Psychosocial treatment research with ethnic minority populations: ethical considerations in conducting clinical trials

Racial/Ethnic Disparities in Consistent Reporting of Smoking-Related Behaviors

This study assessed the effect of race/ethnicity on the prevalence of inconsistent reports regarding ever smoking, time since smoking cessation, and age of initiating regular smoking. We used the Tobacco Use Supplement to the Current Population Survey data, which came from a test-retest reliability study, and considered three racial/ethnic subpopulations, Hispanics, Non-Hispanic (NH) Blacks and NH Whites. Initial exploration of highly disagreeing reports of time since smoking cessation and age of onset of regular smoking initiation indicated that the majority of these reports corresponded to NH Whites. However, the proportion of the extremely discrepant reports was very small (less than 0.8%), and these reports were not included in the main analyses. Univariate analyses revealed that for each smoking measure, NH Whites tended to report most consistently when compared to Hispanics and NH Blacks. However, the only statistically significant result was that Hispanics were more likely to report their regular smoking initiation age inconsistently than were NH Whites. Analyses that adjusted for other factors confirmed this finding, i.e., Hispanics were 1.8 times more likely to provide inconsistent reports of their age of onset of regular smoking than were NH Whites. Furthermore, these analyses showed that the impact of race/ethnicity on the prevalence of inconsistent reporting may depend on other factors, e.g., age and employment status. For example, non-employed NH Blacks were 1.9 times more likely to recant ever smoking than were non-employed NH Whites. The lower consistency in reports by Hispanics and NH Blacks underscores the importance of developing new survey design and research strategies for detecting relatively small differences in reporting among the racial/ethnic minorities. Additional efforts to motivate racial/ethnic minorities to participate in national surveys may not only help increase representation of these subpopulations in study samples but also help improve overall data quality.

Characteristics associated with inpatient versus outpatient status in older adults with bipolar disorder

OBJECTIVES

This is an exploratory analysis of ambulatory and inpatient services utilization by older persons with type I bipolar disorder experiencing elevated mood. The association between type of treatment setting and the person's characteristics is explored within a framework that focuses upon predisposing, enhancing, and need characteristics.

METHOD

Baseline assessments were conducted with the first 51 inpatients and 49 outpatients 60 years of age and older, meeting criteria for type I bipolar disorder, manic, hypomanic, or mixed episode enrolled in the geriatric bipolar disorder study (GERI-BD) study. We compared participants recruited from inpatient versus outpatient settings in regard to the patients' predisposing, enabling, and need characteristics.

RESULTS

Being treated in an inpatient rather than an outpatient setting was associated with the predisposing characteristic of being non-Hispanic caucasian (odds ratio [OR]: 0.1; P = .005) and past history of treatment with first-generation antipsychotics (OR: 6.5; P < .001), and the need characteristic reflected in having psychotic symptoms present in the current episode (OR: 126.08; P < .001).

CONCLUSION

Ethnicity, past pharmacologic treatment, and current symptom severity are closely associated with treatment in inpatient settings. Clinicians and researchers should investigate whether closer monitoring of persons with well-validated predisposing and need characteristics can lead to their being treated in less costly but equally effective ambulatory rather than inpatient settings.

Ethical complexities of screening for depression and intimate partner violence (IPV) in intervention studies

Background

Intervention studies for depression and intimate partner violence (IPV) commonly incorporate screening to identify eligible participants. The challenge is that current ethical evaluation is largely informed by the four principle approach applying principles of beneficence, non-maleficence, and respect for justice and autonomy. We examine three intervention studies for IPV, postnatal depression (PND) and depression that used screening from the perspective of principlism, followed by the perspective of a narrative and relational approach. We suggest that a narrative and relational approach to ethics brings to light concerns that principlism can overlook.

Discussion

The justification most commonly used to incorporate screening is that the potential benefits of identifying intervention efficacy balance the risk of individual harm. However, considerable risks do exist. The discovery of new information may result in further depression or worries, people might feel burdened, open to further risk, unsure of whether to disclose information to family members and disappointed if they are allocated to a control group. This raises questions about study design and whether the principle of equipoise remains an adequate justification in studies with vulnerable groups. In addition, autonomy is said to be respected because participants give informed consent to participate. However, the context of where recruitment is undertaken has been shown to influence how people make decisions.

Summary

The four principles have been subjected to criticisms in recent years but they remain prominent in public health and medical research. We provide a set of simple, interrogative questions that are narrative and relationally driven which may assist to further evaluate the potential impacts of using screening to identify eligible research participants in intervention studies. A narrative and relational based approach requires seeing people as situated within their social and cultural contexts, and as existing within relationships that are likely to be affected by the results of screening information.

