Participation of older adults in health programs and research: a critical review of the literature

Feasibility and clinical applicability of a novel power wheelchair training approach

PURPOSE

To evaluate the feasibility and the clinical applicability of administering the COMET (cognition, occupation, mobility, evaluation and training) intervention.

MATERIALS AND METHODS

A pilot research was conducted with adults who were being considered for power wheelchair (PWC) provision, or who were recently provided a PWC, and who had been identified to benefit from a PWC training. The COMET intervention applies a goal directed, client-centred and occupation-based approach. Feasibility and applicability indicators were collected for: process, resources, management and treatment. Indicators were evaluated as "successful/unsuccessful". Clinical outcomes included the Goal Attainment Scale (GAS), the Canadian Occupational Performance Measure (COPM), the Power mobility Indoor Driving Assessment (PIDA) and the Wheelchair Skills Test (WST).

RESULTS

Four females (62.5 ± 3.5 years) with cognitive impairment participated in the study. Among the 13 indicators, 10 were successfully achieved. Indicators that did not meet the criteria for success were adherence rate, safety and treatment for the PIDA. Two adverse events were reported, with one minor injury. Participants demonstrated better than expected results on the GAS, the COPM scores and the WST. However, only two reported an improvement beyond 4% of the PIDA.

CONCLUSIONS

With few modifications, the COMET intervention and the study protocol will be feasible and applicable in clinical practice. Individuals with complex cognitive and mobility impairment demonstrated abilities to learn PWC use. Further investigation of the COMET intervention is required to evaluate its efficacy.Implications for rehabilitationA novel power wheelchair (PWC) training approach adapted to individual with complex mobility and cognitive impairments was developed: the COMET (cognition, occupation, mobility, evaluation and training) intervention.The COMET intervention applies a goal directed, client-centred and occupation-based approach.With minor modifications, the COMET intervention may be feasible and clinically applicable to train individuals with complex motor and cognitive impairments how to use a PWC.Further evaluation of the COMET intervention and lager control trialsare suggested.

Feasibility of a 12-Month Follow-Up in Swiss Older Adults after Post-Acute Care in Nursing Homes-A Pilot Study

(1) Background: Post-acute care (PAC) aims to support functional recovery in older adults after acute hospitalization in order to regain a sufficient level of self-care facilitating their return home. However, the long-term outcomes of PAC are understudied due to challenges in recording a follow-up. We aimed to investigate the feasibility of a 12-month follow-up after PAC in Swiss nursing homes, examining practicability and potential factors influencing participation rate. (2) Methods: Collection of one-year follow-up data among 140 eligible patients after PAC in nursing homes was attempted. Patients were recruited using letters and phone calls between August and December 2017. We compared baseline data of all initial PAC patients with those who declined participation in the follow-up to identify factors potentially influencing participation. (3) Results: Overall mortality at 12 months was 25% (n = 35 of 140). Of the 105 survivors, 53 (50%) refused participation, 26 (25%) were interviewed, and 26 (25%) were lost to follow-up. Comparison of baseline characteristics between participants and objectors indicated significant statistical differences in Mini-Mental State Examination (MMSE) scores (participants mean of 26.0 [SD 3.92] vs. objectors mean of 23.5 points [SD 4.40], p = 0.015). Further, logistic regression showed statistically significantly greater odds of participation (OR 1.25 [95% CI 1.06-1.48]) for each point increase in MMSE scores. (4) Conclusions: Long-term follow-up studies in older adults after PAC are challenging due to high mortality and dropout rates. Of note, intact cognitive function at baseline was associated with a higher willingness to participate in a follow-up phone interview. The assessment of cognitive function should be considered when estimating the participation rate in older patients.

Longitudinal Studies 1: Determinants of Risk

Longitudinal or observational study designs are important methodologies to investigate potential associations that may not be amenable to randomized controlled trials. In many cases, they may be performed using existing data and are often cost-effective ways of addressing important questions. The major disadvantage of observational studies is the potential for bias. The absence of randomization means that one can never be certain that unknown confounders are present, and specific studies designs have their own inherent forms of bias. Careful study design may minimize bias. Establishing casual association based on observational methods requires due consideration of the quality of the individual study and knowledge of their limitations.

Evaluation of the feasibility of an error-minimized approach to powered wheelchair skills training using shared control

BACKGROUND

Powered wheelchairs promote participation for people with mobility limitations. For older adults with cognitive impairment, existing training methods may not address learning needs, leading to difficulty with powered wheelchair skills. Error-minimized training, facilitated by shared control technology, may provide learning opportunities more suited to this population.

OBJECTIVE

The objective of this study was to evaluate the feasibility of an error-minimized approach to powered wheelchair skills training using shared control in residential care. Feasibility indicators were hypothesized a priori to be feasible for use in a definitive RCT.

