Different types of distrust in clinical research among whites and African Americans

Development and validation of the Trust in Multidimensional Healthcare Systems Scale (TIMHSS)

CONTEXT

The COVID-19 pandemic has reignited a commitment from the health policy and health services research communities to rebuilding trust in healthcare and created a renewed appetite for measures of trust for system monitoring and evaluation. The aim of the present paper was to develop a multidimensional measure of trust in healthcare that: (1) Is responsive to the conceptual and methodological limitations of existing measures; (2) Can be used to identify systemic explanations for lower levels of trust in equity-deserving populations; (3) Can be used to design and evaluate interventions aiming to (re)build trust.

METHODS

We conducted a 2021 review of existing measures of trust in healthcare, 72 qualitative interviews (Aug-Dec 2021; oversampling for equity-deserving populations), an expert review consensus process (Oct 2021), and factor analyses and validation testing based on two waves of survey data (Nov 2021, n = 694; Jan-Feb 2022, n = 740 respectively).

FINDINGS

We present the Trust in Multidimensional Healthcare Systems Scale (TIMHSS); a 38-item correlated three-factor measure of trust in doctors, policies, and the system. Measurement of invariance tests suggest that the TIMHSS can also be reliably administered to diverse populations.

CONCLUSIONS

This global measure of trust in healthcare can be used to measure trust over time at a population level, or used within specific subpopulations, to inform interventions to (re)build trust. It can also be used within a clinical setting to provide a stronger evidence base for associations between trust and therapeutic outcomes.

Unraveling non-participation in genomic research: A complex interplay of barriers, facilitators, and sociocultural factors

Although genomic research offering next-generation sequencing (NGS) has increased the diagnoses of rare/ultra-rare disorders, populations experiencing health disparities infrequently participate in these studies. The factors underlying non-participation would most reliably be ascertained from individuals who have had the opportunity to participate, but decline. We thus enrolled parents of children and adult probands with undiagnosed disorders who had declined genomic research offering NGS with return of results with undiagnosed disorders (Decliners, n = 21) and compared their data to those who participated (Participants, n = 31). We assessed: (1) practical barriers and facilitators, (2) sociocultural factors-genomic knowledge and distrust, and (3) the value placed upon a diagnosis by those who declined participation. The primary findings were that residence in rural and medically underserved areas (MUA) and higher number of barriers were significantly associated with declining participation in the study. Exploratory analyses revealed multiple co-occurring practical barriers, greater emotional exhaustion and research hesitancy in the parents in the Decliner group compared to the Participants, with both groups identifying a similar number of facilitators. The parents in the Decliner group also had lower genomic knowledge, but distrust of clinical research was not different between the groups. Importantly, despite their non-participation, those in the Decliner group indicated an interest in obtaining a diagnosis and expressed confidence in being able to emotionally manage the ensuing results. Study findings support the concept that some families who decline participation in diagnostic genomic research may be experiencing pile-up with exhaustion of family resources - making participation in the genomic research difficult. This study highlights the complexity of the factors that underlie non-participation in clinically relevant NGS research. Thus, approaches to mitigating barriers to NGS research participation by populations experiencing health disparities need to be multi-pronged and tailored so that they can benefit from state-of -the art genomic technologies.

Age-Specific Barriers and Facilitators to Research Participation Amongst African Americans in Observational Studies of Memory and Aging

BACKGROUND

Black/African Americans experience a high burden of Alzheimer disease and related dementias yet are critically underrepresented in corresponding research. Understanding barriers and facilitators to research participation among younger and older African Americans is necessary to inform age-specific strategies to promote equity in studies of early- and late-onset neurodegenerative diseases.

STUDY DESIGN

Survey respondents (n = 240) rated barriers and facilitators of research participation. Age-specific differences were evaluated using nonparametric Kruskal-Wallis tests across respondents aged 18-44 years (n = 76), 45-64 years (n = 83), and ≥ 65 years (n = 81). Strategies to mitigate barriers and promote facilitators were further explored via community-based focus groups. Pooled frequency of common themes discussed in focus groups were evaluated and compared across different ages including ≥ 45 years, ≥ 65 years, and mixed ages ≥ 45 years.

RESULTS

Younger respondents (aged 18-44 and 45-64 years) expressed a greater need for flexibility in when, where, and how research testing takes place versus adults ≥ 65 years. Focus groups emphasized long-lasting consequences of systemic racism and the need to build and foster trust to resolve barriers and promote research engagement amongst African Americans.

DISCUSSION

Age-specific strategies are needed to increase engagement, address recruitment disparities, and promote retention of African American participants in memory and aging studies across the lifespan.

Perceptions of Caring Recruitment Among Older Adults: African Americans and Non-Latinx Whites

BACKGROUND

African Americans (AAs) are underrepresented in health-related research studies. Few studies have investigated how behaviors of study recruiters affect recruitment of older AAs versus non-Latinx Whites (NLWs).

OBJECTIVES

The aim of this study was to explore whether caring behaviors influence AA and NLW older adults' decision to participate in hypothetical, high-commitment, health-related research studies and differences in participants' enrollment decisions by race.

METHODS

Using a descriptive, cross-sectional study design, guided by Kristen Swanson's middle-range theory of caring, a research-savvy sample of 60 AA and 60 NLW adults (age > 65 years) were randomly assigned one of two written vignettes. The concept of caring behaviors was manipulated and illustrated in a hypothetical recruitment scenario. A participant feedback survey was used to assess (a) participants' perceptions of caring and uncaring behaviors exhibited by the fictitious research recruiter, (b) differences in their willingness to participate based on vignette type, and (c) participants' judgment of the research recruiter as being caring or uncaring. A chi-square test assessed the association among categorical variables (caring behavior and participants' race).

RESULTS

Participants who received the vignette with the high caring recruiter were more than twice as likely to agree to participate in the study than those who received the vignette with the low caring recruiter. AA and NLW participants did not differ in their likelihood to agree to participate. Participants who received the caring vignette and judged the recruiter as caring were 5 times as likely to agree to participate in the high-commitment study than those who received the uncaring vignette ( p < .001). Associations did not vary by race.

DISCUSSION

This experimental study of equally recruited older adults from an existing longitudinal study revealed that caring behaviors in recruitment strategies are associated with an increased likelihood of participation in high-commitment research with older adults. The research-savvy AA participants were just as likely to participate in the hypothetical high-commitment research as their NLW peers when the fictional research recruiter was perceived as having caring behaviors. When targeting specific populations, it is essential to employ nuanced recruitment approaches where the study recruiters are attuned to caring behaviors.

Testing Vicarious Experiences as Antecedents of Medical Mistrust: A Survey of Black and White Americans

In response to recent calls to examine medical mistrust antecedents, the present study investigated the influence of negative healthcare (personal, vicarious interpersonal, vicarious media) and racial discrimination (personal, vicarious interpersonal, vicarious media) experiences on medical mistrust, and whether these relationships were mediated by perceived racism and perceived financial corruption in healthcare. Multigroup structural equation modeling was utilized to test the model using a cross-sectional survey of Black and White adults. Personal negative healthcare experiences and vicarious media racial discrimination experiences were directly related to medical mistrust for Black and White participants. Additionally, personal negative healthcare experiences exerted indirect effects through both perceived racism in healthcare and perceived financial corruption in healthcare. Vicarious media racial discrimination experiences exerted indirect effects through perceived financial corruption for both Black and White participants and through perceived racism for Black participants. Finally, both types of vicarious interpersonal experiences and racial discrimination experiences exerted indirect effects through perceived racism for White participants. The findings have implications for medical mistrust scholarship going forward. It is necessary to acknowledge the role vicarious experiences plays in medical mistrust antecedents, which may include recognizing the impact of news depictions of racial discrimination on patients' behaviors. Additionally, there is a need to further investigate the role of perceived financial corruption in healthcare in medical mistrust.

