Recruitment of black elderly for clinical research studies of dementia: the CERAD experience

A Mini-Review of Strategies for Recruiting Older African Americans to Alzheimer's Disease Research

African Americans experience higher incidence and prevalence of Alzheimer's disease (AD). Yet, they continue to be underrepresented in AD research, limiting the ability to generalize findings to the increasingly diverse US population. To reduce AD disparities, targeted efforts are needed to increase the representation of African Americans in AD research. This mini review identified evidence-based strategies that increased research participation among older African Americans. Four recruitment strategies emerged from eight published peer-reviewed studies that directly evaluated the effectiveness of strategies aimed at increasing the number of African American participants in Alzheimer's research. The strategies include community outreach and education, face-to-face discussions, remote access, and referral and partnership with local organizations. Across different locations, these strategies increased the number of African Americans enrolled into AD research, the number of people that signed up to donate their brains for AD research upon death, and the knowledge and perception of AD in the communities. Targeted efforts are effective in increasing AD research participation among older African Americans, especially when combined with approaches that emphasize transparency and mutual trust and involve the community as stakeholders in the research process.

Depression and HIV risks: Engaging older African American women in HIV prevention education through the church

This report describes the recruitment of a sample of older African American women to test the effectiveness of an educational HIV prevention intervention that sought to reduce depressive symptoms and thereby HIV risks in this population. The outreach venue is the Black church. A framework for maximizing response is suggested. Of 62 women who participated in two arms of the intervention, 29 were assigned randomly to a four-session discussion group (experimental condition) and 33 were assigned to a one-session informational group (control condition) focused on HIV prevention education. Between-within subjects analyses of variance showed that participation in the study was associated with a significant improvement in the women's psychological status, i.e., decreased depressive symptoms. This change in depressive symptoms was due in part to the experimental condition assignment. Implications for future HIV prevention interventions, research, and methods used to maximize the probability of response among older African American women are discussed.

Utilizing Community Engagement Studios to Inform Clinical Trial Design at a Center of Excellence for Alzheimer’s Disease

Despite the disproportionate burden of Alzheimer’s disease in older adults of color, the scientific community continues to grapple with underrepresentation of racial and ethnic minorities in clinical research. Our Center of Excellence for Alzheimer’s Disease (CEAD) collaborated with a local community partner to conduct community engagement (CE) studios to effectively involve our community of diverse older adults in the early planning stages of a clinical trial. Given the COVID-19 pandemic, the in-person studio format was adapted to allow for virtual, real-time participation. Our objective is to describe the process and feasibility of conducting virtual CE studios in an older adult population. Ninety percent of participants were non-Hispanic Black community-dwelling woman aged 60 years and older. The overall background and proposed clinical trial design was presented to the participants who then made recommendations regarding potential recruitment strategies, the use of culturally relevant language to describe the study, and logistical recommendations to improve participation and retention among community members. Our CEAD successfully conducted virtual CE studios during the COVID-19 pandemic, by partnering with a community-based organization, to engage community stakeholders about clinical trial design. CEADs are in a unique position to implement CE studios to better support patient access to clinical trials.

A national open-access research registry to improve recruitment to clinical studies

INTRODUCTION

Barriers to recruitment for dementia studies are well documented. As part of the UK government's Dementia 2020 strategy, a nationally consistent system to increase public engagement and participation in research was launched in February 2015.

METHODS

We describe the development of the "Join Dementia Research" registry, including evolution of policy, involvement of people with dementia in co-production, data requirements, governance, technology, and the impact on study recruitment and what factors may have contributed to the services success.

RESULTS

The UK-wide online, telephone, and postal service has registered 47,071 volunteers, with 33,139 people (67.9% of all volunteers) taking part in 378 studies, with 49,954 total study enrolments. This has taken place across 295 research sites, involved 1522 researchers, and resulted in 134 peer-reviewed publications.

DISCUSSION

Public registries of individuals interested in research, with user-provided data enabling basic phenotyping, are effective at increasing public engagement with research and removing barriers to study recruitment. Deeper pheno/genotyping could be undertaken to improve matching, but how and when that information is collected will be a key factor.

Strategies for the Recruitment and Retention of Racial/Ethnic Minorities in Alzheimer Disease and Dementia Clinical Research

Background:

Racial/ethnic minorities have among the highest risks for Alzheimer disease and dementia, but remain underrepresented in clinical research studies.

Objective:

To synthesize the current evidence on strategies to recruit and retain racial/ethnic minorities in Alzheimer disease and dementia clinical research.

Methods:

We conducted a systematic review by searching CINAHL, EMBASE, MEDLINE, PsycINFO, and Scopus. We included studies that met four criteria: (1) included a racial/ethnic minority group (African American, Latino, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander); (2) implemented a recruitment or retention strategy for Alzheimer disease or dementia clinical research; (3) conducted within the U.S.; and (4) published in a peer-reviewed journal.

Results:

Of the 19 included studies, 14 (73.7%) implemented recruitment strategies and 5 (26.3%) implemented both recruitment and retention strategies. Fifteen studies (78.9%) focused on African Americans, two (10.6%) on both African Americans and Latinos, and two (10.5%) on Asians. All the articles were rated weak in the study quality. Four major themes were identified for the recruitment strategies: community outreach (94.7%), advertisement (57.9%), collaboration with health care providers (42.1%), and referral (21.1%). Three major themes were identified for the retention strategies: follow-up communication (15.8%), maintain community relationship (15.8%), and convenience (10.5%).

Conclusion:

Our findings highlight several promising recruitment and retention strategies that investigators should prioritize when allocating limited resources, however, additional well-designed studies are needed. By recruiting and retaining more racial/ethnic minorities in Alzheimer disease and dementia research, investigators may better understand the heterogeneity of disease progression among marginalized groups. PROSPERO registration #CRD42018081979.

