Recruitment of a rural, southern, predominantly African-American population into a diabetes self-management trial

Intervening to reduce sedentary behavior among African American elders: the "Stand Up and Move More" intervention

Background

Reducing sedentary behavior is a promising intervention target for improving health for older adults; however, few interventions include African American communities. The purpose of this research was to extend the reach of an effective sedentary behavior intervention to African American elders.

Methods

Two pilot studies assessed the feasibility (retention, adherence, and safety) and acceptability (participant and leader perspectives) of a 4-wk "Stand Up and Move More" (SUMM) intervention. Sedentary behavior (self-reported and monitor-derived), function (short physical performance battery), and quality of life (SF-36) were measured at baseline (wk0), postintervention (wk4), and follow up (wk12; study 1) to examine preliminary effectiveness of the intervention. Participants (N=26) attended SUMM or an attention-matched stress management intervention (study 2). The magnitude of treatment effects were determined using Hedge's g effect size calculations [small (g=0.20 to 0.49), moderate (g=0.50 to 0.79), large (g>0.80)].

Results

Retention and adherence rates ranged from 50%-100% and 80%-100%, respectively. There were no adverse events. Participants expressed high satisfaction, and the leader of the SUMM intervention indicated that the intervention content was beneficial. Hedges' g revealed negligible to small changes in sedentary behavior (g<0.50) following SUMM. There were moderate to large improvements in function (g=0.51-0.82) and quality of life (g=0.54-1.07) from wk0 to wk4 in study 1; and moderate to large improvements in function (g=0.51-0.88) from wk0 to wk4 in study 2. There was a moderate improvement in quality of life (SF-36 emotional role limitations g=0.54) in the SUMM group only.

Conclusion

Given its feasibility, safety, and acceptability, SUMM may be a promising intervention to improve functioning and well-being among African American elders.

Community-based participatory research to engage disadvantaged communities: Levels of engagement reached and how to increase it. A systematic review

Community-based participatory research (CBPR) is one of the most used community engagement frameworks to promote health changes in vulnerable populations. The more a community is engaged, the more a program can impact the social determinants of health. The present study aims to measure the level of engagement reached in randomized controlled trials (RCTs) using CBPR in disadvantaged populations, and to find out the CBPR components that better correlate with a higher level of engagement. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase, Web of Science, MEDLINE, Cochrane and Scopus databases were queried. Engagement level was assessed using the revised version of IAP2 spectrum, ranging from "inform" to "shared leadership" . Fifty-one RCTs were included, belonging to 36 engagement programs. Fourteen CBPR reached the highest level of engagement. According to the multivariate logistic regression, a pre-existing community intervention was associated with a higher engagement level (OR = 10.08; p<0.05). The variable "institutional funding" was perfectly correlated with a higher level of engagement. No correlation was found with income status or type of preventive programs. A history of collaboration seems to influence the effectiveness in involving communities burdened with social inequities, so starting new partnerships remains a public health priority to invest on. A strong potentiality of CBPR was described in engaging disadvantaged communities, addressing social determinants of health. The key findings described above should be taken into account when planning a community engagement intervention, to build up an effective collaborative field between researchers and population.

Use of comprehensive recruitment strategies in the glycemia reduction approaches in diabetes: A comparative effectiveness study (GRADE) multi-center clinical trial

BACKGROUND/AIMS

We present and describe recruitment strategies implemented from 2013 to 2017 across 45 clinical sites in the United States, participating in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study, an unmasked, randomized controlled trial evaluating four glucose-lowering medications added to metformin in individuals with type 2 diabetes mellitus (duration of diabetes <10 years). We examined the yield of participants recruited through Electronic Health Records systems compared to traditional recruitment methods to leverage access to type 2 diabetes patients in primary care.

METHODS

Site selection criteria included availability of the study population, geographic representation, the ability to recruit and retain a diverse pool of participants including traditionally underrepresented groups, and prior site research experience in diabetes clinical trials. Recruitment initiatives were employed to support and monitor recruitment, such as creation of a Recruitment and Retention Committee, development of criteria for Electronic Health Record systems queries, conduct of remote site visits, development of a public screening website, and other central and local initiatives. Notably, the study supported a dedicated recruitment coordinator at each site to manage local recruitment and facilitate screening of potential participants identified by Electronic Health Record systems.

