Costs and strategies in minority recruitment for osteoporosis research

REPRESENTATION AND EXTRAPOLATION: EVIDENCE FROM CLINICAL TRIALS. THE QUARTERLY JOURNAL OF ECONOMICS 2024;139:575-635. [PMID: 38859982 PMCID: PMC11164133 DOI: 10.1093/qje/qjad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

This article examines the consequences and causes of low enrollment of Black patients in clinical trials. We develop a simple model of similarity-based extrapolation that predicts that evidence is more relevant for decision-making by physicians and patients when it is more representative of the group being treated. This generates the key result that the perceived benefit of a medicine for a group depends not only on the average benefit from a trial but also on the share of patients from that group who were enrolled in the trial. In survey experiments, we find that physicians who care for Black patients are more willing to prescribe drugs tested in representative samples, an effect substantial enough to close observed gaps in the prescribing rates of new medicines. Black patients update more on drug efficacy when the sample that the drug is tested on is more representative, reducing Black-white patient gaps in beliefs about whether the drug will work as described. Despite these benefits of representative data, our framework and evidence suggest that those who have benefited more from past medical breakthroughs are less costly to enroll in the present, leading to persistence in who is represented in the evidence base.

Barriers and strategies for recruiting participants who identify as racial minorities in musculoskeletal health research: a scoping review

Objective

Visible minorities are disproportionately affected by musculoskeletal disorders (MSD) and other diseases; yet are largely underrepresented in health research. The purpose of this scoping review was to identify barriers and strategies associated with increasing recruitment of visible minorities in MSD research.

Methods

Electronic databases (MEDLINE, EMBASE, CINAHL, and PsycInfo) were searched. Search strategies used terms related to the concepts of 'race/ethnicity', 'participation', 'research' and 'musculoskeletal'. All research designs were included. Two reviewers independently screened titles and abstracts, completed full-text reviews, and extracted data. Papers that did not focus on musculoskeletal research, include racial minorities, or focus on participation in research were excluded. Study characteristics (study location, design and methods; sample characteristics (size, age, sex and race); MSD of interest) as well as barriers and strategies to increasing participation of visible minorities in MSD research were extracted from each article and summarized in a table format.

Results

Of the 4,282 articles identified, 28 met inclusion criteria and were included. The majority were conducted in the United States (27 articles). Of the included studies, the groups of visible minorities represented were Black (25 articles), Hispanic (14 articles), Asian (6 articles), Indigenous (3 articles), Middle Eastern (1 article), and Multiracial (1 article). The most commonly cited barriers to research participation were mistrust, logistical barriers (e.g., transportation, inaccessible study location, financial constraints), and lack of awareness or understanding of research. Strategies for increasing diversity were ensuring benefit of participants, recruiting through sites serving the community of interest, and addressing logistical barriers.

Conclusion

Understanding the importance of diversity in MSD research, collaborating with communities of visible minorities, and addressing logistical barriers may be effective in reducing barriers to the participation of visible minorities in health research. This review presents strategies to aid researchers in increasing inclusion in MSD-related research.

Working to Increase Stability through Exercise (WISE): screening, recruitment, and baseline characteristics

Background

The aim of this paper is to describe the utility of various recruitment modalities utilized in the Working to Increase Stability through Exercise (WISE) study. WISE is a pragmatic randomized trial that is testing the impact of a 3-year, multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers or delivered via DVD on the rate of serious fall-related injuries among adults 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The modified goal was to recruit 1130 participants over 2 years in three regions of Pennsylvania.

Methods

The at-risk population was identified primarily using letters mailed to patients of three health systems and those over 65 in each region, as well as using provider alerts in the health record, proactive recruitment phone calls, radio advertisements, and presentations at community meetings.

