Recruiting from the community: lessons learned from the diabetes care for older adults project

Recruitment challenges and strategies: Lessons learned from an early-stage dyadic intervention (innovative practice)

An increasing number of family caregivers are seeking services and support due in large part to the dramatic increase in the number of older adults obtaining dementia diagnoses. This paper describes barriers and challenges experienced by our research team in recruiting early-stage dementia caregiving dyads into research studies. Effective recruitment and screening strategies to address these barriers are also discussed. Recruitment and enrollment success depends on these strategies as well as having well-trained recruitment staff who are knowledgeable about the study and have experience working with older adults, and more specifically, persons with dementia.

Sampling, recruitment, and retention in a bereavement intervention study: experiences from the Living After Loss Project

This article reports on the sampling and recruitment challenges, as well as the strategies used to address them in the Living After Loss (LAL) project, a bereavement intervention study conducted in Salt Lake City and San Francisco comparing two 14-week group conditions with follow-up. We encountered three major challenges: 1) difficulty determining eligibility for some potential participants who were contacted, 2) locating and recruiting nonwhites, and 3) unavailable phone numbers for approximately one-third of those we attempted to contact. Despite these challenges, we achieved a 42% response rate with a sample size of 328 participants comprising 15% nonwhite. Eighty-five percent of the participants completed all of the follow-up data points. Leading factors in participants' decisions to join and remain in the study were 1) opportunities to obtain help and support, 2) to potentially help other bereaved individuals, 3) to contribute to research, and 4) their on-going interactions with a professional, empathetic, and culturally sensitive project staff. Effectively focusing recruitment efforts and carefully and systematically training research staff were among the most effective strategies we employed and therefore suggest for those planning similar investigations.

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.

Issues in Recruitment, Retention, and Data Collection in a Longitudinal Nutrition Study of Community-Dwelling Older Adults With Early-Stage Alzheimer's Dementia

The Nutrition-Memory Study (NMS) followed evolution of nutrition status among elderly community-dwelling individuals with Alzheimer's disease (AD). Participants, age-matched to cognitively intact controls, were recruited from three university hospital memory clinics. Incentives encouraged retention; flexible procedures and caregiver collaboration permitted collection of nutrition information from AD patients. Of 71 patients referred by the clinics, 55 (77.5%) were eligible, 42 (76.4% of eligible) were recruited with their caregivers, and 40 (72.7%) completed the baseline. Thirty-two patient—caregiver dyads completed the first three interviews (58.1% of eligible; 80% of recruited); 26 of the 32 dyads (81.3% of recruited) completed four of the five interviews, and 14 (43.8% of recruited) were seen at all five study visits. Ensuring successful recruitment and retention in this clientele requires strong links between the research team and target community, ensuring relevance of the study to participants, and being mindful of the burden levied on patient—caregiver dyads.

Evaluation of a mass mailing recruitment strategy to obtain a community sample of women for a clinical trial of an incontinence prevention intervention

OBJECTIVES

Questions exist about using mass mailings to recruit representative samples to participate in clinical trials. The MESA Prevention Study (Medical, Epidemiologic and Social Aspects of Aging), a randomized controlled clinical trial to prevent urinary incontinence (UI), utilized a mass mailing recruitment procedure to recruit a representative sample of women to participate in a behavioral modification program. This paper seeks to expand the literature of mass mailing recruitment strategies for prevention studies by describing the procedures used to recruit healthy, continent, post-menopausal women aged 55-80 years.

METHODS

Sociodemographic data collected from recruited subjects is compared with on-line national census data to evaluate the representativeness of the sample recruited from a purchased mailing list.

RESULTS

The mass mailing procedure resulted in 3.3% positive response. Of those that returned a positive response, 37.6% were deemed eligible at first screening. Comparisons of study demographic data with state and county census data indicate that the sample obtained was representative of the communities.

CONCLUSIONS

The mass mailing strategy was an effective means of recruiting a representative sample of women, aged 55-80. Short falls and recommendations for successful community sample recruitment strategies for clinical trials in older adult women are elaborated upon.

The effects of a web-based intervention on the physical outcomes associated with diabetes among adults age 60 and older: a randomized trial

BACKGROUND

The emergence of the World Wide Web in the last decade has made it feasible for the Internet to be a vehicle for chronic disease management.

METHODS

A randomized controlled trial (n = 62) testing the effects of a 6-month web-based intervention plus usual care, compared with usual care alone, among adults 60 years of age and older with diabetes. The outcomes were hemoglobin A1c (HbA1c), blood pressure, weight, cholesterol, and high-density lipoprotein (HDL) levels.