METHODS

A 2 × 2 factorial RCT compared an error-minimized powered wheelchair skills training program (Co-pilot) to a control intervention at two doses (6 sessions vs. 12 sessions). Data were collected on the feasibility of study processes (e.g., recruitment), resources (e.g., participant time), management (e.g., technology reliability), and training outcomes (e.g., adverse events, clinical outcomes).

RESULTS

Twenty-five older adults with cognitive impairment participated in the study. Technical issues were encountered in 14.5% of training sessions. Participants receiving 6 sessions of training adhered better to the treatment than those receiving 12 sessions. All participants learned the skills required for PWC use with minor errors, regardless of the training method or dose. Co-pilot participants and trainers reported feelings of safety and training benefits with the use of shared control technology.

CONCLUSIONS

Individuals with mild to moderate cognitive impairment are able to learn the skills required to drive a powered wheelchair in as few as six training sessions. Further evaluation of the Co-pilot training program is required.IMPLICATIONS FOR REHABILITATIONShared control teleoperation technology may be used to augment learning in older adults with cognitive impairments.Evaluation of the feasibility of use of novel rehabilitation technologies is critical prior to engaging in large-scale clinical research.Individuals with cognitive impairment are able to learn the required skills for operation of a powered wheelchair.

The Intellectual Disability Mortality Disadvantage: Diminishing With Age?

On average, adults with intellectual disability (ID) have higher mortality risk than their peers in the general population. However, the effect of age on this mortality disadvantage has received minimal attention. Using data from the 1986-2011 National Health Interview Survey-Linked Mortality Files (NHIS-LMF), discrete time hazard models were used to compare mortality risk for adults with and without ID by age and gender. Increased mortality risk was present for all adults with ID, but was most pronounced among younger age females. The mortality differential between those with and without ID diminished with increased age for both females and males. Findings support the argument that heterogeneity of frailty may explain differences in mortality risk between those with and without ID.

Nonparticipation of Older Adults in a Heart Disease Self-Management Project

Nonparticipation is an important issue in gerontological research. However, literature describing factors influencing participation of older adults in disease management programs is limited. This article contributes to the understanding of nonparticipation in older adults by reviewing the relevant literature and delineating a strategy for assessing the impact of nonparticipation on the generalizability of findings. Involvement in a study of an educational intervention for teaching self-management skills was investigated. Four hundred elderly cardiac patients were divided into three groups: participants in the self-management program evaluation; nonparticipants who declined involvement in the study, but agreed to provide a limited amount of information via telephone interview; and those who refused involvement of any kind. Participants were most likely to be male, with more formal education, who were more worried about their heart conditions, and less likely to perceive that help was available to them. Nonparticipants mentioned "time constraints," "transportation," and "physical limitations" as primary barriers to involvement.

The STAYWELL Program-Maximizing Elders' Capacity for Independent Living Through Health Promotion and Disease Prevention Activities

The STAYWELL Program, an 8-session health promotion/disease prevention pro-gram for older adults, was found to have a significant impact on elder participants' health-related beliefs and behaviors. This quasi-experimental study's 146 participants were recruited from 8 western New York senior citizen centers, and 70% (n = 102) were available for a 9-month follow-up assessment. As compared with elders on a waiting list, study participants who experienced the STAYWELL intervention ex-pressed significantly healthier beliefs and reported behavioral changes indicative of a healthier lifestyle at follow-up. All of the intervention effect sizes observed may be characterized as large to very large: (1) The intervention group expressed healthier beliefs as assessed using the healthy belief index-at follow-up, three quarters of them scored higher on this measure than the average person in the waiting list comparison group (U3 = 77.3%); (2) the intervention group engaged in healthier behaviors as assessed by using the healthy behavior index (U3 = 92.4%); and (3) they also took fewer medications (U3 = 74.2%); all p < .05. Extant cohorts in this field (more than 20,000 elders) may offer collaborative opportunities for needed longer follow-up of health outcome end-points.

Intervening on Exercise and Nutrition in Older Adults

Presented are the basic design, methods, and baseline data analyses for the Study of Exercise and Nutrition in Older Rhode Islanders (SENIOR Project) an experimental study to investigate the relative effectiveness of a 12-month, stage of readiness to change-based multiple-behavior intervention (exercise and nutrition) compared to single-behavior interventions in a community-dwelling population of 1,277 older adults. Relationships between stage of readiness to change in the two target behaviors, as well as the relationship between stage of readiness and self-reported exercise levels and fruit and vegetable consumption, were examined using a combination of Pearson chi-squares, analyses of variance (ANOVA), and Spearman’s rank order correlations. Stage of change (SOC) for fruit and vegetable consumption was significantly associated with the dietary measure, and SOC for exercise was associated with both the three physical activity measures and servings of fruits and vegetables per day. Overall, individual older adult's readiness to change seems largely to be behavior-specific.