RESULTS

The study achieved the enrollment goal of 5000 participants, meeting its target with Black/African American (20%), Hispanic/Latino (18%), and age ≧60 years (42%) subgroups but not with women (36%). Recruitment required 1 year more than the 3 years originally planned. Sites included academic hospitals, integrated health systems, and Veterans Affairs Medical Centers. Participants were enrolled through Electronic Health Record queries (68%), physician referral (13%), traditional mail outreach (7%), TV, radio, flyers, and Internet (7%), and other strategies (5%). Early implementation of targeted Electronic Health Record queries yielded a greater number of eligible participants compared to other recruitment methods. Efforts over time increasingly emphasized engagement with primary care networks.

CONCLUSION

Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness successfully recruited a diverse study population with relatively new onset of type 2 diabetes mellitus, relying to a large extent on the use of Electronic Health Record to screen potential participants. A comprehensive approach to recruitment with frequent monitoring was critical to meet the recruitment goal.

Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review

There has not been a significant improvement in the rate of clinical trial accrual in more than 20 years. Worse, the challenge of inadequate representation among racial and ethnic minorities also persists, deepening disparities in health. Community-Based Participatory Research (CBPR) is a participatory communication method that centers on effective dialogue between researchers and community stakeholders with the goal of creating an equitable partnership for health and social change. The objective of the current study was to provide an update since a systematic review in 2012, on the current status of the empirical research, with a particular focus on the elements of CBPR methods used to improve the rate of accrual of members of racial and ethnic minority communities for clinical trials. Our systematic review found a large increase in the number of CBPR related studies and studies related to racial and ethnic representation in research. More than 85% of studies employing CBPR methods saw statistically positive outcomes. Specifically, the elements of CBPR that are associated with these positive outcomes include community partner participation in (1) a study advisory committee, (2) data collection, (3) the development of interventions, and (4) participant recruitment. However, the results of our study indicate that researchers need to be more transparent about the extent of community participation as well as more thoroughly and accurately describe the nature of the partnership with members of minority communities in order to build upon the scientific literature on community-engaged methods.

Identifying Patient Profiles for Developing Tailored Diabetes Self-Management Interventions: A Latent Class Cluster Analysis

Purpose

Interventions that are tailored to the specific psychosocial needs of people with diabetes may be more effective than a “one size fits all” approach. The purpose of this study is to identify patient profiles with distinct characteristics to inform the development of tailored interventions.

Methods

A latent class cluster analysis was conducted with data from the ENCOURAGE trial based on participant responses to 6 baseline psychosocial measures, including trust in physicians, perceived discrimination, perceived efficacy in patient–physician interactions, social support, patient activation, and diabetes distress. The trial’s primary outcomes were hemoglobin A1c, body mass index, systolic blood pressure, low-density lipoprotein cholesterol, and quality of life; secondary outcomes were diabetes distress and patient engagement.

Results

Three classes of participants were identified: Class 1 (n = 72) had high trust, activation, perceived efficacy and social support; low diabetes distress; and good glycemic control (7.1 ± 1.3%). Class 2 (n = 178) had moderate values in all measures with higher baseline A1c (8.1 ± 2.1%). Class 3 (n = 155) had high diabetes distress; low trust, patient engagement, and perceived efficacy; with similar baseline A1c (8.2 ± 2.1%) as Class 2. Intervention effects differed for these 3 classes.

Conclusion

Three distinct subpopulations, which exhibited different responses to the ENCOURAGE intervention, were identified based on baseline characteristics. These groups could be used as intervention targets. Future studies can determine whether these approaches can be used to target scarce resources efficiently and effectively in real-world settings to maximize the impact of interventions on population health, especially in impoverished communities.

Health Disparities in Recruitment and Enrollment in Research

Despite advances in thoracic oncology research, the benefits of new discoveries are not universally experienced. A lack of representation of racial/ethnic minorities and individuals of low socioeconomic status in clinical trials and thoracic research contributes to persistent health care disparities. It is critical that improved racial, ethnic, and socioeconomic diversity is achieved in our trials and research, if we are to attain generalizability of findings and reduction of health care disparities. Culturally tailored and community-based approaches can help improve recruitment and enrollment of marginalized groups in thoracic research, which is an essential step toward achieving health equity and advancing medical science.

Community-Engaged Approaches for Minority Recruitment Into Clinical Research: A Scoping Review of the Literature

Underrepresentation of racial and ethnic minority populations in clinical research persists in the United States, highlighting the unmet ideals of generalizability and equity of research findings and products. Previous systematic reviews exploring various facets of this phenomenon concluded that community engagement with minority groups may effectively promote recruitment and retention, but the ways in which community-engaged approaches have been used for recruitment have not been examined. We performed a scoping review of the literature to identify studies of community-engaged recruitment processes. The search resulted in 2842 articles, of which 66 met inclusion criteria. These articles demonstrated a relatively large literature base of descriptive studies conveying details of community engagement approaches to enhance recruitment of minority research participants. We summarize key aspects of current practices across the spectrum of community engagement. A gap in the literature is the relative lack of the comparative studies among different engagement strategies.

