The new NIH and FDA medical research policies: targeting gender, promoting justice

'Experimental pregnancy' revisited

In this paper, I reflect on an important article by Bob Veatch in the inaugural issue of the Hastings Center Report, entitled "Experimental Pregnancy." It is a report and elegant analysis of the Goldzieher Study, in which nearly 400 women were randomized to receive hormonal contraception or placebo absent consent or disclosure about placebo use, resulting in several pregnancies. Noting the study's limited notoriety, I first consider the narratives that have instead dominated bioethics' approach to pregnancy and research: thalidomide and diethylstibesterol (DES). These narratives have facilitated a narrow focus on avoiding fetal risk, to the exclusion of other ethically relevant considerations. I then revisit "Experimental Pregnancy" and offer two ways in which Bob's analysis serves as an important corrective, first, by foregrounding research subjects (persons who are or may become pregnant), and second, by normalizing pregnancy and thus foregrounding foundational ethical considerations that are sometimes lost amidst pregnancy's presumed exceptionalism.

Contextualising sex and gender research to improve women's health: An early- and mid-career researcher perspective

The field of sex and gender research in health and medicine is growing, and many early- and mid-career researchers (EMCRs) are developing skills in this area. As EMCRs specialising in sex and gender research, we aim to better understand sex- and gender-based determinants of human health, challenge long-standing and pervasive gender biases, and contribute to improving the evidence base upon which clinical guidelines and policy interventions are developed. To effectively achieve these goals, we believe that EMCRs would benefit from understanding the challenges of working in this space and participate in driving change in three key areas. First, in creating greater links between the goals of sex and gender research and addressing systemic bias against women and gender minorities, to effectively translate knowledge about sex and gender differences into improved health outcomes. Second, in expanding the reach of sex and gender research to address women's health in an intersectional way and ensure that it also benefits the health of men, transgender and gender-diverse people and those who are intersex. Third, in working with others in the scientific community to improve methods for sex and gender research, including updating data collection practises, ensuring appropriate statistical analyses and shifting scientific culture to recognise the importance of null findings. By improving focus on these three areas, we see greater potential to translate this research to improve women's health and reduce health inequities for all.

A Scoping Review of Gender, Sex and Sexuality Differences in Polysubstance Use in Adolescents and Adults

BACKGROUND

Polysubstance use is a common, problematic behavior that increases risk of harm to self and others. Research suggests that rates may vary based on gender, sex and sexuality. Understanding the current state of this literature may inform prevention and treatment of polysubstance use, leading to reduced public health burden.

OBJECTIVES

This review aimed to synthesize research on gender, sex and sexuality differences in polysubstance use in adults and adolescents.

METHODS

A scoping review was conducted using all EBSCO databases, PubMed and Google Scholar to identify articles examining the effects of gender, sex and sexuality on polysubstance use. Polysubstance use was defined broadly as the use of any combination of substances over any time period and included licit (alcohol, tobacco) and illicit substances, concurrent and simultaneous use, from lifetime to daily use and use at any frequency. Studies were considered if they were published in peer-reviewed journals between January 1990 and October 2020 and were written in English. Publicly available data sources were also utilized to fully capture prevalence data that has not been published elsewhere.

RESULTS

Findings were mostly inconsistent and often conflicting. Only two findings were generally consistent: adult men were overall more likely to report polysubstance use than adult women, and sexual and gender minorities report more frequent polysubstance use than non-minorities.

CONCLUSIONS

Research has been unable to clearly elucidate differences in polysubstance use prevalence and patterns according to gender, sex and sexuality. Several recommendations are offered to advance future research and address limitations of current research.

[How to Study the Sex and Gender Effect in Biomedical Research?]

Men and women are different, but this difference has not been well reflected in clinical trials and preclinical studies of biomedical science. Gender medicine, which systematically analyzes research results according to sex and gender, has been emphasized to overcome this problem. On the other hand, researchers still have difficulty in applying gender medicine to their research. To perform rigorous gender medicine, using correct terms, a thorough literature review during research planning, appropriate statistical analysis and reporting, and cautious interpretation of the results are necessary. Applying gender medicine will increase the reproducibility of studies, promote discoveries, expand the study relevance, and ultimately improve patient care in both men and women. Here, this study reviewed the practical issues on applying gender medicine to both preclinical and clinical studies in the field of biomedical science.