Development and Validation of the Perceptions of Research Trustworthiness Scale to Measure Trust Among Minoritized Racial and Ethnic Groups in Biomedical Research in the US

IMPORTANCE

Historically, trust in biomedical research has been lower among minoritized racial and ethnic groups who are underrepresented in and excluded from research, with the same groups experiencing worse health outcomes. Unfortunately, instruments that measure trust may not capture components of trust relevant to minoritized racial and ethnic groups.

OBJECTIVE

To develop and validate a scale to measure trust in biomedical research among minoritized racial and ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, community-based survey study compared trust and distrust in biomedical research among Black, Latino, and White subgroups in the US using the Perceptions of Research Trustworthiness (PoRT) scale. The scale was developed between March 22, 2016, and September 19, 2018, as part of this study, and its structure, reliability, and validity were examined during pilot (n = 381) and validation (n = 532) phases between February 4, 2019, and July 27, 2021. Convenience samples of adult participants (aged ≥18 years) were recruited locally (Nashville, Tennessee, and San Antonio, Texas) and nationally through the ResearchMatch and Cint online platforms.

MAIN OUTCOMES AND MEASURES

Overall and individual item Trust and Distrust subscale scores were compared. Overall Trust and Distrust scores were compared by race and ethnicity using a Kruskal-Wallis H test and individual item scores were compared using independent samples t test.

RESULTS

Of the 532 participants in the scale validation study, 144 (27.1%) were Black, 90 (16.9%) were Latino, and 282 (53.0%) were White. Participants had a median age of 43 years (range, 18-90 years), 352 (66.2%) were women, and 198 (37.2%) had educational attainment levels less than a college degree. Factor analysis of the 18-item PoRT scale revealed a 2-factor structure with two 9-item PoRT subscales (Trust and Distrust), which demonstrated high internal consistency (Cronbach α = 0.72 and 0.87, respectively). Mean (SD) Trust subscale scores were lower among Black (34.33 [2.02]) and Latino (34.55 [1.97]) participants compared with White participants (36.32 [1.81]; P < .001). Mean (SD) Distrust subscale scores were higher among Black (21.0 [2.15]) and Latino (20.53 [2.21]) participants compared with White participants (18.4 [2.03]; P < .001). Individual item results showed that Black and Latino participants were less trusting and more distrusting than White individuals on items related to risks, harms, secrecy, confidentiality, and privacy.

CONCLUSIONS AND RELEVANCE

These findings suggest that the PoRT scale incorporates trust and trustworthiness concepts relevant among Black and Latino individuals and may allow more precise assessment of trust in research among these groups.

Leveraging multistakeholder engagement to develop an implementation blueprint for a brief trauma-focused cognitive behavioral therapy in primary care

Objective: The implementation of evidence-based treatments (EBTs) to address posttraumatic stress disorder (PTSD) is a public health priority. Successful EBT implementation requires effective collaboration between multiple stakeholder groups, including hospital leaders, providers, and patients, to build buy-in for this effort. Method: We describe our implementation science approach to meaningful stakeholder engagement, as part of a hybrid type I effectiveness-implementation trial of Skills Training in Affective and Interpersonal Regulation for PTSD treatment in primary care (STAIR-PC) at a large safety net hospital. We used primary care and patient community advisory boards (CABs) to interpret key informant interviews and identify strategies to adapt the intervention to ensure fit with the primary care setting. We documented our stakeholder engagement methodology through comprehensive field notes and minutes from CAB meetings, detailing the focus of meetings, suggestions for intervention and delivery adaptations, decision-making processes, and how disagreements about adaptations between stakeholders were resolved. To support replicability, we specify and operationalize implementation strategies to be used across each implementation phase of the trial. Results: Key strategies involved a) ensuring that research questions are relevant to both patients and clinical providers; b) tailoring interventions that are flexible and adaptable to the needs of the local setting; c) continuous engagement of patients and providers throughout the implementation process; and d) building mutual respect, trust, and credibility between the research team, various provider groups, and patients. Conclusions: Our approach to engaging stakeholders informed an implementation blueprint to guide implementation of EBTs for PTSD in safety net hospital primary care clinics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Beyond Personal Experiences: Examining Mediated Vicarious Experiences as an Antecedent of Medical Mistrust

African Americans consistently report higher levels of medical mistrust than their White counterparts. As a result, medical mistrust is considered to be a contributor to racial health disparities. Despite calls to address medical mistrust, few studies have explicitly examined it as a phenomenon of interest; those that have, tended to focus on personal experiences while neglecting vicarious experiences. The current study a) explicitly tests the effects of two types of news story content on reported levels of medical mistrust within an African American adult sample and b) examines two widely used medical mistrust measures. Participants (N = 410) were randomly assigned to view a news story based on a 2 (health care, non-health care) x 2 (racial discrimination, nonracial discrimination) experimental design. Results indicated that individually, both health care content and racial discrimination content increased race-based medical mistrust, but had no effect on general medical mistrust. However, when all four conditions were examined, exposure to health-related racial discrimination stories resulted in higher levels of race-based and general medical mistrust than non-health, nonracial discrimination stories. Findings are discussed in terms of the theoretical and practical implications for health communication scholars.

African American Women's Maternal Healthcare Experiences: A Critical Race Theory Perspective

Black women are experiencing pregnancy-related complications at a significantly higher rate than women of other races in the U.S., as Black women are three to four times likely to die from pregnancy-related complications compared to non-Hispanic White women. Structural barriers and different forms of marginalization continue to limit Black women's access to quality healthcare services. Through critical race theory, we examine what structural barriers exist in the U.S. healthcare system, one that limits access to quality care during their prenatal and postnatal doctor's visits. Using qualitative in-depth interviews, 31 African American women, living in Milwaukee, WI, shared their pregnancy stories. The emergent themes include, institutionalized care - racially insensitive biomedical approach, race and class - unfair treatment based on health insurance, and race as a social concept - dismissed pain concerns because you are a strong Black woman. These themes reveal the experience of racial discrimination toward African American women through healthcare [communicative] practices that are often times seen as "standard" practices, albeit marginalizing minority populations. Findings from this study offer insights for healthcare providers on communicative practices that foster a racially-safe healthcare environment for African American women.

Perceived discrimination, adherence to antiretroviral therapy, and HIV care engagement among HIV-positive black adults: the mediating role of medical mistrust

Perceived discrimination and medical mistrust are contributors to HIV inequities. The current study examined whether medical mistrust mediated the associations between perceived discrimination and adherence to antiretroviral therapy (ART) as well as care engagement in a sample of 304 Black adults living with HIV. Perceived discrimination and medical mistrust were measured using validated scales; ART adherence was electronically monitored for a month; care engagement was determined by medical record data. Results support significant total indirect effects from perceived discrimination (due to HIV-serostatus, race, sexual orientation) to ART adherence through three types of medical mistrust (towards healthcare organizations, one's physician, and HIV-specific mistrust). The total indirect effects were also significant for care engagement and were largely driven by mistrust towards one's own physician. Findings suggest interventions at the provider or healthcare organization levels should address medical mistrust to improve the health and well-being of Black Americans living with HIV.

