osteoarthritis are needed to confirm of our findings and before any changes in therapeutics based on hemoglogin levels are considered in the care of patients with osteoarthritis.

Successful recruitment and retention of Latino study participants

A high prevalence of risk behaviors among the rapidly growing Latino youth population in the United States adds urgency to the need to identify effective recruitment and retention strategies for research studies and prevention programs. The objectives of this study are to (a) describe the culturally responsive recruitment and retention strategies used in the Familias Fuertes-Georgia program and (b) discuss the evaluation of the relative importance of these strategies. Familias Fuertes (i.e., Strong Families) is a community-based, primary prevention program for families in Latin America with children between the ages of 10 and 14 years. The main program goal is to reduce high-risk behaviors among adolescents by strengthening family relationships and promoting self-regulation and positive conflict resolution strategies. A pilot feasibility study was conducted to determine the appropriateness of the Familias Fuertes program for Latino families living in the United States. To promote participation, 15 culturally responsive recruitment and retention strategies were developed using a three-step process. These strategies contributed to the successful recruitment and retention of Familias Fuertes-Georgia study participants. Participating parents, the community liaison, and the community leader evaluated the relative importance of the 15 culturally responsive recruitment and retention strategies. Three of the strategies emerged as more important than others: face-to-face recruitment by the community liaison; bilingual, bicultural, and experienced facilitators; and free on-site child care. Further research is needed to develop strategies promoting the participation of male caregivers/fathers.

Process evaluation of a multiple risk factor perinatal programme for a hard-to-reach minority group

AIM

This article is a report of an evaluation of a multiple risk factor perinatal programme tailored to ethnic Turkish women in the Netherlands.

BACKGROUND

The programme was directed at multiple risk factors and aimed at improving maternal lifestyle, infant care practices and psychosocial health during pregnancy and after delivery. The programme was carried out by ethnic Turkish community health workers in collaboration with midwives and physiotherapists.

METHODS

Our multiple case study included three Parent-Child Centres providing integrated maternity and infant care. Participants (n = 119) were first and second generation pregnant ethnic Turkish women with relatively unfavourable risk profiles. Data were collected between 2005 and 2008 using mixed methods, including field notes, observations and recordings of group classes, attendance logs, semi-structured individual interviews, a focus group interview, and structured questionnaires.

FINDINGS

Most participants (82%) were first generation ethnic Turkish; 47% had a low educational level; 43% were pregnant with their first child; and 34% had a minimal knowledge of the Dutch language. The community health workers' Turkish background was vital in overcoming cultural and language barriers and creating a confidential atmosphere. Participants, midwives and health workers were positive about the programme. Midwives also observed improvements of knowledge and self-confidence amongst the participants. The integration of the community health workers into midwifery practices was crucial for a successful programme implementation.

CONCLUSIONS

A culturally sensitive perinatal programme is able to gain access to a hard-to-reach minority group at increased risk for poor perinatal health outcomes. Such a programme may be well received and potentially effective.

Belief in AIDS origin conspiracy theory and willingness to participate in biomedical research studies: findings in whites, blacks, and Hispanics in seven cities across two surveys

PURPOSE

The purpose of this study was to determine whether a belief in the AIDS origin conspiracy theory is related to likelihood or fear of participation in research studies.

METHODS

The Tuskegee Legacy Project Questionnaire was administered via random-digit-dialed telephone interview to black, white, and Hispanic participants in 4 cities in 1999 and 2000 (n = 1,133) and in 3 cities in 2003 (n = 1,162).

RESULTS

In 1999, 27.8% of blacks, 23.6% of Hispanics, and 8% of whites (P ≤ .001) reported that it was "very or somewhat likely" that AIDS is "the result of a government plan to intentionally kill a certain group of people by genocide." In 2003, 34.1% of blacks, 21.9% of Hispanics, and 8.4% of whites (P ≤ .001) reported the same.

