Methodological issues in the recruitment of ethnic minority subjects to research via the Internet: a discussion paper

Suicidal Thoughts and Behaviors Among Transgender Adults in Relation to Education, Ethnicity, and Income: A Systematic Review

Introduction: This systematic review assessed the impact of race/ethnicity, education, and income on transgender individual's lifetime experience of suicidal thoughts and behaviors (SITB) in gray and published literature (1997-2017). Methods: Sixty four research projects (108 articles) were identified in WorldCat, PubMed, and Google Scholar. Articles were included if they were published in Canada or the United States, included original quantifiable data on transgender SITBs, and had ≥5 participants, at least 51% of whom were ≥18 years. Results: Across all projects suicide ideation averaged 46.55% and attempts averaged 27.19%. The majority of participants were Caucasian, whereas the highest rate of suicide attempts (55.31%) was among First Nations, who accounted for <1.5% of participants. Caucasians, by contrast, had the lowest attempt rate (36.80%). More participants obtained a bachelor's degree and fewer an associate or technical degree than any other level of education. Suicide attempts were highest among those with ≤some high school (50.70%) and lowest among those with an advanced degree (30.25%). More participants made an income of $20-$50,000/year and less $10-$20,000 than any other income bracket. Conclusion: SITBs, among the transgender population, are both universally high and impacted by race/ethnicity, educational attainment, and income. These findings may be useful in creating culturally and factually informed interventions for transgender individuals experiencing SITBs and in informing future research on this topic.

Achieving Health Equity with e-Healthystrides©: Patient Perspectives of a Consumer Health Information Technology Application

Objective

We describe the implementation, clinical outcomes and participant perspectives for e-Healthystrides©.

Setting

Three independent ambulatory clinics and an historic African American (AA) church.

Participants

Adults with diagnosed diabetes mellitus type 2.

Intervention

e-Healthystrides© health coach facilitated intervention.

Primary outcome

Acquisition of three new self-management behaviors.

Secondary outcomes

Blood pressure, blood glucose, A1c, attrition rate and participant perspectives of e-Healthystrides©.

Methods

A convergent parallel mixed method design was used in both pilot studies.

Results

Two hundred and sixty-four participants, aged ~62±16 years, enrolled. Attrition at 52 weeks varied 50%-90% by site. Low engagement users were defined mainly by anxiety with putting health information online. The primary outcome was achieved in 36% of our participants, with the top 3 self-management behaviors acquired being: reducing risk (24.5%); healthy eating (23.7%); and monitoring (16.4%). Problem solving had the lowest rate of achievement (.91%). Blood pressure improved significantly at all sites at 12 weeks and at clinics A,B,C at 52 weeks. Blood glucose improved at 12 weeks: clinic A (P=.0001), B (P=.003), C (P=.001) and D (P=.03); but, at 52 weeks, only clinics A (P=<.0001) and B (P=.0001). Participants felt empowered by features of e-Healthystrides©. Engagement with health coaches and peers was highly valued.

Conclusions

e-Healthystrides© is effective for self-management behavior change. Participants showed the best success with healthy coping, healthy eating, and monitoring behaviors. They felt empowered by access to health information and valued interaction with coaches and peers. Our findings support strong relational/social network strategy with a role for coaches as guides (apomediaries) who facilitate skill acquisition using technology.

Assessing Diabetes-Relevant Data Provided by Undergraduate and Crowdsourced Web-Based Survey Participants for Honesty and Accuracy

Background

To eliminate health disparities, research will depend on our ability to reach select groups of people (eg, samples of a particular racial or ethnic group with a particular disease); unfortunately, researchers often experience difficulty obtaining high-quality data from samples of sufficient size.

Objective

Past studies utilizing MTurk applaud its diversity, so our initial objective was to capitalize on MTurk’s diversity to investigate psychosocial factors related to diabetes self-care.

Methods

In Study 1, a “Health Survey” was posted on MTurk to examine diabetes-relevant psychosocial factors. The survey was restricted to individuals who were 18 years of age or older with diabetes. Detection of irregularities in the data, however, prompted an evaluation of the quality of MTurk health-relevant data. This ultimately led to Study 2, which utilized an alert statement to improve conscientious behavior, or the likelihood that participants would be thorough and diligent in their responses. Trap questions were also embedded to assess conscientious behavior.