Features associated with successful recruitment of diverse patients onto cancer clinical trials: report from the American College of Surgeons Oncology Group

BACKGROUND

The clinical trials mechanism of standardized treatment and follow-up for cancer patients with similar stages and patterns of disease is the most powerful approach available for evaluating the efficacy of novel therapies, and clinical trial participation should protect against delivery of care variations associated with racial/ethnic identity and/or socioeconomic status. Unfortunately, disparities in clinical trial accrual persist, with African Americans (AA) and Hispanic/Latino Americans (HA) underrepresented in most studies.

STUDY DESIGN

We evaluated the accrual patterns for 10 clinical trials conducted by the American College of Surgeons Oncology Group (ACOSOG) 1999-2009, and analyzed results by race/ethnicity as well as by study design.

RESULTS

Eight of 10 protocols were successful in recruiting AA and/or HA participants; three of four randomized trials were successful. Features that were present among all of the successfully recruiting protocols were: (1) studies designed to recruit patients with regional or advanced-stage disease (2 of 2 protocols); and (2) studies that involved some investigational systemic therapy (3 of 3 protocols).

DISCUSSION

AA and HA cancer patients can be successfully accrued onto randomized clinical trials, but study design affects recruitment patterns. Increased socioeconomic disadvantages observed within minority-ethnicity communities results in barriers to screening and more advanced cancer stage distribution. Improving cancer early detection is critical in the effort to eliminate outcome disparities but existing differences in disease burden results in diminished eligibility for early-stage cancer clinical trials among minority-ethnicity patients.

Strategies for recruiting African American men into prostate cancer screening studies

BACKGROUND

Recruitment for research and clinical trials continues to be challenging. Prostate cancer is the most commonly diagnosed cancer in men and disproportionately affects African American men; thus, effective recruitment strategies are essential for this population.

OBJECTIVES

The aim of this study was to focus on innovative and effective recruitment strategies for research on prostate cancer with minorities.

METHODS

A systematic description is provided of the recruitment efforts for a hermeneutic phenomenological qualitative study of African American men's experiences in decision making on whether to have a prostate cancer screening.

RESULTS

Seventeen African American men were enrolled from rural Central Virginia. Recruiting strategies were targeted on places where African American men usually are found but that are rarely used for recruitment: barbershops, community health centers, and churches. Word of mouth was also used, and most of the participants (n = 11) were reached through this method.

DISCUSSION

Recruitment efforts have been noted to be particularly challenging among minorities, for numerous reasons. Making minority recruitment a priority in any research or clinical trial is essential in gaining a representative sample. Word of mouth is a powerful tool that is often forgotten but should be looked at in further detail.

ETHICAL CONSIDERATIONS FOR COGNITIVE-BEHAVIORAL THERAPISTS IN PSYCHOTHERAPY RESEARCH TRIALS

Psychotherapy research studies can place particular demands on clinicians, patients, and research staff due to the need to balance the pursuit of knowledge with the offer of treatment. However, the literature with regard to ethical considerations in psychotherapy trials is minimal. The current paper aims to depict CBT community standards of practice in the context of two NIMH-funded treatment trials of major depression, both involving CBT and medication. We describe issues that arose; discuss the ethical considerations involved; and describe our course of action, along with our rationale.

Challenges and strategies in recruitment of ethnically diverse populations for cancer nursing research

PURPOSE/OBJECTIVES

To describe common barriers, identify challenges for researchers, and provide strategies for recruitment and retention of ethnic minority groups for cancer nursing research.

DATA SOURCES

Computerized search of databases, published articles, abstracts, master's theses, and doctoral dissertations.

DATA SYNTHESIS

Social, economic, and cultural factors present challenges to recruitment of minorities into research. Knowing the culture of the target population, developing trust, engaging the community, and using tailored materials are strategies for recruitment and retention of minorities.

CONCLUSIONS

Knowledge of potential barriers and challenges to research with diverse populations provides the foundation for the development of strategies for successful recruitment of minorities in cancer nursing research.

IMPLICATIONS FOR NURSING

Increasing ethnic minorities in research will generate knowledge that will contribute to culturally competent cancer care.

Ethical Issues in Research with Hispanic Drug Users: Participant Perspectives on Risks and Benefits

There has been considerable discussion in the research ethics literature concerning special researcher responsibilities in studying vulnerable populations, including whether or not drug addicts, as a result of their health condition and craving for drugs, constitute a vulnerable group from a human subject perspective. In the assessment of ethical issues, researchers in recent years have begun to recognize the critical importance of hearing the subject's voice and learning the concerns and attitudes of those who participate in research. To date, however, despite a significant increase in studies of not-in-treatment drug users, little attempt has been made to determine the perspectives of drug users about participation in research, especially ethnic minority drug users, and in particular, Hispanic drug users. Based on recent findings of a study of drug user attitudes and perspectives on research, this paper reports on the perceived risks and benefits of participation in research of a subsample of Hispanic street drug users from Hartford, Connecticut

Understanding the African American Research Experience (KAARE): Implications for HIV Prevention

