Respondents' attitudes regarding participation in an epidemiologic study

The interaction of personal, contextual, and study characteristics and their effect on recruitment and participation of pregnant women in research: a qualitative study in Lebanon

Background

Declining participation rates are impeding health research. Little is known about factors influencing the decision to participate in low- and middle-income countries (LMIC). Therefore, this paper reports on the various individual factors and their with contextual factors in influencing participation in research among pregnant women and the recommendations to enhance their recruitment in Lebanon.

Methods

This study used a qualitative research design drawing on focus groups and in-depth interviews. The Theoretical Domain Framework guided data collection and analysis. The three participant groups included: Group 1-Pregnant women (n = 25) attending public pre-natal events and antenatal clinics in Beirut; Group 2-Pregnant women (n = 6) already enrolled in the ongoing Mother and Infant Nutritional Assessment birth cohort study; Group 3-Key informants (n = 13) including health care workers involved in recruiting pregnant women. Conversations were audio recorded, transcribed, translated into English, and thematically analyzed.

Results

Three main factors influencing participation were revealed, with each factor encompassing several sub-themes: (1) personal factors (altruism, self-confidence, personal interest in the topic, previous understanding of the nature and purpose of research, education level, and previous research experience), (2) contextual factors (societal factors, family and friends), and (3) study characteristics (burden of the study, ethical considerations, incentives, and research interpersonal skills and physician endorsement to participate). The results suggested a dynamic interaction among the identified factors, forming two intersecting axes, with a four-quadrant configuration. The y- and x-axes represented personal factors and contextual factors, respectively. Individuals positioned on the lower-left quadrant were the least likely to participate; those on the upper-right quadrant were the most likely to participate; while those on the upper-left and lower-right quadrants were indecisive. Study characteristics seemed to affect the decision of pregnant women to participate situated in any of the four quadrants. Specific recommendations to improve participation were also identified.

Conclusions

Our findings suggested an interaction of personal factors, contextual factors, and study characteristics affecting subjects’ participation. This interaction integrates factors into a novel dynamic framework that could be used in future studies. The recommendations identified may help improve participation of pregnant women in health research hence enhancing the quality and generalizability of research findings in LMIC.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0616-5) contains supplementary material, which is available to authorized users.

Clinical Research with Older African Americans and Latinos

This study examines the social and health priorities of older African Americans and Latinos and their attitudes about participation in clinical research. Focus group discussions were conducted with older Latinos and African Americans, and a survey was mailed to key informants from 117 community-based organizations serving primarily older African Americans or Latinos. Results indicate that affordable housing, enough money to meet their needs, adequate transportation, and safer neighborhoods were urgent priorities for older Latinos and African Americans and superseded their health concerns. Distrust of researchers, lack of information, caregiver obligations, fear of experimentation, and lack of benefits were identified as barriers to research participation. Results indicate that community members are willing to participate in research provided they are fully informed of the research and perceive tangible benefits and congruence between the objectives of researchers and participants.

Research recruitment through US central cancer registries: balancing privacy and scientific issues

Cancer registries are a valuable resource for recruiting participants for public health-oriented research, although such recruitment raises potentially competing concerns about patient privacy and participant accrual. We surveyed US central cancer registries about their policies for research contact with patients, and results showed substantial variation. The strategy used most frequently (37.5% of those that allowed patient contact), which was among the least restrictive, was for investigators to notify patients' physicians and then contact patients with an opt-out approach. The most restrictive strategy was for registry staff to obtain physician permission and contact patients with an opt-in approach. Population-based studies enhance cancer control efforts, and registry policies can affect researchers' ability to conduct such studies. Further discussion about balanced recruitment approaches that protect patient privacy and encourage beneficial research is needed.

The effect of physician permission versus notification on research recruitment through cancer registries (United States)

OBJECTIVE

To determine how physicians responded when investigators inquired about contacting patients identified through a central cancer registry, and to examine participation rates under physician permission versus notification approaches.

METHODS

We analyzed existing data from seven observational epidemiologic studies conducted in North Carolina between 1993 and 2004, capitalizing on a 'natural experiment' that arose when the state registry changed from a policy requiring investigators to obtain physician permission to one requiring only physician notification.

RESULTS

When a notification approach was used, physicians approved researcher contact with a higher proportion of patients, and a higher proportion of physicians approved contact with or provided eligibility information about all patients requested, compared with a permission approach. Among physicians who were contacted under both approaches, the proportion of patients for whom they approved contact or provided information was significantly higher when they were notified. Physician notification was also associated with higher patient contact and overall response rates. Patient cooperation rates did not differ between the two approaches, suggesting that patients did not respond negatively to the fact that their physician was not explicitly asked to provide permission.

