Gatekeeping by Professionals in Recruitment of Pediatric Research Participants: Indeed an Undesirable Practice

Using patient portals for large-scale recruitment of individuals underrepresented in biomedical research: an evaluation of engagement patterns throughout the patient portal recruitment process at a single site within the All of Us Research Program

OBJECTIVE

To evaluate the use of patient portal messaging to recruit individuals historically underrepresented in biomedical research (UBR) to the All of Us Research Program (AoURP) at a single recruitment site.

MATERIALS AND METHODS

Patient portal-based recruitment was implemented at Columbia University Irving Medical Center. Patient engagement was assessed using patient's electronic health record (EHR) at four recruitment stages: Consenting to be contacted, opening messages, responding to messages, and showing interest in participating. Demographic and socioeconomic data were also collected from patient's EHR and univariate logistic regression analyses were conducted to assess patient engagement.

RESULTS

Between October 2022 and November 2023, a total of 59 592 patients received patient portal messages inviting them to join the AoURP. Among them, 24 445 (41.0%) opened the message, 8983 (15.1%) responded, and 3765 (6.3%) showed interest in joining the program. Though we were unable to link enrollment data with EHR data, we estimate about 2% of patients contacted ultimately enrolled in the AoURP. Patients from underrepresented race and ethnicity communities had lower odds of consenting to be contacted and opening messages, but higher odds of showing interest after responding.

DISCUSSION

Patient portal messaging provided both patients and recruitment staff with a more efficient approach to outreach, but patterns of engagement varied across UBR groups.

CONCLUSION

Patient portal-based recruitment enables researchers to contact a substantial number of participants from diverse communities. However, more effort is needed to improve engagement from underrepresented racial and ethnic groups at the early stages of the recruitment process.

Community midwives' and health visitors' experiences of research recruitment: a qualitative exploration using the Theoretical Domains Framework

BACKGROUND

Successful research is frequently hampered by poor study recruitment, especially in community settings and with participants who are women and their children. Health visitors (HVs) and community midwives (CMs) are well placed to invite young families, and pregnant and postnatal women to take part in such research, but little is known about how best to support these health professionals to do this effectively.

AIM

This study uses the Theoretical Domains Framework (TDF) to explore the factors that influence whether HVs and CMs invite eligible patients to take part in research opportunities.

METHOD

HVs (n = 39) and CMs (n = 22) working in four NHS Trusts and one community partnership in England completed an anonymous, online survey with open-ended questions about their experiences of asking eligible patients to take part in the research. Qualitative data were analysed using directed content analysis and inductive coding to identify specific barriers and enablers to patient recruitment within each of the 14 theoretical domains.

FINDINGS

Six key TDF domains accounted for 81% of all coded responses. These were (a) environmental context and resources; (b) beliefs about capabilities; (c) social/professional role and identity; (d) social influences; (e) goals; (f) knowledge. Key barriers to approaching patients to participate in the research were time and resource constraints, perceived role conflict, conflicting priorities, and particularly for HVs, negative social influences from patients and researchers. Enablers included feeling confident to approach patients, positive influence from peers, managers and researchers, beliefs in the relevance of this behaviour to health care and practice and good knowledge about the study procedures, its rationale and the research topic. The findings suggest that to improve research recruitment involving HVs and CMs, a package of interventions is needed to address the barriers and leverage the enablers to participant approach.

Engaging patients throughout the health system: A landscape analysis of cold-call policies and recommendations for future policy change

Healthcare institutions may often prohibit “cold-calling” or direct contact with a potential research participant when the person initiating contact is unknown to the patient. This policy aims to maintain patient privacy, but may have unintended consequences as a result of physician gatekeeping. In this review, we discuss recruitment policies at the top academic institutions. We propose an ethical framework for evaluating cold-call policies based on three principles of research ethics. In order to maximize engagement of potential research participants, while maintaining patient privacy and autonomy, we then propose several alternative solutions to restrictive cold-call policies, including opt-in or opt-out platforms, a team-based approach, electronic solutions, and best practices for recruitment. As healthcare has evolved with more collaborative, patient-centered, data-driven care, the engagement of potential research participants should similarly evolve.

