Recruitment of older participants in frailty/injury prevention studies

Successes and Challenges in Clinical Trial Recruitment: The Experience of a New Study Team

Participant recruitment is one of the most challenging aspects of a clinical trial, directly impacting both the study's duration and the quality of its results. Therefore, reporting successful recruitment strategies is crucial. This study aimed to document the recruitment tactics and experiences of a research team during a university-based randomized clinical trial, conducted as part of a clinical research immersion program. Recruitment took place from October 2021 to October 2022. Before the study commenced, study team members received formal training in clinical trial participant recruitment from the Principal Investigator. The recruitment strategies were integrated into initial study design, which was approved by the Institutional Review Board. A multimodal approach was employed, incorporating both direct and indirect recruitment methods. These strategies successfully met the enrollment target within the twelve-month period. Throughout the process, team members acquired valuable knowledge in recruitment design and implementation, along with transferable interpersonal and networking skills. In-person recruitment was the most efficient and cost-effective strategy, followed by personal referrals. The primary challenge was accommodating participants' availability. Other study teams should consider these recruitment strategies during their study designs. Additionally, the knowledge and skills gained by this study team underscore the value of experiential learning in research education.

Prevention at home in older persons with (pre-)frailty: analysis of participants' recruitment and characteristics of the randomized controlled PromeTheus trial

BACKGROUND

The "PromeTheus" trial is evaluating a home-based, multifactorial, interdisciplinary prevention program for community-dwelling (pre-)frail older adults. These individuals often suffer from reduced participation, which can complicate the recruitment and enrollment in a clinical trial.

AIMS

The aim of this study was to evaluate different recruitment strategies and differences in participant characteristics in relation to these strategies.

METHODS

This cross-sectional study used baseline data from the randomized-controlled PromeTheus trial, in which community-dwelling (pre-)frail older persons (Clinical Frailty Scale [CFS] 4-6 pt., ≥ 70 years) were recruited via general practitioners ("GP recruitment") or flyers, newspaper articles, and personalized letters ("direct recruitment"). Differences in the sociodemographic, clinical, physical, functional, mobility-related, psychological and social characteristics were analyzed in relation to the recruitment strategy.

RESULTS

A total of 385 participants (mean age = 81.2, SD 5.9 years; women: n = 283, 73.5%) were enrolled, of which 60 (16%) were recruited by GPs and 325 (84%) through direct recruitment. Participants recruited via GPs had significantly higher subjective frailty levels (CFS), were more often physically frail (Fried Frailty Phenotype), and showed lower physical capacity (Short Physical Performance Battery), participation (disability component of the short version of the Late-Life Function and Disability Instrument), and life-space mobility (Life-Space Assessment) compared to those recruited via the direct approach (p = 0.002-0.026). Costs per randomized participant were 94€ for the GP recruitment strategy and €213 for the direct recruitment strategy.

CONCLUSION

Different strategies may be required to successfully recruit (pre-)frail home-living older adults into preventive programs. Direct recruitment strategies, in which potential participants are directly informed about the prevention program, seem to be more promising than GP recruitment but may result in enrolment of persons with less functional impairment and higher recruitment costs.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00024638. Registered on March 11, 2021.

Overcoming recruitment hurdles in clinical trials: An investigation of remote consenting modalities and their impact on workload, workflow, and usability

Travel constraints can hinder the recruitment of eligible research participants in clinical trials, causing research timeline extensions, added costs, underpowered results, and early termination. Remote consenting can help solve these issues by allowing researchers and potential participants to connect remotely. This controlled experimental study investigates the effect of remote consenting on workload, workflow, usability, and barriers and facilitators to its implementation. Using a mixed experimental design, simulated consenting sessions were conducted with three different modalities (remote paper consent, eConsent, and teleconsent) with 23 researchers and 93 research participants. Each session involved a single researcher who experienced all three modalities, while three different research participants were assigned to each modality individually. Research participants and researchers completed surveys measuring workload and usability. Remote consenting allows researchers and participants to connect at their preferred location and time, and teleconsenting was found to be the preferred modality by the researchers, primarily due to its ability to exchange visual cues. However, challenges such as training requirements and technology dependence need to be addressed for widespread implementation. Future research should aim to eliminate these barriers and improve remote consenting modalities to facilitate clinical research participation.

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

Recruitment methods and yield rates for a multisite clinical trial exploring risk reduction for Alzheimer's disease (rrAD)

INTRODUCTION

The risk reduction for Alzheimer's disease (rrAD) trial was a multisite clinical trial to assess exercise and intensive vascular pharmacological treatment on cognitive function in community-dwelling older adults at increased risk for Alzheimer's disease.

METHODS

Eligibility, consent, and randomization rates across different referral sources were compared. Informal interviews conducted with each site's project team were conducted upon study completion.

RESULTS

Initially, 3290 individuals were screened, of whom 28% were eligible to consent, 805 consented to participate (87.2% of those eligible), and 513 (36.3% of those consented) were randomized. Emails sent from study site listservs/databases yielded the highest amount (20.9%) of screened individuals. Professional referrals from physicians yielded the greatest percentage of consented individuals (57.1%). Referrals from non-professional contacts (ie, friends, family; 75%) and mail/phone contact from a site (73.8%) had the highest yield of randomization.

DISCUSSION

Professional referrals or email from listservs/registries were most effective for enrolling participants. The greatest yield of eligible/randomized participants came from non-professional and mail/phone contacts. Future trials should consider special efforts targeting these recruitment approaches.

Highlights

Clinical trial recruitment is commonly cited as a significant barrier to advancing our understanding of cognitive health interventions.The most cited referral source was email, followed by interviews/editorials on the radio, television, local newspapers, newsletters, or magazine articles.The referral method that brought in the largest number of contacts was email but did not result in the greatest yield of consents or eligible participants.The sources that yielded the greatest likelihood of consent were professional referrals (ie, physician), social media, and mail/phone contact from study site.The greatest yield of eligible/randomized participants came from non-professional contacts and mail/phone contact from a site.Findings suggest that sites may need to focus on more selective referral sources, such as using contact mailing and phone lists, rather than more widely viewed recruitment sources, such as social media or TV/radio advertisements.

The challenge of recruiting multimorbid older patients identified in a hospital database to a randomised controlled trial

BACKGROUND

Research involving multimorbid older patients is gaining momentum. However, little is known about how to plan a randomised controlled trial (RCT) involving this group of patients. An evidence-based approach to the challenges of a recruitment process could guide researchers and help prevent underpowered trials.

AIM

To define the number of multimorbid older patients that need to be identified and the number of eligible patients that need to be invited to achieve the desired recruitment number to a RCT.

METHOD

We used recruitment data from the GerMoT trial, a RCT comparing proactive outpatient care based on Comprehensive Geriatric Assessment with usual care. Multimorbid older patients with high healthcare utilisation were recruited to the trial.

RESULTS

Of the 1212 patients identified in a database as meeting the inclusion criteria 838 (70%) could be invited to participate in the trial. The rest could not be invited for a variety of reasons; 162 had moved out of area or into nursing homes and 86 had died before they could be contacted. 113 could not be reached. 450 (54%) of the invited patients agreed to participate.

