Recruiting and retaining low-income, multi-ethnic women into randomized controlled trials: successful strategies and staffing

The role of perceived expertise and trustworthiness in research study and clinical trial recruitment: Perspectives of clinical research coordinators and African American and Black Caribbean patients

This study investigates the role of source credibility on minority participant recruitment, particularly African American and Black Caribbean patients. A total of nine focus groups (N = 48 participants) were conducted with both patient groups and clinical research coordinators (CRCs). Using the elaboration likelihood model as a guiding framework for analysis, this study found that the credibility of research coordinators (or other professionals who recruit for research studies and clinical trials) was instrumental in shaping attitudes of prospective participants. The perspectives of patients and CRCs aligned closely, with few exceptions. For both groups, professionalism and professional displays (clothing, institutional artifacts) enhanced perceived expertise, a core component of credibility. Trustworthiness, another important component of credibility, was fostered through homophily between recruiter and patient, expressions of goodwill and assuaging anxiety about CRCs' financial motivations for recruitment. Additionally, CRCs believed that credibility was supported when CRCs could emphasize transparency and truthfulness in communication. The importance of these findings for the development of empirically-based training programs to improve communication practices in recruitment contexts is discussed.

A systematic review to identify and collate factors influencing patient journeys through clinical trials

Patient-centred trial design and delivery; improves recruitment and retention; increases participant satisfaction; encourages participation by a more representative cohort; and allows researchers to better meet participants' needs. Research in this area mostly focusses on narrow facets of trial participation. We aimed to systematically identify the breadth of patient-centred factors influencing participation and engagement in trials, and collate them into a framework. Through this we hoped to assist researchers to identify factors that could improve patient-centred trial design and delivery. Robust qualitative and mixed methods systematic reviews are becoming increasingly common in health research. The protocol for this review was prospectively registered on PROSPERO, CRD42020184886. We used the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research Type) framework as a standardised systematic search strategy tool. 3 databases were searched as well as references checking, and thematic synthesis was conducted. Screening agreement was performed and code and theme checking were conducted by 2 independent researchers. Data were drawn from 285 peer-reviewed articles. 300 discrete factors were identified, and sorted into 13 themes and subthemes. The full catalogue of factors is included in the Supplementary Material. A summary framework is included in the body of the article. This paper focusses on outlining common ground that themes share, highlighting critical features, and exploring interesting points from the data. Through this, we hope researchers from multiple specialities may be better able to meet patients' needs, protect patients' psychosocial wellbeing, and optimise trial recruitment and retention, with direct positive impact on research time and cost efficiency.

Locating longitudinal study participants 10 years after last contact: Contemporary approaches to sample retention

AIMS

Despite their advantages, longitudinal studies often face high rates of attrition. This study documents the extensive efforts associated with retaining a longitudinal cohort last contacted 10 years earlier.

METHOD

We examine the processes and outcomes of attempts to reach 1736 individuals who have been part of a multiwave study about growing up in Ontario, Canada. Contact methods include email, phone, text, social media, postal mail, announcements in newspapers, subway stations, and music streaming services.

RESULTS

Challenges included a lack of consistent annual communication with participants, children moving out of the parental home, and changes in email addresses and phone numbers. The most effective contact method was phone; text messages and friend referrals were the least effective. Overall, 41.5% of the original sample was reached. Locating former research participants years later necessitated multiple and repeated contact attempts, and intensive human resources.

CONCLUSION

Ten lessons for effective sample retention are discussed. In summary, reducing attrition depends on a comprehensive study design and an organized and flexible protocol that adapts to a study's ever-changing needs.

Establishing Requirements for Technology to Support Clinical Trial Retention: Systematic Scoping Review and Analysis Using Self-determination Theory

BACKGROUND

Retaining participants in clinical trials is an established challenge. Currently, the industry is moving to a technology-mediated, decentralized model for running trials. The shift presents an opportunity for technology design to aid the participant experience and promote retention; however, there are many open questions regarding how this can be best supported. We advocate the adoption of a stronger theoretical position to improve the quality of design decisions for clinical trial technology to promote participant engagement.

OBJECTIVE

This study aimed to identify and analyze the types of retention strategies used in published clinical trials that successfully retain participants.

METHODS

A systematic scoping review was carried out on 6 electronic databases for articles published from 1990 to September 2020, namely CINAHL, The Cochrane Library, EBSCO, Embase, PsycINFO, and PubMed, using the concepts "retention," "strategy," "clinal trial," and "clinical research." This was followed by an analysis of the included articles through the lens of self-determination theory, an evidence-based theory of human motivation.

RESULTS

A total of 26 articles were included in this review. The motivational strategies identified in the clinical trials in our sample were categorized into 8 themes: autonomy; competence; relatedness; controlled motivation; branding, communication material, and marketing literature; contact, tracking, and scheduling methods and data collection; convenience to contribute to data collection; and organizational competence. The trials used a wide range of motivational strategies. Notably, the trials often relied on controlled motivation interventions and underused strategies to support intrinsic motivation. Moreover, traditional clinical trials relied heavily on human interaction and "relatedness" to support motivation and retention, which may cause problems in the move to technology-led decentralized trials. We found inconsistency in the data-reporting methods and that motivational theory-based approaches were not evident in strategy design.

CONCLUSIONS

This study offers direction and a framework to guide digital technology design decisions for future decentralized clinical trials to enhance participant retention during clinical trials. This research defines previous clinical trial retention strategies in terms of participant motivation, identifies motivational strategies, and offers a rationale for selecting strategies that will improve retention. It emphasizes the benefits of using theoretical frameworks to analyze strategic approaches and aid decision-making to improve the quality of technology design decisions.

Community Health Representatives as Trusted Sources for Increasing Representation of American Indian Communities in Clinical Research

Indigenous and American Indian Alaskan Native (AI/AN) community members are systematically underrepresented in clinical trial research. This paper focuses on exploratory steps to partner with Native Nations of Arizona to engage Community Health Representatives (CHR) as a trusted source for building COVID-19 clinical trial research, including vaccine trials awareness. CHRs are frontline public health workers who apply a unique understanding of the experience, language, and culture of the population served. This workforce has entered the spotlight as essential to the prevention and control of COVID-19.

METHODS

Three Tribal CHR programs were engaged to develop and refine culturally centered educational materials and a pre-post survey using a consensus-based decision-making approach. CHRs used these materials in brief education sessions during regular client home visits and community events.

RESULTS

At 30 days post CHR intervention, participants (N = 165) demonstrated significantly increased awareness about and ability to enroll in COVID-19 treatment and vaccine trials. Participants also described a significant increase in trust in researchers, decreased perceived barriers related to cost for participation in a clinical trial, and improved belief that participation in a COVID-19 clinical trial for treatment was considered a benefit to American Indian and Alaskan Native people.

CONCLUSION

CHRs as trusted sources of information, coupled with culturally centered education materials designed by CHRs for CHR clients, demonstrated a promising approach to improved awareness of clinical trial research generally and COVID-19 trials specifically among Indigenous and American Indian community members of Arizona.

Factors which influence ethnic minority women's participation in maternity research: A systematic review of quantitative and qualitative studies

BACKGROUND

Women from Black, Asian and mixed ethnicity backgrounds in the UK experience higher rates of maternal and neonatal mortality and morbidity, and report poorer experiences of maternity care. Research is required to understand how to reduce these disparities, however, it is acknowledged these groups of women are under-represented in clinical research.

AIM

To investigate factors which influence participation in maternity research for women from an ethnic minority background.

METHODS

A systematic review was conducted to examine influencing factors for research participation. MEDLINE/CINHAL/PsycInfo/EMBASE databases were systematically searched in March 2021 and updated in March 2022. Papers were eligible if they explored maternal research participation and identified a woman's ethnicity in the results. No restrictions were placed on methodology. A convergent integrated approach was used to synthesise findings.

FINDINGS

A total of 14 papers met the inclusion criteria. Results were divided into eight overarching themes. A personalised approach to recruitment and incorporating culturally sensitive communication and considerations enhanced research participation. Distrust around sharing data, a perception of risk to research participation, and research lacking in personal relevance adversely affected the decision to participate. Large variation existed in the quality of the studies reviewed.