Female under-representation in sepsis studies: a bibliometric analysis of systematic reviews and guidelines

OBJECTIVES

The objective of the study was to assess female representation in primary studies underpinning recommendations from clinical guidelines and systematic reviews for sepsis treatment in adults.

STUDY DESIGN AND SETTING

We conducted a bibliometric study. We removed studies pertaining to sex-specific diseases and included quasirandomized, randomized clinical trials (RCTs), and observational studies. We analyzed the female participation-to-prevalence ratio (PPR).

RESULTS

We included 277 studies published between 1973 and 2017. For the 246 studies for which sex data were available, the share of female participation was 40%. Females overall were under-represented relative to their share of the sepsis population (PPR 0.78). Disaggregated results were reported by sex in 57 studies. In univariate analyses, non-intensive care unit setting and consideration of other social health determinants were significantly associated with greater female participation (P < 0.001 and P = 0.023, respectively). In regression models, studies published in 1996 or later were likely to report sex, while RCTs were unlikely to do so (P = 0.019 and P < 0.001, respectively).

CONCLUSION

Our study points to female underenrollment in sepsis studies. Primary studies underpinning recommendations for sepsis have poorly reported their findings by sex.

Beyond Binary: Influence of Sex and Gender on Outcome after Traumatic Brain Injury

Traumatic brain injury (TBI) affects millions of individuals each year and is a leading cause of death and disability worldwide. TBI is heterogeneous and outcome is influenced by a combination of factors that include injury location, severity, genetics, and environmental factors. More recently, sex as a biological variable has been incorporated into TBI research, although there is conflicting literature regarding clinical outcomes in males versus females after TBI. We review the current clinical literature investigating sex differences after TBI. We focus our discussion on differences within contemporary gender categories to suggest that binary categories of male and female are not sufficient to guide clinical decisions for neurotrauma. Some studies have considered physiological variables that influence sex such as hormone cycles and stages in males and females pre- and post-TBI. These data suggest that there are phasic differences within male populations and within female populations that influence an individual's outcome after TBI. Finally, we discuss the impact of gender identity and expression on outcome after TBI and highlight the lack of neurotrauma research that includes non-binary individuals. Social constructs regarding gender impact an individual's vulnerability to violence and consequent TBI, including the successful reintegration to society after TBI. We call for incorporation of gender beyond the binary in TBI education, research, and clinical care. Precision medicine necessarily must progress beyond the binary to treat individuals after TBI.

Patient distrust in pharmaceutical companies: an explanation for women under-representation in respiratory clinical trials?

BACKGROUND

Patient skepticism concerning medical innovations can have major consequences for current public health and may threaten future progress, which greatly relies on clinical research. The primary objective of this study is to determine the variables associated with patient acceptation or refusal to participate in clinical research. Specifically, we sought to evaluate if distrust in pharmaceutical companies and associated psychosocial factors could represent a recruitment bias in clinical trials and thus threaten the applicability of their results.

METHODS

This prospective, multicenter survey consisted in the administration of a self-questionnaire to patients during a pulmonology consultation. The 1025 questionnaires distributed collected demographics, socio-professional and basic health literacy characteristics. Patients were asked to rank their level of trust for pharmaceutical companies and indicate their willingness to participate in different categories of research (pre or post marketing, sponsored by an academic institution or pharmaceutical company). Logistic regression was used to determine factors contributing to "trust" versus "distrust" group membership and willingness to participate in each category of research.

RESULTS

One thousand patients completed the survey, corresponding to a response rate of 97.5%. Data from 838 patients were analyzed in this study. 48.3% of respondents declared that they trusted pharmaceutical companies, while 35.5% declared distrust. Being female (p = 0.042), inactive in the employment market(p = 0.007), and not-knowing the name of one's disease(p = 0.010) are factors related to declared distrust. Distrust-group membership is associated with unwillingness to participate in certain categories of trials such as pre-marketing and industry-sponsored trials.

CONCLUSION

Distrust in pharmaceutical companies is associated with a specific patient profile and with refusal to participate in certain subcategories of trials. This potential recruitment bias may explain the under-representation of certain categories of patients such as women in pre-marketing drug trials.