‘Planning for uncertainty’: narratives on retirement transition experiences

Retirement is a major life transition which is associated in public discourses with reduced economic productivity and a raft of personal vulnerabilities. Consequently, governmental, health and employment sectors have promoted ‘active’ planning of affordable and ‘healthy’ retirements. This study presents a qualitative exploration of retirement transition and preparation experiences among 52 men and women from rural and urban areas of North East England, United Kingdom. The sample was diverse in terms of social class, income level, health status and type of work exit. Health, finance, social relationships and third-age opportunities were required resources for a good transition into retirement, and a degree of planning was required to mobilise these resources. However, the degree of choice and control around the transition to retirement was highly variable and socially structured. The notion of planning was embedded as a normative practice, particularly in relation to finances, but the practice of planning was highly contingent primarily due to personal circumstances (ill-health, bereavement, relationships) and work exit (redundancy, work stress, changes to shift patterns or hours). The findings offer insights into the reasons why many people do not plan and indicate that many of the assumptions associated with retirement planning warrant further consideration both theoretically and practically.

[The feasibility of screening for COPD and asthma in the general population]

INTRODUCTION

There are very few surveys devoted to the prevalence of asthma and COPD in the general population. The Motorola Health System has been developed to make such surveys easier.

OBJECTIVES

The main objective was to assess the acceptability and efficacy of the Motorola Health system in collecting health data at home in the context of an epidemiological study of respiratory health. The secondary objective was to determine whether a home-based survey would lead to a higher participation rate than a hospital-based survey.

METHODS

Four hundred and eighty-three individuals were selected from the electoral rolls of the 15th district of Marseille and randomly divided into two groups: home-based and hospital-based. The protocol included a questionnaire, several measurements: height, weight, blood pressure, spirometry and pulse oxymetry, and blood sampling. All data were transferred to a portable computer.

RESULTS

Data acquisition and transfer worked well. Among the 232 subjects from the home-based survey, 62 (26.7%) participated, whereas only 36 (14.3%) of the 251 subjects from the hospital-based group did so (P<0.001). In an additional telephone survey, participants (13.6%) and non-participants (11.0%) had the same (P<0.9) prevalence of asthma.

CONCLUSION

The Motorola Health System allowed accurate data acquisition and transfer in the context of an epidemiological survey of respiratory health. A home-based survey gave a higher participation rate than a hospital-based one.

Improving the Cooperation Rate of Older Adults and Their Caregivers in Research Surveys

BACKGROUND

Recruiting older adults, their family members and their home care workers as participants in research studies is particularly complicated. This might be due to medical or cognitive problems of the older adult as well as the high workload and shortage of time experienced by caregivers. The present study compared the contribution of two different versions of an advanced letter followed by two different versions of a recruitment phone call to the cooperation rate of older adults, family caregivers and home care workers in a face-to-face survey.

METHODS

A quasi-experimental design was used to compare the contribution of the different types of appeal. A total of 2,014 caregiving units (composed of an older adult, a family member and a home care worker) were randomly sampled from a list of Israeli long-term care insurance beneficiaries. 74.32% of the sampled caregiving units were eligible to participate in the study. The first group of participants received formal and succinctly phrased written and oral appeals - an advanced letter followed by a recruitment phone call. The second group of participants received the original formal and succinctly phrased advanced letter, but a revised recruitment phone call that included a more personal approach, the provision of broader information about the study and the avoidance of words with a possible negative connotation. The third group of participants received both a revised advanced letter and a revised recruitment phone call.

RESULTS

Using the succinctly phrased written and oral appeals, we had a cooperation rate of about 50% for the entire caregiving unit. Using a revised advanced letter and a revised recruitment phone call yielded an increase of 20-25% in the cooperation rate for the entire caregiving unit. Using the revised recruitment phone call and the original advanced letter yielded an increase in the cooperation rate only among migrant home care workers.

CONCLUSION

This study showed that by changing the format of appeal we can increase the cooperation rate of older adults and their caregivers in a research survey. This study also pointed out the importance of the advanced letter.

Longitudinal studies 1: Determination of risk

Longitudinal or observational study designs are important methodologies to investigate potential associations that may not be amenable to randomized controlled trials. In many cases they may be performed using existing data and are often cost-effective ways of addressing important questions. The major disadvantage of observational studies is the potential for bias. The absence of randomization means that one can never be certain that unknown confounders are present, and specific studies designs have their own inherent forms of bias. Careful study design may minimize bias. Establishing casual association based on observational methods requires due consideration of the quality of the individual study and knowledge of their limitations.