CONCLUSIONS

Consideration of a woman's culture and background in the design and the delivery of a maternity research study may facilitate participation, particularly when sampling from a specific population. Further research, informed by women from ethnic minority backgrounds is warranted to develop women-centred recommendations for conducting inclusive maternity research. Prospero registration: www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021261686.

Non-specialist-delivered psychosocial intervention for prenatal anxiety in a tertiary care setting in Pakistan: a qualitative process evaluation

OBJECTIVES

A manualised cognitive-behavioural therapy-based psychosocial intervention for prenatal anxiety called Happy Mother Healthy Baby is being tested for its effectiveness through a randomised control trial in Pakistan. The aim of this study was to evaluate the intervention delivery process and the research process.

DESIGN

Qualitative methods were used to explore in depth the intervention delivery and research process.

SETTING

This process evaluation was embedded within a randomised control trial conducted in a tertiary care facility in Rawalpindi, Pakistan.

PARTICIPANTS

Data were collected through in-depth interviews (n=35) with the trial participants and focus group discussions (n=3) with the research staff. Transcripts were analysed using a Framework Analysis.

RESULTS

The evaluation of the intervention delivery process indicated that it can be effectively delivered by non-specialist providers trained and supervised by a specialist. The intervention was perceived to be culturally acceptable and appropriately addressing problems related to prenatal anxiety. Lack of awareness of 'talking' therapies and poor family support were potential barriers to participant engagement. The evaluation of the research process highlighted that culturally appropriate consent procedures facilitated recruitment of participants, while incentivisation and family involvement facilitated sustained engagement and retention. Lack of women's empowerment and mental health stigma were potential barriers to implementation of the programme.

CONCLUSION

We conclude that non-specialists can feasibly deliver an evidence-based intervention integrated into routine antenatal care in a tertiary hospital. Non-specialist providers are likely to be more cost effective and less stigmatising. Inclusion of family is key for participant recruitment, retention and engagement with the intervention.

TRIAL REGISTRATION NUMBER

NCT03880032.

Associations between use of expressed human milk at 2 weeks postpartum and human milk feeding practices to 6 months: a prospective cohort study with vulnerable women in Toronto, Canada

OBJECTIVES

To examine whether use of expressed human milk in the first two weeks postpartum is associated with cessation of human milk feeding and non-exclusive human milk feeding up to 6 months.

DESIGN

Pooled data from two prospective cohort studies SETTING: Three Canada Prenatal Nutrition Program (CPNP) sites serving vulnerable families in Toronto, Canada.

PARTICIPANTS

337 registered CPNP clients enrolled prenatally from 2017 to 2020; 315 (93%) were retained to 6 months postpartum.

EXCLUSIONS

pregnancy loss or participation in prior related study; Study B: preterm birth (<34 weeks); plan to move outside Toronto; not intending to feed human milk; hospitalisation of mother or baby at 2 weeks postpartum.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main exposure variable: any use of expressed human milk at 2 weeks postpartum.

OUTCOMES

cessation of human milk feeding by 6 months; non-exclusive human milk feeding to 4 months and 6 months postpartum.

RESULTS

All participants initiated human milk feeding and 80% continued for 6 months. Exclusive human milk feeding was practiced postdischarge to 4 months by 28% and to 6 months by 16%. At 2 weeks postpartum, 34% reported use of expressed human milk. Any use of expressed human milk at 2 weeks was associated with cessation of human milk feeding before 6 months postpartum (aOR 2.66; 95% CI 1.41 to 5.05) and with non-exclusive human milk feeding to 4 months (aOR 2.19; 95% CI 1.16 to 4.14) and 6 months (aOR 3.65; 95% CI 1.50 to 8.84).

TRIAL REGISTRATION NUMBERS

NCT03400605, NCT03589963.

Using Intent-to-Attend to Predict Attendance in Community-Based Relationship Education

Government-supported relationship education has provided resources for inclusion of economically vulnerable and ethnically diverse participants; however, many grantees and programs struggled to retain couples in longitudinal studies, which has likely influenced study effects and threatened internal validity. In the present study, we assessed 1,056 couples' baseline relationship satisfaction and intent-to-attend their next scheduled visit while participating in a randomized controlled trial of relationship education and evaluated the predictive ability of their responses to remain in the six-month study. We conducted actor-partner interdependence models for couples, using a probit cross-lagged regression with a structural equation modeling framework, to test the dyadic influence of intent-to-attend on future couple attendance. We also examined the influence of higher or lower baseline relationship satisfaction between partners and group assignment (treatment or wait-list control) on attendance. Intent-to-attend scores were associated with attendance for couples at the one-month follow-up, and early attendance was the biggest predictor of later attendance. Additionally, baseline intent-to-attend scores predicted later intent-to-attend scores for all follow-up time points. However, we found no partner effects, and no effects for the influence of baseline relationship satisfaction or group assignment. We discuss practical suggestions for including intent-to-attend in future studies, relationship education programming, and general therapy practice.

High levels of breastmilk feeding despite a low rate of exclusive breastfeeding for 6 months in a cohort of vulnerable women in Toronto, Canada

Exclusive breastfeeding (EBF) for 6 months is a global public health goal, but measuring its achievement as a marker of population breastmilk feeding practices is insufficient. Additional measures are needed to understand variation in non-EBF practices and inform intervention priorities. We collected infant feeding data prospectively at seven time points to 6 months post-partum from a cohort of vulnerable women (n = 151) registered at two Canada Prenatal Nutrition Program sites in Toronto, Canada. Four categories of breastmilk feeding intensity were defined. Descriptive analyses included the (i) proportion of participants in each feeding category by time point, (ii) use of formula and non-formula supplements to breastmilk, (iii) proportion of participants practising EBF continuously for at least 3 months; and (iv) frequency of transitions between feeding categories. All participants initiated breastmilk feeding with 70% continuing for 6 months. Only 18% practised EBF for 6 months, but 48% did so for at least 3 continuous months. The proportion in the EBF category was highest from 2 to 4 months post-partum. Supplemental formula use was highest in the first 3 months; early introduction of solids and non-formula fluids further compromised EBF at 5 and 6 months post-partum. Most participants (75%) transitioned between categories of breastmilk feeding intensity, with 35% making two or more transitions. Our data show high levels of breastmilk provision despite a low rate of EBF for 6 months. Inclusion of similar analyses in future prospective studies is recommended to provide more nuanced reporting of breastmilk feeding practices and guide intervention designs.

Effective Recruitment of Engineers From Other Companies: Whether to Pull Individuals or Teams?

This study empirically analyzes effective conditions for cross-border “learning by hiring” in the electronics industry. Many previous studies have indicated that the mobility of engineers serves as a conduit for knowledge diffusion and that knowledge is more likely transferred when the geographical distance is short, that is, when the conduit is short. However, the relationship between conduit thickness and density and the knowledge spillover effect has only rarely discussed. The findings of this study suggest that it is more effective to hire multiple people simultaneously for learning by hiring from companies in other countries.

Promoting inclusion in clinical trials-a rapid review of the literature and recommendations for action

Background

Without inclusion of diverse research participants, it is challenging to understand how study findings will translate into the real world. Despite this, a lack of inclusion of those from under-served groups in research is a prevailing problem due to multi-faceted barriers acting at multiple levels. Therefore, we rapidly reviewed international published literature, in relation to clinical trials, on barriers relating to inclusion, and evidence of approaches that are effective in overcoming these.

Methods

A rapid literature review was conducted searching PubMed for peer-reviewed articles that discussed barriers to inclusion or strategies to improve inclusion in clinical trial research published between 2010 and 2021. Grey literature articles were excluded.

Results

Seventy-two eligible articles were included. The main barriers identified were language and communication, lack of trust, access to trials, eligibility criteria, attitudes and beliefs, lack of knowledge around clinical trials, and logistical and practical issues. In relation to evidence-based strategies and enablers, two key themes arose: [1] a multi-faceted approach is essential [2]; no single strategy was universally effective either within or between trials. The key evidence-based strategies identified were cultural competency training, community partnerships, personalised approach, multilingual materials and staff, communication-specific strategies, increasing understanding and trust, and tackling logistical barriers.