RESULTS

A multivariate analysis of covariance controlling for all baseline outcome variables, age, gender, and number of years with diabetes showed significant (P = 0.001) reductions in HbA1c, weight, and cholesterol level and significant improvement in HDL levels in the intervention versus the control group.

CONCLUSIONS

Findings show a web-based intervention was effective in improving HbA1c, weight, cholesterol, and HDL levels at a 6-month follow-up. Future research is needed to investigate the long-term effectiveness of web-based interventions.

Participant Characteristics Predicting Voluntary Early Withdrawal from a Multidisciplinary Program Providing Home-Delivered Meals and Dietitian/Social Work Case Management to Homebound Elders

We examine whether baseline characteristics of participants enrolled in a multidisciplinary program providing home-delivered meals and dietitian/social work case management to homebound seniors predicted voluntary early withdrawal. Sixty-nine participants voluntarily withdrew early and 111 completed the project. Six hypotheses were based on a conceptual framework incorporating (1) agreement between project elements and needs/preferences of individuals and (2) whether participants would improve and no longer require or desire the intervention. Three of the hypotheses were supported by means of logistic regression analysis. Voluntary early withdrawers at baseline: (1) were more mobile, (2) ate less often, and (3) responded that food tastes good less often. The results suggest that carefully considering the interaction of potential participant characteristics and project interventions will improve nutrition project retention.

Preliminary Findings of the Effects of Comorbidities on a Web-Based Intervention on Self-Reported Blood Sugar Readings Among Adults Age 60 and Older with Diabetes

The purpose of this study was to investigate the effectiveness of a Web-based intervention on self-reported blood sugars for older adults with diabetes. Participants who were randomized in the first phase to the intervention group (n = 15) aged 60 and older with diabetes accessed a study Web site that provided them access to an on-line library, advice and counseling from a nurse via e-mail, a personal electronic log of self-management activities, and weekly on-line problem-solving group discussions. Longitudinal mixed-effects modeling was used to investigate the effects of the Web-based intervention on blood sugar levels over a 6-month period. Participants who had fewer than six self-reported medical comorbidities (n = 8) at baseline were more likely to experience a linear decline on blood sugar levels than participants reporting more than six comorbidities. A significant interaction appeared among the time of day blood sugar readings were reported, baseline A1c, and the number of comorbidities. Participants who had more than six comorbidities (n = 7) experienced increased blood sugar levels over the study period, specifically with AM fasting and before bedtime reporting times. Participants with fewer than six comorbidities experienced a decline in blood sugar levels during the same testing times. Findings show that a Web-based intervention was not effective in improving blood sugar readings among adults with six or more comorbidities at baseline. Future research needs to further investigate the role comorbidities may play with the outcomes of Web-based interventions.

Recruiting older people into a large, community-based study of heart failure

This paper highlights some of the challenges encountered when recruiting older people with heart failure into longitudinal, community-based research. It draws on the experience gained in a study to provide insights into the palliative care needs of older people with heart failure and the timing and need for service interventions. Five hundred and forty-two people with heart failure (New York Heart Association (NYHA) stages II-IV) and 213 of their informal carers were recruited from primary care practices in four areas of the UK. Ethical issues arising around gate-keeping, terminology and participant burden are discussed along with challenges faced during the recruitment process. Strategies to increase general practitioner and patient recruitment are provided. The paper concludes that prospective longitudinal studies are of particular relevance to chronic illness, and the complexity of setting up such research must be acknowledged and appropriately resourced.

Recruitment strategies for conducting research on women's retirement

Currently, little information is available to inform new or returning researchers about designing and conducting research on the topic of women and retirement. Few published studies describe how to access non-probability samples of retired women, yet preliminary evidence suggests women possess distinctive characteristics that affect their retirement as well as complicate the recruitment process. In this article, certain challenges and benefits of conducting research with women in retirement are presented. Next, important issues to consider prior to sampling retired women are described. Finally, specific strategies for identifying and recruiting community-dwelling retired women are presented and discussed.

Beating the barriers: recruitment of people with intellectual disability to participate in research

BACKGROUND

The health status of people with intellectual disability (ID) is poor, yet very little research has been done on their health needs. There are several barriers to performing this research. The aim of our research was to examine the significant barriers encountered in recruiting adults with ID to participate in research.

METHODS

Our project was a randomized controlled trial aiming to improve health advocacy of people with ID. We approached many organizations to recruit participants and kept records of our results. Recruitment was very low for the first 4 months. Then we adopted two new recruitment strategies--in-service telephone recruitment and meetings with prospective participants. We then monitored the subsequent recruitment rates. We also questioned participants about the difficulties they encountered when considering recruitment.