Predictors of Participation in Clinical Research

Supplemental digital content is available in the text.

Background

Despite numerous efforts to create more equitable healthcare systems, minority populations face long-standing health disparities compared to White populations. Healthcare research is the necessary foundation for creating equitable health systems and providing patient-centered care. Significant challenges exist, however, with recruiting and engaging underrepresented populations in clinical research.

Objectives

The purpose of this analysis was to determine how research participants' race, trust, and level of education influence participation barriers in clinical research.

Methods

The study used secondary, cross-sectional survey data that were collected between 2014 and 2016 through the former Mid-South Clinical Data Research Network, currently known as the Stakeholders, Technology, and Research Clinical Research Network. Descriptive statistics and Spearman rank correlations were performed between level of education, level of trust, and each attitude statement for each racial category.

Results

A total of 2,190 survey responses were used in the data analysis. The mean age of respondents was 52 years, with majority being women, White, insured, and working full time. Overall, the respondents had favorable attitudes toward research participation. Trust was correlated with agreement in many attitude statements for both White and African American respondents, whereas correlations with education level were more variable depending on racial grouping. Trust level was negatively associated with agreement toward the statement “researchers do not care about me” in White and Native American respondents.

Discussion

The results support the importance of trust to research participation. Generally, education level was not strongly predictive of research participation, although prediction was influenced by race and attitude.

Do prisoners trust the healthcare system?

BACKGROUND

Individuals who are incarcerated have greater healthcare needs than non-justice-involved individuals, yet incarcerated individuals often report substandard care. There are disproportionate numbers of black, indigenous, and people of color (BIPOC) in prison, who, even in general society face greater obstacles to accessing healthcare and have worse health outcomes due to structural racism. Regardless of race, people with criminal justice involvement often report stigma from the non-carceral healthcare system. Providing sufficient healthcare in carceral settings themselves is complicated by lack of privacy and the inherent dialectic of prisons that restrict freedom and providers focusing on healing and health. Based on these adverse experiences, people who are incarcerated may have decreased distrust in the healthcare system, deterring individuals from getting adequate medical care.

METHODS

In this exploratory study, health care system distrust was evaluated among 200 people who were incarcerated using the Revised Health Care System Distrust scale, a community-validated, 9-item measure comprised of 2 subscales (values and competence distrust).

RESULTS

Distrust was moderately and positively associated with participant age (r_s = 0.150, p = 0.034), with the second-oldest quintile (33 to 42-year-olds) reporting the highest level of overall and competence distrust. Participants identifying as Non-Latinx White reported higher competence distrust compared to Latinx and Non-Latinx/Non-White respondents.

CONCLUSIONS

These preliminary findings suggest that select groups of prisoners may be less likely to trust the healthcare system, highlighting an impediment to receiving adequate care while incarcerated. Further study of this topic is warranted.

An Investigation of Associations Between Race, Ethnicity, and Past Experiences of Discrimination with Medical Mistrust and COVID-19 Protective Strategies

This study investigates the associations between three forms of discrimination, race and ethnicity, general medical mistrust, health-specific COVID-19 conspiracy beliefs, and adherence to COVID-19 protective behaviors. Participants (n = 963) completed an online survey during May 2020, when stay-at-home orders and other government mandates were implemented in many states. Results indicate that everyday discrimination and healthcare discrimination were associated with significantly higher general medical mistrust, and healthcare discrimination and structural discrimination were associated with higher endorsement of health-specific COVID-19 conspiracy beliefs. Higher endorsement of health-specific COVID-19 conspiracy beliefs, but not general medical mistrust, was associated with significantly lower engagement in health-specific COVID-19 conspiracy beliefs. This study helps to contextualize racial health disparities during the COVID-19 pandemic and the widespread impact of everyday, structural, and healthcare discrimination in society.

Assessing Perceived Discrimination as Reported by Black and White Women Diagnosed with Breast Cancer

OBJECTIVE

Although a number of factors contribute to racial disparities in breast cancer outcomes, perceived discrimination in healthcare may be a key factor that hinders positive interactions and negatively impacts patient outcomes. The goals of our study were to (1) assess the prevalence of perceived discrimination as reported by breast cancer patients and (2) identify factors related to discrimination in women overall as well as by race.

DESIGN

This study is a secondary analysis of a larger study, "Narrowing the Gaps in Adjuvant Therapy," where a convenience sample of 359 women completed one telephone survey assessing sociodemographics, and attitudes and beliefs concerning breast cancer treatments and care. Chi-square analysis was used to assess the relationship of categorical variables with perceived discrimination, while the F-test was employed for continuous variables. Logistic regression determined predictors of perceived discrimination, a dichotomous variable (none vs. any).

RESULTS

A majority of women were Black (58%), privately insured (85%), and had at least a Bachelor's degree (48%). Discrimination was reported by 32.4% of women, with significantly more Black women reporting discrimination than White women. Insurance status, attitudes toward treatment, and distress factors were significantly related to perceived discrimination. In the logistic model, women who were less trusting of their providers (OR = 0.863 [0.751, 0.993], p = .021) and Black women (OR = 7.241 [0.751, 0.993], p = .039) were more likely to report incidences of discrimination.

CONCLUSIONS

Our findings suggest a need to understand Black survivor's experiences with healthcare. Similarly, future work must focus on identifying ways to improve provider trust amongst breast cancer survivors.

Effect of an Early Palliative Care Telehealth Intervention vs Usual Care on Patients With Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial

IMPORTANCE

National guidelines recommend early palliative care for patients with advanced heart failure, which disproportionately affects rural and minority populations.

OBJECTIVE

To determine the effect of an early palliative care telehealth intervention over 16 weeks on the quality of life, mood, global health, pain, and resource use of patients with advanced heart failure.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, intervention vs usual care randomized clinical trial was conducted from October 1, 2015, to May 31, 2019, among 415 patients 50 years or older with New York Heart Association class III or IV heart failure or American College of Cardiology stage C or D heart failure at a large Southeastern US academic tertiary medical center and a Veterans Affairs medical center serving high proportions of rural dwellers and African American individuals.

INTERVENTIONS

The ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers) intervention comprises an in-person palliative care consultation and 6 weekly nurse-coach telephonic sessions (20-40 minutes) and monthly follow-up for 48 weeks.

MAIN OUTCOMES AND MEASURES

Primary outcomes were quality of life (as measured by the Kansas City Cardiomyopathy Questionnaire [KCCQ]: score range, 0-100; higher scores indicate better perceived health status and clinical summary scores ≥50 are considered "fairly good" quality of life; and the Functional Assessment of Chronic Illness Therapy-Palliative-14 [FACIT-Pal-14]: score range, 0-56; higher scores indicate better quality of life) and mood (as measured by the Hospital Anxiety and Depression Scale [HADS]) over 16 weeks. Secondary outcomes were global health (Patient Reported Outcome Measurement System Global Health), pain (Patient Reported Outcome Measurement System Pain Intensity and Interference), and resource use (hospital days and emergency department visits).