CONCLUSIONS

Whereas blacks and Hispanics were more than 3 times more likely than whites to believe in this AIDS origin conspiracy theory, holding this belief was not associated with a decreased likelihood of participation in, or increased fear of participation in, biomedical research.

Recruitment and retention of patients into emergency medicine clinical trials

The emergency medicine (EM) and prehospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in EM clinical trials and provides strategies from EM and non-EM trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in EM clinical trials.

Prospective evaluation of two recruitment strategies for a randomized controlled cancer prevention trial

PURPOSE

To evaluate two recruitment strategies used during the full-scale randomized, placebo-controlled Selenium and Vitamin E Cancer Prevention Trial (SELECT) at one clinical center.

BACKGROUND

Recruitment of participants to cancer prevention trials is challenging and costly and more efficient methods are needed.

METHODS

SELECT participants were males ≥60 years old who were solicited with two recruitment strategies. In the control strategy, potential participants, identified through purchased mailing lists, were sent a SELECT invitation letter. In the 'spouse' strategy, letters were sent to married postmenopausal women already participating in the Women's Health Initiative (WHI) at our clinical center asking them to provide an enclosed SELECT invitation letter (identical to the one in the control strategy) to the 'man in her life'. Our hypothesis was that SELECT recruitment of men would be enhanced by this indirect mailing to their spouses already participating in a similar program.

RESULTS

In the control strategy, 183,315 invitation letters were mailed to 60,000 men; cumulative response was 2.16%; 600 men ultimately enrolled in SELECT (15.1% of respondents) for a mailing recruitment cost of $259 per participant. In the spouse strategy, 800 women participating in WHI clinical studies had husbands; of the 2214 invitation letters mailed to this group of women, cumulative response was 2.75%; 34 men ultimately enrolled in SELECT (55.7% of respondents) for a mailing recruitment cost of $59 per participant.

LIMITATION

Process information on how invitation letters were handled in the spouse strategy was not collected.

CONCLUSION

A direct mail recruitment strategy was successful in recruiting men to a cancer prevention trial. A recruitment strategy involving indirect mailing to married women participating in a similar research program in the same center did not increase initial response substantially, but a higher proportion of respondents ultimately entered the prevention trial.

Strategies for Recruitment of Healthy Premenopausal Women into the African American Nutrition for Life (A NULIFE) Study

BACKGROUND

Although African American women have an overall lower incidence of breast cancer, African American women <40 years of age are more likely than Caucasian women of all ages and postmenopausal African American women to be diagnosed with breast cancer and exhibit tumor characteristics associated with poorer survival. To begin to address this disparity, studies must be conducted to examine breast cancer preventive factors in this subpopulation of women. However, the strategies needed to recruit younger African American women have not been well defined.

METHODS

In this study, we assessed methods used for recruiting and retaining healthy premenopausal African American women into the African American Nutrition for Life (A NULIFE) Study. The number of women contacted, enrolled, and retained by each recruitment strategy and the efficiency of individual strategies were calculated.

RESULTS

Overall, recruitment through social networking was most effective in contacting large numbers of healthy premenopausal African American women. The worksite recruitment method was the most efficient recruitment strategy employed, with a ratio of 40%. The study participants (n = 164) were more likely to be >or=35 years of age and have completed some college. Additionally, the interpersonal relationships recruitment approach proved most efficient (33%) in retaining participants who completed the yearlong study.

CONCLUSIONS

The findings from this study add to the evolving research literature on minority recruitment strategies for research studies but specifically address effective recruitment of healthy young premenopausal African American women. The results demonstrate the need to use multiple recruitment strategies when recruiting this subgroup of African American women.

Disparities in vascular surgery: is it biology or environment?

Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities.

Identifying the Tuskegee Syphilis Study: implications of results from recall and recognition questions

Background

This analysis assessed whether Blacks, Whites and Puerto-Rican (PR) Hispanics differed in their ability to identify the Tuskegee Syphilis Study (TSS) via open-ended questions following lead-in recognition and recall questions.

