Clinical trial resources on the internet must be designed to reach underrepresented minorities

Barriers to and solutions for representative inclusion across the lifespan and in life course research: The need for structural competency highlighted by the COVID-19 pandemic

Exclusion of special populations (older adults; pregnant women, children, and adolescents; individuals of lower socioeconomic status and/or who live in rural communities; people from racial and ethnic minority groups; individuals from sexual or gender minority groups; and individuals with disabilities) in research is a pervasive problem, despite efforts and policy changes by the National Institutes of Health and other organizations. These populations are adversely impacted by social determinants of health (SDOH) that reduce access and ability to participate in biomedical research. In March 2020, the Northwestern University Clinical and Translational Sciences Institute hosted the "Lifespan and Life Course Research: integrating strategies" "Un-Meeting" to discuss barriers and solutions to underrepresentation of special populations in biomedical research. The COVID-19 pandemic highlighted how exclusion of representative populations in research can increase health inequities. We applied findings of this meeting to perform a literature review of barriers and solutions to recruitment and retention of representative populations in research and to discuss how findings are important to research conducted during the ongoing COVID-19 pandemic. We highlight the role of SDOH, review barriers and solutions to underrepresentation, and discuss the importance of a structural competency framework to improve research participation and retention among special populations.

Reaching Older People With a Digital Fall Prevention Intervention in a Swedish Municipality Context-an Observational Study

Background

There is robust evidence that falls in old age can be prevented by exercise programs that include balance training, functional exercises, and strength training. For the interventions to have a population health impact, outreach to the population of focus with suitable interventions is needed. While digital interventions are promising there is limited knowledge on the characteristics of who is reached. The aim of this study was to describe the recruitment process, estimate reach rate at the population level and to describe participants characteristics and representativeness in a digital fall prevention intervention study.

Methods

In a municipality-based observational study, reach of a digital fall prevention intervention was evaluated. The intervention included a digital exercise programme (Safe Step) and optional supportive strategies, complemented with a range of recruitment strategies to optimize reach. Recruitment during a period of 6 months was open to people 70 years or older who had experienced a fall or a decline in balance the past year. Reach was based on data from the baseline questionnaire including health and demographic characteristics of participants. Representativeness was estimated by comparing participants to a sample of older people from the Swedish National Public Health Survey.

Results

The recruitment rate was 4.7% (n = 173) in relation to the estimated population of focus (n = 3,706). Most participants signed up within the first month of the intervention (n = 131). The intervention attracted primarily women, older people with high education, individuals who used the internet or digital applications almost every day and those perceiving their balance as fair or poor. Safe step participants lived more commonly alone and had higher education and better walking ability in comparison to the Swedish National Public Health Survey.

Conclusions

With a range of recruitment strategies most participants were recruited to a digital fall intervention during the first month. The intervention attracted primarily highly educated women who frequently used the internet or smart technologies. In addition to digital fall prevention interventions, a higher diversity of intervention types (digital and non-digital) is more likely to reach a larger group of older people with different needs.

Clinical Trial Registration

ClinicalTrials.gov, NCT04161625 (Retrospectively registered), https://clinicaltrials.gov/ct2/show/NCT04161625.

Assessing the utility of an online registry for patients monitoring their own warfarin therapy

AIMS

To evaluate the utility of an online self-report registry for patient self-monitoring and self-management (PSM) of warfarin therapy.

METHODS

A prospective observational study of UK-based patients undertaking PSM and recording their international normalised ratio (INR) data via an online registry. Consenting participants recorded INR test dates, results and warfarin dosages using the online registry for a period of 12 months. Participants reported demographic data, disease characteristics and treatment-related adverse events and provided feedback via a survey. Data accuracy was assessed through comparison of INR results recorded online with results stored on 19 INR testing devices. Percentage time spent within therapeutic time in range (TTR) was also examined.

RESULTS

Eighty-seven per cent (39/45) completed the study period. Age ranged from 26 to 83 years, 44% had undertaken PSM for >5 years. Sixty-six per cent (25/38) reported that the registry was easy to navigate and use. Forty-two participants contributed a total of 1669 INR results. Agreement between self-reported INR results and source INR data was high (99%). Mean TTR was 76% (SD 18.58) with 83% having >60% TTR.

CONCLUSIONS

Findings suggest that an online PSM registry is feasible, accurate and acceptable to patients. These findings require confirmation in a larger cohort of PSM patients. An online self-report registry could provide a valuable resource for gathering real world evidence of clinical effectiveness and safety of these developing models of care.