RESULTS

Of 415 participants (221 men; baseline mean [SD] age, 63.8 [8.5] years) randomized to ENABLE CHF-PC (n = 208) or usual care (n = 207), 226 (54.5%) were African American, 108 (26.0%) lived in a rural area, and 190 (45.8%) had a high-school education or less, and a mean (SD) baseline KCCQ score of 52.6 (21.0). At week 16, the mean (SE) KCCQ score improved 3.9 (1.3) points in the intervention group vs 2.3 (1.2) in the usual care group (difference, 1.6; SE, 1.7; d = 0.07 [95% CI, -0.09 to 0.24]) and the mean (SE) FACIT-Pal-14 score improved 1.4 (0.6) points in the intervention group vs 0.2 (0.5) points in the usual care group (difference, 1.2; SE, 0.8; d = 0.12 [95% CI, -0.03 to 0.28]). There were no relevant between-group differences in mood (HADS-anxiety, d = -0.02 [95% CI, -0.20 to 0.16]; HADS-depression, d = -0.09 [95% CI, -0.24 to 0.06]).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial with a majority African American sample and baseline good quality of life did not demonstrate improved quality of life or mood with a 16-week early palliative care telehealth intervention. However, pain intensity and interference (secondary outcomes) demonstrated a clinically important improvement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

African Americans experience disproportionate neurodegenerative changes in the medulla and upper cervical spinal cord in early multiple sclerosis

OBJECTIVE

To compare the temporal changes in the 3-dimensional (3D) structure of the medulla-upper cervical spinal cord region in African American (AA) and white multiple sclerosis (MS) patients to identify early patterns of anatomical change prior to progressive symptom development.

METHODS

Standardized 3-Tesla 3D brain MRI studies were performed at two time points on AA and white MS patients along with controls. Longitudinal changes in volume, surface area, tissue compliance, and surface texture measured in total and within ventral and dorsal compartments were studied. Independent regression models were constructed to evaluate differences between groups.

RESULTS

Thirty-five individuals were studied, 10 AA with MS (female (F): 8; median age [IQR]=33.8 years (y) [10.9], median disease duration: 11.8y [11.3]), 20 white MS patients (F: 10; 35.6y [17.4], 7.23y [8.83], and 5 controls (F: 2, 51.8y [10.2]). Expanded Disability Status Scale scores were 0.0 at baseline and at the second MRI time point. Within the medulla-upper cervical spinal cord, AA versus white MS patients exhibited greater rates of atrophy in total (p<0.0001) and within the ventral (p<0.0001) and dorsal (p<0.0001) compartments, reduced surface area (p<0.0001), and reduced tissue compliance in the ventral (p=0.002) and dorsal (p=0.0005) compartments. The rate of change at the dorsal surface, but not the ventral surface, between MRI time points was also greater in AA relative to white MS patients (p<0.0001).

CONCLUSION

Structural changes in distinct anatomical regions of the medulla-upper cervical spinal cord may be reflective of early and disproportionate neurodegeneration in AA MS as compared to whites.

Improving community participation in clinical and translational research: CTSA Sentinel Network proof of concept study

BACKGROUND

Research participation by members of racial or ethnic minority groups continues to be less than optimum resulting in difficulties to generalization of research findings. Community-engaged research that relies on a community health worker (CHW) model has been found effective in building trust in the community, thereby motivating people to participate in health research. The Sentinel Network study aimed at testing the feasibility of utilizing the CHW model to link community members to appropriate health research studies at each of the research sites.

METHODS

The study was conducted at six Clinical and Translational Science Award institutions (N = 2371) across the country; 733 (30.9%) of the participants were from the University of Florida, 525 (22.0%) were from Washington University in St. Louis, 421 (17.8%) were from the University of California, Davis, 288 (12.1%) were from the University of Michigan, Ann Arbor, 250 (10.5%) were from Rochester, and 154 (6.5%) from Albert Einstein College of Medicine. Trained CHWs from each of these sites conducted regular community outreach where they administered a Health Needs Assessment, provided medical and social referrals, and linked to eligible research studies at each of those sites. A 30-day follow-up assessment was developed to track utilization of services satisfaction with the services and research study participation.

RESULTS

A large majority of people, especially African Americans, expressed willingness to participate in research studies. The top two health concerns reported by participants were hypertension and diabetes.

CONCLUSION

Findings on the rate of navigation and enrollment in research from this study indicate the effectiveness of a hybrid CHW service and research model of directly engaging community members to encourage people to participate in research.

Clinical Trials Participation Among African Americans and the Ethics of Trust: Leadership Perspectives

Background

Assuring health equity throughout the U.S. continues to challenge the public and private research enterprise. Even with some progress, racial and ethnic health disparities continue, particularly among African Americans. Health equity for African Americans is improbable unless participation in clinical trials is measurably increased.

Method

To inform efforts to enhance participation, interviews were conducted with three African American leadership groups from across the country to document their perceptions of why the research community is unable to engage African Americans effectively in clinical trials. The results of thirty-five interviews, conducted from three leadership groups, were analyzed and are reported in this article. The leadership groups include health/education, faith, and civic society.

Ethical Considerations

This research was conducted based upon the ethical protocols of the National Center for Bioethics in Research and Health Care, research ethics, and confidentiality.

Results

Findings indicate that trustworthiness must precede trust; both are essential in enhancing African American participation in research, especially in less understood clinical trials.

Conclusion

Respondents agreed that the research community must demonstrate trustworthiness before trust can be established. They also indicated the importance of increasing the number of African American researchers in leadership roles. Also, suggestions were made regarding the need to develop short and long-term positive relationships between the research community and the African American population, at various levels, if increases in participation in clinical trials are expected. With the likely development of new clinical research and the attention to increasing excess deaths among African Americans, there must be representative numbers of African Americans and other underserved populations in leadership roles if health disparities are to be eliminated and health equity is to be achieved.

Race and Blackness: A Thematic Review of Communication Challenges Confronting the Black Community Within the U.S. Health Care System

Effective communication is integral to the patient–provider relationship. Yet, as a result of structural factors that ignore the unique health care needs of different populations of patients who identify as Black—both African American and African immigrants—are confronted with communication challenges during health care seeking encounters. Using cultural safety as a framework, in this article, we thematically review communication challenges specifically experienced by patients of African descent in the U.S. health care system. In our review, we focus on complications that might arise from discrimination, mistrust, health literacy, and impacts of culture and language barriers on health literacy. In conclusion, we offer recommendations for improving the health care experiences and potential health outcomes for this population, through nursing care and health care delivery.

'Becoming-with' a repeat healthy volunteer: Managing and negotiating trust among repeat healthy volunteers in commercial clinical drug trials

Recent sociological research has raised important sociological and ethical questions about the role of financial rewards in terms of healthy volunteer involvement in clinical trials. Research suggests that it would be parochial to assume financial rewards alone are sufficient to explain repeat healthy volunteering. This paper explores other factors that might explain repeat healthy volunteering behaviours in phase I clinical drug trials. Drawing on qualitative research with healthy volunteers, the paper argues that while healthy volunteers make rational decisions to take part in drug trials, understanding how they become repeat volunteers requires considering varied relationships and networks involved. Drawing on Deleuze's concept of 'event' and 'becoming-with', the paper illustrates the relational, processual and embodied nature of trust in repeat healthy volunteer involvement in clinical drug trials. The paper concludes that repeat healthy volunteering is a constant flux of negotiating trust and mistrust. The paper contributes to sociological debates about trust and public engagement with technological innovations to illustrate trust among healthy volunteers as processual and changeable.