Developing pathways for community-led research with big data: a content analysis of stakeholder interviews

BACKGROUND

Big data (BD) informs nearly every aspect of our lives and, in health research, is the foundation for basic discovery and its tailored translation into healthcare. Yet, as new data resources and citizen/patient-led science movements offer sites of innovation, segments of the population with the lowest health status are least likely to engage in BD research either as intentional data contributors or as 'citizen/community scientists'. Progress is being made to include a more diverse spectrum of research participants in datasets and to encourage inclusive and collaborative engagement in research through community-based participatory research approaches, citizen/patient-led research pilots and incremental research policy changes. However, additional evidence-based policies are needed at the organisational, community and national levels to strengthen capacity-building and widespread adoption of these approaches to ensure that the translation of research is effectively used to improve health and health equity. The aims of this study are to capture uses of BD ('use cases') from the perspectives of community leaders and to identify needs and barriers for enabling community-led BD science.

METHODS

We conducted a qualitative content analysis of semi-structured key informant interviews with 16 community leaders.

RESULTS

Based on our analysis findings, we developed a BD Engagement Model illustrating the pathways and various forces for and against community engagement in BD research.

CONCLUSIONS

The goal of our Model is to promote concrete, transparent dialogue between communities and researchers about barriers and facilitators of authentic community-engaged BD research. Findings from this study will inform the subsequent phases of a multi-phased project with the ultimate aims of organising fundable frameworks and identifying policy options to support BD projects within community settings.

Enrollment and Retention of Men and Women in Health Services Research and Development Trials

INTRODUCTION

Sex- and gender-specific science is essential to inform patient-centered, evidence-based care. Developing such evidence requires adequate inclusion of both women and men in trials. We sought to describe study participation of women and men in Department of Veterans Affairs Health Services Research and Development trials.

METHODS

We identified recent health services research trials from one Health Services Research and Development Center of Innovation and compared the participation of women and men from trial recruitment to study completion. We also calculated the participation to prevalence ratio (PPR) by sex for each trial.

RESULTS

We included eight trials that started recruitment between 2011 and 2014. Only one study purposefully attempted to boost the recruitment of women. Overall, the PPR for women ranged from 0.2 to 4.5, with seven studies having a PPR of greater than 1, indicating that women participated in these trials at proportions greater than their prevalence in the disease population within the Department of Veterans Affairs. The PPR for men ranged from 0.8 to 1.1. Retention was best with those studies that used administrative data for final outcomes assessment. No studies provided results stratified by sex or conducted analyses to explore treatment effect by sex.

CONCLUSIONS

At a single site, women participated in Health Services Research and Development trials at similar or greater rates to men without cross-study efforts to enrich the recruitment or retention of women. Adding strategic recruitment approaches could further boost the proportion of women in Department of Veterans Affairs trials and enable adequately powered sex-based analyses.

Racial differences in two measures of trust in biomedical research

Objective:

Lack of trust toward medical research is a major barrier to research participation, particularly among some population groups. Valid measures of trust are needed to develop appropriate interventions. The study purpose was to compare two previously validated scales that measure trust in biomedical research – one developed by Hall et al. (H-TBR; 2006) and the other by Mainous et al. (M-TBR; 2006) – in relation to socio-demographic variables and attitudes toward research. Differences between Black and White respondents were explored.

Methods:

Two nearly identical surveys – one with H-TBR and the other with M-TBR – were systematically administered to a convenience sample. Internal consistency reliability of each scale was assessed. Associations were computed between scores on each scale with attitudes toward biomedical research and demographic variables (i.e., gender, age, race, and socioeconomic status). The difference between White and Black respondents on each TBR score while controlling for age, education, and race was also investigated.

Results:

A total of 2020 participants completed the H-TBR survey; 1957 completed the M-TBR survey. Mean item scores for M-TBR were higher (F = 56.05, p < 0.001) among Whites than Blacks. Whites also had higher mean item scores than Blacks on H-TBR (F = 7.09, p < 0.001). Both scales showed a strong association with participants’ perceived barriers to research (ps < 0.001) and significant, positive correlations with interest in research participation (ps < 0.001). Age and household income were positive predictors of TBR scores, but the effects of education differed.

Conclusions:

Both scales are internally consistent and show associations with attitudes toward research. Whites score higher than Blacks on both TBR scales, even while controlling for age and socioeconomic status.