CONCLUSION

Notification is likely an efficient way of involving patients' physicians, providing opportunity for physician input but avoiding the burdens associated with requiring their permission.

Attitudes toward participation in a pregnancy and child cohort study

While epidemiological studies aim for high participation rates, it is becoming increasingly difficult to recruit and retain participants in lengthy observational studies. We surveyed women who recently participated in the Pregnancy, Infection, and Nutrition Study during their pregnancy to learn more about what initially motivated them to participate in the study, their attitudes about the study protocol, and whether they would allow their child to participate in future studies. Most women were motivated by their interest in science and learning about their pregnancy. In general, women felt quite comfortable with most aspects of the study. Consent forms, telephone interviews and self-administered questionnaires were the most acceptable components of the study, but even specimen collection was well tolerated by this cohort. Women were less comfortable with the possibility of their child participating in future research. This survey confirmed that once women are enrolled, they tend to be willing to complete most components of an intensive study, suggesting that initial efforts for recruitment are most important.

Patient perspectives on research recruitment through cancer registries

OBJECTIVE

To gain preliminary insight into patients' levels of awareness and preferences about research recruitment through cancer registries.

METHODS

We developed four questions about the North Carolina Central Cancer Registry's educational brochure and about patient preferences regarding physician involvement in research recruitment. These questions were included in the baseline interview conducted among 100 consecutively enrolled participants in the North Carolina Colorectal Cancer Care Outcomes Research Study, an ongoing observational study.

RESULTS

Patients who read the Registry's educational brochure generally reported that it helped them understand that a researcher could contact them, but only about one-fourth of patients recalled receiving and reading the brochure. Over two-thirds of patients said they preferred that researchers contact them directly about their interest in research participation, rather than checking with their physician first. Among patients who wanted their physician involved, most preferred a physician notification rather than a physician permission approach.

CONCLUSIONS

Registry policies about patient education and physician involvement can have an important impact on researchers' ability to conduct population-based studies. Understanding patient perspectives is key to developing balanced policies that protect patients' privacy, as well as facilitate their opportunities to make autonomous decisions about participating in research.

Risks and wrongs in social science research. An evaluator's guide to the IRB

Having an Institutional Review Board (IRB) review and monitor the use of human subjects is now fundamental to ethical research. Yet social scientists appear increasingly frustrated with the process. This article aims to assist evaluators struggling to understand and work with IRBs. The author theorizes why IRBs frustrate and insists there is only one remedy: We must accept the legitimacy of IRB review and (a) learn more about IRB regulations, imperatives, and the new pressures on them; and (b) educate IRBs about social scientific methodologies and empirically demonstrable risks. A research agenda and tips are offered.

Analysis of nonresponse bias in a population-based case-control study on lung cancer

The objective of this study was to identify characteristics of nonrespondents and late respondents in a population-based case-control study on lung cancer conducted in the city of Turin (Italy). Information about demographic and socioeconomic variables of 634 cases and 859 controls who responded to an interview, as well as of 154 cases and 154 controls who did not respond were obtained from census and the public register of Turin. The socioeconomic level of nonrespondents was high in cases but low in controls. Late respondent controls (i.e., individuals who responded after contact through their general practitioner) had socioeconomic characteristics comparable with those of nonrespondents, while they were similar to respondents with respect to demographic variables. The interview of late respondents halved, from 14 to 7%, the magnitude of the bias introduced by nonresponse on the estimate of the association between educational level and lung cancer. Nonresponse, associated with socioeconomic status, is an important potential source of bias in population-based case-control studies, which should always be considered and discussed. The direction and magnitude of the bias can be quantified. General practitioners may contribute to decrease nonresponse bias. Caution should be used in inferring characteristics of nonrespondents on the basis of those of late respondents.

Making epidemiologic studies responsive to the needs of participants and communities: the Carolina Breast Cancer Study experience

In this report, we present the results of surveys administered to participants and nonparticipants in the Carolina Breast Cancer Study (CBCS). Surveys and structured interviews were administered to determine women's concerns regarding participation in research studies, access to health care, and beliefs regarding causes of breast cancer. Survey results showed the highest concern for the growing number of women diagnosed with breast cancer in North Carolina and potential environmental agents that may cause breast cancer. Negative responses were noted for time constraints related to participation and lack of familiarity with epidemiologic research; another concern noted was the lack of centralized information regarding breast cancer treatment. These issues were addressed by (1) developing a web site that provided background information about the CBCS, summaries of published study results, and information about the etiology of breast cancer; and (2) creating a statewide, comprehensive breast cancer resource directory for women who need information about breast cancer diagnosis, treatment, and support. These two projects were carried out in collaboration with breast cancer advocates, and demonstrate the important role that advocates can play in making epidemiologic research more responsive to the needs of communities.