Results

In Study 1, of 4165 responses, 1246 were generated from 533 unique IP addresses completing the survey multiple times within close temporal proximity. Ultimately, only 252 responses were found to be acceptable. Further analyses indicated additional quality concerns with this subsample. In Study 2, as compared with the MTurk sample (N=316), the undergraduate sample (N=300) included more females, and fewer individuals who were married. The samples did not differ with respect to race. Although the presence of an alert resulted in fewer trap failures (mean=0.07) than when no alert was present (mean=0.11), this difference failed to reach significance: F_1,604=2.5, P=.11, ƞ²=.004, power=.35. The modal trap failure response was zero, while the mean was 0.092 (SD=0.32). There were a total of 60 trap failures in a context where the potential could have exceeded 16,000.

Conclusions

Published studies that utilize MTurk participants are rapidly appearing in the health domain. While MTurk may have the potential to be more diverse than an undergraduate sample, our efforts did not meet the criteria for what would constitute a diverse sample in and of itself. Because some researchers have experienced successful data collection on MTurk, while others report disastrous results, Kees et al recently identified that one essential area of research is of the types and magnitude of cheating behavior occurring on Web-based platforms. The present studies can contribute to this dialogue, and alternately provide evidence of disaster and success. Moving forward, it is recommended that researchers employ best practices in survey design and deliberately embed trap questions to assess participant behavior. We would strongly suggest that standards be in place for publishing the results of Web-based surveys—standards that protect against publication unless there are suitable quality assurance tests built into the survey design, distribution, and analysis.

Internet Recruitment of Asian American Breast Cancer Survivors

The purpose of this article is to identify practical issues in Internet recruitment of racial/ethnic minorities by analyzing an Internet intervention study conducted with Asian American breast cancer survivors, and to propose directions for recruitment of racial/ethnic minorities for future Internet research. Six practical issues were identified: (a) a relatively fewer number of Internet communities/groups; (b) hindrances in establishing authenticity;

The Inclusion of African-American Study Participants in Web-Based Research Studies: Viewpoint

The use of Web-based methods for research recruitment and intervention delivery has greatly increased as Internet usage continues to grow. These Internet-based strategies allow for researchers to quickly reach more people. African-Americans are underrepresented in health research studies. Due to this, African-Americans get less benefit from important research that could address the disproportionate health outcomes they face. Web-based research studies are one promising way to engage more African-Americans and build trust with the African-American community. With African-Americans’ increasing access to the Internet using mobile phones and other mobile phone technologies, we advocate for efforts to increase the representation of African-Americans in research studies by using the Internet as a recruitment tool and conclude with recommendations that support this goal.

New mothers' interest in web-based health promotion: association with healthcare barriers, risk status, and user characteristics

OBJECTIVE

Our first aim was to assess the contributions of health-related risks, barriers to healthcare, and user characteristics to new mothers' interest in two Web-based health programs: postpartum weight loss or parenting advice. Our second aim was to determine if the preceding proximal variables diminished associations of income level with interest in Web-based health programs.

SUBJECTS AND METHODS

A mail survey of a stratified random sample was conducted with a resulting analytic sample that included 121 white/Anglo, African American, or Hispanic women of higher and lower income. Weight risk (being overweight or obese) and psychosocial/behavioral risk (alcohol use, depression, smoking) were the predictors of interest in a weight loss program and parenting advice, respectively. Financial, structural, and function factors served as barriers to care. Frequency of Internet use assessed user characteristics. Hierarchical logistic regression analysis was used to evaluate predictors.

RESULTS

Being overweight (adjusted odds ratio [OR], 5.55; 95% confidence interval [CI], 2.18, 14.11) was the only variable to affect likelihood of interest in an Internet-based weight loss program; income level was not a significant predictor. Having two or more psychosocial/behavioral risks (adjusted OR, 0.22; 95% CI, 0.50, 0.92) was the only predictor of interest in Internet-based parenting advice; income level was not a significant predictor after adjusting for other variables (OR, 0.55; 95% CI, 0.19, 1.55).

CONCLUSIONS

The type of risk and program topic decreased or increased likelihood of interest in Internet-based programming. Weight risks increased interest in weight loss programming, but psychosocial/behavioral risks deceased interest in parenting advice.