Willingness to Participate in Vaccine-Related Clinical Trials among Older Adults

The purpose of this study is to understand among a convenience sample of 400 adults aged 60 years of age or older (1) reasons for being willing or unwilling to participate in a vaccine clinical research study and (2) overall perceptions about vaccine clinical research. A cross-sectional study using a sample of older adults residing in the metro-Atlanta area and surrounding neighborhoods was conducted. The study questionnaire contained 37 questions, including questions about socio-demographics and perceptions about clinical trial processes. Statistical analysis was conducted using logistic regression. The adjusted modeling results indicated that sex, distance to research clinic, and being informed about the research findings played a role in the likelihood of an elderly person participating in a vaccine study. Males were more likely to participate in clinical trials as compared to females (OR: 2.486; CI: 1.042–5.934). Most participants were willing to travel up to 25 miles from the research clinic. Of the respondents, 45% were unlikely to participate if the results of the current trial are not shared. Improving access to clinical trials in terms of distance traveled and ensuring streamlined processes to inform participants about the results of the trial in the future would increase willingness to participate in vaccine clinical trials. The survey could serve as a useful tool for conducting vaccine studies and other clinical trials by understanding the barriers specific to the elderly.

Design of a Case Management Approach to Enhance Cancer Screening Trial Retention Among Older African American Men

Purpose:The purpose of this study was to enhance retention among African American men enrolled in a cancer screening trial. Design and Methods:A telephonebased, randomized trial design was used. The intervention group included 352 African American men aged 55+. Case managers contacted participants at least monthly and provided information and referral services to participants and their relatives. Results:The mean age of participants was 65.7 years. A total of 14,978 calls were made resulting in 780 referrals. The 10 most frequent referrals were for scheduling medical appointments, health information, insurance information, legal aid, transportation, cancer screening information, information technology/computer information, employment, housekeeping/chore services, and food programs. Conclusions:The case managers served as links between participants and community-based resources. The types of referrals made could be associated with the age-related needs of the participants.

Ethnoculturally-sensitive practice and Alzheimer's disease

Alzheimer's disease (AD) does not respect the boundaries of ethnicity or culture. Diverse ethnocultural groups adapt to the stresses of AD in their own unique fashion. As the attitudes, values, help-seeking and coping behaviors vary from one individual to another, so also does variation exist among the diverse ethnocultural groups. This paper will review current literature regarding several ethnocultural groups, as well as common attitudes, values, helpseeking and coping behaviors. Skills, values, and knowledge for the ethnoculturally-sensitive practitioner are discussed. Finally, case examples are cited.

Mental health issues and Alzheimer's disease

As the prevalence of Alzheimer's disease (AD) increases, concerns have been voiced regarding how to best maintain and treat those affected. Psychiatric symptoms may be a prominent and influencing factor in decisions regarding the most appropriate level of care. The behavioral manifestations of AD, particularly agitation, may present dilemmas for formal and informal caregivers. The most significant dilemmas surrounding appropriate care for individuals manifesting psychiatric symptoms and negative behaviors may include the safety of caregivers as well as the safety of the diagnosed individual. These dilemmas may be compounded when there is not adequate psychiatric/psychotherapeutic intervention. This paper will seek to examine the psychopathology associated with AD as well as some intensive and restrictive interventions available to formal and informal caregivers when less intensive and less restrictive interventions fail. The intensive and restrictive interventions discussed include institutionalization, physical and chemical restraints, and psychiatric hospitalization.

Effective Sampling of Rare Population Elements

Efficacious sampling methods are needed to recruit representative samples of under-represented research populations. The purpose of this article is to describe and evaluate a step-by-step methodological approach for sampling rare populations (e.g., Black female caregivers and noncaregivers). Using the Medicare Enrollment Database, the researchers conducted a reverse screening strategy and a case-control design to obtain a systematic random sample of the caregivers. After revision of the recruitment strategy and referral goals, the researchers recruited 202 caregivers and 206 noncaregivers. The proportion of elders with caregivers was 11.8 percent compared with a projected yield of 8 percent. Lessons were learned regarding efficiency in sampling methodology, including the importance of having the potential participants respond to an open-ended question regarding their understanding of the study participation, providing agencies with detailed specifications of requested lists, and not allowing the obtained list to age. This article provides a road map for sampling rare populations.

African American Dementia Caregivers

Differences in ethno-cultural perspectives have been previously suggested as the source of variation among ethnic groups regarding their approaches to dementia family caregiving. This study explored the perceptions and experiences that African American caregivers of family members with dementia encountered on their journey toward obtaining a diagnosis of dementia for their loved ones. An overall theme of respect emerged from a focus group session with seven family caregivers. Reports of respecting older family members through `normalization', thereby delaying evaluation for dementia, then encountering a lack of respect from health care providers when one was finally sought, created a duality of respect vs disrespect. This tension constituted a subtle but profound form of caregiver stress that may be unique to African American caregivers, and one that has not been considered in standardized measures. Findings inform providers about important issues to consider when working with and studying dementia caregiving among African American families.

Knowledge and Attitudes in Alzheimer's Disease in a Cohort of Older African Americans and Caucasians

African American participation in Alzheimer's disease (AD) research studies has been historically low. To determine whether older African Americans and Caucasians had different knowledge or attitudes related to AD, we administered the Alzheimer's Disease Knowledge Scale (ADKS) to 67 older African Americans and 140 older caucasians in the greater Atlanta area as well as questions targeting locus of control over general health and AD risks. Older African Americans scored slightly lower on ADKS than older caucasians, with race only accounting for 1.57 (95% confidence interval [CI] 0.57-2.61, P < .001) points of difference in a multivariate model. Attitudes toward AD were also similar between the 2 groups but 1 (35.7%) in 3 adults reported control over general health but not AD risks. In addition to enhancing education content in outreach efforts, there is an urgent need to address the perception that future AD risks are beyond one's own internal control.

Delivering a "dose of hope": a faith-based program to increase older african americans' participation in clinical trials

BACKGROUND

Underrepresentation of older-age racial and ethnic minorities in clinical research is a significant barrier to health in the United States, as it impedes medical research advancement of effective preventive and therapeutic strategies.

OBJECTIVE

The objective of the study was to develop and test the feasibility of a community-developed faith-based intervention and evaluate its potential to increase the number of older African Americans in clinical research.

METHODS

Using a cluster-randomized design, we worked with six matched churches to enroll at least 210 persons. We provided those in the intervention group churches with three educational sessions on the role of clinical trials in addressing health disparity topics, and those in the comparison group completed surveys at the same timepoints. All persons enrolled in the study received ongoing information via newsletters and direct outreach on an array of clinical studies seeking participants. We evaluated the short-, mid-, and longer-term effects of the interventional program on clinical trial-related outcomes (ie, screening and enrollment).