Comparison of Recruitment Strategies for Engaging Older Minority Adults: Results From Take Heart

BACKGROUND

Few published studies report lessons learned for recruiting older adults from racial/ethnic minority, low SES communities for behavioral interventions. In this article, we describe recruitment processes and results for Take Heart, a randomized controlled trial testing the effectiveness of an adapted heart disease self-management program for primarily African American, urban, low SES adults 50 years or older living in Detroit.

METHODS

Older adults were recruited via community-based (CB), electronic medical record (EMR), and in-person hospital clinic (HC) methods. Recruitment processes, demographic characteristics of enrolled participants, yield and cost, lessons learned, and best practices for each method are described.

RESULTS

Within 22 months, 1,478 potential participants were identified, 1,223 were contacted and 453 enrolled, resulting in an overall recruitment yield of 37%. The CB method had the highest yield at 49%, followed by HC at 36% and EMR at 16%. Of six CB approaches, information sessions and flyers had the highest yields at 60% and 59%, respectively. The average cost of recruiting and enrolling one participant was $142.

CONCLUSIONS

CB, EMR, and HC methods each made important contributions to reaching our recruitment goal. The CB method resulted in the highest recruitment yield, while EMR had the lowest. Face-to-face interaction with community members and hiring a community health worker were particularly useful in engaging this population. Further research is needed to confirm these findings in urban, minority, low SES populations of older adults.

Modifiable Barriers for Recruitment and Retention of Older Adults Participants from Underrepresented Minorities in Alzheimer's Disease Research

Clinical Alzheimer's disease (AD) trials currently face a critical shortfall of thousands of eligible participants, which inflates the duration and cost of the clinical study as well as threatens the scientific merit of promising clinical interventions. This recruitment crisis is further compounded by the fact that underrepresented and marginalized populations-particularly those identifying as a racial or ethnic minority, those with low socioeconomic status, or living in rural areas-have been historically underrepresented in ongoing AD clinical trials despite overwhelming evidence that such populations are at increased risk for developing dementia. As a result of various recruitment barriers, current AD clinical studies frequently reflect a decreasingly representative segment of the US population, which threatens the overall generalizability of these findings. The current narrative review provides an updated examination and critique of common recruitment barriers and potential solutions, as well as a discussion of theoretical approaches that may address barriers disproportionately experienced by underrepresented communities. AD clinical researchers are encouraged to take purposive action aimed at increasing diversity of enrolled AD clinical trial cohorts by actively identifying and quantifying barriers to research participation-especially recruitment barriers and health disparities that disproportionately prevent underrepresented and marginalized populations from participating in research. Furthermore, researchers are encouraged to closely track which individuals who express interest in AD research ultimately enroll in research studies to examine whether AD research participation is appropriately representative of the intended population for whom these new and novel AD interventions are being designed.

How patient and community involvement in diabetes research influences health outcomes: A realist review

BACKGROUND

Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes.

OBJECTIVE

This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self-management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis.

MAIN RESULTS

Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co-design and co-deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes.

DISCUSSION AND CONCLUSIONS

Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Strategies for recruitment and retention of underrepresented populations with chronic obstructive pulmonary disease for a clinical trial

BACKGROUND

Recruitment and retention are two significant barriers in research, particularly for historically underrepresented groups, including racial and ethnic minorities, patients who are low-income, or people with substance use or mental health issues. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and disproportionately affects many underrepresented groups. The lack of representation of these groups in research limits the generalizability and applicability of clinical research and results. In this paper we describe our experience and rates of recruitment and retention of underrepresented groups for the Aides in Respiration (AIR) COPD Health Coaching Study.

METHODS

A priori design strategies included minimizing exclusion criteria, including patients in the study process, establishing partnerships with the community clinics, and ensuring that the health coaching intervention was flexible enough to accommodate patient needs.