CONCLUSIONS

In our study, we have shown that it is possible to achieve a good consent rate despite older participants with multimorbidity. This can be used when planning an RCT for this patient group, who are often excluded from clinical trials. Our results are specific to a context that provides similar abilities to identify and recruit patients as can be seen in Sweden.

The MoveStrong program for promoting balance and functional strength training and adequate protein intake in pre-frail older adults: A pilot randomized controlled trial

BACKGROUND

Balance and functional strength training can improve muscle strength and physical functioning outcomes and decrease the risk of falls in older adults. To maximize the benefits of strength training, adequate protein intake is also important. However, the number of older individuals that consume enough protein or routinely engage in strength training remains low at less than 5% and even lower for activities that challenge balance. Our primary aim was to assess the feasibility of implementing a model (MoveStrong) of service delivery to teach older adults about balance and functional strength training and methods to increase protein intake.

METHODS

This study was a closed cohort stepped wedge randomized controlled trial. We recruited individuals ≥60 years considered pre-frail or frail with at least one chronic condition who were not currently engaging in regular strength training from Northern (rural) and Southern (urban) Ontario sites in Canada. The primary outcome was feasibility of implementation, defined by recruitment, retention, and adherence, and safety (defined by monitoring adverse events). We also reported participants' and providers' experience with MoveStrong, adaptations to the model based on participant's and provider's experience, and program fidelity.

RESULTS

We recruited 44 participants to the study and the average adherence rate was 72% with a retention of 71%. The program had a high-fidelity score. One person experienced a fall-related injury during exercise, while two other participants reported pain during certain activities. Five individuals experienced injuries or health problems that were not related to the program. Suggestions for future trials include modifying some exercises, exploring volunteer assistance, increasing the diversity of participants enrolled, and considering a different study design.

CONCLUSIONS

Our pilot trial demonstrates the feasibility of recruitment and adherence for a larger multisite RCT of balance and functional strength training with attention to protein intake in pre-frail and frail older adults.

Recruitment and Screening Methods in Alzheimer's Disease Research: The FIT-AD Trial

BACKGROUND

Recruiting older adults with Alzheimer's disease (AD) dementia into clinical trials is challenging requiring multiple approaches. We describe recruitment and screening processes and results from the FIT-AD Trial, a single site, pilot randomized controlled trial testing the effects of a 6-month aerobic exercise intervention on cognition and hippocampal volume in community-dwelling older adults with mild-to moderate AD dementia.

METHODS

Ten recruitment strategies and a four-step screening process were used to ensure a homogenous sample and exercise safety. The initial target sample was 90 participants over 48 months which was increased to 96 to allow those in the screening process to enroll if qualified. A tertiary analysis of recruitment and screening rates, recruitment yields and costs, and demographic characteristics of participants was conducted.

RESULTS

During the 48-month recruiting period, 396 potential participants responded to recruitment efforts, 301 individuals were reached and 103 were tentatively qualified. Of these, 67 (69.8%) participants completed the optional magnetic resonance (MRI) imaging and seven were excluded due to abnormal MRI findings. As a result, we enrolled 96 participants with a 2.92 screen ratio, 2.14 recruitment rate, and 31.9% recruitment yield. Referrals (28.1%) and Alzheimer's Association events/services (21.9%) yielded over 49% of the enrolled participants. Total recruitment cost was $ 38,246 or $ 398 per randomized participant.

CONCLUSIONS

A multi-prong approach involving extensive community outreach was essential in recruiting older adults with AD dementia into a single-site trial. For every randomized participant, three individuals needed to be screened. Referrals were the most cost-effective recruitment strategy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

High adherence and low dropout rate in a virtual clinical study of atopic dermatitis through weekly reward-based personalized genetic lifestyle reports

INTRODUCTION

Clinical trials often suffer from significant recruitment barriers, poor adherence, and dropouts, which increase costs and negatively affect trial outcomes. The aim of this study was to examine whether making it virtual and reward-based would enable nationwide recruitment, identify patients with variable disease severity, achieve high adherence, and reduce dropouts.

METHODS

In a siteless, virtual feasibility study, individuals with atopic dermatitis (AD) were recruited online. During the 8-week study, subjects used their smartphones weekly to photograph target AD lesions, and completed patient-oriented eczema measure (POEM) and treatment use questionnaires. In return, subjects were rewarded every week with personalized lifestyle reports based on their DNA.

RESULTS

Over the course of the 11 day recruitment period, 164 (82% women and 18% men) filled in the form to participate, of which 65 fulfilled the inclusion criteria and signed the informed consent. Ten were excluded as they did not complete the mandatory study task of returning the DNA sample. 55 (91% women, 9% men) subjects returned the DNA sample and were enrolled throughout Denmark, the majority outside the Copenhagen capital region in rural areas with relatively low physician coverage. The mean age was 28.5 (SD ±9.5 years, range 18-52 years). The baseline POEM score was 14.5±5.6 (range 6-28). Based on the POEM, 7 individuals had mild, 28 had moderate, 17 had severe, and 3 had very severe eczema. The retention rate was 96% as 53 out of 55 enrolled completed the study. The adherence was very high, and more than 90% of all study tasks were completed. Follow up of 41 subjects showed that 90% would take part again or continue if the study had been longer.

CONCLUSION

A virtual trial design enables recruitment with broad geographic reach and throughout the full spectrum of disease severity. Providing personalized genetic reports as a reward seems to contribute to high adherence and retention.

The Tribulations of Trials: Lessons Learnt Recruiting 777 Older Adults Into REtirement in ACTion (REACT), a Trial of a Community, Group-Based Active Aging Intervention Targeting Mobility Disability

BACKGROUND

Challenges of recruitment to randomized controlled trials (RCTs) and successful strategies to overcome them should be clearly reported to improve recruitment into future trials. REtirement in ACTion (REACT) is a United Kingdom-based multicenter RCT recruiting older adults at high risk of mobility disability to a 12-month group-based exercise and behavior maintenance program or to a minimal Healthy Aging control intervention.

METHODS

The recruitment target was 768 adults, aged 65 years and older scoring 4-9 on the Short Physical Performance Battery (SPPB). Recruitment methods include the following: (a) invitations mailed by general practitioners (GPs); (b) invitations distributed via third-sector organizations; and (c) public relations (PR) campaign. Yields, efficiency, and costs were calculated.

RESULTS

The study recruited 777 (33.9% men) community-dwelling, older adults (mean age 77.55 years (SD 6.79), mean SPPB score 7.37 (SD 1.56)), 95.11% white (n = 739) and broadly representative of UK quintiles of deprivation. Over a 20-month recruitment period, 25,559 invitations were issued. Eighty-eight percent of the participants were recruited via GP invitations, 5.4% via the PR campaign, 3% via word-of-mouth, and 2.5% via third-sector organizations. Mean recruitment cost per participant was £78.47, with an extra £26.54 per recruit paid to GPs to cover research costs.