RESULTS

Initial recruitment of participants yielded less than one-third of the expected number. Additional strategies implemented were partially successful. Significant barriers to recruitment included several sectoral issues and the challenges arising from the research process.

CONCLUSIONS

While this population is a difficult one to reach for research, attempts to do so should not be abandoned, because the potential health benefits for this underserved group far outweigh the recruitment barriers experienced.

Lessons learned: patient recruitment strategies for a type 2 diabetes intervention in a primary care setting [corrected]

PURPOSE

This study reports on methods and strategies employed to increase participation rates in diabetes interventions and discusses the reach and representativeness of the Diabetes Priority Program.

METHODS

A passive mail-out procedure was used to contact patients of participating primary care physicians. Patients who did not return the refusal postcard were contacted. Several attempts were made to contact potential participants. Brochures, "wrong number" postcards, posters, and reports for clinic staff were strategies used to increase participation.

RESULTS

The recruitment process resulted in a participation rate of 83% among patients who were contacted and eligible. These participants appeared to be representative of both nonparticipants and persons with diabetes in Colorado. In contrast, a low percentage of primary care physicians, estimated at 3%, took part in the program despite efforts to make the program brief, nonintrusive, and compatible with usual care.

CONCLUSIONS

Recruitment is currently challenging and will become even more difficult with the privacy regulations that affect healthcare research and the public distrust of solicitations. To increase participation rates, it is important that the clinic staff promotes and supports the program, and that participant lists are accurate and adequate in size.

Recruiting Community-Dwelling Elderly at Risk for Physical Disability into Exercise Research

The article describes the process of identifying 100 community-dwelling elderly adults at risk for physical disability, yet not functionally disabled, for participation in a research project to develop appropriate exercise programs for at-risk elderly. Over a period of 14 months, initial contact was made with 941 older adults, 11% of whom (101 people) were eligible for and willing to complete all stages of the study protocol. The most successful recruitment strategies were a mass mailing followed by a telephone call and advertising in a newspaper with a large circulation (rather than a local paper). Aspects of the recruitment and retention of study participants are discussed.

Consent and refusal in dementia research: conceptual and practical considerations

This article discusses types of consent refusals, rates of refusal, factors that affect consent, and methods to increase rates of consent in elderly research participants and in those with dementia in particular. Refusals can be categorized according to several types: complete refusal, refusal that is time-contingent, partial refusal, and contingent agreement. Rates of consent vary greatly across studies of persons with dementia. This variation can also be affected by different methodologies of calculating rates, in addition to differences in content of studies, populations, and procedures. To warrant consent, a study must first be scientifically sound, with a high likelihood of advancing knowledge, and must provide maximal protection to participants. Consent rates are affected by the following factors: levels of anticipated risks and benefits of the study, relationships among the different caregivers involved in the care of the potential subject, the ability of the researcher to properly identify and locate the person who needs to provide consent, characteristics and attitudes of the person providing consent, and the method of obtaining consent, including timing, location, method of presentation, and type of consent requested. An understanding of these issues can assist the researcher in tailoring research procedures so as to maximize rates of consent. It also raises ethical issues that warrant further discussion concerning the process of obtaining consent from and for persons with dementia.

Recruitment issues in healthcare research: the situation in home care

A global shift in the setting of healthcare from hospitals and long-term care institutions to homes and communities has been accompanied by the growth of interest in the home as a site of healthcare research. Home care researchers have identified the recruitment of research subjects as a significant concern. The present descriptive, exploratory study used qualitative, semi-structured interviews with home care researchers (n = 9) to illuminate the challenges related to recruitment. The results suggest that while home care research shares recruitment issues common to other forms of health research, it has unique concerns. Factors affecting recruitment in home care studies include non-dedicated recruiters, the current context of healthcare restructuring, and gatekeeper and participant feelings about the home as a setting for care and research. Reasons for refusal to participate may be more complex in home care research given the meanings care recipients attribute to their 'homes'. Home care researchers may also face unique ethical and/or moral dilemmas. This paper recommends the routine reporting of recruitment problems, increased inclusion of minority subjects to ensure sample representativeness and further studies of the subjective meanings of 'home' as it is associated with healthcare treatment.