Results

Over 24 months of recruitment, 209,301 recruitment letters were mailed, resulting in 6818 telephone interviews. The two most productive recruitment methods were letters (72% of randomized participants) and the research registries at the University of Pittsburgh (11%). An average of 211 letters were required to be mailed for each participant enrolled. Of those interviewed, 2854 were ineligible, 2,825 declined to enroll and 1139 were enrolled and randomized. Most participants were female (84.4%), under age 75 (64.2%), and 50% took an osteoporosis medication. Not having a prior fragility fracture was the most common reason for not being eligible (87.5%). The most common reason provided for declining enrollment was not feeling healthy enough to participate (12.6%).

Conclusions

The WISE study achieved its overall recruitment goal. Bulk mailing was the most productive method for recruiting community-dwelling older adults at risk of serious fall-related injury into this long-term physical activity intervention trial, and electronic registries are important sources and should be considered.

Lessons Learned and Strategies for Recruitment of Diverse, Low-income Patients into an Integrative Medical Group Visit Clinical Trial

OBJECTIVE

Description of recruitment methods and lessons learned in a randomized controlled trial of underserved patients using an integrative medical group visits intervention.

METHODS

Comparison of the demographic characteristics of participants screened and consented to the study as well as description of recruitment methods used.

OUTCOME MEASURES

This paper examines the characteristics of patients who were eligible compared to those who were not, characteristics of patients at the different sites, and patient characteristics over time (by comparing various cohorts) based on our experiences recruiting underserved patients.

RESULTS

We screened 338 patients, with 205 (60.6%) meeting eligibility criteria and 159 patients randomized and consented. 133 patients were found ineligible, with the most common reasons being low depression scores (n = 20), manic symptoms (n = 20), and psychotic symptoms (n = 19), and alcohol use (n = 15). We found demographic differences in patients recruited by different methods and at different sites- patients referred by provider letter were older than those referred by self-referral or provider referral (mean age/SD vs. mean age/SD, p = 0.0001). For site-specific differences, patients at DH were older (53 SD = 12.3) than those at the Boston Medical Center (49 SD = 11.3) and CSHC (p = 0.048) in pair-wise comparisons. Patients at DH were also more likely to be white (25%) as compared to BMC (18%) and DH (7%), while those at CSHC were more likely to be black (70%) (p = 0.008).

Connecting communities to health research: development of the Project CONNECT minority research registry

INTRODUCTION

Prevention and treatment standards are based on evidence obtained in behavioral and clinical research. However, racial and ethnic minorities remain relatively absent from the science that develops these standards. While investigators have successfully recruited participants for individual studies using tailored recruitment methods, these strategies require considerable time and resources. Research registries, typically developed around a disease or condition, serve as a promising model for a targeted recruitment method to increase minority participation in health research. This study assessed the tailored recruitment methods used to populate a health research registry targeting African-American community members.

METHODS

We describe six recruitment methods applied between September 2004 and October 2008 to recruit members into a health research registry. Recruitment included direct (existing studies, public databases, community outreach) and indirect methods (radio, internet, and email) targeting the general population, local universities, and African American communities. We conducted retrospective analysis of the recruitment by method using descriptive statistics, frequencies, and chi-square statistics.

RESULTS

During the recruitment period, 608 individuals enrolled in the research registry. The majority of enrollees were African American, female, and in good health. Direct and indirect methods were identified as successful strategies for subgroups. Findings suggest significant associations between recruitment methods and age, presence of existing health condition, prior research participation, and motivation to join the registry.

CONCLUSIONS

A health research registry can be a successful tool to increase minority awareness of research opportunities. Multi-pronged recruitment approaches are needed to reach diverse subpopulations.

Effort required in eligibility screening for clinical trials

PURPOSE

Determining eligibility for a clinical trial (CT) typically requires a lengthy manual review of data for a single evaluation. The cost associated with eligibility screening is typically not compensated through contracts supporting CTs.

