Optimizing Recruitment of Black Adolescents into Behavioral Research: A Multi-Center Study

Evaluating representativeness: recruitment for a virtual family-based intervention focused on the transition from pediatric to adult diabetes care†

OBJECTIVE

Recruiting representative samples of youth for behavioral health interventions is challenging yet necessary to translate research into practice and eliminate health disparities. Transition-aged youth with type 1 diabetes (T1D) represent a vulnerable population; not enough attention is given to their inclusion in behavioral health interventions. Behavioral Family Systems Therapy for Diabetes Transition (BFST-DT) is an intervention aimed at improving transition readiness and is currently being pilot tested. The objectives of this study are to (1) evaluate the representativeness of the enrolled sample based on demographic and medical characteristics and (2) evaluate recruitment communication preferences.

METHODS

Thirty adolescents (Mage = 16.57 years) with T1D and their caregiver(s) were recruited from a large urban hospital. Demographic and medical variables were collected via electronic medical record. Research staff recorded recruitment details about communication attempts and methods and reasons for participation decline.

RESULTS

Those who enrolled in the intervention had more insulin pump usage than the recruitment population. Those who enrolled communicated primarily over email, while those who declined preferred phone. The length of time before a participation decision was communicated was similar between the enrolled and declined groups at about 6 weeks. The main reason for declining to participate was lack of interest.

CONCLUSIONS

Recruitment strategies were mostly effective in recruiting a representative sample of adolescents with T1D. Findings have implications for recruiting populations that are challenging to engage in intervention research. Future research should prioritize the stratification of historically underrepresented groups during recruitment.

Insights from Team Clinic: A Person-Centered Virtual Peer Group Care Model Adapted for Marginalized and Historically Excluded Youth with Type 1 Diabetes (T1D)

BACKGROUND

Despite advancements in T1D care regimens, racially and ethnically diverse youth with low income continue to experience worse health outcomes, more psychosocial challenges, and higher barriers to care. Alternative care models are needed to address the needs of this population.

METHODS

Team Clinic is a person-centered virtual peer group (VPG) care model that was assessed in a 15-month, pragmatic randomized controlled trial. Youth (ages 10-17) and their families were assigned to study arms based on their clinician's group (standard care or person-centered care, PCC) and then randomized to VPGs or no groups.

RESULTS

Data from 79 youth and their families were examined. While positive outcomes were seen across all study groups, youth that participated in Team Clinic (PCC + VPG) reported the largest increases in resilience at the end of the study (+7.42, to 51.63, p = 0.009). These participants also reported the lowest levels of depressive symptoms as assessed by PHQ-8 scores (-5.07, p = 0.002) at the end of the study.

CONCLUSION

Team Clinic can serve as an alternative care model for racially and ethnically diverse youth with T1D and their families. VPGs can provide unique benefits, including an increase in resilience, a decrease in depressive symptoms, and a safe space for families to connect, learn, and receive support.

Strategies for Equitable Recruitment to Engage Underrepresented Youth and Their Families into Clinical Research: Findings from the BEAD-T1D Pilot Study

INTRODUCTION

To address disparities in clinical research, we present strategies to optimize recruitment of underrepresented families into the Building the Evidence to Address Disparities in Type 1 Diabetes (BEAD-T1D) study.

METHODS

A bilingual/bicultural Latino research assistant (RA) was hired to facilitate culturally congruent recruitment for pediatric type 1 diabetes families. The RA screened, approached, and consented families using their preferred language, time of contact, and answered personal concerns around research. Families were given the option to consent during outpatient clinic visits (in-person, or virtually via video/phone call) at a pace set by the parent/guardian to ensure understanding.

RESULTS

Sixty-four families (Hispanic-65%, Non-Hispanic White [NHW]-17%, Non-Hispanic Black-1%, and Other-4%) were eligible. Of 49 approached, 32 consented (39 ± 7.9 years; female-81%; Hispanic-72%, NHW-28%, <50K income-69%, Spanish-speaking-50%). Clinic approaches were important to successful consent: 87% of the clinic approaches resulted in consent. Barriers to clinic approaches for RA included late/no response from clinicians, care team ending visit, and bandwidth/connectivity issues. Facilitators to clinic approaches included collaborative clinic care teams, flexible RA hours, and patient screening days in advance. We exceeded our recruitment goals for surveys (31/30), focus groups/interviews (26/20), and advisory board (22/10).