Motivators and challenges to research recruitment - A qualitative study with midwives

OBJECTIVE

To explore midwives' experiences of recruiting participants to research studies conducted by other researchers.

DESIGN

An inductive qualitative study.

METHODS

Individual face-to-face or telephone interviews using a semi-structured interview guide. Interviews were analysed thematically.

SETTINGS

One large urban maternity hospital in Ireland.

PARTICIPANTS

A purposive sample of 19 midwives FINDINGS: Three co-dependent themes emerged: intrinsic motivations, extrinsic motivations and challenges. Intrinsic motivations included midwives' personal beliefs about the value of research in general, its potential to improve practice, and their perceptions of how robust a particular study was and how it might impact on an individual woman and her baby. This included an inherent desire to shield some women, those who were perceived to have ongoing health issues or be anticipating a sub-optimal pregnancy outcome, from being offered study information. Extrinsic motivations related to the complexity of a research study and a specific researcher's characteristics. Challenges to offering potential participants research study information and, therefore, to successful recruitment included time constraints, workload and the volume of research being conducted simultaneously.

KEY CONCLUSIONS

Participants navigated the two, sometimes competing, worlds of clinical practice and clinical research. Set in the context of workload and the volume of research being conducted simultaneously, midwives' perceptions of a study's robustness, clarity, its potential impact on individual women and ability to improve practice governed their motivation to offer information on research studies to potential participants.

IMPLICATIONS FOR PRACTICE

Inviting clinicians to assess the study information may improve its clarity and create opportunities to discuss the potential value and recruitment bias. Researchers should be available to address clinicians' questions about particular research studies. At an organisational level, a system for managing the volume of research activity is required.

Feasibility of parent communication training with remote coaching using smartphone apps

BACKGROUND

Communication training for parents of young children with neurodisability is often delivered in groups and includes video coaching. Group teaching is problematic when there is wide variation in the characteristics and needs amongst participants.

AIMS

To assess the potential feasibility and acceptability of delivering one-to-one parent training supported by remote coaching using smartphone apps and of conducting further trials of the intervention.

METHODS & PROCEDURES

We aimed to recruit eight children aged 12-48 months with motor disorders and communication difficulties and to provide families with individual parent training in six weekly home visits supplemented by remote coaching via smartphone apps. For outcome measurement, parents recorded their interaction with their child thrice weekly during baseline (3 weeks), intervention, post-intervention (3 weeks) and follow-up (1 week). Measures comprised parent responsiveness and counts of children's communication and vocalization. Research design feasibility was measured through rates of recruitment, attrition, outcome measure completion and agreement between raters on outcome measurement. Intervention feasibility was assessed through the proportion of therapy sessions received, the number of videos and text messages shared using the apps in remote coaching, and message content. Parents were interviewed about the acceptability of the intervention and trial design. Interviews were transcribed and analyzed using inductive thematic analysis.

OUTCOMES & RESULTS

Nine children were recruited over 16 weeks. All fitted the inclusion criteria. Four families withdrew from the study. Five families completed the intervention. No family submitted the target number of video recordings for outcome measurement. Interrater agreement was moderate for child communication (K = 0.46) and vocalization (K = 0.60) and high for The Responsive Augmentative and Alternative Communication Style scale (RAACS) (r_s = 0.96). Parents who completed the intervention reported positive experiences of the programme and remote coaching via the apps. Therapist messages via the app contained comments on parent and child behaviour and requests for parental reflection/action; parental messages contained reflections on children's communication.

CONCLUSIONS & IMPLICATIONS

The intervention and study design demanded high levels of parental involvement and was not suitable for all families. Recording shorter periods of interaction via mobile phones or using alternative methods of data collection may increase feasibility of outcome measurement.

The child's perspective on discomfort during medical research procedures: a descriptive study

OBJECTIVE

The evaluation of discomfort in paediatric research is scarcely evidence-based. In this study, we make a start in describing children's self-reported discomfort during common medical research procedures and compare this with discomfort during dental check-ups which can be considered as a reference level of a 'minimal discomfort' medical procedure. We exploratory study whether there are associations between age, anxiety-proneness, gender, medical condition, previous experiences and discomfort. We also describe children's suggestions for reducing discomfort.