RESULTS

From 2012 to 2013, we enrolled a balanced cohort of 221 persons in the program. At a 3-month follow-up, mean intention to seek information about clinical trials was higher than baseline in both treatment (mu=7.5/10; sigma=3.1) and control arms (mu=6.6/10; sigma=3.3), with the difference more pronounced in the treatment arm. The program demonstrated strong retention at 3-month (95.4%, 211/221) and 6-month timepoints (94.1%, 208/221).

CONCLUSIONS

The "Dose of Hope" program addressed an unmet need to reach an often overlooked audience of older African Americans who are members of churches and stimulate their interest in clinical trial participation. The program demonstrated its appeal in the delivery of effective messages and information about health disparities, and the role of clinical research in addressing these challenges.

Overcoming Recruitment Barriers in Urban Older Adults Residing in Congregate Living Facilities

Background. Participation of minority older adults in mental health research has been limited by mistrust, transportation difficulties, lack of knowledge, and insufficient community partnership. We describe strategies utilized to overcome these recruitment barriers. Methods. Our target population included 553 public housing residents of older adult high-rise buildings in Rochester, NY. We had a two-stage cross-sectional study: Stage 1 was a health survey for all residents and Stage 2 was a psychiatric interview of English-speaking residents aged 60 years and older. Recruitment occurred through mailings, onsite activities, and resident referrals. Results. Stage 1 had 358 participants (64.7% response) and Stage 2 had 190 (61.6% target population response), with higher participation among African Americans. We found some strategies effective for overcoming recruitment barriers. First, we partnered with a community agency and organized onsite educational activities to improve residents' trust. Second, the study occurred entirely onsite, which facilitated participation of functionally impaired residents. Third, onsite activities allowed the residents to learn about the study and complete surveys in person. Fourth, we provided immediate incentives that resulted in many study referrals. Conclusions. Although recruitment of minority older adults presents unique challenges, a multifaceted community-tailored approach mitigated several recruitment barriers in this mental health study.

Strategies for research recruitment and retention of older adults of racial and ethnic minorities

HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.4 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Strategies for Research Recruitment and Retention of Older Adults of Racial and Ethnic Minorities" found on pages 14-23, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until April 30, 2018. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVE 1. Identify strategies and barriers for the recruitment and retention of older adults of racial and ethnic minorities in cognitive aging research. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The numbers of Hispanic and African American older adults in the United States are expected to increase by 86% and more than 31%, respectively. African American and Hispanic American individuals are more likely than Caucasian individuals to have chronic health conditions, and researchers have argued that these health disparities may contribute to their higher rates of dementia-related illnesses. The current article explores strategies to improve participation in cognitive aging research by older adults, particularly minority older adults. The cultural aspects of cognitive aging are examined, especially the role of stigma and stereotype threat. The perceptions of cognitive aging of African American and Hispanic older adults are also described. Specific strategies are presented that have been successfully implemented to improve recruitment and retention in research targeting minority older adults. Strategies that yielded retention of minority older adults included advertising and marketing a randomized clinical trial, media relations, intervention tailoring, and adaptation of psychometric instruments.

Barriers and facilitators of African American participation in Alzheimer disease biomarker research

African Americans experience a greater risk of Alzheimer disease (AD), but are underrepresented in AD research. Our study examined barriers and facilitators of AD research participation among African Americans. Investigators conducted 11 focus groups with African American participants (n=70) who discussed barriers and facilitators to AD research participation including lumbar puncture studies. The moderator and comoderator independently reviewed the transcripts, identified themes, and coded transcripts for analysis. Participants were predominately female (73%) with a mean age of 52 years (range 21 to 86 y). Concerns and attitudes were consistent across education, socioeconomic status, and sex. Mistrust was a fundamental reason for nonparticipation. Additional barriers included insufficient information dissemination in the African American community, inconvenience, and reputation of the researcher and research institution. Barriers to participation in AD biomarker studies were fear of the unknown and adverse effects. Altruism and relevance of research projects to the individual, family members, or the African American community facilitate participation. Increased participation results from relationships with the community that extend beyond immediate research interests, dissemination of research findings, and emphasis on relevance of proposed studies. Pervasive barriers impede African American participation in AD research but can be overcome through a sustained presence in the community.

Challenges and opportunities: recruitment and retention of African Americans for Alzheimer disease research: lessons learned

For more than 3 decades, the recruitment and retention of African Americans for research in Alzheimer disease have been regarded as difficult undertakings with poor results. The typical explanation for failure to respond to research participation options is a widespread mistrust of research and the biomedical community. Mistrust is a reasonable response; given the historic reality of malfeasance, victimization, and mistreatment over the course of the research participation history of African Americans. The challenges are real but there are opportunities for successful recruitment and retention of African Americans for research including research on Alzheimer disease. Participation, however, comes with specific terms and considerations. Two of the most prominent criteria for research recruitment and retention are the transparency and accountability of the investigator, which may determine how he or she proceeds from the start of the process throughout the steps of recruitment, retention, and subsequent follow-up with the community.

A model for the design and implementation of a participant recruitment registry for clinical studies of older adults

BACKGROUND

The identification and enlistment of suitable participants into clinical studies is often challenging, requiring a large commitment of time and staff resources. The recruitment and retention of populations typically underrepresented in research present additional challenges to enrollment of sufficient numbers of participants in clinical studies. Inadequate participation may undermine the pace and direction of new treatment discoveries.

PURPOSE

Registries of potential research participants are powerful tools to support research by providing a framework to streamline screening and recruitment and to maintain a communication history with potential research participants. The authors present a model for the development and implementation of a web-based database system to support recruitment, enrollment, and retention of potential study participants in close alignment with the goals of the Wisconsin Alzheimer's Disease Research Center (ADRC).

METHODS

The required data elements and major information domains for the registry were identified using a structured problem-solving and system design approach and the collaboration of a multidisciplinary team of stakeholders. The system performance, utility, and usability were assessed through multiple iterations with the users.

RESULTS

The process-oriented approach culminated in a multifaceted tool that combined contact management and potential research participant registration to assist with the challenges of recruitment and retention in clinical research. A unique feature of the registry design model was its contact management capabilities for efficient tracking of all contacts with registrants.

LIMITATIONS

We have focused on the development and implementation of a system for the recruitment of older adults with specific cognitive and medical characteristics. However, our procedures for identifying data needs and database system utility and functionality can be transferred easily to other populations and settings. As with any multipurpose registry database system, careful management and training are essential to optimize efficiency.