CONCLUSIONS

REACT successfully recruited to target. Response rates were lower than initially predicted and recruitment timescales required adjustment. Written invitations from GPs were the most efficient method for recruiting older adults at risk of mobility disability. Targeted efforts could achieve more ethnically diverse cohorts. All trials should be required to provide recruitment data to enable evidence-based planning of future trials.

Factors associated with clinical trials that fail and opportunities for improving the likelihood of success: A review

Clinical trials are time consuming, expensive, and often burdensome on patients. Clinical trials can fail for many reasons. This survey reviews many of these reasons and offers insights on opportunities for improving the likelihood of creating and executing successful clinical trials. Literature from the past 30 years was reviewed for relevant data. Common patterns in reported successful trials are identified, including factors regarding the study site, study coordinator/investigator, and the effects on participating patients. Specific instances where artificial intelligence can help improve clinical trials are identified.

Recruitment of older adults into randomized controlled trials: Issues and lessons learned from two community-based exercise interventions in Shanghai

BACKGROUND

With the increasing need for high-quality exercise interventions in China, relatively little is known about issues and challenges related to recruitment of older Chinese adults into exercise-based disease prevention interventions. This study aims to describe the recruitment process and outcomes of 2 exercise interventions conducted in Shanghai, China.

METHODS

Recruitment information was ascertained from 2 community-based randomized controlled trials for 2 exercise interventions, the first designed to improve health outcomes for older women with knee osteoarthritis and the second to study changes in cognitive function in adults with mild cognitive impairment. Results were summarized in terms of recruitment sources, number screened, screening-to-enrollment ratios, and costs.

RESULTS

Recruitment was primarily achieved through working with local residential divisions (i.e., neighborhood associations and residential committees). Both studies achieved their planned target number of older adults (45 and 46, respectively) within a 1-year time frame, with a screening-to-randomized ratio of 5:1 and demonstrated excellent retention rates (range 87%-93%) at 6 months. The recruitment cost for the 2 studies averaged RMB 189 (about USD 30) per initial recruit and RMB 738 (about USD 119) per participant randomized. Some major issues encountered during the recruitment process included (1) the use of community neighborhoods to support the conduct of the projects, (2) access to participants, and (3) feasibility.

CONCLUSION

Analysis of the 2 randomized controlled trials has provided valuable insights into the recruitment process and identified resources that can help better planning and recruitment for future interventions. Recommendations aimed at increasing the success of future recruitment efforts are provided.

Engaging older patients in cardiovascular research: observational analysis of the ICON-1 study

Background

As a consequence of population ageing, the number of older patients presenting with acute coronary syndrome (ACS) is increasing. The historical underrepresentation of older patients in many pivotal ACS clinical trials undermines the practice of evidence-based medicine in this high-risk cohort. This study evaluates the feasibility of recruitment of older patients to a longitudinal, clinical study.

Methods

The study to Improve Cardiovascular Outcomes in high-risk patieNts with ACS (ICON-1) is an observational, prospective cohort study investigating predictors of poor outcome in older patients with ACS. All patients aged ≥75 years, referred to a tertiary cardiovascular centre in the North East of England for coronary angiography with a view to urgent percutaneous coronary intervention, were screened for inclusion. A screening log was prospectively maintained, and a detailed analysis was performed to identify the factors associated with recruitment and non-recruitment to ICON-1.

Results

Of the 629 patients screened over 34 months, 457 (72.7%) satisfied the a priori-defined study inclusion/exclusion criteria. Of those eligible to participate, 300 (68.5%) provided informed consent and were recruited to the study; 59 (13.5%) were unable to consent due to a lack of capacity or limitations in communication, and 79 patients (18.0%) declined to participate in the study. Those lacking adequate capacity to consent were older than those able to provide informed consent (83.0±4.7 vs 81.0±4.7 years, p=0.002). Women were more likely to decline than men (25.1% vs 10.0%, p<0.001).

Conclusions

The recruitment of patients was robust, comparing favourably to previous longitudinal studies within this age group. Although enrolling older people to research remains challenging, this cohort is enthusiastic to participate. The contribution of older patients must not be ignored, particularly in the setting of an ever-ageing population, in whom cardiovascular disease burden is high.

Trial registration number

NCT01933581; Pre-results.

Workshop characteristics related to chronic disease self-management education program attendance

Using the national dissemination of Chronic Disease Self-Management Education (CDSME) programs, the purposes of this study were to (1) document intervention attendance rates as related to the number of participants enrolled in the workshop and (2) compare the relationship between workshop attendance and workshop size by delivery site rurality and type. Data were analyzed from the first 100,000 middle-aged and older adults who participated in CDSME workshops spanning 45 states, Puerto Rico, and the District of Columbia as part of the American Recovery and Reinvestment Act of 2009 Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative. Descriptive statistics are reported for all participants, then separately by each delivery site type. Ratios between the number of workshop participants and the number of workshop sessions attended were calculated and graphed based on the rurality of delivery and separately for the leading five delivery site types. Associations between the number of workshop participants and the number of sessions attended differed by delivery site rurality and type. Findings have implications for participant retention and workshop delivery costs, which can assist program deliverers to strategically plan implementation efforts in their areas.

Translation of fit & strong! For middle-aged and older adults: examining implementation and effectiveness of a lay-led model in central Texas

The Fit & Strong! program is an evidence-based, multi-component program promoting physical activity among older adults, particularly those suffering from lower-extremity osteoarthritis. The primary purpose of the study is to examine if the Fit & Strong! program translated into a lay-leader model can produce comparable outcomes to the original program taught by physical therapists and/or certified exercise instructors. A single-group, pre–post study design was employed, and data were collected at the baseline (n = 136 participants) and the intervention conclusion (n = 71) with both baseline and post-intervention data. The measurements included socio-demographic information, health- and behavior-related information, and health-related quality of life. Various statistical tests were used for the program impact analysis and examination of the association between participant characteristics and program completion. As in the original study, there were statistically significant (p < 0.05) improvements in self-efficacy for exercise, aerobic capacity, joint stiffness, level of energy, and amount and intensity of physical activities. The odds of completing the program were significantly lower for the participants from rural areas and those having multiple chronic conditions. Successful adaptation of the Fit & Strong! program to a lay-leader model can increase the likelihood of program dissemination by broadening the selection pool of instructors and, hence, reducing the potential issue of resource limitation. However, high program attrition rates (54.1%) emphasize the importance of adopting evidence-based strategies for improving the retention of the participants from rural areas and those with multiple chronic conditions.

Health indicators associated with falls among middle-aged and older women enrolled in an evidence-based program

BACKGROUND

Evidence-based fall prevention programs primarily attract older women, who are increasingly burdened by fall-related injuries. However, little is known about the relationship between older female participants' baseline health status and self-reported falls over the course of fall prevention interventions. Using data from A Matter of Balance/Volunteer Lay Leader Model (AMOB/VLL) workshops, this study examines female participants' sociodemographics and health indicators associated with self-reported falls at baseline and postintervention.