Needs, Priorities, and Recommendations for Engaging Underrepresented Populations in Clinical Research: A Community Perspective

Engaging underrepresented groups in outcomes research is a public health priority for reducing health and health care disparities; yet, engaging these groups is challenging. Failure to involve these underrepresented populations in research further exacerbates these disparities. This article presents the health and research priorities of diverse groups of underrepresented populations in biomedical research, their concerns for participating in research, and strategies to engage them in their healthcare and research studies. Eleven community listening sessions, ranging from 7 to 13 community members each (N = 117), representing racial/ethnic minority, economically disadvantaged (e.g., uninsured), and hearing impaired communities. We used an inductive, qualitative content analysis approach to analyze the data for emerging themes. We identified the following themes: Uncertainties of underrepresented populations regarding research participation; Ineffective communication about research opportunities and research findings; Research on primary care and prevention are priorities for underrepresented populations in research; and Research teams need training in cultural competence and humility. Underrepresented groups provided research priorities, concerns, and strategies to engage them in their healthcare and in research studies. Findings from this study could facilitate improvement of research participation among underrepresented groups, ultimately reducing health disparities and improving quality of life among groups commonly omitted from research recruitment and participation.

Anti-Egalitarianism, Legitimizing Myths, Racism, and “Neo-McCarthyism” in Social Epidemiology and Public Health: A Review of Sally Satel's PC, M.D

Sally Satel's PC, M.D.: How Political Correctness Is Corrupting Medicine constitutes an attempt to weaken the influence of egalitarian and antiracist scholarship in contemporary public health. This book has been widely distributed and has received many positive reviews in academia and the general press. Surprisingly, Satel has enlisted the direct or indirect support of prominent public health academics. The authors' critical review of this book indicates that Satel uses a combination of tactics to convince the reader of the danger involved in egalitarian public health efforts. Among them are insults, traditional “red baiting” tactics, “triangulation,” exaggeration, emotionally charged examples, omissions, and a strong appeal to individual responsibility to explain social inequalities in health. PC, M.D. reveals a scientific and ideological conflict over the determinants of health in populations that takes place within and outside the public health discipline. Efforts such as PC, M.D. suggest that social epidemiologists and other egalitarian public health scholars are having some impact in shaping how the public views health disparities.

Interpreting angina: symptoms along a gender continuum

BACKGROUND

'Typical' angina is often used to describe symptoms common among men, while 'atypical' angina is used to describe symptoms common among women, despite a higher prevalence of angina among women. This discrepancy is a source of controversy in cardiac care among women.

OBJECTIVES

To redefine angina by (1) qualitatively comparing angina symptoms and experiences in women and men and (2) to propose a more meaningful construct of angina that integrates a more gender-centred approach.

METHODS

Patients were recruited between July and December 2010 from a tertiary cardiac care centre and interviewed immediately prior to their first angiogram. Symptoms were explored through in-depth semi-structured interviews, transcribed verbatim and analysed concurrently using a modified grounded theory approach. Angiographically significant disease was assessed at ≥70% stenosis of a major epicardial vessel.

RESULTS

Among 31 total patients, 13 men and 14 women had angiograpically significant CAD. Patients describe angina symptoms according to 6 symptomatic subthemes that array along a 'gender continuum'. Gender-specific symptoms are anchored at each end of the continuum. At the centre of the continuum, are a remarkably large number of symptoms commonly expressed by both men and women.

CONCLUSIONS

The 'gender continuum' offers new insights into angina experiences of angiography candidates. Notably, there is more overlap of shared experiences between men and women than conventionally thought. The gender continuum can help researchers and clinicians contextualise patient symptom reports, avoiding the conventional 'typical' versus 'atypical' distinction that can misrepresent gendered angina experiences.

Analogs of microgravity: head-down tilt and water immersion

This article briefly reviews the fidelity of ground-based methods used to simulate human existence in weightlessness (spaceflight). These methods include horizontal bed rest (BR), head-down tilt bed rest (HDT), head-out water immersion (WI), and head-out dry immersion (DI; immersion with an impermeable elastic cloth barrier between subject and water). Among these, HDT has become by far the most commonly used method, especially for longer studies. DI is less common but well accepted for long-duration studies. Very few studies exist that attempt to validate a specific simulation mode against actual microgravity. Many fundamental physical, and thus physiological, differences exist between microgravity and our methods to simulate it, and between the different methods. Also, although weightlessness is the salient feature of spaceflight, several ancillary factors of space travel complicate Earth-based simulation. In spite of these discrepancies and complications, the analogs duplicate many responses to 0 G reasonably well. As we learn more about responses to microgravity and spaceflight, investigators will continue to fine-tune simulation methods to optimize accuracy and applicability.

Assessing Heterogeneity of Treatment Effects: Are Authors Misinterpreting Their Results?

OBJECTIVE

To determine whether investigations of heterogeneity of treatment effects (HTE) in randomized-controlled trials (RCTs) are prespecified and whether authors' interpretations of their analyses are consistent with the objective evidence.