CONCLUSION

Adding a contact management element to the registry design significantly improved the efficiency of communication between clinical study coordinators and potential research participants, as well as the communication among coordinators.

The validation of a new measure quantifying the social quality of life of ethnically diverse older women: two cross-sectional studies

BACKGROUND

To our knowledge, the available psychometric literature does not include an instrument for the quantification of social quality of life among older women from diverse ethnic backgrounds. To address the need for a tool of this kind, we conducted two studies to assess the initial reliability and validity of a new instrument. The latter was created specifically to quantify the contribution of a) social networks and resources (e.g., family, friends, and community) as well as b) one's perceived power and respect within family and community to subjective well-being in non-clinical, ethnically diverse populations of older women.

METHODS

In Study 1, we recruited a cross-sectional sample of primarily non-European-American older women (N = 220) at a variety of community locations. Participants were administered the following: a short screener for dementia; a demographic list; an initial pool of 50 items from which the final items of the new Older Women's Social Quality of Life Inventory (OWSQLI) were to be chosen (based on a statistical criterion to apply to the factor analysis findings); the Single Item Measure of Social Support (SIMSS); and the Medical Outcome Study 36-item Short-Form Health Survey (MOS SF-36). Study 2 was conducted on a second independent sample of ethnically diverse older women. The same recruitment strategies, procedures, and instruments as those of Study 1 were utilized in Study 2, whose sample was comprised of 241 older women with mostly non-European-American ethnic status.

RESULTS

In Study 1, exploratory factor analysis of the OWSQLI obtained robust findings: the total variance explained by one single factor with the final selection of 22 items was over 44%. The OWSQLI demonstrated strong internal consistency (α = .92, p < .001), adequate criterion validity with the SIMSS (r = .33; p < .01), and (as expected) moderate concurrent validity with the MOS SF-36 for both physical (r = .21; p < .01) and mental (r = .26; p < .01) quality of life. In order to confirm the validity of the 22-item OWSQLI scale that emerged from Study 1 analyses, we replicated those analyses in Study 2, although using confirmatory factor analysis. The total variance accounted for by one factor was about 42%, again quite high and indicative of a strong single-factor solution. Study 2 data analyses yielded the same strong reliability findings (i.e., α = .92, p < .001). The 22-item OWSQLI was correlated with the SIMSS (r = .27, p < .001) in the expected direction. Finally, correlations with the MOS SF- 36 demonstrated moderate concurrent validity for physical (r = .14; p < .01) and mental (r = .18; p < .01) quality of life, as expected.

CONCLUSIONS

The findings of these two studies highlight the potential for our new tool to provide a valid measure of older women's social quality of life, yet they require duplication in longitudinal research. Interested clinicians should consider using the OWSQLI in their assessment battery to identify older women's areas of lower versus higher social quality of life, and should establish the maximization of patients' social quality of life as an important therapeutic goal, as this variable is significantly related to both physical and mental health.

Recruiting intergenerational African American males for biomedical research Studies: a major research challenge

The health and well-being of all individuals, independent of race, ethnicity, or gender, is a significant public health concern. Despite many improvements in the status of minority health, African American males continue to have the highest age-adjusted mortality rate of any race-sex group in the United States. Such disparities are accounted for by deaths from a number of diseases such as diabetes, human immunodeficiency virus (HIV), cancer, and cardiovascular disease, as well as by many historical and present social and cultural constructs that present as obstacles to better health outcomes. Distrust of the medical community, inadequate education, low socioeconomic status, social deprivation, and underutilized primary health care services all contribute to disproportionate health and health care outcomes among African Americans compared to their Caucasian counterparts. Results of clinical research on diseases that disproportionately affect African American males are often limited in their reliability due to common sampling errors existing in the majority of biomedical research studies and clinical trials. There are many reasons for underrepresentation of African American males in clinical trials, including their common recollection and interpretation of relevant historical of biomedical events where minorities were abused or exposed to racial discrimination or racist provocation. In addition, African American males continue to be less educated and more disenfranchised from the majority in society than Caucasian males and females and their African American female counterparts. As such, understanding their perceptions, even in early developmental years, about health and obstacles to involvement in research is important. In an effort to understand perspectives about their level of participation, motivation for participation, impact of education, and engagement in research, this study was designed to explore factors that impact their willingness to participate. Our research suggests that: (1) African American males across all ages are willing to participate in several types of research studies, even those that require human samples; (2) their level of participation is significantly influenced by education level; and (3) their decision to participate in research studies is motivated by civic duty, monetary compensation, and whether they or a relative has had the disease of interest. However, African American males, across all age groups, continue to report a lack of trust as a primary reason for their unwillingness to participate in biomedical research. There is an ongoing need to continue to seek advice, improve communication, and design research studies that garner trust and improve participation among African American males as a targeted underrepresented population. Such communication and dialogues should occur at all age levels of research development to assess. current attitudes and behaviors of African American males around participation.

Barriers to participation in mental health research: findings from the Genetics and Psychosis (GAP) Study

The aim of this study was to investigate why people with a first episode of psychosis choose or decline to participate in mental health research, using a qualitative study design. Participants were recruited via referrals from the Genetics and Psychosis (GAP) study. A total of 26 individuals with a first-episode of psychosis (nine of whom declined participation in the GAP study and 17 who participated) were individually interviewed and asked about their attitudes towards mental health research participation. Thematic analysis of interview transcripts was used to determine dominant themes and sub-themes on what constituted barriers and facilitators to participation. Reasons for research participation identified included a desire to help others, curiosity, and positive experiences with clinicians. Decisions to participate or not were also influenced by practical issues, including the timing of the approach, researchers' communication skills and whether individuals had concerns that it may be potentially harmful to their health. Other barriers to participation included patients' conceptualizations of mental health problems and the influence of other inpatients. Information on barriers and facilitators to recruitment in mental health research could inform recruitment strategies, thereby maximizing recruitment rates and minimizing the risk of selection biases.