CONCLUSIONS

We identified that culturally and linguistically congruent staff, flexible recruitment practices, and prioritizing participant availability were solutions to recruit a diverse study cohort resulting exceeding recruitment goals. Cultural interpersonal relationships formed with families addressed barriers to research participation within and outside of the medical system. These strategies suggest equitable clinical trial recruitment is feasible in diabetes research.

The moderating role of diabetes distress on the effect of a randomized eHealth intervention on glycemic control in Black adolescents with type 1 diabetes

OBJECTIVE

Due to systemic inequities, Black adolescents with type 1 diabetes are more likely to have suboptimal glycemic control and high rates of diabetes distress, but tailored interventions for this population are lacking. In primary outcomes of a randomized clinical trial, a family-based eHealth intervention improved glycemic control in Black adolescents with type 1 diabetes and elevated depressive symptoms. The present study is a secondary analysis of these clinical trial data examining the moderating effect of diabetes distress on the efficacy of the intervention.

METHODS

Using secondary data from a multicenter randomized clinical trial (Clinicaltrials.gov [NCT03168867]), caregiver-adolescent dyads were randomly assigned to either up to three sessions of an eHealth parenting intervention (n = 75) or a standard medical care control group (n = 74). Black adolescents (10 years, 0 months to 14 years, 11 months old) with type 1 diabetes and a caregiver willing to participate were eligible. Adolescents reported their diabetes distress at baseline, and hemoglobin A1c (HbA1c) data were collected at baseline, 6-, 13-, and 18-month follow-up.

RESULTS

No between-group contrasts emerged in a linear mixed-effects regression (p's > .09). Within-group contrasts emerged such that adolescents assigned to the intervention who reported high diabetes distress had lower HbA1c at the 18-month follow-up relative to baseline (p = .004); the 18-month decrease in HbA1c was -1.03%.

CONCLUSIONS

Black adolescents with type 1 diabetes and high levels of diabetes distress showed significant decreases in HbA1c following a family-based eHealth intervention, suggesting diabetes distress may be a key moderator of intervention efficacy within this population.

Tailored approach to participant recruitment and retention to maximize health equity in pediatric cancer research

BACKGROUND

Lack of diversity in participants throughout the research process limits the generalizability of findings and may contribute to health disparities. There are unique challenges to recruitment of families to pediatric cancer research studies, especially for those from disadvantaged backgrounds. Thus, there is a need to evaluate the most effective recruitment and retention strategies to optimize equitable recruitment of diverse participants.

METHODS

The present study adapted and implemented methods outlined previously in the literature. These previous efforts were developed to address barriers to pediatric research, behavioral health intervention research and research with Black adolescents. Recruitment and retention strategies are described across four different time points: pre-approach, initial connection, building connection and follow-up. Eligible families of children with a pediatric cancer diagnosis were approached during a routine oncology visit. Once consented, enrollment and retention rates over three timepoints of data collection were recorded and evaluated.

RESULTS

Results indicated high rates of enrollment (86%) and retention (95%) for eligible participants. There were no trends in heightened attrition for any specific subgroup.

CONCLUSIONS

The findings of this study are promising and suggest these recruitment and retention strategies may be useful in recruiting individuals from disadvantaged backgrounds.

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Comparison of recruitment methodologies for clinical trials: Results from the time for living and caring (TLC) intervention study

BACKGROUND

Recruiting participants for research studies is a critical yet challenging task. Community-engaged recruitment strategies have gained prominence as effective means to engage diverse populations and ensure the representativeness of study samples. This case study aims to investigate the cost and effectiveness of various recruitment methods in enhancing research participation.

METHODS

A comparative approach was employed to assess the outcomes of five different recruitment strategies used in the Time for Living & Caring (TLC) research study. Data on recruitment success, participant demographics, and retention rates were collected and analyzed using descriptive statistics, including ANOVA and Chi-squares, to statistically compare the outcomes associated with 5 different recruitment methodologies. The recruitment methodologies included two community-engaged strategies (community partner referral and community-based recruiters), a clinical database, social media, and word-of-mouth referral.

CONCLUSION

The meta-data used to build this methodological case study describe different recruitment methodologies that may be used for clinical trials. This data-driven evaluation provides examples and considerations for researchers when developing budgets and proposals for future clinical trials. The primary finding is that there are tradeoffs in terms of cost, time, labor, and ultimately the representativeness of the sample, based on the type of recruitment methodology chosen.

Acceptability of a Self-Led Mindfulness-Based Intervention for Teens with Type 1 Diabetes: Pilot Randomized Controlled Trial

BACKGROUND

Diabetes distress among adolescents with type 1 diabetes has been associated with suboptimal diabetes outcomes, including lower quality of life, increased diabetes self-management challenges, and suboptimal glycemic outcomes.