Cancer survivorship issues: life after treatment and implications for an aging population

The US population of cancer survivors age ≥ 65 years will continue to grow rapidly over the next few decades. This growth will be driven largely by the aging of the national population. With the diffusion of earlier detection and more effective therapies, the majority of these individuals can expect to live long term after diagnosis. This often vulnerable group of survivors poses significant challenges for both researchers and clinicians with regard to how best to document and address its unique health care needs. In this article, we briefly review the long-term and late-occurring effects of cancer and its treatment in older survivors, review information on current patterns of post-treatment care and the evolving guidelines for this care, and discuss opportunities for future research.

Measuring care transition quality for older patients with musculoskeletal disorders

OBJECTIVE

The aim of the current study was to examine the ability of a performance measurement scale, the Care Transitions Measure (CTM) adequately to assess the quality of care transitions among a complex population of older musculoskeletal (MSK) rehabilitation patients.

METHODS

Fifteen older (aged 60+) patients with MSK disorders were recruited from two inpatient rehabilitation units. A telephone interview was conducted three to four weeks post-discharge; this included the CTM and global questions used for construct validation. To assess inter-rater reliability, the CTM was re-administered to ten subjects in a second interview six to ten days later. Participant comments were recorded in an effort to gauge how respondents understood and interpreted items.

RESULTS

The CTM demonstrated acceptable inter-rater reliability for the overall score (intraclass correlation coefficient = 0.77; p = 0.03), in spite of only fair agreement for specific items. The internal consistency was high (Cronbach's alpha = 0.94). The construct validity was supported; however, qualitative data suggest that additional items should be considered for inclusion, and the need for revisions to the wording of the response options and some items.

CONCLUSIONS

Although the CTM proved to be reliable for an MSK population, there is a need for modifications to improve the construct validity and utility of the CTM. Recommendations for scale improvement are made. The results of the present study support efforts to improve the outcomes of care transitions, care planning and the overall quality of life for older rehabilitation patients.

Who participates in chronic disease self-management (CDSM) programs? Differences between participants and nonparticipants in a population of multimorbid older adults

BACKGROUND

Self-care management is recognized as a key component of care for multimorbid older adults; however, the characteristics of those most likely to participate in Chronic Disease Self-Management (CDSM) programs and strategies to maximize participation in such programs are unknown.

OBJECTIVES

To identify individual factors associated with attending CDSM programs in a sample of multimorbid older adults.

RESEARCH DESIGN

Participants in the intervention arm of a matched-pair cluster-randomized controlled trial of the Guided Care model were invited to attend a 6-session CDSM course. Logistic regression was used to identify factors independently associated with attendance.

SUBJECTS

All subjects (N = 241) were aged 65 years or older, were at high risk for health care utilization, and were not homebound.

MEASURES

Baseline information on demographics, health status, health activities, and quality of care was available for CDSM participants and nonparticipants. Participation was defined as attendance at 5 or more CDSM sessions.

RESULTS

A total of 22.8% of multimorbid older adults who were invited to CDSM courses participated in 5 or more sessions. Having better physical health (odds ratio [95% confidence interval] = 2.3 [1.1-4.8]) and rating one's physician poorly on support for patient activation (odds ratio [95% confidence interval] = 2.8 [1.3-6.0]) were independently associated with attendance.

CONCLUSIONS

Multimorbid older adults who are in better physical health and who are dissatisfied with their physicians' support for patient activation are more likely to participate in CDSM courses.

Study of participation barriers in family-focused prevention: research issues and preliminary results

There is a growing body of literature which argues for more research on barriers to participation in family-focused interventions, particularly among at-risk families. Following a review of research needs and issues suggested by the literature, this article presents results from a study which 1) evaluates reasons for decisions against participation in a family-focused prevention intervention project and 2) compares characteristics of intervention project participants with those of non-participants. Data on reasons for refusing participation were collected from non-participants during a recruitment telephone interview and via a mail survey. Results indicated that the most frequent reasons given for decisions against participation concerned intervention time demands and research-related requirements such as videotaping. There were no significant differences between participants and non-participants on any sociodemographic variables. Analyses of the relationships between reasons for participation refusal and sociodemographic subgroupings of non-participants, however, suggested that variations exist among these subgroups. Overall, results highlight the feasibility and importance of data collection on intervention project non-participants, both to clarify potential participation barriers and to gather data on sample representativeness.

Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial

Due to the ageing population, there is an increased demand for home care services. Restorative care is one approach to improving home care services, although there is little evidence to support its use in the community setting. The objective of this trial was to evaluate the impact of a restorative home care service for community-dwelling older people. The study was a cluster randomised controlled trial undertaken at a home care agency in New Zealand. The study period was from December 2005 to May 2007. Older people were interviewed face-to-face at baseline, four and 7 months. A total of 186 older people who received assistance from a home care agency participated in the study, 93 received restorative home care and 93 older people received usual home care. The primary outcome measure was change in health-related quality of life (measured by the Short Form 36 [SF36] Health Survey). Secondary outcomes were the physical, mental, and social well-being of older people (Nottingham Extended Activities of Daily Living, Timed Up and Go, Mastery scale, Duke Social Support Index). Findings revealed that compared with usual care, the intervention demonstrated a statistically significant benefit in health-related quality of life (SF36) at 7 months for older people (mean difference 3.8, 95% CI -0.0 to 7.7, P = 0.05). There were no changes in other scale measurements for older people in either group over time. There was a statistically significant difference in the number of older people in the intervention group identified for reduced hours or discharge (29%) compared with the control group (0%) (P < 0.001). In conclusion, a restorative home care service may be of benefit to older people, and improves home care service efficacy.

Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture

Introduction

Complex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings.

Methods

A qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition. A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data.

Results

Four factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints.

Conclusions

Our research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.

Variability in frontotemporal brain structure: the importance of recruitment of African Americans in neuroscience research

Background

Variation in brain structure is both genetically and environmentally influenced. The question about potential differences in brain anatomy across populations of differing race and ethnicity remains a controversial issue. There are few studies specifically examining racial or ethnic differences and also few studies that test for race-related differences in context of other neuropsychiatric research, possibly due to the underrepresentation of ethnic minorities in clinical research. It is within this context that we conducted a secondary data analysis examining volumetric MRI data from healthy participants and compared the volumes of the amygdala, hippocampus, lateral ventricles, caudate nucleus, orbitofrontal cortex (OFC) and total cerebral volume between Caucasian and African-American participants. We discuss the importance of this finding in context of neuroimaging methodology, but also the need for improved recruitment of African Americans in clinical research and its broader implications for a better understanding of the neural basis of neuropsychiatric disorders.

Methodology/Principal Findings

This was a case control study in the setting of an academic medical center outpatient service. Participants consisted of 44 Caucasians and 33 ethnic minorities. The following volumetric data were obtained: amygdala, hippocampus, lateral ventricles, caudate nucleus, orbitofrontal cortex (OFC) and total cerebrum. Each participant completed a 1.5 T magnetic resonance imaging (MRI). Our primary finding in analyses of brain subregions was that when compared to Caucasians, African Americans exhibited larger left OFC volumes (F _1,68 = 7.50, p = 0.008).

Conclusions

The biological implications of our findings are unclear as we do not know what factors may be contributing to these observed differences. However, this study raises several questions that have important implications for the future of neuropsychiatric research.

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.

Longitudinal studies and determination of risk

Longitudinal and observational study designs are important methodologies to investigate potential associations that may not be amenable to RCTs. In many cases, they may be performed using existing data and are often cost-effective ways of addressing important questions. The major disadvantage of observational studies is the potential for bias. The absence of randomization means that one can never be certain that unknown confounders are present, and specific studies designs have their own inherent forms of bias. Careful study design may minimize bias. Establishing a casual association based on observational methods requires due consideration of the quality of the individual study and knowledge of its limitations.

The challenges of clinical trials in the exclusion zone: the case of the frail elderly

Frail older people have been systematically excluded from randomised controlled trials (RCT). We aim to recruit older, frail hospitalised patients in an RCT and evaluate the frailty index (FI) as a measure to describe the types of people included in the study. We recruited 315 hospitalised patients aged 65 years; age ranged from 60 to 102 years. Baseline assessment scores ranged as follow: Mini-Mental Status Examination from 7 to 30, Barthel index from 5 to 100 and FI from 2 to 24. Total deaths were 20 (6%). We demonstrated that it is feasible to recruit frail older people into RCTs. The FI does not show any 'floor' or 'ceiling' effects. We can measure frailty in an RCT cohort, and we believe that clinical trials should include more frail older people and that the use of an FI can facilitate such trials and generate reliable data to guide future medical practice in a rapidly ageing society.

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.

Effective recruitment of parents into family-focused prevention research: A comparison of two strategies

Recent literature highlights the need for more effective recruitment and retention strategies in prevention research. This article reports an investigation of the effectiveness of two recruitment strategies for a family-focused substance abuse prevention study. The first strategy offered prospective participants two points at which they could make a decision about their level of involvement in the research project and required only a limited initial time commitment. The second strategy required an initial commitment to participate in all phases of the project. The investigation was conducted with 208 rural families participating in the pilot phase of a five-year prevention study. There were three primary findings. First, both strategies were effective, yielding higher recruitment rates than would be predicted from relevant literature. Second, the strategy requiring a limited time commitment showed significantly higher rates of recruitment into the pretest, but was associated with significantly lower posttest retention rates. Third, data trends emerged but there were no statistically significant differences between the two recruitment strategy groups across a range of intervention participation indicators.