RESULTS

Challenges to recruitment included lack of spirometric data in patient records, space constraints at the clinic sites, barriers to patient access to clinic sites, lack of current patient contact information and poor patient health. Of 282 patients identified as eligible, 192 (68%) were enrolled in the study and 158 (82%) completed the study. Race, gender, educational attainment, severity of disease, health literacy, and clinic site were not associated with recruitment or retention. However, older patients were less likely to enroll in the study and patients who used home oxygen or had more than one hospitalization during the study period were less likely to complete the study. Three key strategies to maximize recruitment and retention were identified during the study: incorporating the patient perspective, partnering with the community clinics, and building patient rapport.

CONCLUSIONS

While the AIR study included design features to maximize the recruitment and retention of patients from underrepresented groups, additional challenges were encountered and responded to during the study. We also identified three key strategies recommended for future studies of COPD and similar conditions. Incorporating the approaches described into future studies may increase participation rates from underrepresented groups, providing results that can be more accurately applied to patients who carry a disparate burden of disease.

TRIAL REGISTRATION

This trial was registered at ClinicalTrial.gov at identifier NCT02234284 on August 12, 2014. Descriptor number: 2.9 Racial, ethnic, or social disparities in lung disease and treatment.

Impact of Peer Support on Acute Care Visits and Hospitalizations for Individuals With Diabetes and Depressive Symptoms: A Cluster-Randomized Controlled Trial

OBJECTIVE

Comorbid depression is associated with increased health care utilization and cost. We examined the effects of peer support on acute care (AC) and hospital utilization in individuals with diabetes with or without depressive symptoms.

RESEARCH DESIGN AND METHODS

This was a cluster-randomized controlled trial conducted in 2010-2012, with the clusters being practices and their surrounding communities. Adults with type 2 diabetes who wanted help with self-management were eligible to participate. Those without a doctor, with limited life expectancy, with plans to move within the next year, and with an unwillingness to work with a peer advisor were excluded. Intervention participants received 1 year of peer support. Control participants received usual care. The Patient Health Questionnaire (PHQ-8) (range 0-24; 5 indicates mild and 10 indicates moderate depressive symptoms) assessed depressive symptoms. AC and hospital utilization were measured by self-report. Data were collected at baseline, 6 months, and 12 months. Quasi-Poisson regression using generalized estimating equations examined differences in utilization per year attributable to the intervention for those with and without mild depressive symptoms (and separately, moderate depressive symptoms), controlling for imbalance across treatment arms.

RESULTS

At baseline, half of the sample reported mild depressive symptoms (52% intervention and 48% control, P = 0.37), a quarter reported moderate depressive symptoms (25% intervention and 26% control, P = 1.0), and there were no significant differences in utilization. A total of 168 intervention (six clusters) and 187 control (five clusters) participants had follow-up data. In individuals with mild depressive symptoms, the incident rate ratio (IRR) for hospitalization among intervention compared with control was 0.26 (95% CI 0.08-0.84) per 10 patient-years. The IRR for AC was 0.55 (95% CI 0.28-1.07) per 10 person-years. Findings were similar for individuals with moderate depressive symptoms.

CONCLUSIONS

Peer support lowered AC visits and hospitalizations for individuals with depressive symptoms but not for those without depressive symptoms; these findings can guide resource allocation for population health management.

The prevalence of patient engagement in published trials: a systematic review

PLAIN ENGLISH SUMMARY

With the growing movement to engage patients in research, questions are being asked about who is engaging patients and how they are being engaged. Internationally, research groups are supporting and funding patient-oriented research studies that engage patients in the identification of research priorities and the design, conduct and uptake of research. As we move forward, we need to know what meaningful patient engagement looks like, how it benefits research and clinical practice, and what are the barriers to patient engagement?We conducted a review of the published literature looking for trials that report engaging patients in the research. We included both randomized controlled trials and non-randomized comparative trials. We looked at these trials for important study characteristics, including how patients were engaged, to better understand the practices used in trials. Importantly, we also discuss the number of trials reporting patient engagement practices relative to all published trials. We found that very few trials report any patient engagement activities even though it is widely supported by many major funding organizations. The findings of our work will advance patient-oriented research by showing how patients can be engaged and by stressing that patient engagement practices need to be better reported.

BACKGROUND

Patient-Oriented Research (POR) is research informed by patients and is centred on what is of importance to them. A fundamental component of POR is that patients are included as an integral part of the research process from conception to dissemination and implementation, and by extension, across the research continuum from basic research to pragmatic trials [J Comp Eff Res 2012, 1:181-94, JAMA 2012, 307:1587-8]. Since POR's inception, questions have been raised as to how best to achieve this goal.We conducted a systematic review of randomized controlled trials and non-randomized comparative trials that report engaging patients in their research. Our main goal was to describe the characteristics of published trials engaging patients in research, and to identify the extent of patient engagement activities reported in these trials.