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

Successful minority recruitment and adherence in physical activity Internet-based research: the WIN study

BACKGROUND

Researchers studying physical activity often face challenges dealing with recruitment and resources, particularly when conducting longitudinal Internet-based research. Commonly raised methodological problems such as minority recruitment, participant commitment, and participant-staff involvement are addressed through a theoretically driven recruitment and adherence protocol in The Women's Exercise Injuries: Incidence and Risk Factors (WIN) Internet-based study.

OBJECTIVES

The objectives of this paper were to review and suggest solutions to problems of: (1) low recruitment of diverse samples, (2) low adherence, and (3) staffing needs.

METHODS

We recruited 1303 community-dwelling women and followed them through a multiple-phase, longitudinal, Internet-based study. Recruitment and adherence data were analyzed through descriptive methods and logistic regressions to examine participant adherence and sociodemographic factors and predictors of who entered the long-term phase of the study.

RESULTS

We successfully retained 71.6% of the sample through 4 recruitment phases. Twenty-seven percent of the initially recruited sample was racial/ethnically diverse, 24% began the long-term phase, and 23% completed. Several strategies to enhance participant commitment were successfully used during the practice phase, providing a successful, low staff to participant ratio. Logistic regression indicated being married, being older, and having greater Internet skills were predictive of successfully entering the long-term phase of the study.

CONCLUSIONS

Recruitment and compliance protocols were successful in meeting overall and racial/ethnic enrollment and recruitment goals. The theoretically based practice phase techniques were successful in re-engaging noncompliant participants. Strategies for minority enrollment and compliance are evaluated.

A systematic review of the factors influencing African Americans' participation in cancer clinical trials

OBJECTIVE

This systematic review was conducted to synthesize the existing evidence regarding key considerations influencing African Americans' participation in cancer clinical trials (CCTs).

METHODS

The PubMed and PsycINFO databases were searched to identify peer-reviewed publications during the last decade (2002-2011) that met our inclusionary criteria. Our search utilized Boolean combinations of the following terms: "clinical trial"; "cancer"; "neoplasm"; "African American"; "Black"; "caregiver"; "decision making"; "recruitment"; "companion"; "family"; "significant other"; and "social support".

RESULTS

A total of 267 articles were identified in the database searches. Of these articles, a total of 31 were determined to meet the inclusion criteria and were retained for review. Key issues that emerged as impediments to a successful recruitment of African Americans to CCTs included negative attitudes towards clinical trials, low levels of knowledge and awareness regarding CCTs, religious beliefs, and structural barriers, such as transportation, childcare, and access to health care. Recommendations from physicians, family members, and friends may promote CCT participation. Multimedia, and culturally-appropriate recruitment approaches may also be effective in soliciting participation among African Americans.

CONCLUSION

Existing research underscores the importance of social support from family and friends, cultural appropriateness and sensitivity from physicians and in the design of the CCT, and enhanced education among African Americans in decision-making processes. As African Americans are underrepresented in CCTs, targeted strategies to enhance recruitment efforts and improve cancer treatment outcomes are essential.

The utilization of oncology web-based resources in Spanish-speaking Internet users

OBJECTIVES

There currently are few web-based resources written in Spanish providing oncology-specific information. This study examines utilization of Spanish-language oncology web-based resources and evaluates oncology-related Internet browsing practices of Spanish-speaking patients.

METHODS

OncoLink (http://www.oncolink.org) is the oldest and among the largest Internet-based cancer information resources. In September 2005, OncoLink pioneered OncoLink en español (OEE) (http://es.oncolink.org), a Spanish translation of OncoLink. Internet utilization data on these sites for 2006 to 2007 were compared.

RESULTS

Visits to OncoLink rose from 4,440,843 in 2006 to 5,125,952 in 2007. OEE had 204,578 unique visitors and 240,442 visits in 2006, and 351,228 visitors and 412,153 visits in 2007. Although there was no time predilection for viewing OncoLink, less relative browsing on OEE was conducted during weekends and early morning hours. Although OncoLink readers searched for information on the most common cancers in the United States, OEE readers most often search for gastric, vaginal, osteosarcoma, leukemia, penile, cervical, and testicular malignancies. Average visit duration on OEE was shorter, and fewer readers surveyed OEE more than 15 minutes (4.5% vs. 14.9%, P < 0.001).

CONCLUSIONS

Spanish-speaking users of web-based oncology resources are increasingly using the Internet to supplement their cancer knowledge. Limited available resources written in Spanish contribute to disparities in information access and disease outcomes. Spanish-speaking oncology readers differ from English-speaking readers in day and time of Internet browsing, visit duration, Internet search patterns, and types of cancers searched. By acknowledging these differences, content of web-based oncology resources can be developed to best target the needs of Spanish-speaking viewers.