Training Needs of Clinical and Research Professionals to Optimize Minority Recruitment and Retention in Cancer Clinical Trials

The study of disparities in minority recruitment to cancer clinical trials has focused primarily on inquiries among minority patient populations. However, clinical trial recruitment is complex and requires a broader appreciation of the multiple factors that influence minority participation. One area that has received little attention is minority recruitment training for professionals who assume various roles in the clinical trial recruitment process. Therefore, we assessed the perspectives of cancer center clinical and research personnel on their training and education needs toward minority recruitment for cancer clinical trials. Ninety-one qualitative interviews were conducted at five U.S. cancer centers among four stakeholder groups: cancer center leaders, principal investigators, referring clinicians, and research staff. Interviews were recorded and transcribed. Qualitative analyses focused on response data related to training for minority recruitment for cancer clinical trials. Four prominent themes were identified: (1) Research personnel are not currently being trained to focus on recruitment and retention of minority populations; (2) Training for minority recruitment and retention provides for a specific focus on factors influencing minority research participation; (3) Training on cultural awareness may help to bridge cultural gaps between potential minority participants and research professionals; (4) Views differ regarding the importance of research personnel training designed to focus on recruitment of minority populations. There is a lack of systematic training for minority recruitment. Many stakeholders acknowledged the benefits of minority recruitment training and welcomed training that focuses on increasing cultural awareness to increase the participation of minorities in cancer clinical trials.

Does Discrimination Breed Mistrust? Examining the Role of Mediated and Non-Mediated Discrimination Experiences in Medical Mistrust

Medical mistrust is associated with a decreased likelihood of engaging in various health behaviors, including health utilization and preventive screening. Despite calls for research to address medical mistrust, few studies have explicitly delved into antecedents to medical mistrust. The current study a) examines the relationship between discrimination experiences and medical mistrust and b) experimentally tests the influence of mediated vicarious discrimination on reported levels of medical mistrust. Participants (N = 198) were randomly assigned to view news stories in one of four experimental conditions: no exposure, no discrimination control, implicit racial discrimination, and explicit racial discrimination. Results indicated prior personal and vicarious discrimination experiences were related to medical mistrust. Furthermore, exposure to mediated discrimination influenced medical mistrust in different ways for Black and White participants. Among Black participants, medical mistrust was significantly higher for those exposed to the implicit racial discrimination condition than the control condition. Marginal differences were found for White participants such that those exposed to both explicit and implicit racial discrimination conditions reported higher medical mistrust than those exposed to the control condition. Our findings are discussed in terms of the theoretical and practical implications for health communication scholars seeking to examine and influence health behaviors.

Attitudes Toward Genomic Testing and Prostate Cancer Research Among Black Men

INTRODUCTION

Black men are diagnosed with prostate cancer at nearly twice the rate of white men and are underrepresented in prostate cancer research, including validation studies of new clinical tools (e.g., genomic testing). Because healthcare system mistrust has contributed to these disparities for centuries, black men may be less inclined to pursue novel testing, and identification of facilitators to their participation in prostate cancer research studies remains warranted.

METHODS

A community-engaged approach involving a partnership with a community organization was used to conduct seven focus groups in Minnesota, Alabama, and California to explore black men's attitudes toward prostate cancer research participation and genomic testing for prostate cancer. Data were collected and analyzed from April 2015 to April 2017.

RESULTS

Identified genomic testing barriers included a lack of terminology understanding, healthcare system mistrust, reluctance to seek medical care, and unfavorable attitudes toward research. Facilitators included family history, value of prevention, and the desire for health education. Lack of prostate cancer knowledge, prostate-specific antigen testing confusion, healthcare system distrust, and misuse of personal health information were barriers to research study participation. Some black men were motivated to participate in research if it was seen as constructive and transparent.

CONCLUSIONS

Disparities for black men can both motivate and disincentivize participation depending upon a positive or negative view of research. Confusion over prostate cancer clinical care has fueled some mistrust among black men affecting both clinical care and research participation. With increased education, health literacy, and assurances of research integrity and transparency, black men may be more willing to participate in prostate cancer testing and research.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Representativeness of patients enrolled in a primary care clinical trial for heavy/problem substance use

BACKGROUND

The extent to which participants in randomized clinical trials (RCTs) resemble their broader target groups is of particular concern when studying stigmatized conditions such as substance use disorders (SUDs). The present study compared patients who enrolled in a 4-arm clinical trial of SBIRT (screening, brief intervention, and referral to treatment) with eligible patients who declined study participation.

METHODS

Participants (N = 1338) were primary care patients who anonymously completed a computer-delivered health survey and screened positive for heavy/problem alcohol or drug use. Those who consented to the RCT (n = 713) were compared with those who declined (n = 625) on a variety of demographic, substance use, and psychosocial characteristics. Variables significant at P < .20 in univariate analyses were then examined using multivariate logistic regression to determine their combined effect.

RESULTS

The sample was 60% female and 76% African American, with a mean age of 45.2 years. Patients who consented to participate differed from those who declined on 34 (60%) of the 57 variables studied. The most parsimonious model by multivariate regression found that those who consented were older, more likely to be unemployed, and more likely to endorse prescription drug misuse, problems related to drug use, family history of alcohol problems, trouble falling asleep, and a health professional recommendation to lose weight.

CONCLUSION

Patients consenting to the RCT reported a greater number and more severe psychosocial and mental health problems than those who declined study participation. If the higher level of risk among study participants was found in other studies as well, it would raise questions regarding the generalizability of RCT results to broader clinic samples.

Bridging the Data Gap in Breast Cancer Risk Assessment to Enable Widespread Clinical Implementation across the Multiethnic Landscape of the US

Breast cancer remains the second leading cause of cancer death among women and is the most commonly diagnosed cancer in women. Breast cancer risk assessment has been clinically available for nearly 30 years yet is under-utilized in practice for multiple reasons. Incorporation of polygenic risk as well as breast density measurements, promise to increase the accuracy of risk assessment. With that comes the hope that both prevention and screening become more personalized and thus more effective. Incidence rates have been static over the past 15 years and have even increased slightly in African American and Asian/Pacific Islander populations despite the robust data on breast cancer risk reduction measures that exist. Current challenges in reducing breast cancer incidence begin with robust data curation that allows for appropriate risk stratification across our multiethnic population and conclude with the implementation of prevention strategies within our fractured healthcare system.

Local-Level Adult Influenza and Pneumococcal Vaccination Disparities: Chicago, Illinois, 2015-2016

OBJECTIVES

To investigate local-level adult influenza and pneumococcal vaccination disparities to inform targeted interventions.

METHODS

Questions on influenza and pneumococcal vaccination uptake were included in a door-to-door community-based representative survey conducted in 10 Chicago, Illinois, neighborhoods in 2015 and 2016. A total of 1543 adults completed the survey, including 172 adults aged 65 years or older. We calculated adult influenza (≥ 18 years) and pneumococcal (≥ 65 years) vaccination coverage by community area and respondent characteristics.