DATA SOURCES/STUDY SETTING

Trials published in Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine in 1994, 1999, and 2004.

STUDY DESIGN

We reviewed 87 RCTs that reported formal tests for statistical interaction or heterogeneity (HTE analyses), derived from a probability sample of 541 articles.

DATA COLLECTION/EXTRACTION

We recorded reasons for performing HTE analysis; an objective classification of evidence for HTE (termed "clinicostatistical divergence" [CSD]); and authors' interpretations of findings. Authors' interpretations, compared with CSD, were coded as understated, overstated, or adequately stated.

PRINCIPLE FINDINGS

Fifty-three RCTs (61 percent) claimed prespecified covariates for HTE analyses. Trials showed strong (6), moderate (11), weak (25), or negligible (16) evidence for CSD (29 could not be classified due to inadequate information). Authors stated that evidence for HTE was sufficient to support differential treatment in subgroups (10); warranted more research (31); was absent (21); or provided no interpretation (25). HTE was overstated in 22 trials, adequately stated in 57 trials, and understated in 8 trials.

CONCLUSIONS

Inconsistencies in performance and reporting may limit the potential of HTE analysis as a tool for identifying HTE and individualizing care in diverse populations. Recommendations for future studies on the reporting and interpretation of HTE analyses are provided.

Analysis of sex and gender-specific research reveals a common increase in publications and marked differences between disciplines

BACKGROUND

The incorporation of sex and gender-specific analysis in medical research is increasing due to pressure from public agencies, funding bodies, and the clinical and research community. However, generations of knowledge and publication trends in this discipline are currently spread over distinct specialties and are difficult to analyze comparatively.

METHODS

Using a text-mining approach, we have analysed sex and gender aspects in research within nine clinical subspecialties--Cardiology, Pulmonology, Nephrology, Endocrinology, Gastroenterology, Haematology, Oncology, Rheumatology, Neurology--using six paradigmatic diseases in each one. Articles have been classified into five pre-determined research categories--Epidemiology, Pathophysiology, Clinical research, Management and Outcomes. Additional information has been collected on the type of study (human/animal) and the number of subjects included. Of the 8,836 articles initially retrieved, 3,466 (39%) included sex and gender-specific research and have been further analysed.

RESULTS

Literature incorporating sex/gender analysis increased over time and displays a stronger trend if compared to overall publication increase. All disciplines, but cardiology (22%), demonstrated an underrepresentation of research about gender differences in management, which ranges from 3 to 14%. While the use of animal models for identification of sex differences in basic research varies greatly among disciplines, studies involving human subjects are frequently conducted in large cohorts with more than 1,000 patients (24% of all human studies).

CONCLUSIONS

Heterogeneity characterizes sex and gender-specific research. Although large cohorts are often analysed, sex and gender differences in clinical management are insufficiently investigated leading to potential inequalities in health provision and outcomes.

The likelihood of participation in clinical trials can be measured: the Clinical Research Involvement Scales

OBJECTIVE

We developed the Clinical Research Involvement Scales (CRIS) to assess the willingness to participate in a clinical trial.

STUDY DESIGN AND SETTING

Diverse populations (N=919) aged 18 years or older from Atlanta, Georgia, were included in comprehensive testing of the 41-item CRIS instrument. The formative phase focused on item content for the new measures (n=54). Questionnaires from potential vaccine trial participants (n=865), collected at multiple time points, resulted in the evaluation of scale reliability and validity (i.e., attitudes, behavioral and normative beliefs, perceived social support for clinical research participation, social norm compliance, perceptions of the clinical research organization, and perceived relevance of the research endeavor).

RESULTS

Qualitative testing revealed adequate comprehension and content validity of the initial item set. The subjective norms domain (n=3) initially exhibited poor internal consistency in pilot testing (Cronbach's alpha=0.525); yet, rewording of the items resulted in consistently stable measurement improvement (Cronbach's alpha=0.850). Each of the CRIS subscales demonstrated extremely high reliability, ranging from 0.734 to 0.918. Confirmatory factor analysis verified item-factor relationships and determined construct and convergent validity (root mean square error of approximation=0.068; comparative fit index=0.835).

CONCLUSIONS

CRIS is a reliable instrument for measuring community attitudes toward participation in biomedical research studies. Results of this study support the use of these scales to recruit diverse populations to clinical trials.