METHODS

We used a real-time tracking system that captures CT evaluations and provides information on evaluation outcomes and time spent on each eligibility screening by research staff. Using these data, we describe the effort and costs of eligibility screening overall and per enrolled patient for cancer CTs. The study sample included all completed eligibility assessment (evaluation) records for the 18-month study period. We used generalized multinomial modeling to predict evaluation outcomes and then used the resulting parameter coefficients to estimate the effort associated with each participant, adjusted for probability of being enrolled. From these data, we calculated cost associated with eligibility screening.

RESULTS

We found substantial variation in attributed cost by study type and phase. The cost of eligibility screening ranged by study phase from $129.15 to $336.48 per enrolled patient. The estimated annual cost of screening was more than $90,000.

CONCLUSION

This study provides results based on prospectively captured effort to estimate the largely nonreimbursed costs of eligibility screening and suggests that screening can be a significant financial burden to an institution. Centers performing CTs may need to acknowledge the differences in screening costs for different study types when negotiating contracts with funding organizations. Information such as that captured here could support such negotiations to reduce the gap between reimbursed and nonreimbursed costs.

Challenges and opportunities in pain management disparities research: implications for clinical practice, advocacy, and policy

Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward.

PERSPECTIVE

Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

Research agenda for tackling inequalities related to migration and ethnicity in Europe

Reducing ethnic inequalities and inequities in health needs to become a higher priority for public health research. Active involvement of migrant and ethnic minority populations in European population health research is necessary, for data show important inequalities but evidence, particularly on effectiveness, is sparse and strategic overviews rarer still. Ethnically disaggregated health surveillance systems are developing slowly, and pragmatically, often using country of birth. The principles to adopt, given the gaps between the ideal and the current reality, need wider discussion. Ethics may provide both principles and impetus. Doing no harm, doing good, respecting the research participants' autonomy are good starting points. More emphasis is needed on justice, fairness and equality, participation and communicating effectively. Ethnic minority groups are willing participants in trials once linguistic and trust-related barriers are overcome, though recruitment costs are higher. Guidelines and strategies by European bodies with research funding or enforcement responsibilities are needed. The research community needs an infrastructure within which to collect and utilize evidence. Research can help migrant and ethnic minority groups to participate more fully in our multi-ethnic societies.

Successful recruitment and retention of Latino study participants

A high prevalence of risk behaviors among the rapidly growing Latino youth population in the United States adds urgency to the need to identify effective recruitment and retention strategies for research studies and prevention programs. The objectives of this study are to (a) describe the culturally responsive recruitment and retention strategies used in the Familias Fuertes-Georgia program and (b) discuss the evaluation of the relative importance of these strategies. Familias Fuertes (i.e., Strong Families) is a community-based, primary prevention program for families in Latin America with children between the ages of 10 and 14 years. The main program goal is to reduce high-risk behaviors among adolescents by strengthening family relationships and promoting self-regulation and positive conflict resolution strategies. A pilot feasibility study was conducted to determine the appropriateness of the Familias Fuertes program for Latino families living in the United States. To promote participation, 15 culturally responsive recruitment and retention strategies were developed using a three-step process. These strategies contributed to the successful recruitment and retention of Familias Fuertes-Georgia study participants. Participating parents, the community liaison, and the community leader evaluated the relative importance of the 15 culturally responsive recruitment and retention strategies. Three of the strategies emerged as more important than others: face-to-face recruitment by the community liaison; bilingual, bicultural, and experienced facilitators; and free on-site child care. Further research is needed to develop strategies promoting the participation of male caregivers/fathers.

Efficiency and cost-effectiveness of recruitment methods for male Latino smokers

Little is known about the most effective strategies to recruit male Latino smokers to cessation research studies. The purpose of this study was to identify efficient and cost-effective research recruitment strategies for this priority population.