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.

A multifactorial fall prevention programme in the community-dwelling aged: predictors of adherence

BACKGROUND

Overall adherence rates have usually been reported in fall prevention studies, but predictors of adherence have rarely been described. The aim of this study was to determine the adherence rates and the predictors of adherence in four key activities of a multifactorial fall prevention trial.

METHODS

This study is part of a multifactorial fall prevention programme implemented among the 65-year-old or older community-dwelling aged who had fallen at least once during the previous 12 months. Subjects (n = 591) were randomly assigned to an intensive prevention programme or to a counselling group. Four key activities of prevention programme included physical exercise in small groups, psychosocial group activities, lectures and home exercises. Associations between adherence rates and potential predictors were analysed using cumulative logistic regression.

RESULTS

The mean adherence rate was 58% in the physical exercise groups, 25% in the psychosocial groups and 33% in lectures. Subjects performed home-exercises on average 11 times per month. In multivariate analyses, infrequent feelings of loneliness, low self-perceived probability of falling at home and good physical functional abilities were significant predictors of active physical exercise group adherence. Good physical and cognitive functional abilities predicted active psychosocial group adherence. Female gender and good physical and cognitive functional abilities predicted more active lecture adherence.

CONCLUSION

Persons with the poorest physical, cognitive and psychological functional abilities representing the part of the population at highest risk of falling do not seem reachable in multifactorial risk-based intervention.

Recruitment of the elderly into a pharmacologic prevention trial: the Ginkgo Evaluation of Memory Study experience

The difficulty involved in recruiting healthy older adults into clinical trials, especially those involving pharmacologic agents, is an important issue in research. The Ginkgo Evaluation of Memory (GEM) Study, a double-blind, placebo-controlled randomized clinical trial evaluating Ginkgo biloba to prevent dementia, successfully recruited 3072 participants age 75 years and older at four U.S. sites from September 2000 through June 2002. Using targeted mailing lists, an estimated 243,400 study brochures were mailed out to potential participants. Subsequent attempts were made to reach 14,603 households by telephone, from which 12,186 (83.4%) successful contacts were made. Overall, telephone or in-person evaluations identified 2149 (17.6%) ineligible persons for cognitive (20.6%), medical (49.4%), or other (30.0%) reasons. A total of 6944 (57.0%) refused participation resulting in 3072 enrolled into the study, a recruitment rate of 25.2% based on telephone contacts made or 1.3% of all mailed brochures. Recruitment rates were stable over the 21-month enrollment period but were higher for the two urban centers than the two rural ones. Recruitment was dependent most on mailing lists available, density of older adults in the catchment areas, and Institutional Review Board restrictions. Men and persons under age 85 were more likely to enroll. Primary reason for refusals involved lack of interest (48.4%) or self-perceived poor health (16.2%). Over 9% were unwilling to give up current Ginkgo supplementation or would not accept assignment to placebo. An additional 7% did not want another medication and almost 4% had care-giving responsibilities which prevented involvement. Mass mailings were the most successful approach for recruitment at all four sites and the method through which the vast majority of interviewees had learned about the study. Information on the experience of the GEM Study recruitment may be helpful to other clinical trials attempting to randomize older adults into prevention trials.

Personal characteristics of older primary care patients who provide a buccal swab for apolipoprotein E testing and banking of genetic material: the spectrum study

OBJECTIVE

To determine the personal characteristics and reasons associated with providing a buccal swab for apolipoprotein E (APOE) genetic testing in a primary care study.

METHODS

The study sample consisted of 342 adults aged 65 years and older recruited from primary care settings.

RESULTS

In all, 88% of patients agreed to provide a DNA sample for APOE genotyping and 78% of persons providing a sample agreed to banking of the DNA. Persons aged 80 years and older and African-Americans were less likely to participate in APOE genotyping. Concern about confidentiality was the most common reason for not wanting to provide a DNA sample or to have DNA banked.

CONCLUSION

We found stronger relationships between sociodemographic variables of age and ethnicity with participation in genetic testing than we did between level of educational attainment, gender, function, cognition, and affect.

Recruiting Seniors With Chronic Low Back Pain for a Randomized Controlled Trial of a Self-Management Program

OBJECTIVE

To identify recruitment challenges and elucidate specific strategies that enabled recruitment of seniors for a randomized trial on low back pain comparing the Chronic Disease Self-management Program of the Stanford University to a 6-month wait-list control group.

DESIGN

Recruitment for a randomized controlled trial.