Race categorization and the regulation of business and science

Despite the lack of consensus regarding the meaning or significance of race or ethnicity amongst scientists and the lay public, there are legal requirements and guidelines that dictate the collection of racial and ethnic data across a range of institutions. Legal regulations are typically created through a political process and then face varying kinds of resistance when the state tries to implement them. We explore the nature of this opposition by comparing responses from businesses, scientists, and science-oriented businesses (pharmaceutical and biotechnology companies) to U.S. state regulations that used politically derived racial categorizations, originally created to pursue civil rights goals. We argue that insights from cultural sociology regarding institutional and cultural boundaries can aid understanding of the nature of resistance to regulation. The Food and Drug Administration's guidelines for research by pharmaceutical companies imposed race categories on science-based businesses, leading to objections that emphasized the autonomy and validity of science. In contrast, similar race categories regulating first business by the Equal Employment Opportunity Commission (EEOC) and later scientific research sponsored by the National Institutes of Health (NIH) encountered little challenge. We argue that pharmaceutical companies had the motive (profit) that NIH-supported scientists lacked and a legitimate discourse (boundary work of science) that businesses regulated by the EEOC did not have. The study suggests the utility of a comparative cultural sociology of the politics of legal regulation, particularly when understanding race-related regulation and the importance of examining legal regulations for exploring how the meaning of race or ethnicity are contested and constructed in law.

Baseline differences in the HF-ACTION trial by sex

BACKGROUND

In patients with heart failure (HF), assessment of functional capacity plays an important prognostic role. Both 6-minute walk and cardiopulmonary exercise testing have been used to determine physical function and to determine prognosis and even listing for transplantation. However, as in HF trials, the number of women reported has been small, and the cutoffs for transplantation have been representative of male populations and extrapolated to women. It is also well known that peak VO(2) as a determinant of fitness is inherently lower in women than in men and potentially much lower in the presence of HF. Values for a female population from which to draw for this important determination are lacking.

METHODS

The HF-ACTION trial randomized 2,331 patients (28% women) with New York Heart Association class II-IV HF due to systolic dysfunction to either a formal exercise program in addition to optimal medical therapy or to optimal medical therapy alone without any formal exercise training. To characterize differences between men and women in the interpretation of final cardiopulmonary exercise testing models, the interaction of individual covariates with sex was investigated in the models of (1) VE/VCO(2), (2) VO(2) at ventilatory threshold (VT), (3) distance on the 6-minute walk, and (4) peak VO(2).

RESULTS

The women were younger than the men and more likely to have a nonischemic etiology and a higher ejection fraction. Dose of angiotensin converting enzyme inhibitor (ACEI) was lower in the women, on average. The lower ACEI dose may reflect the higher use of angiotensin II receptor blocker (ARB) in women. Both the peak VO(2) and the 6-minute walk distance were significantly lower in the women than in the men. Perhaps the most significant finding in this dataset of baseline characteristics is that the peak VO(2) for women was significantly lower than that for men with similar ventricular function and health status.

CONCLUSION

Therefore, in a well-medicated, stable, class II-IV HF cohort of patients who are able to exercise, women have statistically significantly lower peak VO(2) and 6-minute walk distance than men with similar health status and ventricular function. These data should prompt careful thought when considering prognostic markers for women and listing for cardiac transplant.

Perceptions of clinical research participation among African American women

BACKGROUND

Recruiting minority women into clinical research remains a significant challenge to conducting ethnically representative research. The main objective of this Office on Women's Health, DHHS-funded e-health database evaluation project was to examine African American women 's thoughts and perceptions about the clinical research process and about participation in the University of Michigan Women's Health Registry research database.

METHODS

Thirty-one African American women were recruited from the community to participate in a total of five 90-minute focus group discussions. All sessions were audiotaped and transcribed verbatim. Thematic content analysis was used to identify relevant themes about participation in clinical research and the Women's Health Registry.

RESULTS

Ten common trends were identified. (1) Information about the Women's Health Registry is not reaching the community. (2) Research is perceived as biased to benefit Caucasians. (3) Community involvement by the research team is critical for trust to develop. (4) Research directly relevant to African Americans or their community will encourage participation. (5) Researchers should use existing networks and advertise in appropriate locations. (6) The community needs more information concerning research. (7) Compensation is important. (8) Research that addresses a personal or family medical problem encourages involvement. (9) Minority representation on the research team is a motivator to participation. (10) There is limited time for healthcare-related activities.