Recruitment of a community-based cohort for research on diversity and risk of dementia

We describe the history, development, and success of the recruitment and screening procedures used by researchers at the University of California, Davis Alzheimer's Disease Center (UCD ADC) to facilitate minority enrollment in research. After an initial, unsuccessful approach with satellite clinics in minority neighborhoods, the ADC shifted to an active community outreach approach. Multiple strategies were implemented to remove barriers to research participation such as providing transportation to clinical appointments and offering in-home cognitive screening. Considerable resources were directed toward hiring and training bicultural and bilingual individuals with knowledge of the target populations, both as recruiters and staff involved in clinical assessment. Implementation of these methods resulted in a dramatic increase in the number of ethnic minorities enrolled (and retained) in research protocols, including protocols that are complex and longitudinal. Diversity was achieved on other variables as well; years of education in the cohort range from 0 to 21, with 26% having 8 years or less. The community screen identified candidates for an in depth clinical evaluation and enrollment in longitudinal research, and we examined factors that predicted a positive response to invitation for the clinical evaluation. Individuals with a broader fund of knowledge were more likely to participate independent of other variables including ethnicity and education. When diversity is an important goal active outreach is far more efficacious than clinic-based and advertising-based approaches to recruitment.

An interdisciplinary outreach model of African American recruitment for Alzheimer's disease research

PURPOSE

The African American Outreach Satellite (Satellite) provides educational outreach to facilitate African American recruitment for longitudinal studies at the Washington University Alzheimer's Disease Research Center (ADRC). This descriptive article characterizes the Satellite's recruitment methods, plan for community engagement, results of recruitment efforts, and potential for replication.

DESIGN AND METHODS

The Satellite developed a comprehensive outreach and recruitment plan that identifies and addresses barriers to research participation. The Satellite conducts community outreach and recruitment programs and training for health care providers.

RESULTS

Enrollment of cognitively healthy and mildly demented African Americans for participation in all ADRC studies increased following implementation of the recruitment plan. Current African American participation rates for ADRC studies include 39% for lumbar puncture, 43% for positron emission tomography with Pittsburgh Compound-B, 52% for magnetic resonance imaging, 95% for apolipoprotein E genotype testing, and 100% for clinical and cognitive assessment.

IMPLICATIONS

The Satellite reduces barriers to research participation, encourages retention through sustained interactions with participants and their families, and develops lasting partnerships with community organizations and health professionals who care for African American elders.

Barriers to participation in mental health research: are there specific gender, ethnicity and age related barriers?

BACKGROUND

It is well established that the incidence, prevalence and presentation of mental disorders differ by gender, ethnicity and age, and there is evidence that there is also differential representation in mental health research by these characteristics. The aim of this paper is to a) review the current literature on the nature of barriers to participation in mental health research, with particular reference to gender, age and ethnicity; b) review the evidence on the effectiveness of strategies used to overcome these barriers.

METHOD

Studies published up to December 2008 were identified using MEDLINE, PsycINFO and EMBASE using relevant mesh headings and keywords.

RESULTS

Forty-nine papers were identified. There was evidence of a wide range of barriers including transportation difficulties, distrust and suspicion of researchers, and the stigma attached to mental illness. Strategies to overcome these barriers included the use of bilingual staff, assistance with travel, avoiding the use of stigmatising language in marketing material and a focus on education about the disorder under investigation. There were very few evaluations of such strategies, but there was evidence that ethnically matching recruiters to potential participants did not improve recruitment rates. Educational strategies were helpful and increased recruitment.

CONCLUSION

Mental health researchers should consider including caregivers in recruitment procedures where possible, provide clear descriptions of study aims and describe the representativeness of their sample when reporting study results. Studies that systematically investigate strategies to overcome barriers to recruitment are needed.

Difficulties in recruiting older people in clinical trials: an examination of barriers and solutions

Limited information exists regarding optimal methods for the recruitment and retention of older people in clinical trials. The aim of this review is to identify common barriers to the recruitment of older people in clinical trials and to propose solutions to overcome these barriers. A review of literature was performed to identify common difficulties in recruiting older people. This in combination with our experience during recruitment for a randomized control trial, have highlighted numerous barriers. Population-specific recruitment strategies, simple informed-consent processes, and effective communication between the researcher and subject are effective strategies to overcome these barriers.

Racial Differences in Perceived Burden of Rural Dementia Caregivers

This study explores whether religiosity explains racial differences in caregiving burden for a rural sample of dementia family caregivers. Data are from a probability sample of 74 non-Hispanic White and 67 African American dementia caregivers in rural Alabama. SPSS macros for estimating indirect effects in multiple mediator models are used to test the mediation effects of religiosity. White caregivers report higher burden, are less likely to use religious coping, and less likely to engage in organized religion than do African American caregivers. Church attendance is found to significantly ( B = —.57, p < .05) mediate the racial differences on caregiving burden ( R2 = .07). Religious involvement in general, and church attendance in particular, seem to provide both spiritual and social psychological benefits to dementia caregivers. Thus, supplementing formal services with the services provided by religious organizations may be important in rural areas where formal resources are scarce.

Facilitating aerobic exercise training in older adults with Alzheimer's disease

Emerging science suggests that aerobic exercise might modify the pathophysiology of Alzheimer's disease (AD) and improve cognition. However, there are no clinical practice guidelines for aerobic exercise prescription and training in older adults with AD. A few existing studies showed that older adults with AD can participate in aerobic exercise and improve dementia symptoms, but lack adequate descriptions of their aerobic exercise training programs and their clinical applicability. In this paper, we summarize current knowledge about the potential benefits of aerobic exercise in older adults with AD. We then describe the development of a moderate-intensity aerobic exercise program for this population and report results from its initial testing in a feasibility trial completed by two persons with AD. Two older adults with AD completed the aerobic exercise program. Barriers to the program's implementation are described, and methods to improve more wide-spread adoption of such programs and the design of future studies that test them are suggested.

Racial differences in parents' distrust of medicine and research

OBJECTIVE

To assess and compare the attitudes and trust that African American and white parents have toward their children participating in research.

DESIGN

Self-administered, cross-sectional survey of a convenience sample of parents.

SETTING

Primary Care Center at Children's Hospital of Pittsburgh from August 2004 through April 2005.

PARTICIPANTS

One hundred ninety parents (140 African American and 50 white parents).

OUTCOME MEASURE

Parental distrust of medical research as measured by a summative score of distrusting responses to 8 questions assessing trust in research.

RESULTS

African American parents had significantly greater distrust than white parents (67% vs 50%, P = .04). Education was also associated with having significantly greater distrust (74% of those with <high school education vs 44% of college graduates, P = .03). However, African American race remained a predictor of distrust even when education was controlled for (odds ratio, 2.25; 95% confidence interval, 1.01-5.01).