Cost-effectiveness of a long-term Internet-delivered worksite health promotion programme on physical activity and nutrition: a cluster randomized controlled trial

This study aims to evaluate the cost-effectiveness of a long-term workplace health promotion programme on physical activity (PA) and nutrition. In total, 924 participants enrolled in a 2-year cluster randomized controlled trial, with departments (n = 74) within companies (n = 6) as the unit of randomization. The intervention was compared with a standard programme consisting of a physical health check with face-to-face advice and personal feedback on a website. The intervention consisted of several additional website functionalities: action-oriented feedback, self-monitoring, possibility to ask questions and monthly e-mail messages. Primary outcomes were meeting the guidelines for PA and fruit and vegetable intake. Secondary outcomes were self-perceived health, obesity, elevated blood pressure, elevated cholesterol level and maximum oxygen uptake. Direct and indirect costs were calculated from a societal perspective, and a process evaluation was performed. Of the 924 participants, 72% participated in the first and 60% in the second follow-up. No statistically significant differences were found on primary and secondary outcomes, nor on costs. Average direct costs per participant over the 2-year period were €376, and average indirect costs were €9476. In conclusion, no additional benefits were found in effects or cost savings. Therefore, the programme in its current form cannot be recommended for implementation.

Initial and sustained participation in an internet-delivered long-term worksite health promotion program on physical activity and nutrition

Background

Determinants of participation in health promotion programs are largely unknown. To evaluate and implement interventions, information is needed regarding their reach as well as regarding the characteristics of program users and non-users.

Objective

In this study, individual, lifestyle, and health indicators were investigated in relation to initial, and sustained participation in an Internet-delivered physical activity and healthy nutrition program in the workplace setting. In addition, determinants of program website use were studied.

Methods

Determinants of participation were investigated in a longitudinal study among employees from six workplaces participating in a two-year cluster randomized controlled trial. The employees were invited by email to participate. At baseline, all participants visited a website to fill out the questionnaire on lifestyle, work, and health factors. Subsequently, a physical health check was offered, followed by face-to-face advice. Throughout the study period, all participants had access to a website with information on lifestyle and health, and to fully automated personalized feedback on the questionnaire results. Only participants in the intervention received monthly email messages to promote website visits during the first year and had access to additional Web-based tools (self-monitors, a food frequency questionnaire assessing saturated fat intake, and the possibility to ask questions) to support behavior change. Website use was monitored by website statistics measuring access. Logistic regression analyses were conducted to identify characteristics of employees who participated in the program and used the website.

Results

Complete baseline data were available for 924 employees (intervention: n=456, reference: n=468). Lifestyle and health factors were not associated with initial participation. Employees aged 30 years and older were more likely to start using the program and to sustain their participation. Workers with a low intention to increase their physical activity level were less likely to participate (Odds Ratio (OR)=0.60, 95% Confidence interval (95%CI), 0.43-0.85) but more likely to sustain participation throughout the study period (ORs ranging from 1.40 to 2.06). Furthermore, it was found that smokers were less likely to sustain their participation in the first and second year (OR=0.54, 95%CI 0.35-0.82) and to visit the website (OR=0.72, 95%CI 0.54-0.96). Website use was highest in the periods immediately after the baseline (73%) and follow-up questionnaires (71% and 87%). Employees in the intervention were more likely to visit the website in the period they received monthly emails (OR=5.88, 95%CI 3.75-9.20) but less likely to visit the website in the subsequent period (OR=0.62, 95%CI 0.45-0.85).

Conclusions

Modest initial participation and high attrition in program use were found. Workers with a low intention to change their behavior were less likely to participate, but once enrolled they were more likely to sustain their participation. Lifestyle and health indicators were not related to initial participation, but those with an unhealthy lifestyle were less likely to sustain. This might influence program effectiveness. Regular email messages prompted website use, but the use of important Web-based tools was modest. There is a need for more appealing techniques to enhance retention and to keep those individuals who need it most attracted to the program.

Trial Registration

ISRCTN52854353; http://www.controlled-trials.com/ISRCTN52854353

Case study: An ethics case study of HIV prevention research on Facebook: the Just/Us study

OBJECTIVE

To consider issues related to research with youth on social networking sites online.