Korean immigrant parents' evaluation of the delivery of a parenting program for cultural and linguistic appropriateness and usefulness

The goal of this study was to evaluate the delivery of a parenting program to 17 Korean immigrants for cultural and linguistic appropriateness and usefulness regarding recruitment, retention, program content, and delivery methods. Focus group interview data were audiotaped, transcribed, and analyzed. Themes identified included fit between the parents' desire and what the program offered, effective recruitment and retention strategies, program content and videotapes: based on Western cultural background but useful, helpful role-play and homework, and recommendations (Korean language videotapes, longer classes, extended learning). The findings can be used in adopting the program to increase cultural and linguistic appropriateness.

A comparative analysis of recruitment methods used in a randomized trial of diabetes education interventions

Recruitment methods heavily impact budget and outcomes in clinical trials. We conducted a post-hoc examination of the efficiency and cost of three different recruitment methods used in Journey for Control of Diabetes: the IDEA Study, a randomized controlled trial evaluating outcomes of group and individual diabetes education in New Mexico and Minnesota. Electronic databases were used to identify health plan members with diabetes and then one of the following three methods was used to recruit study participants: 1. Minnesota Method 1--Mail only (first half of recruitment period). Mailed invitations with return-response forms. 2. Minnesota Method 2--Mail and selective phone calls (second half of recruitment period). Mailed invitations with return-response forms and subsequent phone calls to nonresponders. 3. New Mexico Method 3--Mail and non-selective phone calls (full recruitment period): Mailed invitations with subsequent phone calls to all. The combined methods succeeded in meeting the recruitment goal of 623 subjects. There were 147 subjects recruited using Minnesota's Method 1, 190 using Minnesota's Method 2, and 286 using New Mexico's Method 3. Efficiency rates (percentage of invited patients who enrolled) were 4.2% for Method 1, 8.4% for Method 2, and 7.9% for Method 3. Calculated costs per enrolled subject were $71.58 (Method 1), $85.47 (Method 2), and $92.09 (Method 3). A mail-only method to assess study interest was relatively inexpensive but not efficient enough to sustain recruitment targets. Phone call follow-up after mailed invitations added to recruitment efficiency. Use of return-response forms with selective phone follow-up to non-responders was cost effective.

Cultural Considerations in Evidence-Based Practice

The role of culture in evidence-based practice (EBP) is examined using the components of the EBP process as a framework for discussion. Issues that are identified include the recruitment and retention of ethnic groups in research; paternalism and institutional racism in regard to those who cannot afford best practice; and cultural differences between health professionals and patients in their understanding of best practice, health, and illness. Strategies that are suggested to reduce cultural incongruence include shared clinical decision making and development of a cultural knowledge system to improve EBP and outcomes on an organizational level.

Brief report: Under-representation of African americans in autism genetic research: a rationale for inclusion of subjects representing diverse family structures

African American children with autism are seriously under-represented in existing genetic registries and biomedical research studies of autism. We estimated the number of African American children with autism in the St. Louis region using CDC surveillance data and present the outcomes of a concerted effort to enroll approximately one-third of that population into either of two large national genetic autism registries. The results revealed that even after traditional barriers to research participation were addressed and all contacted families expressed a willingness to participate, 67% of the reachable families were disqualified from participation because of family structure alone. Comprehensive efforts-including expansion of eligibility to families of diverse structure-are warranted to facilitate the inclusion of African American children in biomedical research.

Facilitating the recruitment of minority ethnic people into research: qualitative case study of South Asians and asthma

BACKGROUND

There is international interest in enhancing recruitment of minority ethnic people into research, particularly in disease areas with substantial ethnic inequalities. A recent systematic review and meta-analysis found that UK South Asians are at three times increased risk of hospitalisation for asthma when compared to white Europeans. US asthma trials are far more likely to report enrolling minority ethnic people into studies than those conducted in Europe. We investigated approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders.