RESULTS

We observed significant differences in pneumococcal vaccination coverage between community areas (range = 18%-91%). Influenza vaccination coverage differed by gender, age, insurance coverage, acculturation, and confidence or trust in physician. Non-Hispanic Blacks were more likely to be vaccinated when they had higher confidence or trust in their physician (45% vs 20%; P < .01). Mexicans who reported less acculturation were more likely to be vaccinated than were Mexicans who were more acculturated (41% vs 27%; P = .02).

CONCLUSIONS

Striking disparities between neighborhoods and racial/ethnic groups in adult influenza and pneumococcal vaccination coverage highlight the need for improved local-level immunization coverage data.

Adherence, persistence, and discontinuation among Hispanic and African American patients with multiple sclerosis treated with fingolimod or glatiramer acetate

OBJECTIVE

Few studies have examined compliance to disease-modifying therapies (DMTs) for multiple sclerosis (MS) in minority populations. This study compared adherence, discontinuation, and persistence for fingolimod (FTY) and glatiramer acetate (GA) initiators among Hispanic and African American patients with MS.

METHODS

This retrospective claims data study examined Hispanic and African American adults with MS who initiated FTY or GA between September 1, 2010 and June 30, 2014. Outcomes (adherence, discontinuation, and persistence) were analyzed descriptively and with multivariable models, comparing FTY and GA cohorts within racial/ethnic groups. Adherence was assessed using medication possession ratio (MPR) and proportion of days covered (PDC).

RESULTS

There were 171 patients in the Hispanic group (62 FTY, 109 GA) and 210 in the African American group (71 FTY, 139 GA). A larger proportion of GA initiators than FTY initiators were treatment-naïve; other baseline characteristics were similar between cohorts. Hispanic FTY initiators had greater mean MPR, PDC, and persistence and less discontinuation than GA initiators. African American FTY initiators had greater mean PDC than GA initiators; other outcomes favored FTY but were not statistically significant. Multivariable analysis results were consistent with the unadjusted results, but differences between treatment cohorts were not statistically significant.

CONCLUSIONS

Hispanic and African American patients with MS who initiated FTY had higher adherence than those who initiated GA, similar to the general MS population. These findings suggest that adherence should be considered in DMT selection, and racial/ethnic variations in MS disease course may not be primarily attributable to differences in DMT compliance.

A paradigm for understanding trust and mistrust in medical research: The Community VOICES study

BACKGROUND

To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple variables have been identified as factors associated with research participant trust/mistrust. A conceptual model that provides meaningful insight into the interplay of factors impacting trust may promote more ethical research practice and provide an enhanced, actionable understanding of participant mistrust.

METHODS

A structured survey was developed to capture attitudes toward research conducted in emergency situations; this article focuses on items designed to assess respondents' level of trust or mistrust in medical research in general. Community-based interviews were conducted in English or Spanish with 355 New York City residents (white 42%, African American 29%, Latino 22%).

RESULTS

Generally favorable attitudes toward research were expressed by a majority (85.3%), but many respondents expressed mistrust. Factor analysis yielded four specific domains of trust/mistrust, each of which was associated with different demographic variables: general trustworthiness (older age, not disabled); perceptions of discrimination (African American, Latino, Spanish language preference); perceptions of deception (prior research experience, African American); and perceptions of exploitation (less education).

CONCLUSIONS

The four domains identified in the analysis provide a framework for understanding specific areas of research trust/mistrust among disparate study populations. This model offers a conceptual basis for the design of tailored interventions that target specific groups to promote trust of individual researchers and research institutions as well as to facilitate broader research participation.

Enhancing yoga participation: A qualitative investigation of barriers and facilitators to yoga among predominantly racial/ethnic minority, low-income adults

Yoga is underutilized among racial/ethnic minorities and low-income populations. To enhance participation among these demographic groups and to inform a future clinical trial, we conducted a qualitative formative investigation, informed by the Social Contextual Model of health behavior change, to identify barriers and facilitators to yoga that could impact study participation. We recruited twenty-four racially/ethnically diverse adults, with and without prior yoga experience, from a low-income, urban housing community to participate in either an individual interview or focus group. A thematic data analysis approach was employed. Barriers to yoga engagement included the perception that yoga lacks physicality and weight loss benefits, fear of injury, lack of ability/self-efficacy to perform the practices, preference for other physical activities, and scheduling difficulties. Facilitators of yoga engagement included a quality yoga instructor who provides individualized instruction, beginner level classes, and promotional messaging that highlights the potential benefits of yoga, such as stress reduction.

Engaging patients and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial

BACKGROUND

Early palliative care (EPC) is recommended but rarely integrated with advanced heart failure (HF) care. We engaged patients and family caregivers to study the feasibility and site differences in a two-site EPC trial, ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers).

METHODS

We conducted an EPC feasibility study (4/1/14-8/31/15) for patients with NYHA Class III/IV HF and their caregivers in academic medical centers in the northeast and southeast U.S. The EPC intervention comprised: 1) an in-person outpatient palliative care consultation; and 2) telephonic nurse coach sessions and monthly calls. We collected patient- and caregiver-reported outcomes of quality of life (QOL), symptom, health, anxiety, and depression at baseline, 12- and 24-weeks. We used linear mixed-models to assess baseline to week 24 longitudinal changes.

RESULTS

We enrolled 61 patients and 48 caregivers; between-site demographic differences included age, race, religion, marital, and work status. Most patients (69%) and caregivers (79%) completed all intervention sessions; however, we noted large between-site differences in measurement completion (38% southeast vs. 72% northeast). Patients experienced moderate effect size improvements in QOL, symptoms, physical, and mental health; caregivers experienced moderate effect size improvements in QOL, depression, mental health, and burden. Small-to-moderate effect size improvements were noted in patients' hospital and ICU days and emergency visits.

CONCLUSIONS

Between-site demographic, attrition, and participant-reported outcomes highlight the importance of intervention pilot-testing in culturally diverse populations. Observations from this pilot feasibility trial allowed us to refine the methodology of an in-progress, full-scale randomized clinical efficacy trial.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03177447 (retrospectively registered, June 2017).

The Influence of Race and Ethnicity on Becoming a Human Subject: Factors Associated with Participation in Research

Inroduction

The purpose of this study was to explore factors associated with willingness of African Americans and Latinos to participate in biomedical and public health research and to delineate factors that influence the decision to become a human subject.

Methods

We present results from a 2010 random digit-dial telephone survey of 2,455 African American (N = 1191) and Latino (N = 1264) adults. We used standard measures to assess knowledge of research, terminology, informed consent procedures, previous participation in research, health care experiences, social support, risk perception, religiousness, and trust.

Results

Over 60% of both African Americans and Latinos reported they believed people in medical research are pressured into participating. Over 50% said that it was not at all important to have someone of the same race/ethnicity ask them to participate. In a sub-sample of 322 African Americans and 190 Latinos who had previously been asked to participate in a research study, 63% of African Americans and 65% of Latinos consented to participate in a study. Finally, both African Americans (57%) and Latinos (68%) reported willingness to participate in future research. Overall, the multivariate analysis explained 29% of the variability in willingness to participate in future research.