METHODS

Description of the data collection process from 1,588 participants in a randomized controlled trial testing the efficacy of HIV prevention education delivered on Facebook. Using respondent-driven sampling, staff-recruited participants are encouraged to recruit up to three friends to enroll in the study.

RESULTS

Researchers should (a) consider whether an online social networking site is an appropriate place to implement a research study; (b) offer opportunities to review informed consent documents at multiple times and in multiple locations throughout the study; and (c) collect data outside the social networking site and store it behind secure firewalls to ensure it will not be accessible to any person on the social networking site.

CONCLUSIONS

Online social networks are growing in popularity. Conducting research on social media sites requires deliberate attention to consent, confidentiality, and security.

Challenges in recruiting South Asians into prevention trials: health professional and community recruiters' perceptions on the PODOSA trial

BACKGROUND

Recruitment of ethnic minority groups into trials is important. This was studied from the recruiters' perspective in the Prevention of Diabetes and Obesity in South Asians (PODOSA) trial.

METHODS

Semi-quantitative questionnaire survey of all 22 health professionals and 27 community workers involved in Edinburgh and Glasgow. Numbers and proportions were tabulated, while free-text responses were grouped into themes.

RESULTS

The response rate was 40/49 (82%). In the closed questions, family responsibilities, prior general practitioner screening and low interest were the main factors reported by recruiters as hindering referrals (each 28%), followed by fear of needle pricks and finding out their diabetes status (each 23%). The importance of the prevention of diabetes (60%), explaining the trial in a South Asian language (46%), verbal dialogue (43%) and the recruiter's personal relationship with the recruitee (40%) favoured referrals. Health professionals' perceived strength was their knowledge of diabetes (66%), and community workers' strength was explaining the trial in South Asian languages (65%). Strategies to improve recruitment included stronger partnership between researchers and community organizations. The open-ended response identified seven main themes: (1) shortage of recruiters' and recruitees' time; (2) poor understanding of the trial by recruitees; (3) lack of knowledge about the disease among recruitees; (4) lack of motivation and interest among recruitees; (5) delay in receiving appointments from the PODOSA team; (6) mistrust of research; and (7) narrow entry criteria.

CONCLUSION

These insights into recruiters' perspectives should help trialists improve participation by ethnic minority populations.

Socio-demographic psychosocial and clinical characteristics of participants in e-HealthyStrides©: an interactive ehealth program to improve diabetes self-management skills

Diabetes self-management (DSM) training helps prevent diabetic complications. eHealth approaches may improve its optimal use. The aims were to determine a) acceptability of e-HealthyStrides© (an interactive, Internet-based, patient-driven, diabetes self-management support and social networking program) among Morehouse Community Physicians' Network diabetics; b) efficacy for DSM behavior change c) success factors for use of e-HealthyStrides©. Baseline characteristics of pilot study participants are reported. Of those approached, 13.8% agreed to participate. Among participants, 96% were Black, 77% female; age 56±9.2 years; education: 44% college or higher and 15% less than 12th grade; 92.5% with home computers. Over half (51%) failed the Diabetes Knowledge Test. Nearly half (47%) were at goal A1C; 24% at goal blood pressure; 3% at goal LDL cholesterol level. Median (SD) Diabetes Empowerment Scale score = 3.93 (0.72) but managing psychosocial aspects = 3.89 (0.89) scored lower than other domains. There was low overall confidence for DSM behaviors. Assistance with healthy eating was the most frequently requested service. Requestors were more obese with worse A1C than others. Chronic care delivery scored average with high scores for counseling and problem solving but low scores for care coordination and follow up.

Demographic, behavioral, and psychosocial correlates of using the website component of a worksite physical activity and healthy nutrition promotion program: a longitudinal study

Background

Internet-delivered behavior change programs have the potential to reach a large population. However, low participation levels and high levels of attrition are often observed. The worksite could be a setting suitable for reaching and retaining large numbers of people, but little is known about reach and use of Internet-delivered health promotion programs in the worksite setting.

Objective

This study aimed (1) to gain more insight in the use of the website component of a worksite behavior change intervention and (2) to identify demographic, behavioral, and psychosocial factors associated with website use.