Methods

The Tuskegee Legacy Project (TLP) Questionnaire was administered via a Random-Digit Dial (RDD) telephone survey to a stratified random sample of Black, White and PR Hispanic adults in three U.S. cities.

Results

The TLP Questionnaire was administered to 1,162 adults (356 African-Americans, 313 PR Hispanics, and 493 non-Hispanic Whites) in San Juan, PR, Baltimore, MD and New York City, NY. Recall question data revealed: 1) that 89% or more of Blacks, Whites, and PR Hispanics were not able to name or definitely identify the Tuskegee Syphilis Study by giving study attributes; and, 2) that Blacks were the most likely to provide an open-ended answer that identified the Tuskegee Syphilis Study as compared to Whites and PR Hispanics (11.5% vs 6.3% vs 2.9%, respectively) (p ≤ 0.002). Even when probed by a recognition question, only a minority of each racial/ethnic group (37.1%, 26.9%, and 8.6%, for Blacks, Whites and PR Hispanics, respectively) was able to clearly identify the TSS (p < 0.001).

Conclusions

The two major implications of these findings for health disparity researchers are 1) that it is unlikely that detailed knowledge of the Tuskegee Syphilis Study has any current widespread influence on the willingness of minorities to participate in biomedical research, and 2) that caution should be applied before assuming that what community leaders 'know and are aware of' is equally 'well known' within their community constituencies.

Participant recruitment and retention in a pilot program to prevent weight gain in low-income overweight and obese mothers

Background

Recruitment and retention are key functions for programs promoting nutrition and other lifestyle behavioral changes in low-income populations. This paper describes strategies for recruitment and retention and presents predictors of early (two-month post intervention) and late (eight-month post intervention) dropout (non retention) and overall retention among young, low-income overweight and obese mothers participating in a community-based randomized pilot trial called Mothers In Motion.

Methods

Low-income overweight and obese African American and white mothers ages 18 to 34 were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children in southern Michigan. Participants (n = 129) were randomly assigned to an intervention (n = 64) or control (n = 65) group according to a stratification procedure to equalize representation in two racial groups (African American and white) and three body mass index categories (25.0-29.9 kg/m², 30.0-34.9 kg/m², and 35.0-39.9 kg/m²). The 10-week theory-based culturally sensitive intervention focused on healthy eating, physical activity, and stress management messages that were delivered via an interactive DVD and reinforced by five peer-support group teleconferences. Forward stepwise multiple logistic regression was performed to examine whether dietary fat, fruit and vegetable intake behaviors, physical activity, perceived stress, positive and negative affect, depression, and race predicted dropout as data were collected two-month and eight-month after the active intervention phase.

Results

Trained personnel were successful in recruiting subjects. Increased level of depression was a predictor of early dropout (odds ratio = 1.04; 95% CI = 1.00, 1.08; p = 0.03). Greater stress predicted late dropout (odds ratio = 0.20; 95% CI = 0.00, 0.37; p = 0.01). Dietary fat, fruit, and vegetable intake behaviors, physical activity, positive and negative affect, and race were not associated with either early or late dropout. Less negative affect was a marginal predictor of participant retention (odds ratio = 0.57; 95% CI = 0.31, 1.03; p = 0.06).

Conclusion

Dropout rates in this study were higher for participants who reported higher levels of depression and stress.

Trial registration

Current Controlled Trials NCT00944060

Strategies and ethical considerations for the recruitment of young men who have sex with men: challenges of a vaccination trial in Mexico

BACKGROUND

The importance of recruiting and retaining study participants from minority groups is well recognized; however, there are no established rules for recruitment as its success depends on the setting and population.

PURPOSE

To describe and analyze recruitment strategies, ethical considerations, and recruitment outcomes from a study to evaluate the efficacy the Human Papilloma Virus vaccine in young men who have sex with men (MSM).