Despite recognition that the African American population is underrepresented in studies of health and mental health treatment and prevention efforts, few investigations have systematically examined barriers to African American research participation. Without their participation, treatment and prevention strategies designed to curtail the spread of HIV in their communities will be bound to achieve less than optimal outcomes. Based on the assumption that successful recruitment of African Americans requires knowledge of (a) their beliefs about research, (b) their perceptions of the research process and researchers, (c) their motivations to participate, and (d) the historical and social factors that may be the source of at least some ambivalence, the current study undertook semi-structured interviews with 157 African American, low-income mothers residing in a large urban community where they and their children were at high risk for HIV. Given the sensitive nature of the research topic, members of the community were trained to conduct the interviews. Qualitative and quantitative analyses of the interview content suggest that despite having been consented, many participants (a) are not aware of their rights under informed consent and (b) lack knowledge of how the research will be used. Despite this and the subtle suspicion of White researchers held by some, many decide to participate for altruistic reasons. The implications for recruitment of participants in general and African Americans in particular into HIV prevention studies are discussed as are the implications for service providers directly or indirectly involved in the development and delivery of these interventions.

Transition from a pediatric HIV intramural clinical research program to adolescent and adult community-based care services:assessing transition readiness

As treatment options have improved, there has been a significant increase in the life expectancy of HIV-infected children and adolescents. For most adolescents, the time comes when it is appropriate to transition from pediatric care to an adult or community-based provider. In response to a program closure, a transition readiness scale was developed. A total of 39 caregivers of HIV-infected youth (ages 10-18) and 12 youth over the age of 18 years were interviewed at two time points. Barriers associated with transition were identified and addressed between visits. Transition readiness improved and state anxiety decreased significantly from the first time point to the last visit (approximately 7 months later). Not having a home social worker was the most reported concern/need identified. Barriers to transition and interventions utilized to assist with transitioning care are discussed.

Recruiting minority men who have sex with men for HIV research: results from a 4-city campaign

We describe the efforts of a 4-city campaign to recruit Black and Hispanic men who have sex with men into an established HIV epidemiological study. The campaign used community organizing principles and a social marketing model that focused on personnel, location, product, costs and benefits, and promotion. The campaign was developed at the community, group, and individual levels to both increase trust and reduce barriers.The proportion of Hispanic men recruited during the 2002-2003 campaign doubled compared with the 1987 campaign, and the proportion and number of White men decreased by 20%. The proportion of Black men decreased because of the large increase in Hispanic men, although the number of Black men increased by 56%. Successful recruitment included training recruitment specialists, involving knowledgeable minority community members during planning, and having an accessible site with convenient hours.

Use of the National Cancer Data Base to develop clinical trials accrual targets that are appropriate for minority ethnicity patients

BACKGROUND

Disparities in cancer outcome among different subsets of the American population related to ethnic background have been well documented. Clinical trials represent the most powerful strategy for improving cancer treatments, but racial and ethnic minority patients are frequently underrepresented among patients accrued to these protocols. Proof of comparable efficacy for a promising cancer therapy in different groups of patients requires diversity in the clinical trial populations so that study results will be generalizable. Appropriate targets for accrual of minority ethnicity patients have not previously been defined.

METHODS

The National Cancer Database (NCDB) is maintained jointly by the American Cancer Society and the American College of Surgeons. Information submitted by tumor registries throughout the United States represents an estimated 70% of newly diagnosed cancer cases. The authors analyzed NCDB reports on ethnic distribution of patients with breast, prostate, nonsmall cell lung, and colorectal cancer, stratified by stage of disease at diagnosis.

RESULTS

African Americans with cancer of the breast and prostate had the most notable patterns of disproportionate representation among populations with advanced-stage disease. The authors compiled a table of suggested accrual targets for selected solid-organ cancers based on NCDB stage-specific reports.

CONCLUSIONS

Clinical trial results will be more meaningful if participating patients reflect the site- and stage-specific populations that are under study. The authors recommended that clinical trial investigators incorporate accrual targets for minority ethnicity populations into the study design.

Ethical considerations in mental health research with racial and ethnic minority communities

Mental health researchers are now expected to include racial and ethnic diversity in their study samples. These studies meet ethics requirements, but the tendency to focus on deontological ethical objectives has not been sufficient to ensure ethical or equitable outcomes for research participants. To ensure these outcomes, we need to emphasize utilitarian ethical principles that take into account the historical and contemporary processes that have promoted negative outcomes for racial and ethnic minority participants in research. Suggestions are made for how both deontological and utilitarian ethical concerns regarding respect, beneficence and justice can be addressed within a broadened research ethic.

Research ethics for mental health science involving ethnic minority children and youths

In response to U.S. Public Health Service projects promoting attention to disparities in the outcomes of mental health treatments, in July 2001, the American Psychological Association, the National Institute of Mental Health, and the Fordham University Center for Ethics Education convened a group of national leaders in bioethics, multicultural research, and ethnic minority mental health to produce a living document to guide ethical decision making for mental health research involving ethnic minority children and youths. This report summarizes the key recommendations distilled from these discussions.