SETTING

Community-based program offered at 12 locations.

PARTICIPANTS

Community-dwelling seniors 60 years and older with chronic low back pain of mechanical origin.

METHODS

Passive recruitment strategies included advertisement in local and senior newspapers, in senior e-mail newsletters and listservs, in local community centers and businesses. Active strategies included meeting seniors at health fairs, lectures to the public and organizational meetings, and the help of trusted professionals in the community.

RESULTS

A total of 100 white and 20 African American seniors were recruited. The program seemed to have the most appeal to white, middle-class older adults, educated through high school level. Advertisement failed to attract any participants to the program. Successful strategies included interaction with seniors at health fairs and lectures on health care, especially when the program was endorsed by a trusted community professional.

CONCLUSION

Generating interest in the self-management program required keen communication skills because the idea of "self-management" was met with a myriad of responses, ranging from disinterest to disbelief. Generating interest also required active participation within the communities. Initial contacts had to be established with trusted professionals, whose endorsement enabled the project managers to present the concept of self-management to the seniors. More complex recruitment strategies were required for this study involving the self-management approach to back pain than for studies involving treatment.

Patient characteristics associated with participation in a practice-based study of depression in late life: the Spectrum study

OBJECTIVE

An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation.

METHOD

Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined.

RESULTS

In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate.

CONCLUSIONS

Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctor's office.

Special populations recruitment for the Women's Health Initiative: successes and limitations

The Women's Health Initiative (WHI) is a study designed to examine the major causes of death and disability in women. This multi-arm, randomized, controlled trial of over 160,000 post-menopausal women of varying ethnic and socioeconomic backgrounds and a goal of 20% of the study participants from minority populations is perhaps one of the most challenging recruitment efforts ever undertaken. Of the two main study arms, the Clinical Trial (CT) and the Observational Study (OS), the CT arm recruitment goal was to randomize 64,500 postmenopausal women 50-79 years of age. Women enrolled in the study will be followed for a period of 8-12 years. Ten clinical centers, out of a total of 40 throughout the United States, were selected as minority recruitment centers on the basis of their history of interaction with and access to large numbers of women from certain population subgroups. WHI enrollment began in September 1993 and ended in December 1998, resulting in the randomization and enrollment of a total of 161,856 (17.5% minority) women participants (68,135 (18.5% minority) in the CT and 93,721 (16.7%) in the OS). Within the CT arm, WHI achieved 101.7% of the goal of 48,000 participants in the Dietary Modification (DM) component, and 99.4% of the goal of 27,500 in the hormone-replacement component (HRT), with 11.8% overlap between DM and HRT. Of those who expressed initial interest in WHI, African Americans had the highest randomization yields in the DM component and Hispanics had the highest in the HRT component (15.2% and 10.2%, respectively). Overall, mass mailing was the greatest source of randomized participants. In addition, minority clinics found community outreach, personal referrals, and culturally appropriate recruitment materials particularly effective recruitment tools. For minority recruitment, our findings suggest that the key to high yield is reaching the target population through appropriate recruitment strategies and study information that get their attention. Also, once minority subjects are reached, they tend to participate.

Challenges in conducting research with acutely ill hospitalized older patients

The older population is the largest consumer of health care, yet little is known about their nursing needs during acute hospitalization. In undertaking a study to address this issue, the researchers faced many challenges that were related to the complexities of researching acutely ill hospitalized older patients. The purpose of the present discussion paper is to present some of the methodological and pragmatic factors that were encountered so that health professionals and researchers can be aware of the potential obstacles when researching this important area, and plan research accordingly. Potential barriers included the complexity of illness in the older person as a result of comorbidity and iatrogenesis; fatigue; normal age-related processes such as visual/hearing impairment; frequent ward transfer or early discharge; delirium or dementia; and high staff turnover resulting in difficulties in coordinating the study. This paper raises the importance of balancing the need to maximize the rigor of research and the needs of participants. Recommendations for future research are made.

Recruitment and retention of women in two longitudinal studies of recovery from coronary events: A secondary analysis

OBJECTIVE

The objective of this study was to identify demographic and clinical characteristics of women who refused, dropped out of, or completed 2 longitudinal studies about recovery from coronary events and to identify reasons for refusal or drop out.

DESIGN

The study was a secondary analysis of data from 2 longitudinal studies on women's recovery from coronary events.

SAMPLE

The subjects for this study were 254 women recovering from coronary events.

RESULTS

Demographics did not distinguish refusers from completers or dropouts from completers. Completers were more likely than dropouts to have had surgery and to have diabetes mellitus and hypertension. Reasons for refusal and dropout were identified.