METHODS

The recruitment settings were university and community sites in the state of Morelos, Mexico. Eligibility requirement were men between 18 and 23 years old, who were free of anal-genital lesions as confirmed by clinical exploration, HIV negative, with no history of sexual relations with female partners and with fewer than five male lifetime sexual partners. Recruitment goals were 25 study participants in a four and a half month period. In addition to traditional recruitment strategies (flyers and media advertising, specific training of the recruitment team and adequate choice of recruitment sites)-engagement of local leaders in the MSM community formed a crucial part of the strategy. Special consideration was given to confidentiality and respect for study participants and a Bill of Participant Rights was developed as an explicit commitment to respect and acceptance.

RESULTS

In total 723 MSM were initially contacted, 243 filled out the recruitment questionnaire, of which 151 met the criteria to be invited to the clinical examination. After clinical examination and interviews with the recruitment team, 131 fulfilled the inclusion criteria, of whom 73 were enrolled in the study - nearly triple the recruitment goal. Among the initial recruitment strategies (application of the screening questionnaire) attending meetings with MSM activist organizations was the most successful (326), followed by recruitment at bars and dance clubs (107).

LIMITATIONS

The recruitment strategies should be formally evaluated for their effectiveness to identify those which are most successful. In addition, future studies should consider the evaluation of study participants' perceptions of the recruitment strategies.

CONCLUSIONS

Recruiting MSM in a developing country such as Mexico presented multiple challenges. We recommend that future studies actively engage the local MSM community and pay special attention to designing recruitment strategies that guarantee the confidentiality of and respect for participants.

Exploring the "legacy" of the Tuskegee Syphilis Study: a follow-up study from the Tuskegee Legacy Project

The purpose of this follow-up 2003 3-City Tuskegee Legacy Project (TLP) Study was to validate or refute our prior findings from the 1999-2000 4 City TLP Study, which found no evidence to support the widely acknowledged "legacy" of the Tuskegee Syphilis Study (TSS), ie, that blacks are reluctant to participate in biomedical studies due to their knowledge of the TSS. The TLP Questionnaire was administered in this random-digit-dial telephone survey to a stratified random sample of 1162 black, white, and Puerto Rican Hispanic adults in 3 different US cities. The findings from this current 3-City TLP Study fail to support the widely acknowledged "legacy" of the TSS, as awareness of the TSS was not statistically associated with the willingness to participate in biomedical studies. These findings, being in complete agreement with our previous findings from our 1999-2000 4-City TLP, validate those prior findings.

Examining the challenges of recruiting women into a cardiac rehabilitation clinical trial

PURPOSE

To examine the challenges of recruiting women for a 5-year cardiac rehabilitation randomized clinical trial; the aims of the study were to describe the range of recruitment sources, examine the myriad of factors contributing to ineligibility and nonparticipation of women during protocol screening, and discuss the challenges of enrolling women in the trial.

METHODS

The Women's-Only Phase II Cardiac Rehabilitation program used an experimental design with 2 treatment groups. Eligible participants included women who were (1) diagnosed with a myocardial infarction or stable angina or had undergone coronary revascularization within the last 12 months; (2) able to read, write, and speak English; and (3) older than 21 years. Responses to multiple recruitment strategies including automatic hospital referrals, physician office referrals, mass mailings, media advertisements, and community outreach are described. Reasons for ineligibility and nonparticipation in the trial are explored.

RESULTS

Automatic hospital order was the largest source of referral (n = 1,367, 81%) accounting for the highest enrollment rate of women (n = 184, 73%). The barriers to enrollment into the cardiac rehabilitation clinical trial included patient-oriented, provider-oriented, and programmatic factors. Of the referral sources, 52% were screened ineligible for provider-oriented reasons, 31% were ineligible due to patient-oriented factors, and 17.4% were linked to the study protocol. Study nonparticipation of those eligible (73.8%) was largely associated with patient-oriented factors (65.2%), with far less due to provider-related factors (4%) or study-related factors (3.4%).