Conclusions

Results suggest that African Americans and Latinos have no automatic predisposition to decline participation in research studies. These results can inform culturally tailored interventions for ethical recruitment of minorities into research and clinical trials.

Underrepresentation of Hispanics and Other Minorities in Clinical Trials: Recruiters' Perspectives

Clinical trials and research studies often fail to recruit participants from the minorities, hampering the generalizability of results. In order to mitigate this problem, the present study investigated how race/ethnicity affects the process of recruiting people from racial and ethnic minority groups, by conducting 11 focus groups with professional recruiters. Several themes emerged, such as how to adapt to potential participants' language competency and literacy levels, the importance to engage in culturally appropriate verbal and non-verbal communication, and to establish a sense of homophily between recruiters and patients. In addition, recruiters pointed out possible solutions to accommodate socioeconomic concerns, to adapt to contextual factors-including immigration status-and ultimately to respond to potential participants' mistrust of medical research. These findings are discussed, and future recommendations are provided.

Unit Nonresponse in a Population-Based Study of Prostate Cancer

Low unit response rates can increase bias and compromise study validity. Response rates have continued to fall over the past decade despite all efforts to increase participation. Many factors have been linked to reduced response, yet relatively few studies have employed multivariate approaches to identify characteristics that differentiate respondents from nonrespondents since it is hard to collect information on the latter. We aimed to assess factors contributing to enrollment of prostate cancer (PCa) patients. We combined data from the North Carolina-Louisiana (LA) PCa Project's LA cohort, with additional sources such as US census tract and LA tumor registry data. We included specific analyses focusing on blacks, a group often identified as hard to enroll in health-related research. The ability to study the effect of Hurricane Katrina, which occurred amidst enrollment, as a potential determinant of nonresponse makes our study unique. Older age (≥ 70) for blacks (OR 0.65) and study phase with respect to Hurricane Katrina for both races (OR 0.59 for blacks, OR 0.48 for whites) were significant predictors of participation with lower odds. Neighborhood poverty for whites (OR 1.53) also was a significant predictor of participation, but with higher odds. Among blacks, residence in Orleans parish was associated with lower odds of participation (OR 0.33) before Katrina. The opposite occurred in whites, with lower odds (OR 0.43) after Katrina. Our results overall underscore the importance of tailoring enrollment approaches to specific target population characteristics to confront the challenges posed by nonresponse. Our results also show that recruitment-related factors may change when outside forces bring major alterations to a population's environment and demographics.

Facilitating Community Participants' Research Engagement: Community Members' Perceptions of Community-based Research

Objectives

To describe the perspectives of community participants about engaging in community-based participatory research, and then to use the information to develop a model to depict the community participants’ perceptions of interfacing with academic researchers.

Method

A diverse group of Native Hawaiian community-dwelling participants engaged in open-ended and semi-structured focus group interviews, addressing community members’ perceptions of community-based participatory research.

Results

Three key areas were identified: (1) reciprocal trustable is needed; (2) perceptions about the purpose, research intent and expectations; (3) expectations of roles and responsibilities of the researcher(s). A model showing the reciprocity between the academic partner and the community partner is needed to establish the full CBPR process is proposed.

Conclusion

The three themes implied the community participants’ expectations of reciprocal relationships. The dimensions influencing community members’ perceptions of community-based research need to be taken into account when academic researchers interface with community participants. Successful community-based participatory research approaches for addressing the challenges of translating research findings into community actions is enhanced when the expectations of community members are taken into account.

Adaptive Challenges Rising from the Life Context of African-American Caregiving Grandmothers with Diabetes: A Pilot Study

To understand the challenges arising from the context within which diabetic African-American caregiving grandmothers self-manage their diabetes we used the Adaptive Leadership Framework. Additionally, challenges to retaining this population in a longitudinal study were examined. In this exploratory, longitudinal, qualitative pilot study, data were collected at five time-points over 18 months. We coded the data using content analysis and conducted the within-case and cross-case analyses using data matrices. Lack of awareness of available resources, represented a technical challenge within the life context of these grandmothers and the remaining three themes: family upheaval; priority setting (with subthemes of difficulty meeting basic needs and competing demands); and self-silencing and self-sacrifice represented adaptive challenges. The context of African-American grandmothers’ lives created primarily adaptive challenges that were complex and without immediate solutions. Research is needed to develop culturally and contextually appropriate interventions to help this vulnerable group develop capacity for adaptive work.

Barriers to Clinical Research Participation Among African Americans

Clinical research requires representation of racially and ethnically diverse participants to accurately represent the general population. Overall life expectancy of African Americans is shorter than that of the general U.S.

POPULATION

Compared with the other ethnic groups in the United States, African Americans have higher rates of hypertension, stroke, obesity, and diabetes, and higher rates of mortality related to stroke and cancer. Although many health disparities exist among African Americans, they are well underrepresented in clinical research. This article provides an overview of barriers that may influence participation in clinical research among African Americans. Issues of trust, experimentation, communication, and logistics are the most commonly identified barriers. The barriers and facilitators identified in this review may be useful in the development and implementation of recruitment and research strategies that are culturally sensitive and that may enhance trust and willingness to participate among African Americans.

Multiple sclerosis in US minority populations: Clinical practice insights

The heterogeneity of multiple sclerosis (MS) characteristics among various ethnic minority populations is a topic of recent interest. However, these populations are consistently underrepresented in clinical trials, leading to limited data on the effectiveness of treatments in these groups of patients and lack of an evidence-based approach to treatment. In order to achieve optimal disease management in the ethnic minority MS populations, a better understanding of the regional, socioeconomic, and cultural influences that result in underrepresentation of these groups in clinical trials is needed. Furthermore, it would be beneficial to identify the genetic factors that influence disease disparity in these minority populations. Suggestions for the identification and implementation of best practices for fostering the trust of ethnic minority patients with MS and enhancing their participation in clinical trials are offered.

Patient Perspectives on the Learning Health System: The Importance of Trust and Shared Decision Making

We conducted focus groups to assess patient attitudes toward research on medical practices in the context of usual care. We found that patients focus on the implications of this research for their relationship with and trust in their physicians. Patients view research on medical practices as separate from usual care, demanding dissemination of information and in most cases, individual consent. Patients expect information about this research to come through their physician, whom they rely on to identify and filter associated risks. In general, patients support this research, but worry that participation in research involving randomization may undermine individualized care that acknowledges their unique medical histories. These findings suggest the need for public education on variation in practice among physicians and the need for a collaborative approach to the governance of research on medical practices that addresses core values of trust, transparency, and partnership.

ACT2 peer-driven intervention increases enrollment into HIV/AIDS medical studies among African Americans/Blacks and Hispanics: A cluster randomized controlled trial

African American/Black and Hispanic persons living with HIV/AIDS ("AABH-PLHA") are under-represented in HIV/AIDS medical studies (HAMS). This paper evaluates the efficacy of a social/behavioral intervention to increase rates of screening for and enrollment into HAMS in these populations. Participants (N = 540) were enrolled into a cluster randomized controlled trial of an intervention designed to overcome multi-level barriers to HAMS. Primary endpoints were rates of screening for and enrollment into therapeutic/treatment-oriented and observational studies. Intervention arm participants were 30 times more likely to be screened than controls (49.3 % vs. 3.7 %; p < .001). Half (55.5 %) of those screened were eligible for HAMS, primarily observational studies. Nine out of ten found eligible enrolled (91.7 %), almost all into observational studies (95.2 %), compared to no enrollments among controls. Achieving appropriate representation of AABH-PLHA in HAMS necessitates modification of study inclusion criteria to increase the proportion found eligible for therapeutic HAMS, in addition to social/behavioral interventions.