METHODS

Data were analyzed from 837 older women (M = 76.2 years) collected during the statewide AMOB/VLL dissemination in Texas. Longitudinal Poisson regression models, using the generalized estimating equation method, were used to investigate the associations of personal characteristics and health indicators with and reductions in the number of self-reported falls from baseline to postintervention.

FINDINGS

Approximately 21% of participants reported falling at baseline, and the number of reported falls significantly decreased from baseline to postintervention (β = -0.443). At baseline, more unhealthy physical days (β = 0.022), more unhealthy mental days (β = 0.018), and lower Falls Efficacy Scale scores (β = -0.052) were significantly associated with more falls reported at baseline. More falls at baseline was also associated with worse program attendance (β = -0.069). Greater improvements in Falls Efficacy Scale Scores (β = -0.069) and decreases in unhealthy physical health days (β = 0.026) over the course of the intervention were significantly associated with greater reductions in reported falls at postintervention, respectively.

CONCLUSIONS

Findings have implications for identifying at-risk older women upon enrollment, expanding the reach of AMOB/VLL, and leveraging AMOB/VLL to refer participants to other evidence-based exercise, disease management, and mental health interventions.

Lifestyle interventions and independence for elders study: recruitment and baseline characteristics

BACKGROUND

Recruitment of older adults into long-term clinical trials involving behavioral interventions is a significant challenge. The Lifestyle Interventions and Independence for Elders (LIFE) Study is a Phase 3 multicenter randomized controlled multisite trial, designed to compare the effects of a moderate-intensity physical activity program with a successful aging health education program on the incidence of major mobility disability (the inability to walk 400 m) in sedentary adults aged 70-89 years, who were at high risk for mobility disability (scoring ≤ 9 on the Short Physical Performance Battery) at baseline.

METHODS

Recruitment methods, yields, efficiency, and costs are described together with a summary of participant baseline characteristics. Yields were examined across levels of sex, race and ethnicity, and Short Physical Performance Battery, as well as by site.

RESULTS

The 21-month recruiting period resulted in 14,812 telephone screens; 1,635 participants were randomized (67.2% women, 21.0% minorities, 44.7% with Short Physical Performance Battery scores ≤ 7). Of the telephone-screened participants, 37.6% were excluded primarily because of regular participation in physical activity, health exclusions, or self-reported mobility disability. Direct mailing was the most productive recruitment strategy (59.5% of randomized participants). Recruitment costs were $840 per randomized participant. Yields differed by sex and Short Physical Performance Battery. We accrued 11% more participant follow-up time than expected during the recruitment period as a result of the accelerated recruitment rate.

CONCLUSIONS

The LIFE Study achieved all recruitment benchmarks. Bulk mailing is an efficient method for recruiting high-risk community-dwelling older persons (including minorities), from diverse geographic areas for this long-term behavioral trial.

Participant withdrawal: challenges and practical solutions for recruitment and retention in clinical trials

A major challenge in the conduct of clinical trials is recruiting and retaining adequate numbers of study participants. Pressure for steady recruitment and retention is great. A wide range of strategies are used to retain participants; however, some approaches raise ethical questions. This article examines issues of participant retention, literature addressing the volunteer nature of informed consent, the moral distress surrounding participant withdrawal, and potential ethical implications. Strategies are proposed to resolve issues and reduce participant and investigator distress. Case studies of two patients with complex chronic illnesses illustrate practical solutions and lessons learned.

Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada

OBJECTIVE

This paper explores the lessons learned from a series of three randomized controlled trials that included 498 community-living frail older adults (≥65 years) using home care services in Southern Ontario, Canada. Each study was designed to evaluate the effectiveness of different multi-component nurse-led health promotion and disease prevention (HPDP) interventions.

METHODS

The nurse-led HPDP interventions were 6- or 12-month multi-component and evidence-based strategies targeting known risk factors for functional decline and frailty. Across the three studies, a common approach was used to measure the change in health-related quality of life (HRQOL) (SF-36) and the costs of use of health services (Health and Social Services Utilization Inventory) from baseline to the end of the intervention.

RESULTS

The main lesson learned from the three studies is that nurse-led HPDP interventions for frail older home care clients provide greater improvements in HRQOL compared with usual home care. Such approaches are highly acceptable to this population and can be implemented using existing home care resources. Nurse-led HPDP interventions should include multiple home visits, multidimensional screening and assessment, multi-component evidence-based HPDP strategies, intensive case management, inter-professional collaboration, providers with geriatric training and experience, referral to and coordination of community services, and theory use.

CONCLUSION

The results of the three trials underscore the need to reinvest in nurse-led HPDP interventions in home care to optimize HRQOL and promote ageing in place in the target population of frail older adults. More studies are needed to evaluate the effectiveness of additional nurse-led HPDP interventions in other contexts and settings.

Multisite recruitment and data collection among older adults: exploring methods to conserve human and financial resources

The purpose of this article is to describe strategies that were effective in recruitment and data collection among older adults in 3 quantitative studies while decreasing costs in terms of time and money. Factors effective in reducing use of investigators' time and expenses included limiting exclusion of data because of abnormal Mini-Cog scores by careful initial screening and avoiding repeated reminders or follow-up, collecting data in small groups, collapsing consent, dementia screening, and data collection into single sessions, as well as accommodating for sensory and literacy deficits. The cross-sectional, descriptive studies were conducted among community-dwelling older adults attending senior citizen centers and among older adults in independent or assisted living apartments within continuing care retirement communities (CCRCs). In the latest study, a convenience sample (N=152) was recruited and data collection was completed in 4 weeks at a total cost of less than $5,000. Methods common to qualitative research and those commonly used in community-based research were adapted to reduce time and costs for recruitment, screening, and data collection. Given limited availability of research funding, other nursing researchers may find one or more of these methods useful.

Recruitment of Older Adults: Success May Be in the Details

PURPOSE

Describe recruitment strategies used in a randomized clinical trial of a behavioral prospective memory intervention to improve medication adherence for older adults taking antihypertensive medication.

RESULTS

Recruitment strategies represent 4 themes: accessing an appropriate population, communication and trust-building, providing comfort and security, and expressing gratitude. Recruitment activities resulted in 276 participants with a mean age of 76.32 years, and study enrollment included 207 women, 69 men, and 54 persons representing ethnic minorities. Recruitment success was linked to cultivating relationships with community-based organizations, face-to-face contact with potential study participants, and providing service (e.g., blood pressure checks) as an access point to eligible participants. Seventy-two percent of potential participants who completed a follow-up call and met eligibility criteria were enrolled in the study. The attrition rate was 14.34%.

IMPLICATIONS

The projected increase in the number of older adults intensifies the need to study interventions that improve health outcomes. The challenge is to recruit sufficient numbers of participants who are also representative of older adults to test these interventions. Failing to recruit a sufficient and representative sample can compromise statistical power and the generalizability of study findings.