Attitudes and impressions of participants in a study of the causes of childhood cancer

Researchers and ethics committees are increasingly concerned about the perceived emotional impact on individuals following participation in epidemiologic studies. This attitudinal survey was designed to investigate this issue among 751 of the parents who had already given an interview in the UK Childhood Cancer Study (UKCCS), one of the largest case-control studies ever undertaken to investigate the aetiology of cancer in children. Information was collected by postal questionnaire on their reasons for agreeing to take part in the UKCCS, on whether questions had caused distress or difficulty and what their feelings were immediately after the interview and at the time of this survey. Parents were asked if they felt they had benefited in any way by taking part and control parents were asked if they would have taken part without prior consent of their doctor. 90% of both cases and controls felt glad to have taken part immediately after the interview and few reported any anxiety at having done so; 95% of both cases and controls felt satisfied that they had made a worthwhile contribution. Although 18% of cases felt tense and 14% felt unhappy after the interview, over 90% of them felt glad that they had taken part a few weeks later. Of particular interest is that 38% of cases and 24% of controls said they had positively benefited from taking part in the UKCCS and 96% of control mothers did not mind their family doctor giving permission for them to be contacted.

Effects on subject response of information brochures and small cash incentives in a mail-based case-control study

PURPOSE

To investigate the impact on subject response of an information brochure and cash incentives included with mailed questionnaires in case-control studies.

METHODS

A randomized trial was carried out within a case-control study investigating cancer in the Province of Ontario. Brochures were included with half of the mailed questionnaires sent to 7487 cases and 2561 controls. Controls were also sent cash incentives of $2, $5, or no money.

RESULTS

With the brochure, response changed from 75.0% to 75.8% in cases, and from 70.3% to 71.1% in controls. Adjusting for differences in age, residence, sex, and cancer site/status, the change was 0.2% [95% confidence interval (CI) = -1.7-2.1] in cases, and 0.6% (95% CI = -3.1-4.3) in controls. The $2 and $5 incentives increased overall response in controls from 61.9% to 72.8% and 77.2%, respectively, i.e., by 10.9% (95% CI = 6.1-15.6) and 15.1% (95% CI = 10.4-19.7), after adjustment. This effect was largely confined to urban areas (for $2 and $5, respectively: 5.5% and 14.2% in Toronto, 15.3% and 20.4% in other urban areas vs. 2.7% and 1.0% in rural areas; p = 0.02). Response time showed little or no improvement when the brochure was included, but was markedly reduced for both the $2 and $5 incentives.

CONCLUSIONS

Cash incentives can improve subject response in epidemiologic studies, whereas information brochures do not appear to have an effect.

Participation rates in a case-control study: the impact of age, race, and race of interviewer

PURPOSE

Despite concerns about declining participation rates in epidemiologic studies in recent years, relatively few papers have discussed obstacles to recruiting study participants or strategies for optimizing response rates. This report describes factors associated with nonparticipation in a population-based, case-control study of breast cancer and discusses ways to overcome barriers to participation.

METHODS

Contact and cooperation rates were calculated for participants in the Carolina Breast Cancer Study (CBCS), stratified by case status, age, race, and race of interviewer. Demographic and breast cancer risk factor characteristics of partial and full responders also were compared.

RESULTS

Contact rates and cooperation rates varied by case/control status and demographic characteristics. Contact rates were lower among controls, younger women, and black women. Cooperation rates were lower among controls, older women, and black cases. Cooperation rates were higher among both black and nonblack women when participants and interviewers were concordant on race.

CONCLUSIONS

Obstacles to recruitment seem to differ among race and age subgroups, suggesting that recruitment strategies may need to be tailored to potential participants based upon demographic characteristics. Strategies have been implemented to improve response rates in this and other epidemiologic studies; however, additional research and innovation in this area are needed.

Stress and cancer surveys: attitudes of participants in a case-control study

STUDY OBJECTIVE

The aim was to ascertain whether personal interviews carried out for cancer case-control studies cause stress to participants.

DESIGN

Retrospective postal questionnaires were sent to women at least three months after interview for a case-control study of the aetiology of cervical cancer. The questionnaire covered attitudes to taking part in the study, stress engendered by participation, whether any particular questions were distressing, factors relevant to the decision to participate, and the role of their doctor with respect to participation.

SETTING

South East and South West Thames health regions, United Kingdom.

PATIENTS

Patients were women aged 20-45 years at diagnosis with invasive cervical cancer, and population based controls.