Conclusions

Many of the barriers relating to inclusion are the same as those that impact trial design and healthcare delivery generally. However, the presentation of these barriers among different under-served groups may be unique to each population’s particular circumstances, background, and needs. Based on the literature, we make 15 recommendations that, if implemented, may help improve inclusion within clinical trials and clinical research more generally. The three main recommendations include improving cultural competency and sensitivity of all clinical trial staff through training and ongoing personal development, the need to establish a diverse community advisory panel for ongoing input into the research process, and increasing recruitment of staff from under-served groups. Implementation of these recommendations may help improve representation of under-served groups in clinical trials which would improve the external validity of associated findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05849-7.

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

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

Effect on breastfeeding practices of providing in-home lactation support to vulnerable women through the Canada Prenatal Nutrition Program: protocol for a pre/post intervention study

Background

Only one-third of Canadian infants are exclusively breastfed for the first 6 months of life as recommended. Skilled lactation support in the early postpartum period is one strategy for improving breastfeeding outcomes by building breastfeeding self-efficacy and resolving difficulties. Access to such support is limited among vulnerable women, including those who are new immigrants, low income, under-educated, young or single. The Canada Prenatal Nutrition Program (CPNP) aims to improve birth and breastfeeding outcomes among vulnerable women, but currently lacks a formal framework for providing postpartum lactation support.

Methods

This pre/post intervention study will examine the effect on breastfeeding outcomes of an evidence-based in-home lactation support intervention provided through the CPNP. We will enrol 210 pregnant women who intend to breastfeed and are registered CPNP clients at two sites in Toronto, Canada. During the intervention phase, postpartum home visits by International Board Certified Lactation Consultants (IBCLCs) will be pro-actively offered to registered clients of the two sites. Double-electric breast pumps will also be provided to those who meet specific criteria. Infant feeding data will be collected prospectively at seven time points from 2 weeks to 6 months postpartum. Descriptive and regression analyses will be conducted to measure intervention effects. The primary outcome is exclusive breastfeeding at 4 months postpartum. Secondary outcomes include the duration of any and exclusive breastfeeding, timing of introduction of breastmilk substitutes and timing of introduction of solid foods. Breastfeeding self-efficacy will be assessed prenatally and at 2 weeks and 2 months postpartum. Other measures include maternal socio-demographics, infant feeding intentions, maternal depression and anxiety, and household food insecurity. Monitoring data will be used to assess the reach, uptake and fidelity of intervention delivery.

Discussion

Increasing access to skilled lactation support through the CPNP may be an effective means of improving breastfeeding practices among vulnerable women and thereby enhancing health and development outcomes for their infants. This pre/post intervention study will contribute evidence on both the effectiveness and feasibility of this approach, in order to guide the development and further testing of appropriate models of integrating lactation support into the CPNP.

Trial registration

ClinicalTrials.gov (NCT03589963) registered July 18, 2018.

Breastfeeding rates are high in a prenatal community support program targeting vulnerable women and offering enhanced postnatal lactation support: a prospective cohort study

BACKGROUND

In Canada, 91% of all mothers initiate breastfeeding, but 40-50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women. The Canada Prenatal Nutrition Program (CPNP) aims to support breastfeeding among vulnerable women, but there is no formal framework or funding for sites to integrate proactive postnatal breastfeeding support. This research aimed to i) describe infant feeding practices among clients of one Toronto CPNP site using charitable funds to offer a lactation support program (in-home lactation consultant visits, breast pumps); ii) determine whether breastfeeding outcomes at 6 months differ based on maternal sociodemographics and food insecurity; and iii) assess utilization of the lactation support program.

METHODS

Infant feeding practices were collected prospectively at 2 weeks, 2, 4 and 6 months postpartum via telephone questionnaires (n = 199). Maternal sociodemographics were collected at 2 weeks and food insecurity data at 6 months postpartum. Program monitoring records were used to determine utilization of the lactation support program.

RESULTS

Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump.

CONCLUSIONS

This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women. Study registered at clinicaltrials.gov as NCT03400605 .

Factors influencing adolescent girls and young women's participation in a combination HIV prevention intervention in South Africa

Background

For interventions to reach those they are intended for, an understanding of the factors that influence their participation, as well as the facilitators and barriers of participation are needed. This study explores factors associated with participation in a combination HIV prevention intervention targeting adolescent girls and young women (AGYW) aged 15–24-years-old, as well as the perspectives of AGYW, intervention implementers, and facilitators who participated in this intervention.

Methods

This study used mixed-methods approach with quantitative household survey data from 4399 AGYW aged 15–24-years-old in six of the ten districts in which the intervention was implemented. In addition, qualitative methods included a total of 100 semi-structured in-depth interviews and 21 focus group discussions in five of the ten intervention districts with 185 AGYW who participated in one or more of the key components of the intervention, and 13 intervention implementers and 13 facilitators. Thematic analysis was used to explore the perspectives of participating and implementing the intervention.

Results

Findings reveal that almost half of AGYW (48.4%) living in the districts where the intervention took place, participated in at least one of the components of the intervention. For both 15–19-year-olds and 20–24-year-olds, factors associated with increased participation in the intervention included being HIV negative, in school, never been pregnant, and having had a boyfriend. Experiencing intimate partner violence (IPV) and/or sexual violence in the past 12 months was associated with increased levels of participation in the intervention for 20–24-year-olds only. In our analysis of the qualitative data, facilitators to participation included motivating participants to join the interventions through explaining the benefits of the programme. Barriers included misguided expectations about financial rewards or job opportunities; competing responsibilities, interests or activities; family responsibilities including childcare; inappropriate incentives; inability to disrupt the school curriculum and difficulties with conducting interventions after school hours due to safety concerns; miscommunication about meetings; as well as struggles to reach out-of-school AGYW.

Conclusion

Designers of combination HIV prevention interventions need to address the barriers to participation so that AGYW can attend without risking their safety and compromising their family, childcare and schooling responsibilities. Strategies to create demand need to include clear communication about the nature and potential benefits of such interventions, and the inclusion of valued incentives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10462-z.

Effectiveness of Smartphone-Based Mindfulness Training on Maternal Perinatal Depression: Randomized Controlled Trial

BACKGROUND

Despite potential for benefit, mindfulness remains an emergent area in perinatal mental health care, and evidence of smartphone-based mindfulness training for perinatal depression is especially limited.

OBJECTIVE

The objective of this study was to evaluate the effectiveness of a smartphone-based mindfulness training intervention during pregnancy on perinatal depression and other mental health problems with a randomized controlled design.

METHODS

Pregnant adult women who were potentially at risk of perinatal depression were recruited from an obstetrics clinic and randomized to a self-guided 8-week smartphone-based mindfulness training during pregnancy group or attention control group. Mental health indicators were surveyed over five time points through the postpartum period by online self-assessment. The assessor who collected the follow-up data was blind to the assignment. The primary outcome was depression as measured by symptoms, and secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear.

RESULTS

A total of 168 participants were randomly allocated to the mindfulness training (n=84) or attention control (n=84) group. The overall dropout rate was 34.5%, and 52.4% of the participants completed the intervention. Mindfulness training participants reported significant improvement of depression (group × time interaction χ²₄=16.2, P=.003) and secondary outcomes (χ²₄=13.1, P=.01 for anxiety; χ²₄=8.4, P=.04 for positive affect) compared to attention control group participants. Medium between-group effect sizes were found on depression and positive affect at postintervention, and on anxiety in late pregnancy (Cohen d=0.47, -0.49, and 0.46, respectively). Mindfulness training participants reported a decreased risk of positive depressive symptom (Edinburgh Postnatal Depression Scale [EPDS] score>9) compared to attention control participants postintervention (odds ratio [OR] 0.391, 95% CI 0.164-0.930) and significantly higher depression symptom remission with different EPDS reduction scores from preintervention to postintervention (OR 3.471-27.986). Parity did not show a significant moderating effect; however, for nulliparous women, mindfulness training participants had significantly improved depression symptoms compared to nulliparous attention control group participants (group × time interaction χ²₄=18.1, P=.001).

CONCLUSIONS

Smartphone-based mindfulness training is an effective intervention in improving maternal perinatal depression for those who are potentially at risk of perinatal depression in early pregnancy. Nulliparous women are a promising subgroup who may benefit more from mindfulness training.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900028521; http://www.chictr.org.cn/showproj.aspx?proj=33474.