CONCLUSIONS

The degree of parental distrust toward medical research was significantly greater among African American parents. Parental distrust may be a barrier to enrollment of African American children in clinical research. Strategies for overcoming the higher level of distrust in African American parents are warranted for ensuring adequate representation of African American children in clinical research.

Abbreviated Posttraumatic Stress Screen for Ethnically Diverse Older Women

It is difficult for busy health care providers to perform routine screening for older women's posttraumatic stress symptomatology, due, at least partially, to a paucity of instruments specifically tested on such a population. To address this issue, in this preliminarily study we tested an abbreviated screen from the set of 20 items comprising the Distressing Event Questionnaire (DEQ; Kubany, Leisen, Kaplan, & Kelly, 2000) on a convenience sample of 94 ethnically diverse older women (ages 52-105). This new 5-item derivation, named "Brief Posttraumatic Stress Screening Scale (BPSSS)", assesses posttraumatic stress based on the Diagnostic and Statistical Manual of Mental Disorders - IV (DSM-IV; American Psychiatric Association, 1994). Its conciseness reduces the likelihood that older women would become fatigued during assessment, making it ideal for use in busy health care settings. Because the BPSSS has only five items, a single factor was hypothesized to account for a large proportion of the variance in its items, in view of the hypothesized cohesiveness of the tool's five items. We also expected that scores on the screen would correlate (to a certain extent) with those on measures of depression and perceived stress of a non-traumatic and non-medical nature. A standardized alpha of .86 demonstrated high internal consistency of the BPSSS and the exploratory factor analysis showed that one factor accounted for 58% of the five items' variance. Moreover, the correlations of BPSSS scores with scores on non-traumatic stress and depression were moderate yet significant (r = .37, p < .01 and r = .50, p < .01, respectively).

The challenges of clinical trials in the exclusion zone: the case of the frail elderly

Frail older people have been systematically excluded from randomised controlled trials (RCT). We aim to recruit older, frail hospitalised patients in an RCT and evaluate the frailty index (FI) as a measure to describe the types of people included in the study. We recruited 315 hospitalised patients aged 65 years; age ranged from 60 to 102 years. Baseline assessment scores ranged as follow: Mini-Mental Status Examination from 7 to 30, Barthel index from 5 to 100 and FI from 2 to 24. Total deaths were 20 (6%). We demonstrated that it is feasible to recruit frail older people into RCTs. The FI does not show any 'floor' or 'ceiling' effects. We can measure frailty in an RCT cohort, and we believe that clinical trials should include more frail older people and that the use of an FI can facilitate such trials and generate reliable data to guide future medical practice in a rapidly ageing society.

Minority enrollment in Parkinson's disease clinical trials

Under-representation of minorities in clinical trials limits access to information relevant to all segments of the population. We assessed the enrollment of minority subjects with Parkinson's disease (PD) into clinical trials. We searched PubMed for published studies of PD trials conducted in the US over the past 20 years and found that only 41 reported racial/ethnic participation (17%). In those trials reporting race/ethnicity, 8% of subjects were non-white, compared to 20% of the non-white US population over age 60. Results of this study identified the need for better reporting of racial composition in clinical trials and for the enrollment of more minority participants in research studies.

Use of live theater to increase minority participation in Alzheimer disease research

Recruitment and retention of African Americans into Alzheimer disease (AD) research studies poses challenges owing to long-standing socio-economic and cultural differences, pragmatic difficulties in reaching the African American population, and a legacy of distrust of medical research. In this study, we report on our efforts to use live theater to educate African Americans about AD research and to increase minority participation in it. We describe our experiences at the University Memory and Aging Center (Cleveland, OH) in commissioning, writing, and producing several theater productions focused on themes related to African Americans and their experiences dealing with family members with AD. Analysis of recruitment data, gathered before and after one of our productions, indicated that minority enrollment into our Center's Research Registry increased after the play. Survey data, gathered before and after production of a different play, indicated that viewing this piece increased knowledge about: (1) the symptoms of AD; (2) the fact that memory loss is not a part of normal aging; and (3) the greater prevalence of AD among African Americans. Also, after viewing this production, more audience members: (1) reported knowing how to become involved in research; (2) felt comfortable involving family members in research; and (3) would recommend research to others. We conclude that live theater that dramatizes the experiences of a family living with a person with AD can increase knowledge about AD, improve attitudes about taking part in research, and lead to greater participation in AD research studies. An explanatory model is offered to account for our findings.

A description of the process of recruitment for research studies investigating the genetics of psychotic illness

Collecting biometric data on probands and family members is pivotal for advancing the understanding and treatment of any medical disorder with genetic contributions. The process of recruiting probands with psychosis and their family members for genetic studies has proven to be challenging. We present the recruitment strategies of two sites that are collaborating in genetic studies. We review details of referral sources at these sites. Of 69 participants recruited from the University of Pittsburgh, 23% were self-referrals, 30% were encouraged by family, and 47% were encouraged by clinicians. Of 48 probands from the University of Pennsylvania, 6% were self-referrals, 21% were encouraged by family, and 73% were encouraged by clinicians. Qualitative data from focus groups are reviewed. Strategies that helped to facilitate recruitment and foster community networking are discussed. This preliminary study has broad implications as a potential model for collaboration among patient support groups, family groups, clinicians, and researchers.

Cognitive abilities of Alzheimer's patients: perceptions of Black and White caregivers

This study compared Black (n = 97) and White (n = 143) family caregivers regarding the relationship between subjective and objective cognitive assessments of Alzheimer's patients from the Memphis site of the NIA/NINR Resources for Enhancing Alzheimer's Caregivers Health (REACH) randomized clinical trial. Black and White caregivers' subjective ratings (Pearlin Cognitive Status Scale) of their care recipients' cognitive abilities were equivalent, but White Alzheimer's patients had higher objective cognitive performance (Mini-Mental State Examination). In simple regression analysis, race was significantly related to differences between subjective and objective cognitive assessments and remained so when caregiver age, sex, income, education, relationship to care recipient, caregiver bother (burden), and care recipient sex were statistically controlled in multiple regression analysis. Compared to the other group, Black caregivers generally overrated, and White caregivers underrated, their care recipient's cognitive ability. This difference in caregiver's appraisal may affect clinical and behavioral interventions for dementia patients and their caregivers.