METHODS AND FINDINGS

Interviews were conducted with 36 researchers (19 UK and 17 US) from diverse disciplinary backgrounds and ten community leaders from a range of ethnic, religious, and linguistic backgrounds, followed by self-completion questionnaires. Interviews were digitally recorded, translated where necessary, and transcribed. The Framework approach was used for analysis. Barriers to ethnic minority participation revolved around five key themes: (i) researchers' own attitudes, which ranged from empathy to antipathy to (in a minority of cases) misgivings about the scientific importance of the question under study; (ii) stereotypes and prejudices about the difficulties in engaging with minority ethnic populations; (iii) the logistical challenges posed by language, cultural differences, and research costs set against the need to demonstrate value for money; (iv) the unique contexts of the two countries; and (v) poorly developed understanding amongst some minority ethnic leaders of what research entails and aims to achieve. US researchers were considerably more positive than their UK counterparts about the importance and logistics of including ethnic minorities, which appeared to a large extent to reflect the longer-term impact of the National Institutes of Health's requirement to include minority ethnic people.

CONCLUSIONS

Most researchers and community leaders view the broadening of participation in research as important and are reasonably optimistic about the feasibility of recruiting South Asians into asthma studies provided that the barriers can be overcome. Suggested strategies for improving recruitment in the UK included a considerably improved support structure to provide academics with essential contextual information (e.g., languages of particular importance and contact with local gatekeepers), and the need to ensure that care is taken to engage with the minority ethnic communities in ways that are both culturally appropriate and sustainable; ensuring reciprocal benefits was seen as one key way of avoiding gatekeeper fatigue. Although voluntary measures to encourage researchers may have some impact, greater impact might be achieved if UK funding bodies followed the lead of the US National Institutes of Health requiring recruitment of ethnic minorities. Such a move is, however, likely in the short- to medium-term, to prove unpopular with many UK academics because of the added "hassle" factor in engaging with more diverse populations than many have hitherto been accustomed to.

Occupational exposure to dibutyl phthalate among manicurists

OBJECTIVE

To measure manicurists' exposure to dibutyl phthalate (DBP) at work and to determine whether workplace characteristics influence this exposure. DBP is a reproductive and developmental toxicant in rats and is used in nail polish to hold color and prevent chipping.

METHODS

Pre- and postshift spot urine samples were collected from 40 manicurists. Linear regression compared the relationship between the log of the cross-shift differences in urinary phthalate monoester metabolite concentrations and use of workplace exposure control methods.

RESULTS

There was a statistically significant cross-shift increase of 17.4 ng/mL in the urinary concentration of mono-n-butyl phthalate, the major metabolite of DBP. Use of gloves reduced mono-n-butyl phthalate concentrations by 15.1 ng/mL below the preshift concentration compared with a 20.5 ng/mL increase if gloves were not worn.

CONCLUSIONS

Manicurists are occupationally exposed to DBP and glove use may minimize this exposure.

Physical activity as primary prevention to address cancer disparities

OBJECTIVE

To review the research literature on physical activity (PA) intervention trials, with an emphasis on underserved populations.

DATA SOURCE

Research studies, review articles, and books.

CONCLUSION

PA intervention studies have generally shown statistically significant but modest outcomes. Comprehensive intervention designs combining individual-level and physical environmental changes have posted the largest effect sizes, and emerging models are incorporating sociocultural and organizational environmental changes with promising results. Research including or targeting underserved populations poses unique challenges at each stage of the intervention process: design, recruitment, implementation, and evaluation. Synthesis of evidence-based approaches to address these challenges is presented.

IMPLICATIONS FOR NURSING PRACTICE

Promoting PA in underserved communities is essential in improving population-level cancer outcomes. Additional resources are becoming available to nursing researchers and practitioners to aid in the conduct of PA intervention in understudied groups.