Variations in Relationships Between Perceived Stress and Birth Outcomes by Immigration Status

INTRODUCTION

Past research shows that stress during pregnancy predicts adverse birth outcomes. These patterns might differ based on immigration status. Our objective was to analyze differences in relationships between perceived stress during pregnancy and birth outcomes by immigration status.

METHODS

We recruited 81 pregnant women in Canada for a prospective longitudinal study of stress during pregnancy and infant development. Participants completed the Perceived Stress Questionnaire at 16-18, 24-26 and 32-34 weeks of pregnancy. Birth records were available for 73 women, including 24 non-immigrants, 18 long-term immigrants (≥ 5 years), and 31 recent immigrants (< 5 years). We used General Linear Models to test relationships between perceived stress and birthweight, birthweight for gestational age Z-scores, and gestational age, and differences based on immigration status.

RESULTS

Controlling for sociodemographic covariates, we observed interactive relationships between immigration status and perceived stress with birthweight at 16-18 (p = 0.032, partial η² = 0.11) and 24-26 weeks pregnancy (p = 0.012, partial η² = 0.15). Results were similar for birthweight for gestational age Z-scores at 16-18 weeks (p = 0.016, partial η² = 0.13) and 24-26 weeks pregnancy (p = 0.013, partial η² = 0.14). Perceived stress predicted smaller birthweight measurements among long-term immigrants. No relation was found between perceived stress, immigration status and gestational age.

DISCUSSION

Risk of adverse health outcomes, including birth outcomes, tends to increase with duration of residence among immigrants. Stress during pregnancy might represent one risk factor for adverse birth outcomes among long-term immigrant women. Promoting psychosocial health screening and care among immigrant women, and assuring continued care with acculturation, might improve both maternal and infant health outcomes.

Factors that impact on recruitment to randomised trials in health care: a qualitative evidence synthesis

BACKGROUND

Randomised trials (also referred to as 'randomised controlled trials' or 'trials') are the optimal way to minimise bias in evaluating the effects of competing treatments, therapies and innovations in health care. It is important to achieve the required sample size for a trial, otherwise trialists may not be able to draw conclusive results leading to research waste and raising ethical questions about trial participation. The reasons why potential participants may accept or decline participation are multifaceted. Yet, the evidence of effectiveness of interventions to improve recruitment to trials is not substantial and fails to recognise these individual decision-making processes. It is important to synthesise the experiences and perceptions of those invited to participate in randomised trials to better inform recruitment strategies.

OBJECTIVES

To explore potential trial participants' views and experiences of the recruitment process for participation. The specific objectives are to describe potential participants' perceptions and experiences of accepting or declining to participate in trials, to explore barriers and facilitators to trial participation, and to explore to what extent barriers and facilitators identified are addressed by strategies to improve recruitment evaluated in previous reviews of the effects of interventions including a Cochrane Methodology Review.

SEARCH METHODS

We searched the Cochrane Library, Medline, Embase, CINAHL, Epistemonikos, LILACS, PsycINFO, ORRCA, and grey literature sources. We ran the most recent set of searches for which the results were incorporated into the review in July 2017.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that explored potential trial participants' experiences and perceptions of being invited to participate in a trial. We excluded studies that focused only on recruiters' perspectives, and trials solely involving children under 18 years, or adults who were assessed as having impaired mental capacity.

DATA COLLECTION AND ANALYSIS

Five review authors independently assessed the titles, abstracts and full texts identified by the search. We used the CART (completeness, accuracy, relevance, timeliness) criteria to exclude studies that had limited focus on the phenomenon of interest. We used QSR NVivo to extract and manage the data. We assessed methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We used thematic synthesis to analyse and synthesise the evidence. This provided analytical themes and a conceptual model. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. Our findings were integrated with two previous intervention effectiveness reviews by juxtaposing the quantitative and qualitative findings in a matrix.

MAIN RESULTS

We included 29 studies (published in 30 papers) in our synthesis. Twenty-two key findings were produced under three broad themes (with six subthemes) to capture the experience of being invited to participate in a trial and making the decision whether to participate. Most of these findings had moderate to high confidence. We identified factors from the trial itself that influenced participation. These included how trial information was communicated, and elements of the trial such as the time commitment that might be considered burdensome. The second theme related to personal factors such as how other people can influence the individual's decision; and how a personal understanding of potential harms and benefits could impact on the decision. Finally, the potential benefits of participation were found to be key to the decision to participate, namely personal benefits such as access to new treatments, but also the chance to make a difference and help others. The conceptual model we developed presents the decision-making process as a gauge and the factors that influence whether the person will, or will not, take part.

AUTHORS' CONCLUSIONS

This qualitative evidence synthesis has provided comprehensive insight into the complexity of factors that influence a person's decision whether to participate in a trial. We developed key questions that trialists can ask when developing their recruitment strategy. In addition, our conceptual model emphasises the need for participant-centred approaches to recruitment. We demonstrated moderate to high level confidence in our findings, which in some way can be attributed to the large volume of highly relevant studies in this field. We recommend that these insights be used to direct or influence or underpin future recruitment strategies that are developed in a participant-driven way that ultimately improves trial conduct and reduces research waste.

Vulnerable mothers' experiences breastfeeding with an enhanced community lactation support program

The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada fall well below global recommendations, particularly among socially and economically vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and with a novel community lactation support program in Toronto, Canada that included access to certified lactation consultants and an electric breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n = 46 women) were conducted between September and December 2017. Data were analysed using inductive thematic analysis. Study participants reported a strong desire to breastfeed but a lack of preparation for breastfeeding-associated challenges. Three main challenges were identified by study participants: physical (e.g., pain and low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self-efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that the free lactation support helped to address breastfeeding challenges. In their view, the key element of success with the new program was the in-home visit by the lactation consultant, who was highly skilled and provided care in a non-judgmental manner. They reported this support would have been otherwise unavailable due to cost or travel logistics. This study suggests value in exploring the addition of postnatal lactation support to the well-established national CPNP as a means to improve breastfeeding duration and exclusivity among vulnerable women.

Participation, retention, and associated factors of women in a prospective multicenter study on Chlamydia trachomatis infections (FemCure)

Prospective studies are key study designs when attempting to unravel health mechanisms that are widely applicable. Understanding the internal validity of a prospective study is essential to judge a study's quality. Moreover, insights in possible sampling bias and the external validity of a prospective study are useful to judge the applicability of a study's findings. We evaluated participation, retention, and associated factors of women in a multicenter prospective cohort (FemCure) to understand the study's validity.Chlamydia trachomatis (CT) infected adult women, negative for HIV, syphilis, and Neisseria gonorrhoeae were eligible to be preselected and included at three sexually transmitted infection (STI) clinics in the Netherlands (2016-2017). The planned follow-up for participants was 3 months, with two weekly rectal and vaginal CT self-sampling and online questionnaires administered at home and at the clinic. We calculated the proportions of preselected, included, and retained (completed follow-up) women. Associations with non-preselection, noninclusion, and non-retention (called attrition) were assessed (logistic and Cox regression).Among the 4,916 women, 1,763 (35.9%) were preselected, of whom 560 (31.8%) were included. The study population had diverse baseline characteristics: study site, migration background, high education, and no STI history were associated with non-preselection and noninclusion. Retention was 76.3% (n = 427). Attrition was 10.71/100 person/month (95% confidence interval 9.97, 12.69) and was associated with young age and low education. In an outpatient clinical setting, it proved feasible to include and retain women in an intensive prospective cohort. External validity was limited as the study population was not representative (sampling bias), but this did not affect the internal validity. Selective attrition, however (potential selection bias), should be accounted for when interpreting the study results.

Participant-Centered Strategies for Overcoming Barriers to Biospecimen Collection among Spanish-Speaking Latina Breast Cancer Survivors

BACKGROUND

Latinos are underrepresented in biomedical research, particularly biomarker research, yet they constitute the nation's largest ethnic/racial minority. Optimal methods for obtaining biospecimens for biomarker research among Latinos need to be identified. To minimize barriers and enhance participation, this study developed and tested tailored strategies for collecting biomarkers of chronic stress and premature aging among Spanish-speaking Latina breast cancer survivors.