Culturally attuned recruitment, retention, and adherence in Alzheimer disease and associated disorders: a best practices working model

This analysis presents a recruitment, retention, and (treatment and/or research) adherence (RRA) best practices model for targeting Alzheimer disease and associated dementias (ADAD) impacting ethnically diverse populations. RRA practice involves many more factors beyond cultural considerations to be highlighted here. However, it is the cultural dimension where much is at stake, where there is the least comprehensive framework, and where the most ambiguity exists relative to RRA practice. The discussion proceeds on three premises. First, a composite, culturally attuned RRA working model can be assembled from the current literature. Second, culturally speaking, recruitment, retention, and adherence are essentially linked processes. Although each of the components of RRA practice has its own unique set of tasks, culture permeates them all. Third, any RRA practice model that emerges must be tailored to the communities, the specific target populations, and the programmatic circumstances to which the effort is attached.

Recruitment Strategies for Studying Dementia in Later Life among Diverse Cultural Groups

This article provides conceptual and theoretical guidance on approaches to enhance recruiting and retaining diverse populations in dementia research by using a sociocultural perspective and constructivist approach. Informed by this conceptual and theoretical guidance, the article also discusses some of the major barriers to recruitment with ideas on how to address these barriers. Further discussion is provided on building community relations and capacity, and strategies to increase the level of participation in dementia care research. The article ends with best strategies for addressing barriers to recruitment and retention, building community relations and capacity, and increasing participation in research projects.

Personal characteristics of older primary care patients who provide a buccal swab for apolipoprotein E testing and banking of genetic material: the spectrum study

OBJECTIVE

To determine the personal characteristics and reasons associated with providing a buccal swab for apolipoprotein E (APOE) genetic testing in a primary care study.

METHODS

The study sample consisted of 342 adults aged 65 years and older recruited from primary care settings.

RESULTS

In all, 88% of patients agreed to provide a DNA sample for APOE genotyping and 78% of persons providing a sample agreed to banking of the DNA. Persons aged 80 years and older and African-Americans were less likely to participate in APOE genotyping. Concern about confidentiality was the most common reason for not wanting to provide a DNA sample or to have DNA banked.

CONCLUSION

We found stronger relationships between sociodemographic variables of age and ethnicity with participation in genetic testing than we did between level of educational attainment, gender, function, cognition, and affect.

Patient characteristics associated with participation in a practice-based study of depression in late life: the Spectrum study

OBJECTIVE

An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation.

METHOD

Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined.

RESULTS

In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate.

CONCLUSIONS

Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctor's office.

Special populations recruitment for the Women's Health Initiative: successes and limitations

The Women's Health Initiative (WHI) is a study designed to examine the major causes of death and disability in women. This multi-arm, randomized, controlled trial of over 160,000 post-menopausal women of varying ethnic and socioeconomic backgrounds and a goal of 20% of the study participants from minority populations is perhaps one of the most challenging recruitment efforts ever undertaken. Of the two main study arms, the Clinical Trial (CT) and the Observational Study (OS), the CT arm recruitment goal was to randomize 64,500 postmenopausal women 50-79 years of age. Women enrolled in the study will be followed for a period of 8-12 years. Ten clinical centers, out of a total of 40 throughout the United States, were selected as minority recruitment centers on the basis of their history of interaction with and access to large numbers of women from certain population subgroups. WHI enrollment began in September 1993 and ended in December 1998, resulting in the randomization and enrollment of a total of 161,856 (17.5% minority) women participants (68,135 (18.5% minority) in the CT and 93,721 (16.7%) in the OS). Within the CT arm, WHI achieved 101.7% of the goal of 48,000 participants in the Dietary Modification (DM) component, and 99.4% of the goal of 27,500 in the hormone-replacement component (HRT), with 11.8% overlap between DM and HRT. Of those who expressed initial interest in WHI, African Americans had the highest randomization yields in the DM component and Hispanics had the highest in the HRT component (15.2% and 10.2%, respectively). Overall, mass mailing was the greatest source of randomized participants. In addition, minority clinics found community outreach, personal referrals, and culturally appropriate recruitment materials particularly effective recruitment tools. For minority recruitment, our findings suggest that the key to high yield is reaching the target population through appropriate recruitment strategies and study information that get their attention. Also, once minority subjects are reached, they tend to participate.

Involving rural, older African Americans and their female informal caregivers in research

OBJECTIVE

This article presents the methodology, procedures, and results for involving rural, older African Americans and recruiting their female informal caregivers for a well-being and service use study.

METHODS

Using a list of 1,994 Medicare enrollees, this study adapted a reversed screening telephone methodology tested on urban African American elders and their caregivers. It used trained screeners, local African American female interviewers, and a mixed-mode procedure (i.e., telephone and canvassing) to screen elders and recruit caregivers.

RESULTS

Adequate information for 1,547 listings allowed screeners to contact qualified elders meeting the study criteria. Using chi-square analysis, significant differences were found between telephone and canvassing screening methods on nonreferral cases and referral cases. Elders or a proxy referred 286 caregivers. Interviewers obtained 265 of 300 proposed caregiver interviews.

DISCUSSION

Knowledge about the involvement of rural, older African Americans and recruitment of their female informal caregivers in research is essential to understanding recruitment successes and pitfalls in ethnic minority research.

Ethnic minority older adults participating in clinical research: developing trust

OBJECTIVE

African American, Latino, and American Indian older adults are underrepresented in clinical research studies. A significant barrier to participation in research is mistrust of the scientific community and institutions. The aims of this article are to discuss the lack of representation of ethnic minorities in clinical research.

METHODS

This article presents a review of the literature regarding medical research mistrust. Also described are the trust-building activities of the Resource Centers on Minority Aging Research (RCMAR), federally funded centers focused on research and aging in communities of color.

DISCUSSION

The RCMAR centers are building trust with the communities they serve, resulting in the recruitment and retention of ethnic minority older adults in clinical research studies and health promotion projects. Implications are discussed for other researchers toward building trust with ethnic minority elders to increase their participation in research.

Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study

Although there has been considerable interest in racial differences in family caregiving for persons with dementia, most research to date has either ignored racial diversity or based conclusions on small numbers of caregivers drawn primarily from single site studies. The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of caregiving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers. Some results were specific to site, possibly due to differences in recruitment strategies, inclusion/exclusion criteria, and regional differences. Adjustment for covariates, including caregiver relationship to the care recipient, gender, age, socioeconomic status, and care recipient behavioral problems, altered few of these differences. Results are discussed in terms of their relevance to psychosocial intervention programs for ethnically diverse caregivers.