Methods

The study was an observational study among participants from 5 workplaces in a cluster randomized controlled trial. At baseline, all participants visited a study website to fill out the baseline questionnaire. Then a physical health check was done followed by face-to-face advice. After this contact, all participants received an email to promote visiting the website to view their health check results and the personal advice based on the baseline questionnaire. In the subsequent period, only participants in the intervention group received monthly email messages to promote website visits and were offered additional Web-based tools (self-monitors and a food frequency questionnaire [FFQ] assessing saturated fat intake) to support their behavior change. Website use was monitored by website statistics registering website access. Complete data were available for 726 employees. Logistic regression analyses were conducted to identify characteristics of employees who visited and used the website.

Results

In total, 43% of the participants visited the website after the email to promote website visits. Participants who were insufficiently physically active were less likely to visit the website (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.45-0.88), whereas individuals with an elevated total cholesterol level visited the website more often (OR 1.44, 95% CI 1.05-1.98). The monthly emails in the intervention group resulted in higher website use during a 3-month period (18% versus 5% in the reference group, OR 3.96, 95% CI 2.30-6.82). Participants with a positive attitude toward increasing physical activity were less likely to visit the website (OR 0.54, 95% CI 0.31-0.93) or to use the self-monitor and FFQ (OR 0.50, 95% CI 0.25-0.99). Female workers visited the website more often to monitor their behavior and to receive advice on fat intake (OR 2.36, 95% CI 1.14-4.90).

Conclusions

Almost half of the participants used the website component of a worksite behavior change program. Monthly emails were a prompt to visit the website, but website use remained low. More women than men used the website to obtain personalized advice for behavior change. No consistently higher participation was found among those with healthier behaviors. This health promotion program did not provide an indication that healthier subjects are more susceptible to health promotion.

Trial Registration

ISRCTN52854353; http://www.controlled-trials.com/ISRCTN52854353 (Archived by WebCite at http://www.webcitation.org/5smxIncB1)

Using the internet to screen for postpartum depression

OBJECTIVE

To examine the feasibility of using the Internet to screen for postpartum depressive symptoms.

METHODS

A total of 142 participants completed the Postpartum Depression Screening Scale (PDSS) and the Edinburgh Postnatal Depression Scale on the Internet, and these findings were compared with those administered in-person by the authors of the PDSS (Beck and Gable) in recruitment sources, demographic characteristics, psychometric properties, and prevalence of significant postpartum depressive symptoms.

RESULTS

Participants were more likely to be recruited through Internet websites than mailing sources in the Internet study, and participants in the in-person study were recruited through prenatal childbirth classes. A higher proportion of Hispanic and Asian women participated on the Internet compared to the in-person study. The PDSS had excellent internal consistencies and construct validity across Internet and in-person studies. The Internet sample also reported more risk for major postpartum depression (PPD) compared to the community sample (23% vs. 12%).

CONCLUSIONS

The Internet is a viable and feasible tool to screen for PPD. Implications for preventing and treating PPD on the Internet are discussed.

The utility of non-proportional quota sampling for recruiting at-risk women for microbicide research

In the context of a measurement development study designed to contextualize microbicide acceptability, a sample that represented a range of at-risk women and maintained the statistical power needed for validity analyses was required. A non-proportional quota sampling strategy focused on race/ethnicity and number of sexual partners was utilized. This strategy resulted in enrollment of approximately equal proportions of Latina (31%), Black (36%), and White (32%) women, and an approximately 1:2 ratio of single-partnered (29%) and multi-partnered (71%) women. About 17% of women screened were ineligible based on eligibility criteria; an additional 16% were ineligible based on quota closures. Most participants were recruited through word of mouth (39%), community-based organizations (19%), or media sources (19%). Women recruited through word of mouth had the highest screen-to-interview completion percentage (67%). Non-proportional quota sampling is a feasible option for ensuring adequate representation of sample characteristics in microbicide research, but this goal should be weighed against cost and staff burden.