Recruitment of older participants in frailty/injury prevention studies

Despite the lifelong health benefits of physical activity, frailer older adults have typically been excluded from studies promoting more active lifestyles. This study documents the recruitment process and costs from a multisite study to identify effective strategies for recruiting older adults in frailty/injury prevention research. Randomized controlled clinical trials were conducted at 7 sites; an 8th site was a compliance study. Interventions reflected center- and home-based health promotion programs. Site objectives, eligibility criteria, and contact and screening methods were obtained from manuals of operation. Recruitment results (number screened, eligibility rates, randomized to screened ratios) were ascertained from recruitment data. Sites furnished estimated recruitment costs (nonlabor expenses, investigator and staff time, fringe benefits) up to signing the consent form. The sites targeted diverse populations and sample sizes. The majority revised recruitment methods to meet their recruitment goals. Most sites estimated costs of recruitment at over $300 per participant randomized. Recruitment costs were affected by staff time spent alleviating concerns about participants' health, essential interactions with family members, and arranging for transportation. Neither frailty nor intervention intensity was found to be a major predictor of recruitment outcomes. Recruitment expense was associated with selection criteria and frailty status of the target population. Older people can be successfully recruited into beneficial health promotion programs, but it is often challenging. In planning health promotion studies, investigators need to be aware of the numbers of older people they may need to screen and different strategies for increasing recruitment success.

Frail older women's participation in a trial of hormone replacement therapy: perceived benefits and concerns

OBJECTIVE

The aim of this study was to identify the reasons that were important to frail older women's decisions to participate or not participate in a clinical trial of hormone replacement therapy (HRT).

DESIGN

We conducted a cross-sectional study of a community-based sample of physically frail women > or = 75 years old, who were recruited to participate in an intervention trial of HRT. Participants were randomized 2:1 to either HRT or placebo, respectively. Questionnaires measured participants' reasons for participation and nonparticipants' reasons for declining. Five-point scaled responses to questionnaire items ranged from least to most important or least to most concerned.

RESULTS

Sixty-nine women participated (84% white, 16% African American) in the trial. Nonparticipants (n = 41) were older, on average, than participants (83.8+/-4.2 vs. 82.2+/-3.6 years; p = 0.04). Important reasons for participation were reducing risk for Alzheimer's disease and osteoporosis, having more energy, improving self-care ability, and benefiting other women. Fear of cancer from postmenopausal estrogen was the predominant concern of 46% of nonparticipants and 78% of participants (p = 0.08). Recommendation against participation or use of estrogen by a woman's personal physician was the most prevalent additional reason given for nonparticipation.

CONCLUSIONS

Disease prevention and improving self-care abilities were most important to participants. Fear of cancer was not a greater concern for nonparticipants than for participants. The role of the physician in older women's decision-making about use of postmenopausal estrogen seems to be important.

The cost of recruiting Alzheimer's disease caregivers for research

OBJECTIVES

This study examined the cost and outcomes associated with multiple recruitment strategies used to enroll participants in an Alzheimer's disease (AD) caregiver study.

METHODS

Recruitment data were collected as part of an AD caregiving intervention study and examined for number of referrals and participants, yield, personnel cost, materials cost, total cost, and cost per participant.

RESULTS

Recruitment rates varied by method implemented and referral source. Overall, 100 participants were enrolled for a total cost of $10,127, yielding an average per participant cost of $101.00. The Formal Recruitment Method, used at agencies with large participant pools, emerged as the most cost-effective strategy.

DISCUSSION

Recruitment costs varied greatly, depending on the referral sites and their available pool of participants. Substantial time, money, and personnel need to be budgeted for recruitment efforts given the expected costs, the competing pressures in the health care region, and the variability of participant response.

Targeting intermediaries to recruit older women for qualitative, longitudinal research

Crafting a comprehensive recruitment plan for qualitative, longitudinal research requires consideration of many issues, particularly when a culturally diverse sample of older women is to be recruited for interviews conducted in their homes. The development of a detailed recruitment plan for a phenomenological investigation of older widows' experience of home care is described. The plan's two inter-related foci (targeted intermediaries and sequential phases) are presented. Strategies used to recruit participants through each targeted intermediary are explained, and the implementation of the sequential phases of the recruitment process is described. Successes and difficulties are considered in relation to the literature on recruiting older adults for research.

Recruiting participants for community-based research: the Diabetic Retinopathy Awareness Program

PURPOSE

Recruiting participants is a major challenge for population studies. We present the recruitment methods followed by the Diabetic Retinopathy Awareness Program (DRAP), a community-based, randomized, masked, controlled trial to meet and exceed its sample size goals.

METHODS

A county-wide multi-media promotional campaign to recruit and enroll participants in the trial was planned and executed from October 1993 through April 1994, with the assistance of the local news media and community and professional groups. A toll-free 800 number recruitment line was established, and postage-paid recruitment postcards distributed. The trial was designed to examine whether a mailed educational intervention could increase compliance with vision care guidelines among persons with diabetes in the community.