CONCLUSION

Standing hospital orders facilitated enrollment to the cardiac rehabilitation clinical trial, yet women failed to participate predominantly due to significant patient-oriented biopsychosocial barriers.

Improving the quality of care for women with cardiovascular disease: report of a DCRI Think Tank, March 8 to 9, 2007

BACKGROUND

Differences in pathophysiology, diagnosis, and treatment of women with cardiovascular disease compared with men has become a major focus during the past decade. Nevertheless, little attention has focused on improving the quality of healthcare in women compared with other areas of cardiovascular medicine.

METHODS

To address this deficit, Duke University Medical Center convened a national Duke Clinical Research Institute (DCRI) Think Tank meeting, including basic science and clinical researchers, payers, legislators, clinical experts, government regulators, and members of the pharmaceutical and device industries. This report provides an overview of the discussions and proposed solutions.

RESULTS

Discussion concentrated on the development of strategies to improve the quality of health care for women with heart disease. Key components to improve quality care include: (1) enhance the quantity and quality of evidence-based medicine to guide care in women through improvements in trial design, enrollment and retention of women subjects, results analysis and reporting, and better incentives to perform research in women; (2) provide incentives to develop better data in women through mandating changes in the drug and device development and approval processes; (3) incorporate specific recommendations for women into guidelines when data are sufficient; and (4) apply proven sex-based differences in risk stratification, diagnostic testing, and drug usage and dosing in clinical care. Examples of possible strategies are included.

CONCLUSION

The above approach represents a necessary, but not sufficient, platform to improve the overall quality of healthcare in women with cardiovascular disease.

The rise of 'recruitmentology': clinical research, racial knowledge, and the politics of inclusion and difference

Recent debates concerning the biomedical meaning and significance of race have paid relatively little attention to the practical implications of new policies in the US mandating the inclusion of racial and ethnic minorities (along with other 'underrepresented groups') as research subjects in clinical studies. I argue that pressures to enroll underrepresented groups have stimulated the development in the US of an auxiliary science I term 'recruitmentology': an empirical body of studies scientifically evaluating the efficacy of various social, cultural, psychological, technological, and economic means of convincing people (especially members of 'hard-to-recruit populations') that they want to become, and remain, human subjects. Via the filtering of social scientific frameworks into the clinical research domain, recruitmentology has promoted hybrid ways of thinking about race--awkward encounters in which depictions of race as a bounded, quasi-biological medical and administrative category sit uneasily alongside an interest in understanding racial identities and communities as sociocultural phenomena. I analyze how recruitmentologists, in addressing the mandate to recruit racially diverse subject populations, conceptualize race while simultaneously grappling with problems of trust, collective memory, and participation. I also examine how the increasingly transnational character of biomedical research is intensifying the exploitative dimensions of recruitment while further transforming the racialized character of human experimentation. This analysis highlights the tensions underlying projects to eliminate health disparities by race.

Strategies and cost of recruitment of middle-aged and older unmarried women in a cancer screening study

OBJECTIVES

We compared strategies and costs associated with recruiting unmarried middle-aged and older women who partner with women (WPW) and women who partner with men (WPM) into an observational study about experiences with cancer screening.

METHODS

We used targeted and respondent-driven sampling methods to recruit potential participants. Comparable recruitment strategies were used for WPW and WPM.