Gender, racial, and ethnic disclosure in NIH K-Award funded diabetes and obesity clinical trials

In 1993, the National Institutes of Health (NIH) passed The Revitalization Act (Subtitle B) which mandated that all NIH funded clinical trials have "appropriate representation" of minority and women subjects. Our aim was to evaluate the impact of the mandate by examining the reporting and inclusion of minority and female subjects into NIH K-Award funded clinical trials, addressing the minority predominant diagnoses of diabetes and clinical obesity. Using the CRISP search engine and PUBMED, we selected publications published by the National Institute on Aging (NIA) and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) K-grant recipients during 1989-2004, associated with all the diabetes and obesity clinical trials. Studies were stratified into three timeline categories (1989-1993, pre-mandate; 1993-1996, post-mandate, and 1997-present, well past mandate) to evaluate trends in the recruiting of minorities and women before, during, and after the passing of the Revitalization Act. Of the 165 papers, only 37% disclosed race, a number that did not improve over time (p=.15), whereas 92% disclosed gender. Clinical trials that focused on females increased across the 3 timeframes (p < .001) for diabetes studies but not obesity studies. Overall, disclosure of race declined over the 3 timeframes whereas individually, the disclosure of African Americans improved.

The utility of non-proportional quota sampling for recruiting at-risk women for microbicide research

In the context of a measurement development study designed to contextualize microbicide acceptability, a sample that represented a range of at-risk women and maintained the statistical power needed for validity analyses was required. A non-proportional quota sampling strategy focused on race/ethnicity and number of sexual partners was utilized. This strategy resulted in enrollment of approximately equal proportions of Latina (31%), Black (36%), and White (32%) women, and an approximately 1:2 ratio of single-partnered (29%) and multi-partnered (71%) women. About 17% of women screened were ineligible based on eligibility criteria; an additional 16% were ineligible based on quota closures. Most participants were recruited through word of mouth (39%), community-based organizations (19%), or media sources (19%). Women recruited through word of mouth had the highest screen-to-interview completion percentage (67%). Non-proportional quota sampling is a feasible option for ensuring adequate representation of sample characteristics in microbicide research, but this goal should be weighed against cost and staff burden.

Barriers to and Strategies for Recruiting Korean Americans for Community-Partnered Health Promotion Research

While increasing numbers of researchers are targeting ethnic minorities in order to address their health disparities, the unique health needs of Korean Americans are not well known to the mainstream community, and only relatively few systematic research studies have been conducted in this "hard-to reach" population. The purpose of this paper is to describe the barriers to recruiting participants for health promotion research and to identify facilitators in the community that can contribute to this effort. We have analyzed data pertaining to the 14 studies we have conducted since 1998, which included a total sample of about 2,400 Korean Americans. We describe in detail the unique recruitment challenges that we have faced in regard to the culture, language, sociodemographic characteristics of the participants, such as gender and age, and other community level barriers. Multiple strategies at different levels (individual and community) to address these issues are discussed.

Increasing minority research participation through community organization outreach

Recruitment is one of the most significant challenges in conducting research with ethnic minority populations. Establishing relationships with organizations that serve ethnic minority communities can facilitate recruitment. To create a successful recruitment process, a strategic plan of action is necessary prior to implementing community outreach efforts. For this study population of women who were HIV+ and recovering from substance abuse disorder, the authors found that establishing trust with community organizations that serve these women allows for a productive referral relationship. Although the majority of women in this study are African American, the authors were particularly challenged in recruiting Hispanic women. This article presents a recruitment process model that has facilitated our recruitment efforts and has helped the authors to organize, document, and evaluate their community out-reach strategies. This model can be adopted and adapted by nurses and other health researchers to enhance engagement of minority populations.

Reducing cancer disparities for minorities: a multidisciplinary research agenda to improve patient access to health systems, clinical trials, and effective cancer therapy

Ethnic diversity in recruitment is a vital prerequisite to eliminating health disparities in cancer treatment, control and prevention programs. Much anecdotal reporting, but little scientific rigor, has been applied to the study of methods to improve the recruitment of minorities into cancer control or treatment trials. Even the most innovative research is stymied by the lack of representative samples of the populations that the research is designed to serve. The goals of this article are to describe a theory-driven framework for improving minority recruitment to clinical and cancer control trials, to explain organizational prerequisites to improving minority recruitment, and to provide empirical evidence of success in initial efforts to recruit to cancer control studies. These programs are offered as models for improving minority recruitment to cancer-control and -treatment trials, and minority access to cancer treatment in general.