CONCLUSIONS

Clinical and psychosocial variables might play a more important role than demographics in refusal and dropout. Researchers should collect demographic and refusal data at the outset of studies and consider collecting baseline psychosocial data. Researchers should over sample for women without coexisting chronic conditions, and clinicians should educate women about the importance of their participation in studies.

Challenges in conducting research to improve the health of people with Parkinson??s disease and the well-being of their family carers

Parkinson's disease (PD) is a degenerative neurological disorder growing at a rate of 1% per head of population. This disabling condition requires ongoing health support to maintain the person's function, well-being and social engagement, and to maintain the quality of life of the family carer. An outpatient rehabilitation program is being offered at the War Memorial Hospital, Sydney, Australia, to support these outcomes for individuals with PD and their family carers. Although achieving its aims, this multidisciplinary project has identified difficulties for the health team when conducting rehabilitation research with this particular group of people. The paper describes the PD program, outlines these difficulties and makes suggestions to help health staff when conducting research with vulnerable populations.

Can a disease self-management program reduce health care costs? The case of older women with heart disease

BACKGROUND

There is increasing interest in the potential for chronic disease self-management interventions to provide health benefits while reducing health care costs.

OBJECTIVES

To assess the impact of a heart disease management program on use of hospital services; to estimate associated hospital cost savings; and to compare potential cost savings with the cost of delivering the program.

RESEARCH DESIGN

Randomized, controlled study design. Data were collected from hospital billing records during a 36 month period. Multivariate models were used to compare health care use with cost between treatment and control groups. Estimated differences were then compared with the program costs to determine cost-effectiveness.

SUBJECTS

Participants were recruited from 6 hospital sites. Screening criteria included: female, 60 years or older, diagnosed cardiac disease, and seen by a physician approximately every 6 months. The study included 233 women in the intervention group and 219 in the control group. The "Women Take PRIDE" program utilizes a self-regulation process for addressing a problematic area of the heart regimen recommended by each woman's physician. It is tailored to the unique needs of older women.

MEASURES

Hospital admissions, in-patient days, emergency department visits.

RESULTS

Program participants experienced 46% fewer in-patient days (P <0.05) and 49% lower in-patient costs (P <0.10) than women in the control group. No significant differences in emergency department utilization were found. Hospital cost savings exceeded program costs by a ratio of nearly 5-to-1.

CONCLUSIONS

A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan.

Recruiting and screening older, transitional to frail adults in congregate living facilities

Historically older adults have been recruited from the community or from long-term care facilities. The research study, The Effects of Intense Tai Chi Training in the Older Adult, targeted adults 70 years and older who were residing in congregate living facilities and transitioning to frailty according to the Speechley/Tinetti scale. This article describes the strategies that were designed and implemented to recruit and screen the 287 older adults who entered the randomized, single-blinded clinical trial.

Response to direct and indirect recruitment for a randomised dental clinical trial in a multicultural population of elders

OBJECTIVES

Recruitment for randomised clinical trials and community-based studies has received little attention in the dental literature. The goal of this study was to report on our experiences with direct and indirect recruitment methods for a trial to prevent tooth loss in elders.

METHODS

A direct approach, consisting of an introductory lecture with the help of a local contact person in each of the nine community centres, resulted in 208 recruits mostly from minority non-English speaking communities (52%), whereas the other 192 recruits who responded to newspaper announcements (48%) were, in large part, from the English-speaking community.

RESULTS

The response suggests that a more direct and culturally specific approach is more productive when recruiting elders from ethnic minority groups, whereas elders from the dominant culture can be recruited indirectly and for about half the financial cost through newspaper announcements.

CONCLUSION

We conclude, therefore, that both direct and indirect methods are needed to recruit a multiethnic sample of subjects for a trial.

Application of a falls prevention program for older people to primary health care practice

BACKGROUND

Our research group has established the effectiveness of an individually tailored home exercise program to prevent falls and fall injuries in older people in four controlled trials. In one of these trials we evaluated the applicability of the exercise program to routine primary health care practice and the feasibility of nurses implementing the program.

METHODS

People aged 80 years and older, registered with general practices in three exercise (n = 330 participants) and four control centers (n = 120 participants) in New Zealand, were invited to take part by their doctor. We investigated program reach, uptake, and compliance. We carried out physical assessments at baseline and after 1 year to assess the impact of the program.

RESULTS

Most (85%) doctors agreed to take part and they approved 71% of patients to undertake the exercise program. Overall 47% of people invited agreed to participate and 70% of the exercise participants remained exercising at 1 year. Balance score and chair stand time improved by a similar amount in each exercise center compared with the control centers.

CONCLUSIONS

This falls prevention program is acceptable to older people and their doctors. Nurses trained by a physiotherapist can deliver the home exercise program effectively in routine primary health care practice.