RESULTS

During 25 months (June 1, 2003, through June 30, 2005), 773 women were screened for study eligibility; 630 were enrolled (213 WPW, 417 WPM). Average staff time spent for recruitment was 100 min per participant. There were no differences by partner gender in average recruitment time (WPW, 90 min; WPM, 100 min). Print media was the most efficient recruitment mode (time per participant: 10 min for WPW, 15 min for WPM). Recruitment costs differed by partner gender ($140 for WPW, $110 for WPM). Costs associated with print media were $10 per WPW and $20 per WPM. Recruitment through community events had higher costs ($490 per WPW, $275 per WPM) but yielded more women with less education and lower incomes, who identified as a racial or ethnic minority, and self-reported a disability. Compared with WPM, WPW had more education and higher incomes, but were less likely to identify as a racial minority and self-report a disability.

CONCLUSIONS

There was a trade-off between cost and sample diversity for the different recruitment methods. The per-person costs were lowest for print media, but recruitment through community events ensured a more diverse representation of unmarried heterosexual and sexual minority women.

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.

P.O.W. (protect our women): results of a breast cancer prevention project targeted to older African-American women

OBJECTIVE

Encourage older African-American women to participate in breast cancer detection. Breast cancer deaths for older African-American women are higher than for Caucasian counterparts. Effective outreach education about mammography and breast exam is one method to reduce the disparity by encouraging women to enter treatment earlier through earlier diagnosis. Traditional outreach strategies have proven ineffective with this cohort.

METHOD

In this study we utilized the trust placed in known community leaders to recruit older African-American women to participate in breast health education leading to completion of a mammogram. One hundred sixty-two women were identified as participants.

RESULTS

Seventy-nine percent of the women who completed the project obtained mammograms and 9% had mammograms scheduled at 1-month follow-up, whereas 22% of the individuals who received only mailed educational materials completed mammograms and none had scheduled mammograms pending.

DISCUSSION

Health education for difficult-to-reach populations can be effective but requires greater inclusion of community partners to offset issues related to trust, health beliefs, and access.

Perceptions of clinical research participation among African American women

BACKGROUND

Recruiting minority women into clinical research remains a significant challenge to conducting ethnically representative research. The main objective of this Office on Women's Health, DHHS-funded e-health database evaluation project was to examine African American women 's thoughts and perceptions about the clinical research process and about participation in the University of Michigan Women's Health Registry research database.

METHODS

Thirty-one African American women were recruited from the community to participate in a total of five 90-minute focus group discussions. All sessions were audiotaped and transcribed verbatim. Thematic content analysis was used to identify relevant themes about participation in clinical research and the Women's Health Registry.

RESULTS

Ten common trends were identified. (1) Information about the Women's Health Registry is not reaching the community. (2) Research is perceived as biased to benefit Caucasians. (3) Community involvement by the research team is critical for trust to develop. (4) Research directly relevant to African Americans or their community will encourage participation. (5) Researchers should use existing networks and advertise in appropriate locations. (6) The community needs more information concerning research. (7) Compensation is important. (8) Research that addresses a personal or family medical problem encourages involvement. (9) Minority representation on the research team is a motivator to participation. (10) There is limited time for healthcare-related activities.

CONCLUSIONS

Successful recruitment strategies for African American women should feature community-based, culturally appropriate approaches. Online research databases for subject recruitment will likely be successful only if implemented within a broader community-oriented program.

Recruiting vulnerable populations into research: a systematic review of recruitment interventions

BACKGROUND

Members of vulnerable populations are underrepresented in research studies.

OBJECTIVE

To evaluate and synthesize the evidence regarding interventions to enhance enrollment of vulnerable populations into health research studies.

DATA SOURCES

Studies were identified by searching MEDLINE, the Web of Science database, personal sources, hand searching of related journals, and article references. Studies that contained data on recruitment interventions for vulnerable populations (minority, underserved, poor, rural, urban, or inner city) and for which the parent study (study for which recruitment was taking place) was an intervention study were included. A total of 2,648 study titles were screened and 48 articles met inclusion criteria, representing 56 parent studies. Two investigators extracted data from each study.