Selection bias of Internet panel surveys: a comparison with a paper-based survey and national governmental statistics in Japan

PURPOSE

To investigate the selection bias of an Internet panel survey organized by a commercial company.

METHODS

A descriptive study was conducted. The authors compared the characteristics of the Internet panel survey with a national paper-based survey and with national governmental statistics in Japan.

RESULTS

The participants in the Internet panel survey were composed of more women, were older, and resided in large cities. Regardless of age and sex, the prevalence of highly educated people in the Internet panel survey was higher than in the paper-based survey and the national statistics. In men, the prevalence of heavy drinkers among the 30- to 49-year-old population and of habitual smokers among the 20- to 49-year-old population in the Internet panel survey was lower than what was found in the national statistics.

CONCLUSIONS

The estimated characteristics of commercial Internet panel surveys were quite different from the national statistical data. In a commercial Internet panel survey, selection bias should not be underestimated.

Who participates in internet-based worksite weight loss programs?

BACKGROUND

The reach and representativeness are seldom examined in worksite weight loss studies. This paper describes and illustrates a method for directly assessing the reach and representativeness of a internet-based worksite weight loss program.

METHODS

A brief health survey (BHS) was administered, between January 2008 and November 2009, to employees at 19 worksites in Southwest Virginia. The BHS included demographic, behavioral, and health questions. All employees were blinded to the existence of a future weight loss program until the completion of the BHS.

RESULTS

The BHS has a participation rate of 66 percent and the subsequent weight loss program has a participation rate of 30 percent. Employees from higher income households, with higher education levels and health literacy proficiency were significantly more likely to participate in the program (p's < .01).

CONCLUSIONS

Worksite weight loss programs should include targeted marketing strategies to engage employees with lower income, education, and health literacy.

Recruitment for an internet-based diabetes self-management program: scientific and ethical implications

BACKGROUND

Little is known about the reach of Internet self-management interventions.

PURPOSE

The aim of this study was to evaluate different definitions of participation rate and compare characteristics among subcategories of participants and nonparticipants on demographic and clinical factors using de-identified electronic medical record data.

METHODS

Data are presented on recruitment results and characteristics of 2,603 health maintenance organization members having type 2 diabetes invited to participate in an Internet self-management program.

RESULTS

There was a 37% participation rate among all members attempted to contact and presumed eligible. There were several significant differences between participants and nonparticipants and among subgroups of participants (e.g., proactive volunteers vs. telephone respondents) on factors including age, income, ethnicity, smoking rate, education, blood pressure, and hemoglobin A1c.

CONCLUSION

These results have important implications for the impact of different recruitment methods on health disparities and generalization of results. We provide recommendations for reporting of eligibility rate, participation rate, and representativeness analyses.

Racial disparities in utilization of specialist care and medications in inflammatory bowel disease

OBJECTIVES

Optimization of medical therapy and specialist care for inflammatory bowel disease (IBD) may reduce morbidity. We sought to characterize racial disparities in utilization of healthcare and medical therapy for IBD.

METHODS

We performed a cross-sectional study of black (n=137) and white (n=149) IBD patients recruited from an outpatient IBD clinic and through medical record review and telephone interview, compared utilization of IBD specialist services, emergency department (ED) services, and medications. We adjusted racial comparisons for demographic, socioeconomic, and clinical factors.

RESULTS

After adjustment for confounders, blacks were less likely than whites to be under the regular care (defined as at least annual visit) of a gastroenterologist (adjusted odds ratio (aOR) 0.43; 95% confidence interval (CI): 0.25-0.75) or IBD specialist (aOR 0.37; 95% CI: 0.22-0.61). Follow-up with a primary care provider was, however, similar between blacks and whites. Over the preceding 12 months, blacks were more likely than whites to have at least one visit to the ED (aOR 2.02; 95% CI: 1.22-3.35), but there was no difference in hospitalization. Among CD patients with prolonged steroid use, blacks were less likely than whites to have been on infliximab (aOR 0.41; 95% CI: 0.21-0.77), but there were no racial differences in the use of immunomodulators (aOR 0.87; 95% CI: 0.48-1.60).

CONCLUSIONS

There are racial differences in utilization of IBD-related specialist services, ED visits, and infliximab that are independent of income and education. Modifiable barriers to health-care access may have a role in these disparities.

Utilization of internet-based survivorship care plans by lung cancer survivors

BACKGROUND

Persons living after lung cancer remain an important subset of the cancer survivor population who may be at risk for serious health consequences of lung cancer and its treatments. The Institute of Medicine recommends survivorship care plans for all cancer survivors.