EFFECTIVE RECRUITMENT AND RETENTION OF MINORITY RESEARCH PARTICIPANTS

Our ability, as leaders in public health scholarship and practice, to achieve and measure progress in addressing racial/ethnic disparities in health status and health care is severely constrained by low levels of participation of racial/ethnic minority populations in health-related research. Confining our review to those minority groups federally defined as underrepresented (African Americans/blacks, Latinos/Hispanics, and Native Americans/American Indians), we identified 95 studies published between January 1999 and April 2005 describing methods of increasing minority enrollment and retention in research studies, more than three times the average annual output of scholarly work in this area during the prior 15-year period. Ten themes emerged from the 75 studies that were primarily descriptive. The remaining 20 studies, which directly analyzed the efficacy or effectiveness of recruitment/retention strategies, were examined in detail and provided useful insights related to four of the ten factors: sampling approach/identification of targeted participants, community involvement/nature and timing of contact with prospective participants, incentives and logistical issues, and cultural adaptations. We then characterized the current state of this literature, discussing implications for future research needs and directions.

Factors motivating dyspepsia patients to enter clinical research

One of the most influential factors in science and medicine has been the development of placebo-controlled clinical trials. However, recruitment of patients for clinical trials is sometimes a major problem in clinical research. Successful patient recruitment may be enhanced with a clear understanding of the motivating factors that determine a patient's decision to enter a study. We have developed the Patients' Expectations, Attitudes and Knowledge (PEAK) Program consisting of questionnaires designed to study the factors motivating patients to enter a clinical trial, as well as capturing the experiences of research participants. A total of 247 female patients with dyspepsia (mean age: 43.9; range: 18.0-78.0 years) who entered either of two prospective double-blind, randomized, placebo-controlled multicenter trials in the USA completed PEAK Entry questionnaires during the first study visit. Based on their responses, the top three factors motivating patients to join the clinical trial were: interest in receiving investigational treatment with average score (AS) of 4.33 +/- 0.08 (M +/- SEM) on a 5-point scale, possibility of getting skilled professional care (AS = 4.07 +/- 0.09), and altruism expressed as an intention to help develop a new drug for the sake of other people (AS = 3.89 +/- 0.09). Age, ethnicity, and educational status significantly affected motivational factors of patients. These results indicate that recruitment can be enhanced by targeting these motivations in physician/patient communications, informed consent process and advertising for study participants.

Menin suppresses osteoblast differentiation by antagonizing the AP-1 factor, JunD

Mice null for menin, the product of the multiple endocrine neoplasia type 1 (MEN1) gene, exhibit cranial and facial hypoplasia suggesting a role for menin in bone formation. We have shown previously that menin is required for the commitment of multipotential mesenchymal stem cells into the osteoblast lineage in part by interacting with the bone morphogenetic protein (BMP)-2 signaling molecules Smad1/5, and the key osteoblast transcriptional regulator, Runx2 (Sowa H., Kaji, H., Hendy, G. N., Canaff, L., Komori, T., Sugimoto, T., and Chihara, K. (2004) J. Biol. Chem. 279, 40267-40275). However, menin inhibits the later differentiation of committed osteoblasts. The activator protein-1 (AP-1) transcription factor, JunD, is expressed in osteoblasts and has been shown to interact with menin in other cell types. Here, we examined the consequences of menin-JunD interaction on osteoblast differentiation in mouse osteoblastic MC3T3-E1 cells. JunD expression, assessed by immunoblot, gradually increased during osteoblast differentiation. Stable expression of JunD enhanced expression of the differentiation markers, Runx2, type 1 collagen (COL1), and osteocalcin (OCN) and alkaline phosphatase (ALP) activity and mineralization. Hence, JunD promotes osteoblast differentiation. In MC3T3-E1 cells in which menin expression was reduced by stable menin antisense DNA transfection, JunD levels were increased. When JunD and menin were co-transfected in MC3T3-E1 cells, they co-immunoprecipitated. JunD overexpression increased the transcriptional activity of an AP-1 luciferase reporter construct, and this activity was reduced by co-transfection of menin. Therefore, JunD and menin interact both physically and functionally in osteoblasts. Furthermore, menin overexpression inhibited the ALP activity induced by JunD. In conclusion, the data suggest that menin suppresses osteoblast maturation, in part, by inhibiting the differentiation actions of JunD.