METHODS

This study used a community-based participatory approach and selected hair and saliva as noninvasive biospecimens to assess telomere length, the cortisol awakening response (CAR), and hair cortisol concentration. We developed bilingual multimedia instructional materials, and community health workers assisted in collections. Telephone surveys assessed willingness to participate in future studies, barriers to sample collection, and recommendations for improving the strategies.

RESULTS

A total of 103 participants were recruited over 18 months from two rural sites in California, and 88 were retained at 6-month follow-up. At baseline, rates of donating salivary DNA for telomere length measurement, saliva for CAR analysis, and hair for cortisol concentration were 98%, 89%, and 52%, respectively. At follow-up, rates were 83%, 76%, and 55%, respectively. The majority of participants reported being very willing to provide hair (72%) or saliva (74%) for future studies.

CONCLUSIONS

Our results support the feasibility of including minorities in biomedical research. We report excellent rates of saliva collection when community partners are engaged in the process, and when patient-centered and culturally tailored recruitment methods are implemented.

IMPACT

The development of methods to facilitate the inclusion of minorities in biomedical research is critical to eliminate racial/ethnic health disparities.

Lessons learned for recruitment and retention of low-income African Americans

Recruitment and retention of low-income African Americans in clinical trials is challenging. This paper reports recruitment and retention strategies that yielded high rates for both in a clinical trial pilot to improve hypertension self-management among low-income African Americans. The study successfully recruited 96.7% (59 of 61 participants) within a seven month period. Retention rates for the 1, 3, and 6-month post-baseline assessment visits were 91.5%, 88.1%, and 83.1%, respectively. Recruitment and retention strategies include two grounded in previous literature: a culturally sensitive and diverse research team and use of incentives. Four additional strategies were developed for this study to meet the needs of the study site and participants, which included: study site collaboration; ongoing communications; responding to the clinical environment; and addressing participants’ health literacy levels. A discussion of key recruitment and retention strategies and suggestions for future studies focused on low-income African American participants ensues.

Psychosocial Stress, Sedentary Behavior, and Physical Activity during Pregnancy among Canadian Women: Relationships in a Diverse Cohort and a Nationwide Sample

BACKGROUND

Past research shows that psychosocial stress and distress predict sedentary behavior and physical activity, but few studies focus on pregnant women. Our objective was to analyze relationships between psychosocial stress and distress with sedentary behavior and physical activity among pregnant women in Canada.

METHODS

We analyzed objectively-measured sedentary behavior and physical activity at 16-18, 24-26, and 32-24 weeks pregnancy in a sociodemographically diverse cohort of 70 women in Montreal, Canada. Participants completed the Perceived Stress Questionnaire and wore an accelerometer for 3 days that quantified sitting time and steps per day. We used univariate general linear models to analyze relationships between perceived stress with sedentary behavior and physical activity at each evaluation. To assess generalizability, we analyzed relationships between psychological distress with self-reported leisure-time sedentary behavior and daily energy expenditure in transportation and leisure physical activities among a sample representative of 166,095 women in the Canadian Community Health Survey.

RESULTS

In the Montreal cohort, we observed a positive association between perceived stress and sitting time, with small to moderate effect sizes (partial η² = 0.08-0.16). We observed negative relationships between perceived stress and steps per day at the first two evaluations only, with small to moderate effect sizes (partial η² = 0.08-0.11). Relationships for sedentary behavior were similar in the nationwide sample, but with smaller effect sizes (partial η² = 0.02). There were no relationships between distress and physical activity in the nationwide sample.

CONCLUSION

Psychosocial stress represents one risk factor for sedentarity, with relationships evident throughout pregnancy and at the population level. Relationships with physical activity are less consistent, but stress might represent a risk factor for low physical activity in early to mid-pregnancy. Results might guide the development of more comprehensive interventions targeting stress, sedentarity, and physical activity. In particular, integrating psychosocial health into interventions to reduce sedentarity, and including concrete guidelines on sedentary behavior in psychosocial health interventions, might be prioritized.

Recruitment and retention of WIC participants in a longitudinal dietary intervention trial

BACKGROUND

This paper describes strategies and outcomes of techniques to recruit and retain low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in a longitudinal dietary intervention trial.

METHODS

Community engagement strategies, methods to recruit and retain participants, and recruitment and retention rates are reported. Demographic and lifestyle predictors of loss to follow-up, contacts required to reach participants at each data collection point, participant reactions to the recruitment and retention strategies used, and reasons for drop out (assessed among those who discontinued their study involvement) also were examined.

RESULTS

Of 1281 eligible women, 744 were enrolled (58% recruitment rate); retention rates were 87%, 70%, and 55%, respectively, 2 weeks and 3 and 6 months post-intervention. Being unmarried, younger, and having low baseline vegetable intake predicted loss to follow-up. Between 4 and 5 contact attempts and 1 and 2 completed contacts were required to reach participants at each data collection point. Participants endorsed recruiting women while waiting for WIC appointments (as they were accessible, perceived the information provided as informative, and wanted to pass the time) and by word of mouth. Lacking time and loss of interest were commonly reported reasons for not completing assessments and dropout. To improve retention, shortening telephone assessments, conducting the assessments in person, and increasing the amount of incentives were recommended.

CONCLUSION

Despite using recommended strategies, recruitment and retention rates were modest. Research is needed to identify and test approaches to effectively engage WIC-enrolled adults in health intervention trials.

Engagement of Urban, Pregnant Puerto Rican Women in Health Disparities Research

Persistent challenges surround the recruitment of minority women from marginalized communities in health disparities research. These challenges include lack of the following: interest in research participation, trust, positive relationships between researchers and participants/community, and principal investigators from minority groups. The purpose of this article is to describe successful recruitment strategies used in health disparities research with pregnant Puerto Rican women and to suggest ways to ensure the future success of studies on health disparities. Suggested strategies include creating trust, facilitating active participation of stakeholders, and strengthening the research pipeline with undergraduate and graduate nursing students.

Enrollment and Retention of Men and Women in Health Services Research and Development Trials

INTRODUCTION

Sex- and gender-specific science is essential to inform patient-centered, evidence-based care. Developing such evidence requires adequate inclusion of both women and men in trials. We sought to describe study participation of women and men in Department of Veterans Affairs Health Services Research and Development trials.

METHODS

We identified recent health services research trials from one Health Services Research and Development Center of Innovation and compared the participation of women and men from trial recruitment to study completion. We also calculated the participation to prevalence ratio (PPR) by sex for each trial.

RESULTS

We included eight trials that started recruitment between 2011 and 2014. Only one study purposefully attempted to boost the recruitment of women. Overall, the PPR for women ranged from 0.2 to 4.5, with seven studies having a PPR of greater than 1, indicating that women participated in these trials at proportions greater than their prevalence in the disease population within the Department of Veterans Affairs. The PPR for men ranged from 0.8 to 1.1. Retention was best with those studies that used administrative data for final outcomes assessment. No studies provided results stratified by sex or conducted analyses to explore treatment effect by sex.

CONCLUSIONS

At a single site, women participated in Health Services Research and Development trials at similar or greater rates to men without cross-study efforts to enrich the recruitment or retention of women. Adding strategic recruitment approaches could further boost the proportion of women in Department of Veterans Affairs trials and enable adequately powered sex-based analyses.

Recruitment of Immigrant Hispanic Mothers in Research: An Application of the EERC Guidelines

Introduction: Innovative and culturally sensitive strategies are needed to promote research participation among minorities and develop targeted interventions aimed at decreasing health disparities. The purpose of this article is to illustrate application of the EERC (evaluate, engage, reflect, and carefully match) guidelines in facilitating participant recruitment in a study exploring infant feeding practices of Hispanic mothers. Methodology: Retrospective application of the EERC guidelines assessed using data extracted from the researcher-study recruitment field notes. A systematic categorical process was used to determine if each of the guidelines' key concepts were incorporated in the recruitment process. Results: Successful recruitment of 62 immigrant Hispanic mothers (approximately 82% of target goal) was accomplished through implementation of most of EERC criteria (90%) in planning and recruitment phases of the study. Discussion: Application of EERC guidelines facilitates recruitment of minority populations. Enhanced participant recruitment assists in assessment of population-unique conditions and targeted interventions leading to disease prevention and improved outcomes.