METHODS

The MEDLINE®, EMBASE®, Cinahl, PsycINFO, Cochrane Methodology Registry, and Pubmed were searched from May 2011 to June 16th, 2016. Title, abstract and full text screening of all reports were conducted independently by two reviewers. Data were extracted from included trials by one reviewer and verified by a second. All trials that report patient engagement for the purposes of research were included.

RESULTS

Of the 9490 citations retrieved, 2777 were reviewed at full text, of which 23 trials were included. Out of the 23 trials, 17 were randomized control trials, and six were non-randomized comparative trials. The majority of these trials (83%, 19/23) originated in the United States and United Kingdom. The trials engaged a range of 2-24 patients/ community representatives per study. Engagement of children and minorities occurred in 13% (3/23) and 26% (6/23) of trials; respectively. Engagement was identified in the development of the research question, the selection of study outcomes, and the dissemination and implementation of results.

CONCLUSIONS

The prevalence of patient engagement in patient-oriented interventional research is very poor with 23 trials reporting activities engaging patients. Research dedicated to determining the best practice for meaningful engagement is still needed, but adequate reporting measures also need to be defined.

[Community-based research in therapeutic patient education: practices and contributions. A literature review]

INTRODUCTION

Community-based research (CBR) in health involves both researchers and people concerned by the results of the research. It aims to empower populations, using their exposure to the phenomenon being studied as a starting point. The use of CBR in the field of therapeutic patient education (TPE) is of interest, as the two share such characteristics as the desire to foster self-reliance and participation and a culture of interdisciplinarity.

AIM

To characterize CBR in the therapeutic patient education field.

METHODS

A literature search on PUBMED using the keywords ?community-based (participatory) research?, ?patient education?, ?self-care? and ?self-management? retrieved 121 articles. The analysis looked at the type of research, the characteristics of both the populations involved and the co-researchers, the collaborative actions (analysed using a grid from the literature), and the difficulties in implementing these actions.

RESULTS

Thirty-one studies were included. Ten consisted of methodological studies, which tended to show the added value of collaborating with users in implementing TPE programmes compared to standard methods. The remaining 21 studies described the co-design and/or co-execution of new educational programmes. We identified 5 collaborative actions that involved a preparatory phase of the research, and 17 collaborative actions that involved the prioritization, conduct, and analysis of the research and dissemination of the results. Preventive measures are needed for potential methodological, organizational, ethical, and emotional difficulties.

DISCUSSION

The 22 identified actions need to be confirmed by other studies. The analysis grid could ultimately become a tool for guiding researchers for their researches within the CBR framework.

Recruiting African American Children for Research: An Ecological Systems Theory Approach

With health disparities still pervasive and persistent in the United States, medical researchers and social scientists continue to develop recruitment strategies to increase the inclusion of racial/ethnic minority groups in research and interventions. Effective methods for recruiting samples of African American participants for pediatric research may be best understood when situated within an overarching conceptual model-one that serves to organize and explain effective recruitment strategies. A theoretical framework well suited for this purpose is Bronfenbrenner's ecological systems theory, which views individuals as influencing and being influenced by (both directly and indirectly) a series of interconnected social systems. Based on the ecological systems theory and on previous research from multiple domains (e.g., medicine, psychology, public health, social work), in the current article, we review strategies for effective recruitment of African American children and adolescents for research.

Volunteer peer support, diabetes, and depressive symptoms: Results from the ENCOURAGE trial

Aims

Depression in diabetes mellitus (DM) is common and is associated with poor health outcomes. Peer support DM interventions include encouraging interactions that could improve depressive symptoms. We examined intervention effects for those with and without depressive symptoms in a peer support trial.

Methods

The 1-year ENCOURAGE trial included 424 persons with DM living in rural Alabama. Intervention participants worked with community volunteers who encouraged participants to engage in daily self-management; control arm participants received usual care. Outcomes included HbA1c, body mass index (BMI) and quality of life (QoL) with EuroQuol-5D (range 0.0-1.0). Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ-8, range 0-24). Generalized Additive Models (GAM) examined control-intervention differences in changes in HbA1c, BMI, and QoL for those with PHQ-8 ≥ 5 and PHQ-8 < 5.