RESULTS

African Americans were the most frequently targeted population (82% of the studies), while 46% targeted Hispanics/Latinos. Many studies assessed 2 or more interventions, including social marketing (82% of studies), community outreach (80%), health system recruitment (52%), and referrals (28%). The methodologic rigor varied substantially. Only 40 studies (71%) incorporated a control group and 21% used statistical analysis to compare interventions. Social marketing, health system, and referral recruitment were each found to be the most successful intervention about 35-45% of the studies in which they were attempted, while community outreach was the most successful intervention in only 2 of 16 studies (13%) in which it was employed. People contacted as a result of social marketing were no less likely to enroll than people contacted through other mechanisms.

CONCLUSIONS

Further work with greater methodologic rigor is needed to identify evidence-based strategies for increasing minority enrollment in research studies; community outreach, as an isolated strategy, may be less successful than other strategies.

Video recruitment of non-English-speaking participants

Recruitment of underserved participants begins to close the disparity gap evident within disadvantaged communities, and innovative approaches to recruitment support this effort. Literacy, communication, and credibility barriers distance potential research participants. The literature search from 1975 to 2005 included the Cochrane Review, MEDLINE, EBSCO, PsycINFO, Google Scholar, and CINAHL for the terms video recruitment, videotaped, minority recruitment, and research subject recruitment with no documented use of videotape recruitment of non-English-speaking (NES) participants. Based on this review, an innovative recruitment video was developed and targeted to monolingual Hispanic mothers to explain a study using home safety visits. Community assistants collaborated on the script. In 4 minutes, potential participants, some illiterate, saw what they could not read, and also whom they should expect at their door if they decided to participate. A total of 82 women were recruited, and with a retention rate of 95%. Classic minority recruitment barriers are reducible with this approach.

Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the women's health initiative: a cross-sectional analysis

OBJECTIVES

We sought to assess the extent to which race/ethnicity and socioeconomic status (SES) are independently and jointly related to lifetime morbidity burden by comparing the impact of SES on lifetime morbidity among women of different racial/ethnic groups: white, black, Hispanic, American Indian/Alaska Native (AIAN), and Asian/Pacific Islander (API).

METHODS

Using baseline data from the Women's Health Initiative (WHI), a national study of 162,000 postmenopausal women, we measured lifetime morbidity burden using a modified version of the Charlson Index, and measured SES with educational attainment and household income. In multivariable simple polytomous logistic regression models, we first assessed the effect of SES on lifetime morbidity burden among women of each racial/ethnic group, then assessed the combined effect of race/ethnicity and SES.

RESULTS

Five percent of all women in the study population had high lifetime morbidity burden. Women with high lifetime morbidity were more likely to be AIAN or black; poor; less educated; divorced, separated, or widowed; past or current smokers; obese; uninsured or publicly insured. Lower SES was associated with higher morbidity among most women. The extent to which morbidity was higher among lower SES compared to higher SES women was about the same among Hispanic women and white women, but was substantially greater among black and AIAN women compared with white women.

CONCLUSIONS

This study demonstrates the importance of considering race/ethnicity and class together in relation to health outcomes.

Evaluation of a mass mailing recruitment strategy to obtain a community sample of women for a clinical trial of an incontinence prevention intervention

OBJECTIVES

Questions exist about using mass mailings to recruit representative samples to participate in clinical trials. The MESA Prevention Study (Medical, Epidemiologic and Social Aspects of Aging), a randomized controlled clinical trial to prevent urinary incontinence (UI), utilized a mass mailing recruitment procedure to recruit a representative sample of women to participate in a behavioral modification program. This paper seeks to expand the literature of mass mailing recruitment strategies for prevention studies by describing the procedures used to recruit healthy, continent, post-menopausal women aged 55-80 years.

METHODS

Sociodemographic data collected from recruited subjects is compared with on-line national census data to evaluate the representativeness of the sample recruited from a purchased mailing list.

RESULTS

The mass mailing procedure resulted in 3.3% positive response. Of those that returned a positive response, 37.6% were deemed eligible at first screening. Comparisons of study demographic data with state and county census data indicate that the sample obtained was representative of the communities.