Falls efficacy among older adults enrolled in an evidence-based program to reduce fall-related risk: sustainability of individual benefits over time

Grand-scale community rollouts of evidence-based programs seldom have the capacity to examine long-term sustainability of beneficial effects among older adults. This study examined the effectiveness of A Matter of Balance/Volunteer Lay Leader Model, an evidence-based fall risk reduction program, to sustain fall-related efficacy improvements among 282 older adult participants using data collected at 3 time points: baseline, postintervention, and 6-month follow-up. A linear mixed model and multilevel logistic regression models were used. Falls Efficacy Scale and individual item scores significantly increased from baseline to postintervention. While most efficacy-related scores tapered after postintervention, all changes remained significant at 6-month follow-up.

Repeat emergency medical services use by older adults in a rural community: impact on research methods and study length

OBJECTIVES

To evaluate the proportion of emergency medical services (EMS) requests in a rural community made by unique, noninstitutionalized older adults, or individuals making their first request for EMS assistance during the study period, and the impact on research parameters.

METHODS

This study was a retrospective chart review of patients aged 65 years and older cared for by the Geneseo Fire Department Ambulance between February 2004 and May 2005 (period 1) and between July 2006 and October 2007 (period 2). The Geneseo Fire Department Ambulance response territory is a rural community in Upstate New York. We obtained demographic information including age, race, gender, call location, and the frequency of EMS use from the medical record, as well as clinical information including level of prehospital care, chief complaint, and disposition. Descriptive statistics were used for the analysis, along with 95% confidence intervals.

RESULTS

Over two 16-month periods, approximately 70% of the EMS calls by community-dwelling (noninstitutionalized) older adults were from unique individuals. The monthly proportion ranged from 75-100% during the first four months to 43-80% for the remaining 12 months for both groups.

CONCLUSION

In rural, prehospital studies that enroll older adults and last more than four months, approximately 70% of EMS requests are made by unique older adults, or individuals making their first request for EMS assistance. Investigators must consider these results when estimating the enrollment period for prehospital studies.

Engaging the oldest old in research: lessons from the Newcastle 85+ study

BACKGROUND

Those aged 85 and over, the oldest old, are now the fastest growing sector of the population. Information on their health is essential to inform future planning; however, there is a paucity of up-to-date information on the oldest old, who are often excluded from research. The aim of the Newcastle 85+ Study is to investigate the health of a cohort of 85-year-olds from a biological, medical and psychosocial perspective. This paper describes the methods employed for the successful recruitment, retention and evaluation of this cohort.

METHODS

Participants were all individuals born in 1921 and registered with a participating general practice in Newcastle and North Tyneside, UK. Involvement comprised detailed health assessments, by a nurse, in their usual place of residence and/or review of their general practice medical records.

RESULTS

Of the 1453 individuals eligible to participate, 72% (n = 1042) were recruited; 59% (n = 851) consented to both health assessment and review of general practice records. Key factors for successful involvement included protected time to engage with family and other key gatekeepers, minimising participant burden, through for example home based assessment, and flexibility of approach. Cognitive impairment is a significant issue; due consideration should be given to the ethical and legal issues of capacity and consent. Interim withdrawal rates at phase 2 (18 month post baseline), show 88 out of 854 participants (10%) had withdrawn with approval for continued use of data and materials and a further 2 participants (0.2%) had withdrawn and requested that all data be destroyed. Attrition due to death of participants within this same time frame was 135 (16%).

CONCLUSION

Our recruitment rates were good and compared favourably with other similar UK and international longitudinal studies of the oldest old. The challenges of and successful strategies for involving, recruiting and retaining the oldest old in research, including those in institutions, are described to facilitate adequate representation of this growing population in future research into ageing.

Strategies for in-person recruitment: lessons learned from a New Jersey primary care research network (NJPCRN) study

OBJECTIVE

To describe and evaluate participant recruitment for a research study conducted in primary care offices.

METHODS

Nine recruiters administered a written survey to 1485 primary care patients (from 25 practices) during baseline and 1-year follow-up of a quality improvement study aimed at increasing colorectal cancer screening. Before recruitment, recruiters attended training sessions, during which they received tools and information designed to facilitate successful recruitment. Quantitative and qualitative recruitment data were analyzed to assess and describe recruitment efforts.

RESULTS

The overall practice-level recruitment rate was 72.7% (range, 56.3% to 91.4%). Practice characteristics did not affect the recruitment rate. Recruitment rate differed significantly between recruiters (P = .0007) as did nonparticipants' reasons for refusal (P < .0001). Anticipated barriers to recruitment (older age of sampled population, lack of incentives, and discomfort discussing colorectal cancer) did not occur. Two key strategies facilitated recruitment: ((1)) recruiter flexibility and ((2)) building rapport with participants.

CONCLUSION

Recruiters may be more effective if they are able to adapt to participants' needs and successfully build rapport with potential participants. The likelihood of recruitment success may be increased by anticipating potential recruitment barriers and providing training that minimizes the inherent variation that exists among recruiters.

Community-based disability prevention programs for elders: predictors of program completion

Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. Program completion remains an important barrier to their effectiveness. We examined the association between provider relationships and client variables, and program completion in senior centers. Our mixed methods design used secondary data for 719 clients and primary data through telephone interviews with 20 nurses, 23 social workers, and 18 site managers. Quantitative data showed that higher client baseline self-efficacy positively influenced completion and minority status negatively influenced completion. Qualitative data showed that higher focus on provider-client relationships was associated with high completion.

Research participation among older adults with mobility limitation

The purpose of this qualitative descriptive study was to examine reasons for participation in clinical research among older adults with mobility limitation. A purposive sample of 20 men and 20 women aged 70 years or older was recruited. Data were collected by audiotaped telephone interviews using a semistructured interview guide and transcribed verbatim. Participants expect privacy, professionalism by research staff, and respectful treatment. Benefits to protocol adherence include personal education, comparison of their health status with that of others, opportunity to maintain vitality, and altruism. Barriers to protocol adherence are apprehension, in particular a negative impact on their health care, randomization to the control group, and experimental drugs; and inconvenience. Factors promoting study completion are obligation, reciprocity, receipt of test results, health promotion, and socialization. Implications include meeting expectations, providing health education and study results to participants, reducing barriers to participation, and presenting opportunities for interaction with others.

Issues in conducting epidemiologic research among elders: lessons from the MOBILIZE Boston Study

Conducting research in elderly populations is important, but challenging. In this paper, the authors describe specific challenges that have arisen and solutions that have been used in carrying out The MOBILIZE Boston Study, a community-based, prospective cohort study in Massachusetts focusing on falls among 765 participants aged 70 years or older enrolled during 2005-2007. To recruit older individuals, face-to-face interactions are more effective than less personal approaches. Use of a board of community leaders facilitated community acceptance of the research. Establishing eligibility for potential participants required several interactions, so resources must be anticipated in advance. Assuring a safe and warm environment for elderly participants and offering a positive experience are a vital priority. Adequate funding, planning, and monitoring are required to provide transportation and a fully accessible environment in which to conduct study procedures as well as to select personnel highly skilled in interacting with elders. It is hoped that this paper will encourage and inform future epidemiologic research in this important segment of the population.