MATERIALS AND METHODS

A program for the creation of survivorship care plans, OncoLife, was made publicly accessible. Users responded to queries regarding demographics, diagnosis, and treatment and received comprehensive, individualized guidelines for future care addressing issues such as late toxicity, second malignancy, fertility, and tumor recurrence. Data were maintained anonymously with approval from the Institutional Review Board.

RESULTS

From May 2007 to November 2008, 3343 individuals completed OncoLife surveys. Lung cancer survivors comprised 4% (n=142), with a median age at diagnosis of 57 years and median current age of 59 years. Lung cancer survivors were 50% male and 83% Caucasian. Chemotherapy was used in the treatment of 78% of patients with lung cancer, radiation was used in 58%, and surgery was used in 38%. Most lung cancer survivors (62%) reported receiving follow-up care from only an oncologist, while 27% reported being monitored by a primary care provider (PCP) and an oncologist, and 6% saw only a PCP. Only 11% reported receiving survivorship information at the conclusion of therapy.

CONCLUSION

OncoLife represents the first Web-based program for the creation of survivorship care plans, and lung cancer survivors appear willing to use this type of tool. Most have received multimodality care, placing them at risk for treatment-related late effects. Most survivors do not report receiving routine care from a PCP, so attention to survivor healthcare needs by the oncology community is particularly important.

Patient internet use surrounding cancer clinical trials: clinician perceptions and responses

Clinician perceptions of patient internet use related to clinical trials are not well documented. This exploratory study surveyed how cancer care providers at one NCI-designated cancer center viewed patient internet use surrounding cancer trials, including whether it affected patient decision making regarding trial enrollment. The sample included 20 oncologists (59%) and 14 (41%) nurses (n=34). Most clinicians (n=26; 76%) perceived the internet as having an effect on whether or not patients decided to enroll in a cancer trial. Two thirds (n=17; 65%) felt that this effect was positive, including in terms of enhancing patient knowledge of, access to, and enrollment in trials. Clinicians were asked if they ever discussed with their patients the topic of going online to find out more about cancer trials. Over half (n=18; 58%) who responded (n=31) to this item said yes; the rest (n=13; 42%) said no. The majority (n=10; 77%) in the "no" category were among those who reported that the internet had an effect on patient decision making. These data provisionally suggest that clinicians may see the internet as having mostly a positive effect on patient decision making about cancer trials, but that their communication efforts with patients do not always logically follow from this perception. Provider-patient discussion about internet use may be an opportunity for clinicians to contribute to improved patient knowledge of and enrollment in cancer trials. More research is needed to confirm and explain the gap between clinician perception and communication regarding trial-related internet use by cancer patients.

An internet tool for creation of cancer survivorship care plans for survivors and health care providers: design, implementation, use and user satisfaction

Background

Survivorship care plans have been recommended by the Institute of Medicine for all cancer survivors. We implemented an Internet-based tool for creation of individualized survivorship care plans. To our knowledge, this is the first tool of this type to be designed and made publicly accessible.

Objective

To investigate patterns of use and satisfaction with an Internet-based tool for creation of survivorship care plans.

Methods

OncoLife, an Internet-based program for creation of survivorship care plans, was designed by a team of dedicated oncology nurses and physicians at the University of Pennsylvania. The program was designed to provide individualized, comprehensive health care recommendations to users responding to queries regarding demographics, diagnosis, and cancer treatments. After being piloted to test populations, OncoLife was made publicly accessible via Oncolink, a cancer information website based at the University of Pennsylvania which averages 3.9 million page views and over 385,000 unique visits per month. Data entered by anonymous public users was maintained and analyzed.

Results

From May 2007 to November 2008, 3343 individuals utilized this tool. Most (63%) identified themselves as survivors, but also health care providers (25%) and friends/family of survivors (12%). Median age at diagnosis was 48 years (18 - 100+), and median current age 51 (19 - 100+). Most users were Caucasian (87%), female (71%), and college-educated (82%). Breast cancer was the most common diagnosis (46%), followed by hematologic (12%), gastrointestinal (11%), gynecologic (9%), and genitourinary (8%). Of all users, 84% had undergone surgery, 80% chemotherapy, and 60% radiotherapy. Half of users (53%) reported receiving follow-up care from only an oncologist, 13% only a primary care provider (PCP), and 32% both; 12% reported having received survivorship information previously. Over 90% of users, both survivors and health care providers, reported satisfaction levels of “good” to “excellent” using this tool.

Conclusions

Based on our experience with implementation of what is, to our knowledge, the first Web-based program for creation of survivorship care plans, survivors and health care providers appear both willing to use this type of tool and satisfied with the information provided. Most users have never before received survivorship information. Future iterations will focus on expanding accessibility and improving understanding of the needs of cancer survivors in the era of the Internet.