Impact of the Health Insurance Portability and Accountability Act on participant recruitment and retention

Recruiting and retaining an adequate sample is critical to the success of any research project involving humans. Recent reports indicate that the Health Insurance Portability and Accountability Act (HIPAA) privacy rule has adversely affected research. Few resources are available to help researchers navigate the challenges to recruitment and retention after HIPAA privacy rule implementation. This article addresses obstacles to recruitment in prospective clinical research studies related to the HIPAA privacy rule, as well as HIPAA-compliant strategies to enhance recruitment and retention. Recruitment challenges discussed include evolving interpretations of the HIPAA regulations, inability to directly contact potential participants, complexity of HIPAA-required documents, increased costs of recruitment, and an expanding administrative burden. Among the strategies addressed are preparatory research reviews, using clinical collaborators and staff liaisons, prescreening potential participants, minimizing participant burden during the consent process, enhancing participant follow-up, facilitating recruitment for future studies, and streamlining compliance training for staff.

Reach, engagement, and retention in an Internet-based weight loss program in a multi-site randomized controlled trial

Background

Research increasingly supports the conclusion that well-designed programs delivered over the Internet can produce significant weight loss compared to randomized controlled conditions. Much less is known about four important issues addressed in this study: (1) which recruitment methods produce higher eHealth participation rates, (2) which patient characteristics are related to enrollment, (3) which characteristics are related to level of user engagement in the program, and (4) which characteristics are related to continued participation in project assessments.

Methods

We recruited overweight members of three health maintenance organizations (HMOs) to participate in an entirely Internet-mediated weight loss program developed by HealthMedia, Inc. Two different recruitment methods were used: personal letters from prevention directors in each HMO, and general notices in member newsletters. The personal letters were sent to members diagnosed with diabetes or heart disease and, in one HMO, to a general membership sample in a particular geographic location. Data were collected in the context of a 2×2 randomized controlled trial, with participants assigned to receive or not receive a goal setting intervention and a nutrition education intervention in addition to the basic program.

Results

A total of 2311 members enrolled. Bivariate analyses on aggregate data revealed that personalized mailings produced higher enrollment rates than member newsletters and that members with diabetes or heart disease were more likely to enroll than those without these diagnoses. In addition, males, those over age 60, smokers, and those estimated to have higher medical expenses were less likely to enroll (all P < .001). Males and those in the combined intervention were less likely to engage initially, or to continue to be engaged with their Web program, than other participants. In terms of retention, multiple logistic regressions revealed that enrollees under age 60 (P < .001) and those with higher baseline self-efficacy were less likely to participate in the 12-month follow-up (P = .03), but with these exceptions, those participating were very similar to those not participating in the follow-up.

Conclusions

A single personalized mailing increases enrollment in Internet-based weight loss. eHealth programs offer great potential for recruiting large numbers of participants, but they may not reach those at highest risk. Patient characteristics related to each of these important factors may be different, and more comprehensive analyses of determinants of enrollment, engagement, and retention in eHealth programs are needed.

A pilot Internet "value of health" panel: recruitment, participation and compliance

OBJECTIVES

To pilot using a panel of members of the public to provide preference data via the Internet

METHODS

A stratified random sample of members of the general public was recruited and familiarized with the standard gamble procedure using an Internet based tool. Health states were periodically presented in "sets" corresponding to different conditions, during the study. The following were described: Recruitment (proportion of people approached who were trained); Participation (a) the proportion of people trained who provided any preferences and (b) the proportion of panel members who contributed to each "set" of values; and Compliance (the proportion, per participant, of preference tasks which were completed). The influence of covariates on these outcomes was investigated using univariate and multivariate analyses.

RESULTS

A panel of 112 people was recruited. 23% of those approached (n = 5,320) responded to the invitation, and 24% of respondents (n = 1,215) were willing to participate (net = 5.5%). However, eventual recruitment rates, following training, were low (2.1% of those approached). Recruitment from areas of high socioeconomic deprivation and among ethnic minority communities was low. Eighteen sets of health state descriptions were considered over 14 months. 74% of panel members carried out at least one valuation task. People from areas of higher socioeconomic deprivation and unmarried people were less likely to participate. An average of 41% of panel members expressed preferences on each set of descriptions. Compliance ranged from 3% to 100%.

CONCLUSION

It is feasible to establish a panel of members of the general public to express preferences on a wide range of health state descriptions using the Internet, although differential recruitment and attrition are important challenges. Particular attention to recruitment and retention in areas of high socioeconomic deprivation and among ethnic minority communities is necessary. Nevertheless, the panel approach to preference measurement using the Internet offers the potential to provide specific utility data in a responsive manner for use in economic evaluations and to address some of the outstanding methodological uncertainties in this field.