The Groningen Active Living Model, an example of successful recruitment of sedentary and underactive older adults

OBJECTIVE

Many physical activity interventions do not reach those people who would benefit the most from them. The Groningen Active Living Model (GALM) was successful in recruiting sedentary and underactive older adults.

METHOD

In the fall of 2000 older adults in three municipalities in the Netherlands received written information, were visited at home and, if eligible according to the GALM recruitment criteria, filled in the Stages of Change questionnaire and the Voorrips physical activity questionnaire.

RESULTS

By using the strategy we succeeded in including 12.3% of the older adults (315 of the 2551 qualifying participants), 79.4% of whom could be indeed regarded as sedentary or underactive. These results can be considered in line with results described in the literature. The cost of successfully recruiting an older adult was estimated at $84.

CONCLUSIONS

The GALM recruitment strategy is a potentially useful and effective method for reaching community-dwelling sedentary and underactive older adults.

Enhancing participation of older women in surgical trials

BACKGROUND

Older participants are often excluded from clinical trials, precluding a representative sample.

STUDY DESIGN

Using qualitative and quantitative methods, we examined recruitment and retention of older women with pelvic organ prolapse in two surgical trials: the randomized Colpopexy And Urinary Reduction Efforts (CARE) study and the Longitudinal Pelvic Symptoms and Patient Satisfaction After Colpocleisis cohort study. Using focus groups, we developed a questionnaire addressing factors facilitating and impeding the recruitment and retention of older study participants and administered it to research staff. Enrollment-to-surgery ratios, missed visit rates, and dropout rates for older and younger participants were compared using Fisher's exact test, with cut-points of 70 and 80 years for the CARE and Colpocleisis studies, respectively.

RESULTS

Questionnaires were completed by 23 physician investigators and 11 nurses or coordinators (92% response rate). Respondents indicated it was more difficult to recruit older research participants (32%), obtain informed consent (56%), and retain participants to study completion (50%). Challenges to recruitment included caregiver involvement in the decision to participate and participant comorbidities. Perceived barriers to retention were transportation, caregiver availability, and participant fatigue. Data quality was challenged by sensory and cognitive impairment, resulting in a change from telephone interviews to in-person visits in the Colpocleisis study. Older participants did not have higher dropout rates than younger participants. There were no differences in missed in-person visits or telephone interview rates between age groups.

CONCLUSIONS

Strategies, albeit unstudied, could assist investigators in planning surgical trials that successfully enroll and retain older women.

Do older patients who refuse to participate in a self-management intervention in the Netherlands differ from older patients who agree to participate?

BACKGROUND AND AIMS

Refusal of patients to participate in intervention programs is an important problem in clinical trials but, in general, researchers devote relatively little attention to it. In this article, a comparison is made between patients who, after having been invited, agreed to participate in a self-management intervention (participants) and those who refused (refusers). Compared with other studies of refusers, relatively more information could be gathered with regard to both their characteristics and reasons for refusing, because all potential participants were invited personally.

METHODS

Older patients from a Dutch outpatient clinic were invited to participate in a self-management intervention, and their characteristics were assessed. Demographic data were collected, as well as data on physical functioning and lack of emotional support. People who refused to participate were asked to give their reasons for refusing.

RESULTS

Of the 361 patients invited, 267 (74%) refused participation. These refusers were more restricted in their mobility, lived further away from the location of the intervention, and had a partner more often than did the participants. No differences were found in level of education, age or gender. The main reasons given by respondents for refusing to participate were lack of time, travel distance, and transport problems.

CONCLUSIONS

As in many studies, the refusal rate in this study is high, and seems to be related to physical mobility restrictions, travel distance and, partly, to availability of emotional support. These findings may be used to make the recruitment process more effective - for example, by offering transport to the location of the intervention.

Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies

OBJECTIVE

To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants.

METHODS

A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search.

RESULTS

Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour.

CONCLUSIONS

Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed.

PRACTICE IMPLICATIONS

Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics

BACKGROUND

Guidelines recommend multifactorial intervention programmes to prevent falls in older adults but there are few randomised controlled trials in a real life health care setting. We describe the rationale, intervention, study design, recruitment strategies and baseline characteristics of participants in a randomised controlled trial of a multifactorial falls prevention programme in primary health care.

METHODS

Participants are patients from 19 primary care practices in Hutt Valley, New Zealand aged 75 years and over who have fallen in the past year and live independently. Two recruitment strategies were used - waiting room screening and practice mail-out. Intervention participants receive a community based nurse assessment of falls and fracture risk factors, home hazards, referral to appropriate community interventions, and strength and balance exercise programme. Control participants receive usual care and social visits. Outcome measures include number of falls and injuries over 12 months, balance, strength, falls efficacy, activities of daily living, quality of life, and physical activity levels.

RESULTS

312 participants were recruited (69% women). Of those who had fallen, 58% of people screened in the practice waiting rooms and 40% when screened by practice letter were willing to participate. Characteristics of participants recruited using the two methods are similar (p > 0.05). Mean age of all participants was 81 years (SD 5). On average participants have 7 medical conditions, take 5.5 medications (29% on psychotropics) with a median of 2 falls (interquartile range 1, 3) in the previous year.

CONCLUSION

The two recruitment strategies and the community based intervention delivery were feasible and successful, identifying a high risk group with multiple falls. Recruitment in the waiting room gave higher response rates but was less efficient than practice mail-out. Testing the effectiveness of an evidence based intervention in a 'real life' setting is important.

Recruitment and retention in clinical trials of the elderly

The recruitment and retention of elderly patients in clinical trials provide many challenges. Factors affecting recruitment, retention, and cost of recruitment are discussed in this chapter. Various methods are described that were used in recruiting and retaining elderly patients in a Veterans Affairs (VA) Administration clinical trial that compared two newer antiepileptic drugs (AEDs), gabapentin and lamotrigine, to the established standard AED, carbamazepine. Various strategies were utilized in the VA study to improve recruitment, and each strategy's overall effectiveness was monitored. Modification of the patient inclusion criteria, by lowering the age of eligibility from 65 to 60 years, added approximately 100 patients to the study. Replacing five trial sites that had poor recruiting records, extending the patient recruitment period by 3 months, and conducting site visits also improved patient recruitment rates, such that 82.4% of target enrollment (720 patients) was achieved. The main reasons that screened patients were excluded from the study included: lack of seizures during the prior 3 months, unstable medical condition, adequate treatment with an AED, satisfaction with current treatment, and the inability to give informed consent. Retaining patients for 1 year was the primary outcome measure of this trial, with 46.8% of patients completing the year. The most common reasons for early termination were study drug-related adverse events (43.0%) and lack of seizure control (10.8%). Comorbidities and polypharmacy occurred more frequently in the elderly, and both had a negative influence on recruitment and retention.

Recruitment Strategies for a Fall Prevention Program: If We Build It, Will They Really Come?

BACKGROUND

More than one third of adults over the age of 65 suffer a fall each year, facing morbidity and mortality. Modifiable risk factors for falls have been identified, but specific recruitment strategies for prevention programs have not been evaluated. The purpose of this observational study was to evaluate recruitment strategies for a fall prevention program.