The Feasibility of Using Facebook, Craigslist, and Other Online Strategies to Recruit Young African American Women for a Web-Based Healthy Lifestyle Behavior Change Intervention

BACKGROUND

Reports describing successful recruiting of minority participants are available; however, they focus largely on traditional strategies. Internet and mobile devices are widely used, providing alternative approaches, yet less information is available describing the success of these approaches.

OBJECTIVE

This article (1) evaluates the feasibility of using online advertising as a recruiting modality for a healthy lifestyle behavior change intervention targeting young African American women and (2) describes lessons learned to better inform researchers for future directions.

METHODS

African American women, aged 18 to 45 years, with untreated prehypertension and Internet access were eligible for a 12-week randomized study providing physical activity or nutrition behavior change education delivered via online modules. Traditional strategies included flyers, tabletop cards, blood pressure screenings, health fairs, and clinics. Online-related strategies included posting ads on Facebook, Craigslist, and on the university Web site, intranet, and "on-hold" telephone line. Descriptive statistics were used to identify frequency of recruitment strategies. χ Analysis was used to assess differences between enrolled and nonenrolled inquiries.

RESULTS

Among all 176 inquiries, the most frequented strategies were the university Web site (44%), blood pressure screenings (15%), Facebook/Craigslist (13%), and clinics (12%). Enrollment rates differed across recruitment strategies (χ P = .046). The 3 highest enrollment rates were (1) employee in-services (100%), (2) flyers/tabletop cards (31.6%), and (3) word of mouth/physician referral (25%).

CONCLUSION

Online-related strategies are convenient and have great potential for reaching large numbers of people. However, the actual rate of participants successfully enrolled online was proportionally smaller when compared with traditional recruiting strategies.

Reach and representativeness of ethnic minority women in the Health Is Power Study: a longitudinal analysis

Reach is a key factor in translating research to practical application. This study examined reach and representativeness of a multi-city, randomized controlled community health trial in African American (AA) and Hispanic or Latina (HL) women. Participants completed measures of demographics, body mass index (BMI), percent body fat, resting heart rate, and blood pressure followed by a run-in procedure and a randomization meeting. AA were more likely to be screened out initially; HL were more likely to drop out. Participation did not differ by city or recruitment method. Women who completed the post-intervention assessment were more likely to be AA, older, and have higher socioeconomic status (p values < .05). This study showed moderate levels of reach but overrepresented higher educated, wealthier, and older women at the completion of the study. Representativeness can change over the course of the study and impact the practicality of translating research to practice.

Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP): Rationale, design, and methods of a randomized, controlled trial of vitamin C supplementation in pregnancy for the primary prevention of effects of in utero tobacco smoke exposure on infant lung function and respiratory health

Despite strong anti-smoking efforts, at least 12% of American women cannot quit smoking when pregnant resulting in >450,000 smoke-exposed infants born yearly. Smoking during pregnancy is the largest preventable cause of childhood respiratory illness including wheezing and asthma. Recent studies have shown a protective effect of vitamin C supplementation on the lung function of offspring exposed to in utero smoke in a non-human primate model and an initial human trial. Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP) is a randomized, double-blind, placebo-controlled trial to evaluate pulmonary function at 3months of age in infants delivered to pregnant smokers randomized to 500mg/day of vitamin C versus placebo during pregnancy. Secondary aims evaluate the incidence of wheezing through 12months and pulmonary function testing at 12months of age. Women are randomized between 13 and 23weeks gestation from clinical sites in Portland, Oregon at Oregon Health & Science University and PeaceHealth Southwest Medical Center and in Indianapolis, Indiana at Indiana University and Wishard Hospital. Vitamin C supplementation occurs from randomization to delivery. Monthly contact with participants and monitoring of medical records is performed to document medication adherence, changes in smoking and medical history, and adverse events. Pulmonary function testing of offspring occurs at 3 and 12months of age and incidence of wheezing and respiratory illness through 12months is captured via at least quarterly questionnaires. Ancillary studies are investigating the impact of vitamin C on placental blood flow and DNA methylation.

Recruiting pregnant smokers from Text4baby for a randomized controlled trial of Quit4baby

Recruiting pregnant smokers into clinical trials is challenging since this population tends to be disadvantaged, the behavior is stigmatized, and the intervention window is limited. The purpose of this study is to test the feasibility and effectiveness of recruiting pregnant smokers into a smoking cessation trial by sending recruitment text messages to an existing subscriber list. Recruitment messages were sent to subscribers flagged as pregnant in Text4baby, a national text messaging program for pregnant women and mothers. Four recruitment messages were rotated to test the effectiveness of different emotional frames and a financial incentive. Study staff called subscribers who expressed interest to screen for eligibility and enroll eligible women. Between October 6, 2015 and February 2, 2016, 10,194 recruitment messages were sent to Text4baby subscribers flagged as pregnant, and 10.18% (1038) responded indicating interest. No significant increase in cancellation was observed compared to subscribers who received other ad hoc messages. Of respondents, 54.05% (561) were reached by phone for follow-up, and 21.97% (228) were found to be eligible. Among the eligible, 87% (199) pregnant smokers enrolled. The recruitment message with a pride emotional appeal had a significantly higher response (p = 0.02) compared to the recruitment message with no emotional appeal, but enrollment did not significantly differ between recruitment messages with different emotional appeals. The recruitment messages with a reference to financial incentive yielded higher response (p < 0.01) and enrollment (p = 0.03) compared to a recruitment message without. This study demonstrates success recruiting pregnant smokers using text message. Future studies should consider building on this approach for recruiting high-risk populations.

Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA

AIMS AND OBJECTIVES

To identify barriers and supporting factors for breastfeeding, and the dynamic interactions between them, as identified by low-income African American women and lactation peer helpers.

BACKGROUND

Stark breastfeeding disparities exist between African American mothers and their White counterparts in the USA. This pattern is often replicated across the globe, with marginalised populations demonstrating decreased breastfeeding rates. While breastfeeding research focused on sociocultural factors for different populations has been conducted, a more dynamic model of the factors impacting breastfeeding may help identify effective leverage points for change.

DESIGN

Group model building was used as a grounded theoretical approach, to build and validate a model representing factors impacting breastfeeding and the relationships between them.

METHODS

Low-income African American women (n = 21) and lactation peer helpers (n = 3) were engaged in model building sessions to identify factors impacting breastfeeding. A two-cycle process was used for analysis, in vivo and axial coding. The final factors and model were validated with a subgroup of participants.

RESULTS

The participants generated 82 factors that make breastfeeding easier, and 86 factors that make breastfeeding more challenging. These were grouped into 10 and 14 themes, respectively. A final model was constructed identifying three domains impacting breastfeeding: a mother's return to work or school, her knowledge, support and persistence, and the social acceptance of breastfeeding.

CONCLUSIONS

This study documented the sociocultural context within which low-income African American women are situated by identifying factors impacting breastfeeding, and the dynamic interactions between them. The model also provided various leverage points from which breastfeeding women can be supported.

RELEVANCE TO CLINICAL PRACTICE

Postpartum nurses are critical in supporting breastfeeding practices. To be most effective, they must be aware of the factors impacting breastfeeding, some of which may be unique to women based on their culture.

Human biomonitoring from an environmental justice perspective: supporting study participation of women of Turkish and Moroccan descent

BACKGROUND

Environmental justice research shows how socially disadvantaged groups are more exposed and more vulnerable to environmental pollution. At the same time, these groups are less represented and, thus, less visible in biomedical studies. This socioeconomic participation bias is a form of environmental injustice within research practice itself.

METHODS

We designed, implemented and evaluated a targeted recruitment strategy to enhance the participation of socially disadvantaged pregnant women in a human biomonitoring study in Belgium. We focused on women of Turkish and Moroccan descent and developed a setup using personal buddies that enabled information transfer about study conditions in the pre-parturition period as well as support and follow-up with questionnaires in the post-parturition period.

RESULTS

We identified four barriers to the participation of women with a vulnerable social and ethnic background which were related to psychosocial and situational factors. Lack of trust in researchers and no perceived study benefits were important personal barriers; the complex study design and difficult self-administered questionnaires were equally significant barriers.

CONCLUSION

By investing in direct, person-to-person contact with trusted buddies and supported by practical advice about cultural and linguistic sensitivity, it was possible to increase study participation of socially disadvantaged people. Above all, this required openness and flexibility in the mind-set of researchers so that study design and procedures could be better grounded in the experiences and circumstances of underprivileged groups.