Results

Of the 424 participants enrolled at baseline, 355 completed follow-up and had data were that could be included into the study; they were aged 60.2 ± 12.1 years, 87% African American, 75% female, and 39% insulin-treated. In an overall GAM adjusting for imbalance across trial arms and time-related covariates, depressive symptoms improved for all, but after 15 months of follow-up intervention, participants experienced greater reduction in PHQ-8 score than control participants (p = 0.01). In stratified analyses, those with PHQ-8 ≥ 5 had unchanged HbA1c, lost weight (p = 0.03) and improved QoL (p = 0.04). Those with PHQ-8 < 5 also had unchanged HbA1c and lost weight, but did not improve QoL (p = 0.06).

Conclusions

Peer support improved depressive symptoms for all, but resulted in greater weight loss and gains in QoL for those with baseline depressive symptoms compared to those without.

Blood Pressure Measurement Biases in Clinical Settings, Alabama, 2010-2011

Introduction

Blood pressure measurement in clinical care settings seldom follows the protocol recommended by national guidelines, potentially leading to overestimates or underestimates of blood pressure control. We evaluated blood pressure measurement methods as a source of bias in determining blood pressure control among community-dwelling adults with diabetes.

Methods

In a community-based trial of patients with diabetes, we measured both “clinical blood pressure” (clinical BP) (taken by a community nurse or medical assistant instructed to “take the participant’s blood pressure like you do in your own clinic”) and “research blood pressure” (research BP) (research staff followed a guideline-concordant protocol). Each participant had both types of blood pressure assessment on the same day over the course of 2 hours.

Results

The 227 participants had a mean age of 59 years; 86% were black and 74% were women. The mean clinical BP was 5 mm Hg higher than the mean research BP for systolic blood pressure (P < .001) and 2 mm Hg higher for diastolic blood pressure (P < .001). The proportion of participants whose clinical BP was 130/80 mm Hg or higher was 8 percentage points higher than the proportion whose research BP was 130/80 mm Hg or higher (P < .001), and the proportion whose clinical BP was 140/90 mm Hg or higher was 10 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher (P < .001). Among those aged 65 years or older, the proportion whose clinical BP was 130/80 mm Hg or higher was 10 percentage points higher than proportion whose research BP was 130/80 mm Hg or higher, and the proportion whose clinical BP was 140/90 mm Hg or higher was 14 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher. Whites and smokers had the greatest risk for having a clinical BP 5 mm Hg or more higher than their research BP.

Conclusion

Measurement biases in clinical settings may be a component of observed poor blood pressure control rates in real-world settings.

Challenges in the Ethical Review of Peer Support Interventions

PURPOSE

Ethical review processes have become increasingly complex. We have examined how 8 collaborating diabetes peer-support clinical trials were assessed by ethics committees.

METHODS

The ethical reviews from the 8 peer-support studies were collated and subjected to a thematic analysis. We mapped the recommendations of local Institutional Review Boards and ethics committees onto the "4+1 ethical framework" (autonomy, beneficence, non-maleficence, and justice, along with concern for their scope of application).

RESULTS

Ethics committees did not consistently focus on tasks within the 4+1 framework: many conducted reviews of scientific, organizational, and administrative activities. Of the 20 themes identified across the ethical reviews, only 4 fell within the scope of the 4+1 framework. Variation in processes and requirements for ethics committees were particularly evident between study countries. Some of the consent processes mandated by ethical review boards were disproportionate for peer support, increased participant burden, and reduced the practicality of testing an ethical intervention. Across the 8 studies, ethics committees' reviews included the required elements to ensure participant safety; however, they created a range of hurdles that in some cases delayed the research and required consent processes that could hinder the spontaneity and/or empathy of peer support.

CONCLUSION

Ethics committees should avoid repeating the work of other trusted agencies and consider the ethical validity of "light touch" consent procedures for peer-support interventions. The investigators propose an ethical framework for research on peer support.

Peer Coaches to Improve Diabetes Outcomes in Rural Alabama: A Cluster Randomized Trial

PURPOSE

It is unclear whether peer coaching is effective in minority populations living with diabetes in hard-to-reach, under-resourced areas such as the rural South. We examined the effect of an innovative peer-coaching intervention plus brief education vs brief education alone on diabetes outcomes.

METHODS

This was a community-engaged, cluster-randomized, controlled trial with primary care practices and their surrounding communities serving as clusters. The trial enrolled 424 participants, with 360 completing baseline and follow-up data collection (84.9% retention). The primary outcomes were change in glycated hemoglobin (HbA1c), systolic blood pressure (BP), low density lipoprotein cholesterol (LDL-C), body mass index (BMI), and quality of life, with diabetes distress and patient activation as secondary outcomes. Peer coaches were trained for 2 days in community settings; the training emphasized motivational interviewing skills, diabetes basics, and goal setting. All participants received a 1-hour diabetes education class and a personalized diabetes report card at baseline. Intervention arm participants were also paired with peer coaches; the protocol called for telephone interactions weekly for the first 8 weeks, then monthly for a total of 10 months.