CONCLUSIONS

The mass mailing strategy was an effective means of recruiting a representative sample of women, aged 55-80. Short falls and recommendations for successful community sample recruitment strategies for clinical trials in older adult women are elaborated upon.

The Tuskegee Legacy Project: willingness of minorities to participate in biomedical research

The broad goal of the Tuskegee Legacy Project (TLP) study was to address, and understand, a range of issues related to the recruitment and retention of Blacks and other minorities in biomedical research studies. The specific aim of this analysis was to compare the self-reported willingness of Blacks, Hispanics, and Whites to participate as research subjects in biomedical studies, as measured by the Likelihood of Participation (LOP) Scale and the Guinea Pig Fear Factor (GPFF) Scale. The Tuskegee Legacy Project Questionnaire, a 60 item instrument, was administered to 1,133 adult Blacks, Hispanics, and non-Hispanic Whites in 4 U.S. cities. The findings revealed no difference in self-reported willingness to participate in biomedical research, as measured by the LOP Scale, between Blacks, Hispanics, and Whites, despite Blacks being 1.8 times as likely as Whites to have a higher fear of participation in biomedical research on the GPFF Scale.

Hormones and dementia - a comparative study of hormonal impairment in post-menopausal women, with and without dementia

CONTEXT

Women seem to be more vulnerable to dementia, particularly Alzheimer's disease (AD), than men. There is controversy among studies correlating estrogen deficit to cognitive impairment. Because of the sudden drop of estrogens in menopause, this hormonal deficit could represent one of the risk factors for the larger incidence and prevalence of AD in post-menopausal women.

RATIONALE

We therefore wanted to find out if post-menopausal women with dementia, or even in a prior stage, mild cognitive impairment (MCI), would have a more significant deficit of estrogens than post-menopausal women without dementia, or any other type of cognitive problem.

OBJECTIVES

The aim of this study was to detect possible differences of the sex hormone levels among post-menopausal women, simultaneously affected by MCI or dementia, in comparison with a control group without cognitive impairment.

DESIGN, SETTING, AND PARTICIPANTS

A small, multicenter, prospective study was performed on 82 post-menopausal women (41 cases, 41 controls), aged 45-81 years, to investigate their sex hormone balance. The diagnosis of dementia was made according to ICD 9 or 10 and DSM III-R or IV appropriate to the time interval. The diagnosis of probable AD followed the NINCDS-ADRDA criteria. MCI met the Paquid-study criteria. Blood was analyzed in qualified centers for LH, FSH, and 17-beta-estradiol. All women went through a thorough psychiatric examination and those with a suspected hormonal impairment were examined by a gynecologist.

RESULTS

15 cases (36.6%) had impaired hormonal function, compared with 8 controls (19.5%). Of the 15 cases with hormonal impairment, 9 had MCI.

CONCLUSIONS

These preliminary data stress a considerable difference between the sex hormone status of these two populations, showing a tendency towards a more accentuated estrogen deficit linked to cognitive deficit. Enlarging the sample and following the evolution could bring more interesting data.

Recruitment of African American Women to a Walking Program: Eligibility, Ineligibility, and Attrition During Screening

The purposes of this study were to identify strategies successful in the recruitment of African American (AA) women to a home-based walking program and to examine factors that contribute to attrition, eligibility, and ineligibility during the recruitment screening protocol. Of the 696 women who contacted the researchers, 281 (40.4%) women enrolled in the study, 227 (32.6%) were lost to attrition, and 188 (27%) were ineligible. Those not enrolled due to attrition during screening or ineligibility reported more family risk for cardiovascular disease (CVD) and lived in neighborhoods with higher poverty. Although our recruitment strategies may have been successful in attracting low-income AA women, we were not as successful in preventing their attrition during the screening protocol, particularly for those living in poorer neighborhoods.