METHODS

Participants were recruited during an 11-month period at a Level I trauma center. Participants were eligible if >65 years old, living independently, and had a fall. Recruitment modalities included (1) emergency medical services, (2) emergency department (ED), (3) primary care providers, and (4) media exposure leading to self-referral. Data were collected on baseline rate of fall victims seen in the ED, demographics, medical history, and source of referral.

RESULTS

There were 91 individuals referred, with 61 (67%) enrolled. Enrollment rates were higher among patients referred by self or primary care providers than among those referred by emergency medical services or the ED. There were no significant differences in demographics or medical history among the eligible but not referred ED population, the referred population, and the enrolled population. Reasons for not enrolling included inappropriate referral (33%), no response (17%), other illness (13%), and patients thinking that they do not need the services (37%).

CONCLUSIONS

These recruitment strategies were successful in enrolling a representative population of patients at risk for recurrent falls, but could be improved to capture more potential participants. Source of referral has a significant effect on rate of enrollment. We outline challenges and solutions to recruitment.

Lifestyle Interventions and Independence for Elders pilot study: recruitment and baseline characteristics

OBJECTIVES

To describe several recruitment parameters derived from the Lifestyle Interventions and Independence for Elders pilot (LIFE-P) study for use in a full-scale trial of mobility disability prevention.

DESIGN

A description of the recruiting methods and baseline characteristics of a four-site randomized, controlled trial testing the effectiveness of a physical activity intervention at preventing mobility disability.

SETTING

The Cooper Institute, Dallas, Texas; Stanford University, Stanford, California; University of Pittsburgh, Pittsburgh, Pennsylvania; and Wake Forest University, Winston-Salem, North Carolina.

PARTICIPANTS

Community-living persons aged 70 to 89 who were able to walk 400 m within 15 minutes and were at high risk for disability (scoring<10 on the Short Physical Performance Battery (SPPB)) but without comorbidity severe enough to preclude full study participation.

MEASUREMENTS

Measures of efficiency included number of randomized participants per recruitment technique and costs per randomized participant across randomization techniques.

RESULTS

The 9-month recruiting period resulted in 3,141 telephone screens, of which 424 (13.5%) participants were randomized (68.9% women, 25.7% minorities, 41.5% with SPPB scores<8). Forty percent of telephone-screened participants were excluded primarily because of regular participation in physical activity, health exclusions, or self-reported mobility disability. Of the 1,252 persons attempting the physical performance assessments, 41% scored above the SPPB cutoff. Of the 566 remaining eligible, 9.9% could not complete the 400-m walk, and another 18.9% had various medical exclusions. Direct mailing was the most productive recruitment strategy (61.6% of all randomized participants). Recruitment cost approximately $439 per randomized participant.

CONCLUSION

The LIFE study achieved all recruitment goals and demonstrated the feasibility of recruiting high-risk community-dwelling older persons for trials of disability prevention in diverse geographic areas.

When "no" might not quite mean "no"; the importance of informed and meaningful non-consent: results from a survey of individuals refusing participation in a health-related research project

Background

Low participation rates can lead to sampling bias, delays in completion and increased costs. Strategies to improve participation rates should address reasons for non-participation. However, most empirical research has focused on participants' motives rather than the reasons why non-participants refuse to take part. In this study we investigated the reasons why older people choose not to participate in a research project.

Methods

Follow-up study of people living in Tayside, Scotland who had opted-out of a cross-sectional survey on activities in retirement. Eight hundred and eighty seven people aged 65–84 years were invited to take part in a home-based cross-sectional survey. Of these, 471 refused to take part. Permission was obtained to follow-up 417 of the refusers. Demographic characteristics of people who refused to take part and the reasons they gave for not taking part were collected.

Results

54% of those invited to take part in the original cross-sectional survey refused to do so. However, 61% of these individuals went on to participate in the follow-up study and provided reasons for their original refusal. For the vast majority of people initial non-participation did not reflect an objection to participating in research in principle but frequently stemmed from barriers or misunderstandings about the nature or process of the project itself. Only 28% indicated that they were "not interested in research". The meaningfulness of expressions of non-consent may therefore be called into question. Hierarchical log-linear modelling showed that refusal was independently influenced by age, gender and social class. However, this response pattern was different for the follow-up study in which reasons for non-participation in the first survey were sought. This difference in pattern and response rates supports the likely importance of recruitment issues that are research and context specific.

Conclusion

An expression of non-consent does not necessarily mean that a fully informed evaluation of the pros and cons of participation and non-participation has taken place. The meaningfulness of expressions of non-consent may therefore be a cause for concern and should be subject to further research. Many reasons for non-participation may be specific to a particular research topic or population. Information sheets should reflect this by going beyond standardised guidelines for their design and instead proactively seek out and address areas of concern or potential misunderstanding. The use of established behavioural theory in their design could also be considered.

How to Get Older People Included in??Clinical Studies

Older people are systematically excluded from many clinical research studies. In this review, we examine the reasons for this state of affairs and summarise the current knowledge of strategies to increase the rate of participation of older people in clinical studies. Older people want to participate in clinical research and are driven by a mixture of altruism and self-interest. They are often excluded by overt age cut-offs or covert exclusions based on co-morbidity and frailty. Other barriers to participation include communication and cognitive difficulties, transport difficulties, low income and self-imposed agism. Possible strategies to improve recruitment of older people to clinical studies include abolishing age limits, reducing exclusion criteria, and allowing sufficient study time (to recruit and deal with older patients) and money (for reimbursement of their participation costs) in study protocols. Involving older people and their attending health professionals in the design of study protocols may also be helpful. Providing transportation, easy physical access to research institutions and use of personalised and face-to-face recruitment also pay dividends. A variety of recruitment methods have been found to be effective, but tailoring the strategy to the condition and population under study is necessary. Together, these strategies should improve the representation of older people in clinical research and ensure that the evidence base is relevant and useful to all those caring for older people.

Costs of recruiting couples to a clinical trial

Multiple barriers contribute to the slow recruitment of participants to research studies, which in turn extends the time required to translate promising scientific discoveries into proven therapeutic interventions. A small but growing literature is developing on the extraordinary costs of recruiting participants to studies, and thereby demonstrating that underestimating the cost of participant recruitment can contribute to these recruitment problems. These recruitment challenges and costs are exacerbated when the participants' study eligibility is determined by relatively narrowly defined illness parameters. Recruitment challenges are further compounded when dyads (two individuals engaged in a sociologically significant relationship, such as husbands and wives, siblings or extended families) must be recruited to an illness-focused study. For these latter groups, there are no data to guide researchers in how to anticipate those participant recruitment costs. This paper describes the staff costs for a variety of strategies used to recruit participants to a randomized supportive care study for couples who were within 18 months of a prostate cancer diagnosis. Pegged to the value of the U.S. dollar for the period, the average cost of staff time was $288 per recruited and enrolled dyad, plus a promised additional $100 incentive for study retention. Within the strategies used, the staff costs per recruited dyad ranged from $152 to $1688. Accrual per strategy ranged from 0 to 107 enrolled couples. When asked for secondary sources of information about the study, many participants reported more than one source of study referral, reflective of the multifaceted recruitment strategies deployed. In spite of innovative, culturally competent, and broad based recruitment methods, attainment of a diverse sample was difficult to accomplish in this study. Having estimates of the actual cost of recruiting dyads to research studies can help investigators prepare realistic study budgets.