Overcoming recruitment challenges in construction safety intervention research

BACKGROUND

Recruiting workers in small construction companies and securing their participation in voluntary safety programs or safety research poses unique challenges. Worker turnover and worksite changes contribute to difficulties in locating and enrolling participants. Economic pressures and time demands potentially threaten ongoing participation.

METHODS

Six simulation exercises designed to reduce back and fall injuries in small construction companies were developed based on data from focus groups of workers and company owners. Working with a workers' compensation insurer, we had access to owner-operators of general, heavy, and special trade construction companies reporting less than $10,000 in payroll expenses. Recruitment methods included a participation incentive, mailed invitations followed by phone contacts, and follow-up reminders.

RESULTS

Despite using recruitment methods recommended in the literature, participation rates were low over a 2-year intervention period. Because of these difficulties, factors affecting participation or nonparticipation became an additional research focus. Owners' perceptions of already having a good safety record and of the time demands of participation were the most commonly cited reasons for not participating.

CONCLUSIONS

Literature on recruitment emphasizes processes and procedures under investigator control rather than understanding potential participants' judgments about the adequacy of their existing practices and the potential benefits of intervention participation relative to potential time and productivity trade-offs. Greater attention to such judgments may enhance recruitment and participation in under-studied and difficult to access populations.

Differences between African Americans and Whites in their attitudes toward genetic testing for Alzheimer's disease

The possibility of predictive genetic testing for Alzheimer's disease (AD) has prompted examination of public attitudes toward this controversial new health-care option. This is the first study to examine differences between Whites and African Americans with regard to: (1) interest in pursuing genetic testing for AD, (2) reasons for pursuing testing, (3) anticipated consequences of testing, and (4) beliefs about testing. We surveyed a convenience sample of 452 adults (61% white; 39% African American; 78% female; mean age = 47 years; 33% with family history of AD). Both racial groups indicated general interest in predictive genetic testing for AD, viewed it as having many potential benefits, and believed it should be offered with few restrictions. However, in comparison to whites, African Americans showed less interest in testing (p < 0.01), endorsed fewer reasons for pursuing it (p < 0.01), and anticipated fewer negative consequences from a positive test result (p < 0.001). These preliminary findings show important distinctions between whites and African Americans in their attitudes toward genetic testing for AD. These differences may have implications for how different racial and ethnic groups will respond to genetic testing programs and how such services should be designed. Future research in real-life testing situations with more representative samples will be necessary to confirm these racial and cultural differences in perceptions of genetic testing.

Consent and refusal in dementia research: conceptual and practical considerations

This article discusses types of consent refusals, rates of refusal, factors that affect consent, and methods to increase rates of consent in elderly research participants and in those with dementia in particular. Refusals can be categorized according to several types: complete refusal, refusal that is time-contingent, partial refusal, and contingent agreement. Rates of consent vary greatly across studies of persons with dementia. This variation can also be affected by different methodologies of calculating rates, in addition to differences in content of studies, populations, and procedures. To warrant consent, a study must first be scientifically sound, with a high likelihood of advancing knowledge, and must provide maximal protection to participants. Consent rates are affected by the following factors: levels of anticipated risks and benefits of the study, relationships among the different caregivers involved in the care of the potential subject, the ability of the researcher to properly identify and locate the person who needs to provide consent, characteristics and attitudes of the person providing consent, and the method of obtaining consent, including timing, location, method of presentation, and type of consent requested. An understanding of these issues can assist the researcher in tailoring research procedures so as to maximize rates of consent. It also raises ethical issues that warrant further discussion concerning the process of obtaining consent from and for persons with dementia.

Barriers to the participation of African-American patients with cancer in clinical trials: a pilot study

BACKGROUND

African-American patients have been under-represented in oncology clinical trials. Better understanding barriers to African-American participation may help increase the accrual of African-American patients onto clinical trials.

METHODS

Two hundred eighteen patients with malignant disease (72 African-American patients and 146 white patients) were recruited from the Duke Cancer Clinic and from Duke Oncology Outreach Clinics (DOORS). Patients were interviewed using a standardized survey. Questions included patients' knowledge of cancer, religious/spiritual beliefs, satisfaction with medical care, knowledge of clinical trials, reasons for participating or refusing to participate in a clinical trial, financial/transportation issues, and demographic factors, such as age and education. Data on attitudes and belief were analyzed for group differences between African-American patients and white patients as well as between patients who were treated at the Duke Cancer Clinic and patients who were treated at DOORS clinics.

RESULTS

Willingness to participate in a clinical trial depended on both race and clinic site. Forty-five percent of white patients, compared with 31% of African-American patients, were willing to participate in a clinical trial (P = 0.05). white and African-American patients who were treated at the Duke Cancer Clinic were more willing to participate in a trial compared with their counterparts who were treated at DOORS clinics (47% vs. 37%, respectively; P = 0.09). The greatest differences between groups (African-American patients vs. white patients and Duke Cancer Clinic patients vs. DOORS patients) were education and income: Much greater percentages of African-American patients and DOORS patients did not complete high school and had annual incomes < $15,000. In addition, more African-American patients than white patients believed that God would determine whether they would be cured or would die from their disease. In a multivariate analysis, education, income, and belief that God would determine the patient's outcome also were correlated with a decreased willingness to participate in clinical trials.

CONCLUSIONS

Factors associated with religion, education, and income, rather than race, may be major barriers to clinical trial participation. Interventions that target education and income may increase the recruitment of African-American oncology patients onto clinical trials.

Recruiting older African American men to a cancer screening trial (the AAMEN Project)

PURPOSE

This article describes the demographic characteristics of participants in a randomized trial (the AAMEN Project) designed to recruit older (aged 55+ years) African American men to a cancer screening trial.

DESIGN AND METHODS

The AAMEN Project is a recruitment trial developed for African American men aged 55+ years living in southeastern Michigan.

RESULTS

Of the 34,376 African American men in the study, 37.6% had low incomes and 62.4% had moderate-to-high incomes. The average age of the men was 63.3 years (SD = 5.9 years). Among men who were eligible and interested in participating, the proportion of men with low incomes was significantly greater than the proportion of men with moderate-to-high incomes (p <.001).

IMPLICATIONS

The AAMEN Project demonstrated success in recruiting a substantial proportion of men with low incomes as well as men with moderate-to-high incomes. These findings may facilitate the development of future recruitment efforts involving older African American men.