Changing epidemiology of hepatitis B in a U.S. community

Despite a reduction in newly acquired hepatitis B virus (HBV) infections since the mid-1980s, HBV remains an important cause of liver disease in the U.S. We report the prevalence of chronic HBV infection in a U.S. community and describe demographic and clinical characteristics. The Rochester Epidemiology Project records healthcare encounters of residents of Olmsted County, Minnesota. For all cases with a potential diagnosis of hepatitis B in this database, complete medical records were reviewed to identify subjects who met the inclusion criteria, i.e., a clinician diagnosis of chronic HBV infection and a laboratory record of positive hepatitis B surface antigen (HBsAg). There were 191 residents with chronic HBV infection in the community, consisting of 53% Asian, 29% African, 13% Caucasian, and 5% other or unknown race. The overall age- and sex-adjusted prevalence of HBV in this community was 0.15% in 2000. The race-specific prevalence was highest among Asians (2.1%), followed by African Americans (1.9%). The prevalence among Caucasians was 0.02%. Overall, 86% were born outside the U.S., 98% of whom were non-Caucasian. A total of 131 residents were tested for HBV replicative status, of whom 27% had viral replication. Of those tested for aminotransferases (n = 184), 28% had an abnormal value at least once. In a multivariable regression analysis, replicative status was the most influential (odds ratio [OR] = 5.98, P <.01) factor associated with abnormal aminotransferase values, followed by male gender (OR = 3.69) and age greater than 40 years (OR = 2.32 per decade). In conclusion, in this Midwestern community, chronic HBV infection was predominantly seen in immigrants from endemic parts of the world.

Osteoporosis health-related behaviors in secular and orthodox Israeli Jewish women

OBJECTIVE

To compare patterns of osteoporosis health-related behaviors in peri and postmenopausal ultra-orthodox and secular Jewish women.

METHODS

Interviews were conducted with 277 Israeli-Jewish women aged 45+. Health behaviors examined included: physical activity, smoking behavior, alcohol consumption, hormone replacement usage, screening behavior, calcium intake, pharmacological prevention, and help-seeking patterns. Correlates included demographic variables, health characteristics, knowledge, susceptibility beliefs, and familiarity with the disease.

RESULTS

Low proportions of women in both groups participated in physical activities, but differed in type. Calcium intake was deficient in both groups. Education was the only correlate of calcium intake among secular women, and previous experience with the disease was the main determinant among orthodox women. Compared with the secular group, a considerably lower proportion of orthodox women reported using HRT or having performed a bone density examination. Orthodox participants' level of knowledge about osteoporosis was significantly lower as well. Education was an important correlate of knowledge in both groups, as was having performed a bone density examination. Higher age and being menopausal were important correlates of knowledge only for secular women. Having a family member suffering from the disease was associated with higher levels of knowledge among orthodox women. Marked differences were found in the participants' sources of information across groups.

CONCLUSIONS

Findings emphasize the need to expand education in all areas of osteoporosis health-related behaviors among ultra-orthodox women, and in calcium intake and exercise for secular women as well. The transmission of the information should be adapted to the practices of each group.