CONCLUSIONS

Successful recruitment strategies for African American women should feature community-based, culturally appropriate approaches. Online research databases for subject recruitment will likely be successful only if implemented within a broader community-oriented program.

Enrollment of racial/ethnic minorities in NIAID-funded networks of HIV vaccine trials in the United States, 1988 to 2002

OBJECTIVE

The purpose of this study was to analyze enrollment of racial/ethnic minorities in Phase I and Phase II HIV vaccine trials in the U.S. conducted by National Institute of Allergy and Infectious Diseases (NIAID)-funded networks from 1988 to 2002.

METHODS

A centralized database was searched for all NIAID-funded networks of HIV vaccine trial enrollment data in the U.S. from 1988 through 2002. The authors reviewed data from Phase I or Phase II preventive HIV vaccine trials that included HIV-1 uninfected participants at low to moderate or high risk for HIV infection based on self-reported risk behaviors. Of 66 identified trials, 55 (52 Phase I, 3 Phase II) met selection criteria and were used for analyses. Investigators extracted data on participant demographics using statistical software.

RESULTS

A total of 3,731 volunteers enrolled in U.S. NIAID-funded network HIV vaccine trials from 1988 to 2002. Racial/ethnic minority participants represented 17% of the overall enrollment. By pooling data across all NIAID-funded networks from 1988 to 2002, the proportion of racial/ethnic minority participants was significantly greater (Fisher's exact test p-value < 0.001) in Phase II trials (278/1,061 or 26%) than in Phase I trials (347/2,670 or 13%). By generalized estimating equations, the proportion of minorities in Phase I trials increased over time (p = 0.017), indicating a significant increase in racial/ethnic minority participants from 1988 to 2002.

CONCLUSIONS

There has been a gradual increase in racial/ethnic minority participation in NIAID-funded network HIV vaccine trials in the U.S. since 1988. In the light of recent efficacy trial results, it is essential to continue to increase the enrollment of diverse populations in HIV vaccine research.

Dialysis dose as a determinant of adequacy

The intent-to-treat analyses of all patients in the HEMO trial suggested that increases in dose of dialysis as measured by urea Kt/V were of marginal or no benefit when dialysis was provided in a 3 times/wk schedule. The as-treated analysis in the HEMO trial pointed to markedly increased mortality when the delivered dose decreased even slightly below the targeted dose, evidence of a dose-targeting bias. The intent-to-treat HEMO study results suggested a potential interaction between sex and the dose-mortality relationship, and this also has been found in some cross-sectional studies, the cause of which remains unexplained. Whether dialysis dose should continue to be targeted based on urea distribution volume (V), or targeted to a body size measure that is a lower power of body weight (such as body surface area), remains an open question. The lack of benefit of increasing the dialysis dose in a 3 times/wk setting is more understandable if one looks at measures of equivalent continuous solute removal, such as the standard Kt/V. Differences in standard Kt/V in the 2 dose arms of the HEMO trial, for example, were only about 15%. Without going into removal of very large solutes (eg, beta-2-microglobulin), which is discussed elsewhere in this issue, or protein-bound uremic solutes, the only way to provide significantly more dialysis dose may be to move to more frequent dialysis schedules and/or to very long session lengths. Here, benefit may be related as much to better control of salt and water balance as to better removal of uremic toxins.

A comprehensive ethical framework for responsibly designing and conducting pharmacologic research that involves pregnant women

OBJECTIVE

We present and defend ethically justified guidelines for pharmacologic research that involves pregnant women.

STUDY DESIGN

We explain the ethical concept of the fetus as a patient and identify its ethical implications for the design and conduct of pharmacologic research that is intended to benefit pregnant women.

RESULTS

This concept justifies criteria for the initiation of early-phase clinical investigation, the initiation of controlled trials, the use of placebo control subjects, the stopping of randomized controlled trials, the determination of when an experimental intervention should be regarded as standard of care, and research that involves adolescents. The informed consent process should be shaped by the pregnant patient's obligation to take in to account her beneficence-based obligations to a fetal patient. Selection criteria should not be based on abortion preference. And, physicians are justified ethically in referring pregnant women to trials.

CONCLUSION

The concept of the fetus as a patient plays an essential role in the ethically justified design and conduct of pharmacologic research in pregnant women.