Improving pregnancy outcome in obese women: the UK Pregnancies Better Eating and Activity randomised controlled Trial

Background

Obesity in pregnancy is associated with insulin resistance, which underpins many common complications including gestational diabetes mellitus (GDM) and fetal macrosomia.

Objectives

To assess the effect of a complex behavioural intervention based on diet and physical activity (PA) on the risk of GDM and delivery of a large-for-gestational age (LGA) infant.

Design

Three phases: (1) the development phase, (2) the pilot study and (3) a multicentre randomised controlled trial (RCT) comparing a behavioural intervention to improve glycaemic control with standard antenatal care in obese pregnant women. A cost–utility analysis was undertaken to estimate the cost-effectiveness of the health training (intervention) over and above standard care (control).

Setting

Pilot study: antenatal clinics in four inner-city UK hospitals. RCT: eight antenatal clinics in eight UK inner-city hospitals.

Participants

Women were eligible for inclusion if they had a body mass index of ≥ 30 kg/m2, were pregnant with a single fetus and at 15+0to 18+6weeks’ gestation, were able to give written informed consent and were without predefined disorders.

Intervention

The intervention comprised an initial session with a health trainer, followed by eight weekly sessions. Dietary advice recommended foods with a low dietary glycaemic index, avoidance of sugar-sweetened beverages and reduced saturated fats. Women were encouraged to increase daily PA.

Main outcome measures

Development phase: intervention development, acceptability and optimal approach for delivery. Pilot study: change in dietary and PA behaviours at 28 weeks’ gestation. RCT: the primary outcome of the RCT was, for the mother, GDM [as measured by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG)’s diagnostic criteria] and, for the infant, LGA delivery (i.e. customised birthweight ≥ 90th centile for gestational age).

Results

Development phase: following a literature meta-analysis, a study of dietary intention questionnaires and semistructured interviews, an intervention based on behavioural science was developed that incorporated optimal and acceptable methods for delivery. Pilot study: the pilot study demonstrated improvement in dietary behaviours in the intervention compared with the standard care arm but no increase in objectively measured PA. Process evaluation demonstrated feasibility and general acceptability. RCT: the RCT showed no effect of the intervention on GDM in obese pregnant women or the number of deliveries of LGA infants. There was a reduction in dietary glycaemic load (GL) and reduced saturated fat intake, an increase in PA and a modest reduction in gestational weight gain, all secondary outcomes. Lower than expected was the number of LGA infant deliveries in all women, which suggested that universal screening for GDM with IADPSG’s diagnostic criteria, and subsequent treatment, may reduce the number of deliveries of LGA infants. According to the cost–utility analysis, the estimated probability that the UK Pregnancies Better Eating and Activity Trial (UPBEAT) behavioural intervention is cost-effective at the £30,000/quality-adjusted life-year willingness-to-pay threshold was 1%.

Limitations

Included the high refusal rate for participation and self-reported assessment of diet and PA.

Conclusions

The UPBEAT intervention, an intense theoretically based intervention in obese pregnant women, did not reduce the risk of GDM in women or the number of LGA infant deliveries, despite successfully reducing the dietary GL. Based on total cost to the NHS provider and health gains, the UPBEAT intervention provided no supporting evidence to suggest that the intervention represents value for money based on the National Institute for Health and Care Excellence benchmarks for cost-effectiveness.

Future work

Alternative strategies for reducing the risk of GDM in obese pregnant women and the number of LGA infant deliveries should be considered, including development of clinically effective interventions to prevent obesity in women of reproductive age, of clinically effective interventions to reduce weight retention following pregnancy and of risk stratification tools in early pregnancy.

Trial registration

Current Controlled Trials ISRCTN89971375 and UK Clinical Research Network Portfolio 5035.

Funding

This project was funded by the NIHR Programme Grant for Applied Research programme and will be published in full inProgramme Grants for Applied Research, Vol. 5, No. 10. See the NIHR journals library website for further project information. Contributions to funding were also provided by the Chief Scientist Office CZB/4/680, Scottish Government Health Directorates, Edinburgh; Guys and St Thomas’ Charity, Tommy’s Charity (Lucilla Poston, Annette L Briley, Paul T Seed) and the NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK and the Academy of Finland, Finland. Keith M Godfrey was supported by the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre. Lucilla Poston and Keith M Godfrey were supported by the European Union’s Seventh Framework Programme (FP7/2007-2013), project EarlyNutrition under grant agreement number 289346.

Demographics of patients receiving Intravitreal anti-VEGF treatment in real-world practice: healthcare research data versus randomized controlled trials

BACKGROUND

While randomized controlled trials (RCTs) are based on strict inclusion/exclusion criteria, non-interventional studies (NISs) might provide additional information to guide management in patients more representative to the real-world setting. The aim of this study was to compare baseline characteristics of patients receiving intravitreal treatment in the NIS OCEAN with those from published RCTs.

METHODS

The ongoing OCEAN study enrolled patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME) or branch/central retinal vein occlusion (B/CRVO). Baseline patient characteristics were compared by indication within the OCEAN cohort. Furthermore, the characteristics were set in reference to those of published RCTs in the same indications. Confidence intervals (CIs) were calculated and assessed for statistically significant differences as indicated by non-overlapping CIs.

RESULTS

Patient characteristics in the NIS OCEAN were evaluated for 3,614 patients with nAMD, 1,211 with DME, 204 with BRVO and 121 with CRVO. Between these groups, significant differences in mean age, gender distributions, and mean baseline VA were seen, reflecting known differences between the indications. Compared to the patient characteristics of published RCTs (trials selected by literature search: nAMD: 13 RCTs, DME: 9, RVO: 5), the OCEAN patients' mean age was significantly higher in every indication. The gender distributions across the trials were comparable, with only few differences between OCEAN and the RCTs. Regarding the mean baseline VA, notable differences were found in nAMD and in DME, with VA significantly higher in some RCTs and lower in others.

CONCLUSIONS

The described differences underline the complementarity of NISs and RCTs. OCEAN covers a broader spectrum and more variability of patients than do RCTs. As baseline values may have impact on the treatment response (ceiling effect), there is an ongoing need for research in all patient subgroups. Country-specific assessments of patient populations can better reflect the real-world situation. NISs can deliver insights that RCTs may not, as NISs can include non-typical patients, patients with comorbidities, a broader age spectrum and patients of various disease stages.

TRIAL REGISTRATION

The NIS OCEAN was registered on www.clinicaltrials.gov (identifier: NCT02194803 ).

Successful Strategies for Practice-Based Recruitment of Racial and Ethnic Minority Pregnant Women in a Randomized Controlled Trial: the IDEAS for a Healthy Baby Study

BACKGROUND

Racial/ethnic minority patients are often underrepresented in clinical trials. Efforts to address barriers to participation may improve representation, thus enhancing our understanding of how research findings apply to more diverse populations.

METHODS

The IDEAS (Information, Description, Education, Assistance, and Support) for a Healthy Baby study was a randomized controlled trial (RCT) of an intervention to reduce barriers to using publicly reported quality data for low-income, racial/ethnic minority women. We used strategies grounded in a health equity framework to address barriers to recruitment and retention in three domains: preparation, process, and patient-centeredness. "Preparation" included teaching study staff about health inequities, role-playing skills to develop rapport and trust, and partnering with clinic staff. "Processes" included use of electronic registration systems to pre-screen potential candidates and determine when eligible participants were in clinic and an electronic database to track patients through the study. Use of a flexible protocol, stipends, and consideration of literacy levels promoted "patient-centeredness."

RESULTS

We anticipated needing to recruit 800 women over 18 months to achieve a completion goal of 650. Using the recruitment and retention strategies outlined above, we recruited 746 women in 15 months, achieving higher recruitment (87.1 %) and retention rates (97.3 %) than we had anticipated.

DISCUSSION

These successful recruitment and retention strategies used for a large RCT promoted inclusivity and accessibility. Researchers seeking to recruit racial and ethnic minority pregnant women in similar settings may find the preparation, process, and patient-centered strategies used in this study applicable for their own studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01784575 , 1R21HS021864-01.