RESULTS

A total of 2308 persons with diabetes were interviewed for eligibility and 813 enrolled in the intervention trial, exceeding the original recruitment goals of 1800 and 600, respectively. Those who completed the enrollment interview reflected county demographics. During recruitment, newspaper, television and radio stories featured the study; pharmacies and physician offices displayed study materials; public service announcements appeared in local print and broadcast media. The largest single recruitment response was a local television news report, followed by a newspaper story.

CONCLUSIONS

These experiences substantiate the need for a comprehensive coordinated approach, using planned multiple sources, to achieve recruitment success. By engaging the lay and professional communities along with the media, recruitment costs can be kept to a minimum. Participant costs can be minimized by employing a toll-free number and eliminating study participant travel, thus allowing for inclusion of traditionally underserved populations. This approach is applicable to other studies, where community-based participation is desired.

Recruiting adults with osteoarthritis into an aquatic exercise class: strategies for a statewide intervention

OBJECTIVE

Although research suggests that regular exercise can be helpful in reducing the dysfunction and discomfort of osteoarthritis, promoting exercise among older adults within this population is neither straightforward nor easily accomplished. This article describes the various methods, and their relative success rates, that were employed to recruit older adults throughout the state of Washington into an aquatic exercise program.

METHODS

Strategies included a recruitment letter distributed to Arthritis Foundation (AF) members in Washington state, local media news coverage, physician referrals, and advertisements in local papers and newsletters.

RESULTS

The most successful methods for enrolling participants were through the AF recruitment letters and local television coverage. The AF recruitment letter was the most expensive method of generating responses, while the television coverage was the least expensive.

CONCLUSIONS

Collaborating with a well-reputed community-based organization and capitalizing on available publicity resources are important strategies researchers can use to gain access to a difficult and geographically dispersed population.

Participation in a diabetes education and care program: experience from the diabetes care for older adults project

There is very little reported information concerning the participation of older adults in diabetes education and care programs, factors related to their attendance, and the influence of attendance on program outcomes. In this study, which was part of a larger study of insulin therapy, subjects (> or = 65 years old) assigned to the intensive management group (n = 53) were provided with educational sessions during the 18-month study period. Data for this group were examined to determine factors that influenced enrollment and attendance. Attendance rates for individual participants averaged 72% during the first 6 months and 68% during the subsequent 12 months. Demographic factors, baseline knowledge test scores, and baseline glycosylated hemoglobin levels did not significantly influence participation. Greater distance from the clinic and shorter time using insulin were significantly related (P = .05) to attendance. Perceived benefits of the program included diabetes education (45%), glucose control (23%), and interacting with others who have diabetes (23%).

Evaluating minority recruitment into clinical studies: how good are the data?

PURPOSE

There has been much publicized concern about difficulty with minority recruitment into research studies, particularly since minority inclusion in randomized clinical trials was mandated by the 1993 National Institutes of Health Revitalization Act. We reviewed recruitment data in published reports from clinical studies to assess the actual degree of success in recruiting minorities versus whites and to identify barriers to recruitment.

METHODS

We abstracted articles published between September 1993 and February 1995 that reported detailed results of participant recruitment for studies conducted in the United States.

RESULTS

Of 65 articles meeting our eligibility criteria (median sample size, 1323), only one (1.5%) reported the racial/ethnic composition of potential study participants. Only two articles (3.1%) provided information about the racial/ethnic composition of eligible subjects, and only one (1.5%) provided information about the racial/ethnic composition of refusing subjects. For enrolled subjects, race/ethnicity was less likely to be reported (58.5%) than were age (90.8%) or gender (80.0%).

CONCLUSIONS

The published literature currently contains insubstantial data to either refute or prove that there are differential recruitment rates among minorities as compared with whites. Changes in reporting will be needed in order to track progress in this area.

Roadblocks encountered in recruiting patients for a study of sleep disruption in Alzheimer's disease

Recruitment strategies and the roadblocks encountered in a clinical trial are described. A four-group, repeated measures design was used to test the effects of three sleep-related behavioral interventions on sleep disruption and related variables in Alzheimer's disease patients and their primary caregivers. Despite extensive recruitment efforts, enrollment did not meet expectations. Data analysis revealed three types of roadblocks to recruitment: caregiver resistance, provider resistance, and a mismatch of the disease characteristics with protocol requirements. Recommendations are made to help others solve recruitment problems.