DESIGN

Cross-sectional descriptive study.

SETTING

Paediatric research at three academic hospitals.

PATIENTS

357 children with and without illnesses (8-18 years, mean=10.6 years) were enrolled: 307 from paediatric research studies and 50 from dental care.

MAIN OUTCOME MEASURES

We measured various generic forms of discomfort (nervousness, annoyance, pain, fright, boredom, tiredness) due to six common research procedures: buccal swabs, MRI scans, pulmonary function tests, skin prick tests, ultrasound imaging and venepunctures.

RESULTS

Most children reported limited discomfort during the research procedures (means: 1-2.6 on a scale from 1 to 5). Compared with dental check-ups, buccal swab tests, skin prick tests and ultrasound imaging were less discomforting, while MRI scans, venepunctures and pulmonary function tests caused a similar degree of discomfort. 60.3% of the children suggested providing distraction by showing movies to reduce discomfort. The exploratory analyses suggested a positive association between anxiety-proneness and discomfort.

CONCLUSIONS

The findings of this study support the acceptability of participation of children in the studied research procedures, which stimulates evidence-based research practice. Furthermore, the present study can be considered as a first step in providing benchmarks for discomfort of procedures in paediatric research.

Are positive experiences of children in non-therapeutic research justifiable research benefits?

BACKGROUND

Conducting non-therapeutic research is ethically challenging because participation conveys risks and burden and no health benefit. In this paper, we report the positive experiences of a diverse group of healthy and ill children (6-18 years) who participated in non-therapeutic research studies and discuss whether these positive experiences can justifiably be viewed as benefits.

METHODS

We used semistructured interviews from an earlier study about children's experiences in clinical research and did a secondary analysis on the positive experiences of the children in the non-therapeutic studies (N=30). Interviews were analysed using 'thematic' analysis.

RESULTS

The interviewed children most frequently mentioned as positive experiences of non-therapeutic research participation helping others and the gratification that comes with it, possible health benefits in the future, having fun and new/increased knowledge about the human body, hospitals and doing research. Less frequently mentioned were getting a present, not having to go to school and getting extra attention from healthcare staff.

CONCLUSIONS

Our study shows that children participating in non-therapeutic research have various positive experiences while taking part. We argue that some of these justifiably could be taken into the risk-benefit analysis in certain situations or maybe even as a standard part of this analysis. This may help to increase the number of (crucial) non-therapeutic studies with children.

Primary care physicians' views about gatekeeping in clinical research recruitment: A qualitative study

BACKGROUND

Clinical research is increasingly being undertaken in primary care settings. This development offers both benefits and challenges. The ethical challenges of occupying the roles of both clinician and researcher may be accentuated in primary care settings, where relationships are longer lasting and medical conditions are less acute. This article examines primary care physicians' experiences of undertaking research, particularly their decision making about recruiting patients in the context of their own dual roles.

METHODS

This project comprised in-depth interviews with eight Australian primary care physicians working in general or specialist practices that were involved in clinical research. Data were analyzed using inductive thematic analysis.

RESULTS

Physicians involved in recruiting their patients into clinical trials acted as gatekeepers; they were selective about which patients to recruit and did not necessarily approach all patients who met the research eligibility criteria. Physicians' accounts suggested they prioritized their clinician role over their researcher role. In addition to the rigor and merit of the research, physicians considered the possible benefit of trial participation for individual patients. Physicians described making recruitment decisions based on their perceived knowledge of patients' personal, behavioral, and attitudinal characteristics-often derived from their long-standing relationships with their patients.

CONCLUSION

Our data show evidence of gatekeeping by primary care physicians when deciding to participate in, and recruit their patients to, clinical studies. We argue that such gatekeeping is a way of addressing the dual and sometimes conflicting roles of clinician and researcher. It need not be ethically problematic, but primary care physicians should be reflexive about their recruitment practices and biases. In addition, this form of gatekeeping should be explicitly recognized in protocol design and the analysis of trial findings.