RESULTS

Due to real-world constraints, follow-up was protracted, and intervention effects varied over time. The analysis that included the 68% of participants followed up by 15 months showed only a significant increase in patient activation in the intervention group. The analysis that included all participants who eventually completed follow-up revealed that intervention arm participants had significant differences in changes in systolic BP (P = .047), BMI (P = .02), quality of life (P = .003), diabetes distress (P = .004), and patient activation (P = .03), but not in HbA1c (P = .14) or LDL-C (P = .97).

CONCLUSION

Telephone-delivered peer coaching holds promise to improve health for individuals with diabetes living in under-resourced areas.

Contributions of Peer Support to Health, Health Care, and Prevention: Papers from Peers for Progress

SUBSTANTIAL: evidence documents the benefits of peer support provided by community health workers, lay health advisors, promotores de salud, and others. The papers in this supplement, all supported by the Peers for Progress program of the American Academy of Family Physicians Foundation, contribute to the growing body of literature addressing the efficacy, effectiveness, feasibility, reach, sustainability, and adoption of peer support for diabetes self-management. They and additional papers supported by Peers for Progress contribute to understanding how peer support can be implemented in real world settings. Topics include examination of the peers who provide peer support, reaching the hardly reached, success factors in peer support interventions, proactive approaches, attention to emotions, peer support in behavioral health, dissemination models and their application in China, peer support in the patient-centered medical home, research challenges, and policy implications.

Strategies addressing barriers to clinical trial enrollment of underrepresented populations: a systematic review

BACKGROUND

Underrepresentation of racial and ethnic minorities in clinical trials remains a reality while they have disproportionately higher rates of health disparities.

OBJECTIVE

The purpose of this study was to identify successful community-engaged interventions that included health care providers as a key strategy in addressing barriers to clinical trial enrollment of underrepresented patients.

DESIGN

A systematic review of the literature on interventions addressing enrollment barriers to clinical trials for racial and ethnic minorities was performed in Ovid MEDLINE, EBSCO Megafile, and EBSCO CINAHL. The systematic review identified 360 studies, and 20 were selected using the inclusion criteria. An iterative process extracted information from the eligible studies.

RESULTS

The 20 selected studies were analyzed and then grouped by first author, nature of the clinical research initiative, priority populations, key strategies, and study outcomes. Nine of the studies addressed cancer clinical trials and 11 related to chronic medical conditions, including diabetes, hypertension management, and chronic kidney disease. The key strategies employed were categorized according to their presumed impact on barriers incurred at distinct steps in study recruitment: clinical trial awareness, opportunity to participate, and acceptance of enrollment. The strategies were further categorized by whether they would address barriers associated with minority perceptions of the research process and barriers related to how studies were designed and implemented.

CONCLUSION

Multiple and flexible strategies targeting providers and participants at provider sites and within communities might be needed to enroll underrepresented populations into clinical trials.

Assessing peer advisor intervention fidelity using video skits in a peer support implementation trial

In community-based interventions involving lay health workers, or "community health workers," peer-client interactions are not typically observed by investigators, creating challenges in assessing intervention fidelity. In the context of a community-based randomized controlled trial of the effectiveness of peer support on diabetes outcomes of people with diabetes in rural Alabama, a region characterized by poverty and low literacy, we developed a video assessment tool that assessed participant perceptions of peer-client interactions. The video assessment consisted of four short skits on areas of emphasis during peer training: directive versus nondirective counseling style and setting a specific versus a more general goal. The video tool was evaluated for association with questionnaire-derived measures of counseling style and goal setting among 102 participants. For counseling style, 44% of participants reported that their peer advisor was most similar to the nondirective skit. For goal setting, 42% reported that their peer advisor was most similar to the specific goal skit. There was no statistically significant relationship between skit selection and questionnaire-derived measures. The video assessment was feasible, but results suggest that video and questionnaire assessments in this population yield different results. Further validation to better understand the differences between questionnaire reports and video assessment is warranted.

Association of pain with HbA1c in a predominantly black population of community-dwelling adults with diabetes: a cross-sectional analysis

AIMS

To assess the relationship between pain and HbA(1c) levels in a predominantly black population with diabetes, and to determine whether self-management behaviours (exercise and diet) and symptoms of depression mediate this relationship.