MEASUREMENTS AND MAIN RESULTS

The response rate was 90%. Nearly all respondents were glad they had participated, while only 2/226 regretted taking part. Half the respondents (115/226) perceived some actual benefit from taking part. The interview carried out in the case-control study was both long and detailed and included topics such as numbers of sexual partners and history of sexually transmitted diseases. As expected, the questions causing most concern to interviewees were those on number of sexual partners, but only 13% of participants were bothered by these questions and only 4% felt inclined to terminate the interview early.

CONCLUSIONS

The lack of evidence of stress caused by this potentially difficult interview suggests that, in the hands of experienced interviewers, stress is unlikely to be caused by participation. Many participants felt that they had benefited from taking part. Doctors and ethics committees should find these results reassuring.

Characteristics of respondents and nonrespondents in a prospective study of osteoporosis

During 1981-1982, a cohort of elderly Japanese Americans living in Hawaii was recruited for an epidemiologic study of osteoporosis. The male subjects were simultaneously being examined for an epidemiologic study of heart disease. Baseline data collected from both the men and women at a previous heart disease examination were used to compare responders vs nonresponders. The target population for the osteoporosis study consisted of 1685 men and 1594 women. Of these, 1379 men (81.8%) and 1105 women (72.0%) participated in the initial osteoporosis examination. For each sex, nonrespondents were older and had higher systolic blood pressure levels than did the respondents. Male nonresponders had a higher stroke prevalence and more frequent recent use of vasodilator medicine. Female nonresponders had a less frequent history of having ever taken female hormones than did the responders. The responders and nonresponders were reasonably similar in other respects, as indicated by the comparison of more than 40 other variables. This suggests that nonresponse bias is probably not a major influence in exposure-disease associations in this osteoporosis cohort. We believe this is the first published report dealing with nonresponse characteristics in a cohort study of osteoporosis.

Ethical issues in psychosocial research among patients with cancer

The ethical implications of psychosocial research among patients with cancer are discussed. Two key issues were identified: obtaining informed consent and the impact of participating in research. Barriers to obtaining genuinely informed consent are described, as well as the costs and benefits of participation in research. Recommendations are made for the conduct of future research, relating to the removal of barriers to informed consent and monitoring the impact of the research process on its subjects.

Factors encouraging cohort maintenance in a longitudinal study

Maintenance of the cohort is one of the primary challenges of a longitudinal study. At the end of 3 years of follow up in the Framingham Children's Study, a longitudinal study of young children and their parents, 100 of the original 106 families (94.3%) have remained in the study. A questionnaire was administered to identify factors contributing to the high rate of follow up to this point in the study. The attitudes of the staff, feedback to the subjects, the staff's handling of questions and problems, and association with the Framingham Heart Study emerged as the most important factors influencing continued participation in the study. In addition, 99% of the subjects stated that they believed the medical research to be important. We conclude that the quality of the communication with study participants and the subjects' perceived importance of the research have been the key factors in maintaining the cohort in this longitudinal epidemiologic study.

[Response level of controls selected from the municipal registry]

The results related to the controls response rate in a case-control study are presented. The study was designed to learn about the relationship between the occupational exposure to toxic products in the parents and the development of acute leukemia in childhood. 128 cases were enrolled in the study and each case was matched by sex and age (less than 15 years) to a control. Controls were selected from the Municipal roll of the same city or town in which the case has been living during the diagnosis. We contacted the control's mother by phone or by personal visit. The response rate was 47.9% and near to a half of non responses was due to errors in the addresses registered in the Municipal roll. The validity of this source of controls in Spain can be questioned in the light of the high percentage of errors. We also discuss the potential selection bias introduced in the study due to the way we selected controls.

Next-of-kin attitudes regarding participation in an epidemiologic case-control study

We assessed next-of-kin's attitudes about participating in an epidemiologic case-control study of adult acute nonlymphocytic leukemia. Responses from a mailed questionnaire indicated that 95 per cent were glad they participated. While 74 per cent benefited, 18.5 per cent were bothered in some way. Results concerning the need to obtain physician permission before contacting next-of-kin were inconclusive; however, 8 of 10 females contacted by the case's physician considered consent necessary.

A study of women who refused to participate in a community survey of psychiatric disorder

The bias resulting from nonresponse causes problems for all epidemiological research. This study investigated the characteristics of those who refused to participate in a community survey of female psychiatric disorder. The demographic characteristics of refusers were similar to those previously reported. When compared to responders, those who refused tended to be older, never married and not widowed, of lower socioeconomic status and urban dwellers. No differences in physical illness requiring hospitalization or inpatient and outpatient psychiatric illness, as assessed through hospital records, were discerned between refusers and responders. Reasons for refusal are discussed. The bias problem may get worse as changing community attitudes to privacy and patients' rights lead to greater refusal rates.