Evidence-based medicine, heterogeneity of treatment effects, and the trouble with averages

Evidence-based medicine is the application of scientific evidence to clinical practice. This article discusses the difficulties of applying global evidence ("average effects" measured as population means) to local problems (individual patients or groups who might depart from the population average). It argues that the benefit or harm of most treatments in clinical trials can be misleading and fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few. Heterogeneity of treatment effects reflects patient diversity in risk of disease, responsiveness to treatment, vulnerability to adverse effects, and utility for different outcomes. Recognizing these factors, researchers can design studies that better characterize who will benefit from medical treatments, and clinicians and policymakers can make better use of the results.

Race: predictor versus proxy variable? Outcomes after spinal cord injury

OBJECTIVE

To examine the impact of race on acute, rehabilitation, and long-term outcomes after spinal cord injury (SCI).

DESIGN

Two case control studies (study 1: acute and rehabilitation outcomes, study 2: long-term outcomes) in which white and nonwhite individuals were matched case for case on multiple demographic, medical, and geographic characteristics with the rationale being that a case-control methodology would increase the internal validity of the design, thereby increasing confidence in the assertion that any between-group differences observed may be specifically attributed to race.

SETTING

Data drawn from the Spinal Cord Injury Model Systems. Institutional practice and general community.

PARTICIPANTS

Study 1: 187 pairs of individuals, study 2: 158 pairs of matched individuals.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures assessed included economic (eg, cost of care), treatment-related (eg, length of hospital stay), functional (eg, FIM instrument), and medical (eg, number of medical complications) variables, as well as self-reported life satisfaction, level of handicap, and mental and physical health.

RESULTS

In study 1, none of the outcome measures differed significantly across racial groups. Similarly, study 2 failed to indicate significant differences in any of the outcome variables across racial groups, with the exception that nonwhites were at increased risk of greater self-reported handicap in the area of mobility. Power analyses indicated these finding were not merely the result of inadequate power.

CONCLUSION

For the outcomes assessed in studies 1 and 2, race appeared to act primarily as a proxy for other variables (eg, injury severity, age, educational achievement), which in turn may be associated with poor outcome after SCI. Theoretical implications and recommendations are discussed.

What's to know about study recruitment? We asked recruiters

To address the historic lack of research on women's health and women's exclusion from many significant clinical trials, governmental mandates have been implemented to increase their participation. To accomplish recruitment goals, it is imperative that a better understanding is reached about women's attitudes about research. In an effort to contribute information about recruitment, focus groups with study recruiters from San Francisco Bay Area research facilities were convened. Study recruiters provide a unique perspective on women's decision-making processes. The focus group discussions provided information on successful recruitment techniques employed by research recruiters that may be replicated across research studies.

The health of women in transition from welfare to employment

Although numerous studies of welfare policy exist, studies of women's health within the context of U.S. welfare reform policy have been limited. From an ecological health perspective, welfare policy shapes the immediate environment in which women live. The environment has long been recognized by nursing as a major determinant of health status. Using data from the Washington State Family Income Study (FIS), this research examined women's psychosocial health when making the transition from welfare receipt to employment. No differences in psychosocial health were found between women leaving welfare for employment and those remaining on welfare (p > .05 on depression, self-esteem, self-efficacy, and emotional support). This finding is consistent with earlier qualitative research, which indicates the life circumstances of women leaving welfare for paid employment rarely improve. To better understand how public policies such as those related to welfare affect the lives and health of women, additional research is sorely needed.

Engaging women's interest in colorectal cancer screening: a public health strategy

Screening rates for colorectal cancer are unacceptably low. New guidelines, public education campaigns, and expanded coverage of screening costs by healthcare insurance are expected to increase screening rates, but interventions targeting women may accelerate this change. Most American women already participate in regular cancer screening, in the form of Papanicolaou (Pap) tests and mammography, so they may be receptive to tailored messages about the need to add regular colorectal cancer screening to their preventive health regimen. In addition, their role in promoting the health of family members may position women to influence screening behavior in family and friends. Women may be particularly valuable change agents in populations where screening rates are traditionally low, such as medically underserved populations, the elderly or low socioeconomic status groups with competing health priorities, and populations with cultural values or practices inconsistent with the adoption of a new screening behavior. To serve as agents of change in their family and social networks, women must understand that colorectal cancer is not solely a man's disease and that the benefits of colorectal screening are similar to those of Pap testing and mammography. Colorectal cancer screening should also be promoted within a framework of a lifelong strategy for health maintenance for both men and women. The message to women should emphasize the value of colorectal cancer screening rather than the disagreement among experts over preferred screening strategies and should emphasize the value of shared decision making between the patient and her healthcare provider.