Exploratory Subset Analysis of African Americans From the PointBreak Study: Pemetrexed-Carboplatin-Bevacizumab Followed by Maintenance Pemetrexed-Bevacizumab Versus Paclitaxel-Carboplatin-Bevacizumab Followed by Maintenance Bevacizumab in Patients With Stage IIIB/IV Nonsquamous Non-Small-Cell Lung Cancer

INTRODUCTION

African Americans have a greater incidence of lung cancer than whites and have been underrepresented in clinical trials. In the PointBreak trial (pemetrexed-carboplatin-bevacizumab and maintenance pemetrexed-bevacizumab [PemCBev] vs. paclitaxel-carboplatin-bevacizumab and maintenance bevacizumab [PacCBev]), 10% of the patients were African American. PointBreak had negative findings; PemCBev did not demonstrate superior overall survival (OS).

MATERIALS AND METHODS

PointBreak subgroup efficacy and safety data were retrospectively analyzed: African Americans versus whites for PemCBev; PemCBev versus PacCBev in African Americans; and academic versus community settings for African Americans. Hazard ratios (HRs) and P values were derived from a multivariate Cox proportional hazards model after adjusting for covariates.

RESULTS

Of 939 intent-to-treat (ITT) patients, 94 were African American and 805 were white. African-American enrollment was uniform across the study sites (median, 1 African American per site). In the PemCBev arm, OS (HR, 1.125; P = .525), progression-free survival (PFS) (HR, 1.229; P = .251), response (P = .607), and toxicity profiles were similar in African Americans versus whites. For African Americans, OS (HR, 1.375; P = .209), PFS (HR, 0.902; P = .670), response (P = 1.000), and toxicity profiles were similar in the PemCBev versus PacCBev arm. For African Americans, no significant differences were seen in OS (HR, 0.661; P = .191) or PFS (HR, 0.969; P = .915) in academic versus community practice settings.

CONCLUSION

In the PemCBev arm, this exploratory analysis showed no significant differences between African Americans and whites for the efficacy outcomes or toxicity profiles. Consistent with the ITT population negative trial result, for African Americans, the median OS was not superior for either arm. For African Americans, PFS and OS were similar in the academic and community settings. Additional outcomes data for African Americans should be collected in lung cancer studies.

Perspectives on barriers and facilitators to minority recruitment for clinical trials among cancer center leaders, investigators, research staff, and referring clinicians: enhancing minority participation in clinical trials (EMPaCT)

BACKGROUND

The study of disparities in minority recruitment to cancer clinical trials has focused primarily on inquiries among minority populations. Yet very little is known about the perceptions of individuals actively involved in minority recruitment to clinical trials within cancer centers. Therefore, the authors assessed the perspectives of cancer center clinical and research personnel on barriers and facilitators to minority recruitment.

METHODS

In total, 91 qualitative interviews were conducted at 5 US cancer centers among 4 stakeholder groups: cancer center leaders, principal investigators, research staff, and referring clinicians. All interviews were recorded and transcribed. Qualitative analyses of response data was focused on identifying prominent themes related to barriers and facilitators to minority recruitment.

RESULTS

The perspectives of the 4 stakeholder groups were largely overlapping with some variations based on their unique roles in minority recruitment. Four prominent themes were identified: 1) racial and ethnic minorities are influenced by varying degrees of skepticism related to trial participation, 2) potential minority participants often face multilevel barriers that preclude them from being offered an opportunity to participate in a clinical trial, 3) facilitators at both the institutional and participant level potentially encourage minority recruitment, and 4) variation between internal and external trial referral procedures may limit clinical trial opportunities for racial and ethnic minorities.

CONCLUSIONS

Multilevel approaches are needed to address barriers and optimize facilitators within cancer centers to enhance minority recruitment for cancer clinical trials.

Perceived racial discrimination, but not mistrust of medical researchers, predicts the heat pain tolerance of African Americans with symptomatic knee osteoarthritis

OBJECTIVE

Studies have shown that perceived racial discrimination is a significant predictor of clinical pain severity among African Americans. It remains unknown whether perceived racial discrimination also alters the nociceptive processing of painful stimuli, which, in turn, could influence clinical pain severity. This study examined associations between perceived racial discrimination and responses to noxious thermal stimuli among African Americans and non-Hispanic Whites. Mistrust of medical researchers was also assessed given its potential to affect responses to the noxious stimuli.

METHOD

One-hundred and 30 (52% African American, 48% non-Hispanic White) community-dwelling older adults with symptomatic knee osteoarthritis completed two study sessions. In session one, individuals provided demographic, socioeconomic, physical and mental health information. They completed questionnaires related to perceived lifetime frequency of racial discrimination and mistrust of medical researchers. In session two, individuals underwent a series of controlled thermal stimulation procedures to assess heat pain sensitivity, particularly heat pain tolerance.

RESULTS

African Americans were more sensitive to heat pain and reported greater perceived racial discrimination as well as greater mistrust of medical researchers compared with non-Hispanic Whites. Greater perceived racial discrimination significantly predicted lower heat pain tolerance for African Americans but not non-Hispanic Whites. Mistrust of medical researchers did not significantly predict heat pain tolerance for either racial group.

CONCLUSION

These results lend support to the idea that perceived racial discrimination may influence the clinical pain severity of African Americans via the nociceptive processing of painful stimuli.

What factors influence minority use of National Cancer Institute-designated cancer centers?

BACKGROUND

National Cancer Institute (NCI) cancer centers provide high-quality care and are associated with better outcomes. However, racial and ethnic minority populations tend not to use these settings. The current study sought to understand what factors influence minority use of NCI cancer centers.

METHODS

A data set containing California Cancer Registry (CCR) data linked to patient discharge abstracts identified all patients with colorectal cancer (CRC) who were treated from 1996 through 2006. Multivariable models were generated to predict the use of NCI settings by race. Geographic proximity to an NCI center and patient sociodemographic and clinical characteristics were assessed.

RESULTS

Approximately 5% of all identified patients with CRC (n = 79,231) were treated in NCI settings. The median travel distance for treatment for all patients in all hospitals was ≤ 5 miles. A higher percentage of minorities lived near an NCI cancer center compared with whites. A baseline multivariable model predicting use showed a negative association between Hispanic ethnicity and NCI center use (odds ratio, 0.71; 95% confidence interval, 0.64-0.79). Asian/Pacific Islander patients were more likely to use NCI centers (odds ratio, 1.41; 95% confidence interval, 1.28-1.54). There was no difference in use noted among black patients. Increasing living distance from an NCI cancer center was found to be predictive of lower odds of use for all populations. Medicare and Medicaid insurance statuses were positively associated with NCI center use. Neighborhood-level education was found to be a more powerful predictor of NCI use than poverty or unemployment.

CONCLUSIONS

Select minority groups underuse NCI cancer centers for CRC treatment. Sociodemographic factors and proximity to NCI centers are important predictors of use. Interventions to address these factors may improve minority attendance to NCI cancer centers for care.