Dissemination of physical activity promotion interventions in underserved populations

Achieving minimum physical activity levels of 30 or more minutes per day will require a variety of intervention strategies to engage each segment of an aging and increasingly ethnically diverse U.S. population. This article presents a focused review of the sparse literature on the diffusion of evidence-based physical activity interventions that are culturally appropriate for underserved populations. Related literature and experiential insights inform this discussion, because so few published studies report outcome data beyond the first diffusion phase of intervention development and evaluation. Three brief case studies are presented to further illustrate and exemplify key concepts and processes at several different stages in diffusing physical activity interventions. Successful engagement of underserved populations reflects a delicate balance between embracing group customs and values and recognizing the nonmonolithic nature of any sociodemographically defined group. The costs of failing to promulgate effective physical activity interventions in these groups continue to mount, in dollars, health, and lives. Researchers, practitioners, decision makers, and policymakers must partner to bridge the evidentiary gap so that the physically active lifestyle choices become the easier choices.

Using probability vs. nonprobability sampling to identify hard-to-access participants for health-related research: costs and contrasts

This article compares the recruitment costs and participant characteristics associated with the use of probability and nonprobability sampling strategies in a longitudinal study of older hemodialysis patients and their spouses. Contrasts were made of people who accrued to the study based on probability and nonprobability sampling strategies. Probability-based sampling was more time-efficient and cost-effective than nonprobability sampling. There were no significant differences between the respondents identified through probability and nonprobability sampling on age, gender, years married, education, work status, and professional job status. Respondents from the probability sample were more likely to be Protestant and less likely to be Catholic than those from the nonprobability sample. Respondents from the probability sample were more likely to be Black, whereas those from the nonprobability sample were more likely to be White. There are strengths and shortcomings associated with both nonprobability and probability sampling. Researchers need to consider representativeness and external validity issues when designing sampling and related recruitment plans for health-related research.

Gait characteristics in nondisabled community-residing nonagenarians

OBJECTIVE

To determine gait performance in community-residing nonagenarians.

DESIGN

Nested case-control study.

SETTING

Community.

PARTICIPANTS

Thirty-one nondisabled nonagenarians (17 women) and 170 young-old controls (age range, 70-85y) participating in a longitudinal study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Systematic clinical and quantitative gait assessments. We also examined the association of gait velocity with death over a 1-year period.

RESULTS

Nonagenarian men had better performance on all quantitative gait parameters examined compared with women. Male sex (beta=.58; 95% confidence interval [CI], 9.95-38.89) and depressive symptoms (beta=-.34; 95% CI, -6.73 to -0.04) were independently associated with gait velocity in multivariate linear regression models. The 6 hypertensive nonagenarians on angiotensin-converting enzyme (ACE) inhibitors had faster gait velocity (median, 103.1cm/s) compared with the 8 hypertensive nonagenarians not on ACE inhibitors (median, 77.5cm/s; P=.029). Nonagenarians had worse quantitative gait parameters compared with the young-old controls, although the differences were less marked when subjects with clinically normal gaits in both groups were compared. Gait velocity did not predict survival over 1-year follow-up.

CONCLUSIONS

Gait characteristics in nondisabled community-residing nonagenarians are associated with male sex, depressive symptoms, and medications. The quantitative gait measures in this sample of nondisabled nonagenarians provide a yardstick to compare younger-age groups.

Social marketing as a framework for recruitment: illustrations from the REACH study

OBJECTIVE

Recruitment is often the most challenging aspect of research with older persons. Social marketing--applying marketing techniques to influence the behavior of target audiences to improve their welfare--can help researchers identify factors that influence recruitment.

METHODS

Illustrations of social marketing principles are provided from the Resources for Enhancing Alzheimer's Caregiver Health project, a national Alzheimer's caregivers study that targeted ethnic and racial minorities.

RESULTS

Social marketing principles--the six Ps of participants, product, price, place, promotion, and partners--provide a theoretical framework for organizing and planning recruitment activities, including developing varying strategies to define the target audience (participants), develop the intervention (product), manage time and trouble (price), target the audience, improve accessibility (place), promote the study, and develop and work with partners.

DISCUSSION

Strategies to enhance recruitment are often undertaken without a comprehensive plan. A social marketing plan provides a framework to map out the steps in recruitment that will be needed and to plan for allocations of time, staff, and resources.

Patient recruitment to a randomized clinical trial of behavioral therapy for chronic heart failure

Background

Patient recruitment is one of the most difficult aspects of clinical trials, especially for research involving elderly subjects. In this paper, we describe our experience with patient recruitment for the behavioral intervention randomized trial, "The relaxation response intervention for chronic heart failure (RRCHF)." Particularly, we identify factors that, according to patient reports, motivated study participation.

Methods

The RRCHF was a three-armed, randomized controlled trial designed to evaluate the efficacy and cost of a 15-week relaxation response intervention on veterans with chronic heart failure. Patients from the Veterans Affairs (VA) Boston Healthcare System in the United States were recruited in the clinic and by telephone. Patients' reasons for rejecting the study participation were recorded during the screening. A qualitative sub-study in the trial consisted of telephone interviews of participating patients about their experiences in the study. The qualitative study included the first 57 patients who completed the intervention and/or the first follow-up outcome measures. Factors that distinguished patients who consented from those who refused study participation were identified using a t-test or a chi-square test. The reason for study participation was abstracted from the qualitative interview.

Results

We successfully consented 134 patients, slightly more than our target number, in 27 months. Ninety-five of the consented patients enrolled in the study. The enrollment rate among the patients approached was 18% through clinic and 6% through telephone recruitment. The most commonly cited reason for declining study participation given by patients recruited in the clinic was 'Lives Too Far Away'; for patients recruited by telephone it was 'Not Interested in the Study'. One factor that significantly distinguished patients who consented from patients who declined was the distance between their residence and the study site (t-test: p < .001). The most frequently reported reason for study participation was some benefit to the patient him/herself. Other reasons included helping others, being grateful to the VA, positive comments by trusted professionals, certain characteristics of the recruiter, and monetary compensation.

Conclusions

The enrollment rate was low primarily because of travel considerations, but we were able to identify and highlight valuable information for planning recruitment for future similar studies.

Achieving recruitment goals through community partnerships: the SENIOR Project

This article discusses the process of developing collaborative relationships for a community-based health promotion project. A partnership was established among the university, the city where the intervention took place, and the community senior center. A community advisory board was created to identify the strengths, diversity, and needs of each partner. The community advisory board guided the partnership to recruit 1,277 older adults to participate in the intervention study. A sample was deemed representative after comparison with Census 2000 data, with gender and educational attainment being similar.