Guidelines for research recruitment of underserved populations (EERC)

PURPOSE

Despite concerted efforts to establish health equity, significant disparities persist. One roadblock to eliminating health disparities is the inadequate recruitment of underserved populations, which prevents researchers from creating culturally-tailored interventions. To further develop the science of recruitment, we argue that a systematic approach should be applied to research participant recruitment. Given the lack of practical and comprehensive recruitment conceptual frameworks or guidelines in the literature, the authors propose newly synthesized guidelines for research recruitment of underserved populations: EERC (evaluate, engage, reflect, and carefully match).

METHODS

The EERC guidelines are delineated, and the application of these guidelines is illustrated through a study recently conducted by the authors.

RESULTS

The guidelines consist of the following four components: 1. Evaluate the composition of the research team; 2. Engage fully with the community by working with key informants and cultural insiders; 3. Reflect the unique cultural characteristics of the community in the research conduct; and 4. Carefully use a matching technique. The application component of the article demonstrates concrete examples of how the guidelines can enhance research recruitment for an underserved population.

CONCLUSION

The authors intend these guidelines to be broadly applicable for research teams regardless of research design or characteristics of the underserved population. Application of these guidelines in nursing and health science will contribute to increasing research recruitment of underserved populations, with the goal of reducing health disparities and achieving health equity for all persons.

Improving children's health and development in British Columbia through nurse home visiting: a randomized controlled trial protocol

Background

Nurse-Family Partnership is a nurse home visitation program that aims to improve the lives of young mothers and their children. The program focuses on women who are parenting for the first time and experiencing socioeconomic disadvantage. Nurse visits start as early in pregnancy as possible and continue until the child reaches age two years. The program has proven effective in the United States – improving children’s mental health and development and maternal wellbeing, and showing long-term cost-effectiveness. But it is not known whether the same benefits will be obtained in Canada, where public services differ. The British Columbia Healthy Connections Project therefore involves a randomized controlled trial evaluating Nurse-Family Partnership’s effectiveness compared with existing (usual) services in improving children’s mental health and early development and mother’s life circumstances. The trial’s main aims are to: reduce childhood injuries by age two years (primary outcome indicator); reduce prenatal nicotine and alcohol use; improve child cognitive and language development and behaviour at age two years; and reduce subsequent pregnancies by 24 months postpartum. Potential explanatory factors such as maternal mental health (including self-efficacy) are also being assessed, as is the program’s impact on exposure to intimate-partner violence. To inform future economic evaluation, data are also being collected on health and social service access and use.

Methods/design

Eligible and consenting participants (N = 1040) are being recruited prior to 28 weeks gestation then individually randomized to receive existing services (comparison group) or Nurse-Family Partnership plus existing services (intervention group). Nurse-Family Partnership is being delivered following fidelity guidelines. Data are being collected during in person and telephone interviews at: baseline; 34–36 weeks gestation; and two, 10, 18 and 24 months postpartum. Additional data will be obtained via linkages from provincial datasets. Recruitment commenced in October 2013 and will continue for approximately three years.

Discussion

This trial will provide important information about the generalizability of Nurse-Family Partnership to the Canadian context. Findings will be published in peer-reviewed journals and shared with policymakers and practitioners through extensive public health collaborations already underway.

Trial registration

Registered July 18, 2013 with ClinicalTrials.gov Identifier: NCT01672060.

The Experience of Direct Outreach Recruitment in the National Children's Study

OBJECTIVE

Few studies have reported the outcome of direct outreach methods for recruitment of research participants in population-based samples. We describe the relationship of outreach strategies that are tailored to specific community factors to recruitment and consent outcomes in 10 National Children's Study direct outreach study locations (all were single counties).

METHODS

Each study center collected data from a target population of women who resided in selected county segments that were sampled based on a geographic area probability sampling design. Based on county characteristics of the 10 study locations, each study center used site-specific marketing approaches (direct mail, mass media, provider referrals, social networking) to recruit study participants. Recruitment success was measured by the number of recruited women as well as by a qualitative assessment of the effectiveness of various recruitment methods.

RESULTS

The number of women who consented varied from 67 to 792. The majority of women were pregnant at the time of consent. Community awareness varied from <1% to 70%. Although no significant associations were found between community characteristics and recruitment success, we found that certain types of outreach strategies enhanced recruitment.

CONCLUSIONS

In a small sample of 10 US counties, recruitment success was not associated with community characteristics. It was, however, associated with certain types of outreach strategies that may be more effective in close-knit communities.

A Personal Touch: The Most Important Strategy for Recruiting Latino Research Participants

People from non-White racial groups and other underserved populations, including Latinos, are frequently reluctant to participate in research. Yet their participation into research is foundational to producing information that researchers and health care providers need to address health disparities. The purpose of this article is to describe challenges we have encountered along with culturally relevant strategies we used in five research studies to recruit Mexican American participants from community settings, some of whom were also of low socioeconomic status. We found that the most effective recruitment strategies reflect the common cultural values of personalismo, simpátia, confianza, respeto, and familismo.

Women in HIV cure research: multilevel interventions to improve sex equity in recruitment

Women are underrepresented in HIV cure research. In this paper we discuss the rationale for including women and propose multilevel strategies to improve sex equity in HIV cure research. The inadequate inclusion of women in HIV cure research is concerning for both scientific and ethical reasons. Biological responses to HIV and HIV treatment, as well as social contexts, differ between men and women, and this may affect the efficacy of curative interventions. Strategies for improving sex equity in HIV cure research include addressing eligibility criteria, adapting recruitment strategies, engaging community members early in the research process, and promoting funder policy changes. We conclude by describing the Gender, Race, and Clinical Experience (GRACE) study, which is one example of how women can be effectively recruited into HIV-related clinical trials. While HIV cure research is currently in the early stages, as it continues to develop it is important to mobilise for adequate inclusion of women.

Predictors of Study Attrition in a Randomized Controlled Trial Evaluating a Perinatal Home-Visiting Program with Mothers with Psychosocial Vulnerabilities

Objective

Randomised controlled trials evaluating perinatal home-visiting programs are frequently confronted with the problem of high attrition rates. The aim of the present study is to identify predictors of study attrition in a trial evaluating a perinatal home-visiting program in France.

Materials and Methods

CAPEDP is a French randomized trial comparing a perinatal home-visiting program using psychologists versus usual care (N = 440). The first assessment was at inclusion into the trial at the 27^th week of pregnancy and the final assessment when the child reached the age of two. Attrition rates were calculated at 3 and 24 months postpartum. Stepwise logistic regression was used to identify predictors of early (between inclusion and 3 months postpartum) and later (between 3 and 24 months postpartum) attrition among social, psychological and parenting factors.

Results

Attrition rates were 17% and 63% at 3 and 24 months respectively. At 24 months, there was significantly more attrition in the control arm (70.6%) compared to the intervention arm (55.2%). Five independent predictors of early attrition were identified: having already had an abortion; having greater attachment insecurity as measured with the Vulnerable Attachment Style Questionnaire (VASQ); having lower global severity of psychiatric symptoms as assessed with the Symptom Check-List (SCL-90) at inclusion, being neither currently employed nor studying; and declaring no tobacco consumption during pregnancy. Being randomized into the control arm, having undergone early parental loss before age 11 and having lower global severity of psychiatric symptoms (SCL-90) at 3 months postpartum were the only variables associated with later attrition.

Conclusion

This study provides key information for identifying mothers who may require specific support to avoid study attrition in trials evaluating a home-visiting program.

Retention of African American Women in a Lifestyle Physical Activity Program

The purpose of the article is to examine how well individual characteristics, neighborhood characteristics, and intervention participation predict study retention and staff level of effort needed for retention, using a cohort of African American women enrolled in a physical activity program. Secondary data analysis was conducted from a randomized clinical trial. Participants were aged 40 to 65 years without major signs/symptoms of cardiovascular disease. Assessments were conducted at community sites in/bordering African American communities. Study retention was 90%. Of those retained, 24% required moderate/high level of staff effort for retention. Retention was predicted by being older, having lower perceived neighborhood walkability, living in neighborhoods with greater disadvantage and crime, and having greater program participation. More staff effort was predicted by participants being younger, having more economic hardships, poorer health, or lower intervention participation. We may be able to identify people at baseline likely to require more staff effort to retain.