METHODS

We analysed cross-sectional data from 417 community-dwelling individuals with diabetes in rural Alabama, USA. Binary logistic regression was used to analyse the relationship between pain and HbA(1c) levels, defined as relatively good [≤ 64 mmol/mol (≤ 8.0%)] and relatively poor [> 64 mmol/mol (> 8.0%)], after adjusting for sociodemographics, insulin use, medication count, cigarette smoking history and body mass index (BMI). We examined the mediating roles of exercise, diet, and symptoms of depression using bootstrapping.

RESULTS

Participants were primarily black (86.6%), female (76.1%) and reported an annual income of ≤$20,000 (52.7%). Their mean (sd) age was 59.6 (12.8) years. The majority of the participants reported moderate to extreme pain (71.5%). Participants reporting pain were more than twice as likely to have HbA(1c) levels > 64 mmol/mol (8.0%) in the fully adjusted model (odds ratio 2.33 [95% CI 1.28-4.24]; P < 0.05). Diet significantly mediated the relationship between pain and HbA(1c) control (β = 0.06; 95% CI: 0.01-0.17), but only in the unadjusted model. Exercise and symptoms of depression were not significant mediators.

CONCLUSIONS

A significant independent relationship between pain and HbA(1c) control was found in this mainly black population, which was not explained by self-management behaviours or symptoms of depression. Future research is needed to delineate the mechanism by which pain influences HbA(1c) control, especially among black people with diabetes on low incomes.

Perceptions of and barriers to use of generic medications in a rural African American population, Alabama, 2011

Introduction

Using generic medications for chronic diseases provides efficacy similar to that of brand-name medication use, but at a lower price, potentially enhancing adherence. However, previous studies show that disadvantaged people, who may particularly benefit from cost savings, have low trust of generics and increased reluctance to switch to generics. The rural South includes areas of high poverty and minority communities whose members are at high risk for poor health outcomes; however, whether such beliefs exist in these communities has not been reported. We sought to obtain qualitative insight into beliefs about generic medication use among African Americans in the rural South.

Methods

Investigators conducted 4 focus groups with 30 community members from Alabama’s Black Belt area. Transcribed discussions were analyzed and common themes identified.

Results

Participants were primarily unemployed middle-aged women, one-fourth of whom were uninsured and more than half of whom had a high school education or less. Barriers to generic medication use included perceptions that generics are less potent than brand-name medications, require higher doses, and, therefore, result in more side effects; generics are not “real” medicine; generics are for minor but not serious illnesses; the medical system cannot be trusted; and poor people are forced to “settle” for generics.

Conclusion

Although education about generics could rectify misinformation, overcoming views such as mistrust of the medical system and the sense of having to settle for generics because of poverty may be more challenging. Policy makers and providers should consider these perspectives when working to increase generic drug use in these populations.

Efficacy and effectiveness as aspects of cluster randomized trials with nursing home residents: methodological insights from a pneumonia prevention trial

This report discusses how methodological aspects of study efficacy and effectiveness combine in cluster randomized trials in nursing homes. Discussion focuses on the relationships between these study aspects in the Pneumonia Reduction in Institutionalized Disabled Elders (PRIDE) trial, an ongoing cluster randomized clinical trial of pneumonia prevention among nursing home residents launched in October 2009 in Greater New Haven, Connecticut. This clinical trial has enrolled long-term care nursing home residents, over 65years in age, who have either inadequate oral care or swallowing difficulty, previously identified risk factors for pneumonia. It has used a multicomponent intervention consisting of manual tooth/gum brushing, 0.12% chlorhexidine oral rinse administered twice daily by nurses, and upright feeding positioning at meals to reduce rates of radiographically documented pneumonia. Cluster randomization is attractive for nursing home intervention studies because physical proximity and administrative arrangements make it difficult to deliver different interventions to residents of the same nursing home. Implementing an intervention in an entire home requires integration into the daily life of residents and into the administrative procedures of the nursing home. This characteristic of nursing home cluster randomized trials makes them approximate "real-world" research contexts, but implementation can be challenging. The PRIDE trial of pneumonia prevention utilized specific methodological choices that include both efficacy and effectiveness elements. Cluster randomized trials in nursing homes having elements of both efficacy and effectiveness (i.e., hybrid designs) can address some of the methodological challenges of conducting clinical research in nursing homes; they have distinctive advantages and some limitations.