OBJECTIVE

This study examined the feasibility and acceptability of a scalable self-led mindfulness-based intervention to reduce diabetes distress in adolescents with type 1 diabetes.

METHODS

Adolescents (N=25) aged between 14 and 18 years diagnosed with type 1 diabetes completed a baseline assessment. Participants were randomized to receive a 10-week self-guided mindfulness-based stress reduction workbook program (e-book or paper option) immediately (n=15) or after a 10-week wait (n=10). During the intervention period, participants completed weekly assignments and feedback surveys. At 10 weeks and 20 weeks, follow-up assessments were completed.

RESULTS

Findings indicated that participants did not find the original intervention feasible or acceptable. Adolescents reported barriers to completing the weekly material, such as that they forgot or that the material was not sufficiently related to their diabetes management. Adolescents also reported that a digital format rather than a workbook or e-book may be more acceptable. Results from weekly surveys provided the foundation for recommendations for future iterations of the mindfulness-based intervention for adolescents with type 1 diabetes.

CONCLUSIONS

Participant feedback informed recommendations for self-led mindfulness programs for youth with type 1 diabetes. Adolescents indicated that a shorter, digital mindfulness-based intervention focused on diabetes-specific behaviors may be more helpful.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05115175; https://clinicaltrials.gov/study/NCT05115175.

Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes

Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.

Epigenetic age in African American adolescents with type 2 diabetes: A cross-sectional case-control study protocol

Background and Aims

Type 2 diabetes (T2D) is a disease caused by a relative insulin deficiency compared to the significant insulin requirement needed by the body to achieve glycemic control. T2D in adolescence appears to be increasing in prevalence over the past several decades, necessitating studies to understand for the onset of the disease to occur early in the lifespan. Given the high burden of disease, specifically in young African American adolescents, our study chose to focus initially on feasibility of recruitment of this population.

Methods

Data was collected at a single study center at Children's of Alabama. The protocol was completed as part of routine care or at a study visit. The study team was able to leverage the Electronic Medical Record to prescreen eligible patients to discuss the study. A variety of times of day were utilized to improve likely of success with reaching potential participants. Inclusion criteria for patients with T2D was focused on the adolescent population (ages 12-18 years), with no history of an obesity syndrome. DNA methylation age will be calculated using the EPIC 850K array. Statistical analysis will be done using linear regression analysis, adjusting for covariates.

Conclusions

This study's aim was to screen and enroll young African American adolescents for a study investigating epigenetic aging and T2D. Our study found that more direct contact (face-to-face- or phone call) improve success of recruitment. Leveraging the electronic medical record also helped improve success with pre-screening participants. Challenges included recruiting participants who might come from long distances to a tertiary care center. Consolidating appointments helped improve the success of reaching these participants. Other challenges included frequent address changes and changed phone numbers. Close attention to the barriers as well as the successes will aid in understanding effective strategies for this important population.

The Naturalistic Cannabis Administration Protocol (NCAP): A Proof-of-Concept Study

Lab-based studies examining the effects of cannabis administration on human behavior compromise ecological validity due to the influence of set and setting. Contextual factors of clinical settings have long been recognized as producing measurable changes in physiology, emotionality, and cognition. Among people who use drugs, these settings may be associated with higher levels of perceived stigma and stereotype threat which may meaningfully confound the effects of cannabis on outcomes of interest. Recent liberalization of cannabis regulation may allow novel and more ecologically valid approaches to assessing the acute effects of cannabis. The Naturalistic Cannabis Administration Protocol (NCAP) is a novel paradigm for the study of acute cannabis effects in an ecologically valid manner. Two independent studies demonstrated the safety and feasibility of the NCAP. Participants (N= 79; Mage = 25.44, SD = 5.67) self-administered the cannabis of their choice in their home and then (Study 1; n= 47) engaged in a leisure activity or (Study 2; n= 32) underwent cognitive assessment remotely via videoconference following cannabis administration. The NCAP was well tolerated across samples with no reported adverse events. These findings provide a rationale for the adoption of the NCAP to reduce research barriers and develop our research capabilities to fit the landscape of cannabis use today.

Recruiting historically under-represented individuals into Project ECHO Diabetes: using barrier analysis to understand disparities in clinical research in the USA

OBJECTIVES

Individuals under-recruited in diabetes research studies include those not seen at endocrinology centres and those from rural, low socioeconomic and/or under-represented racial/ethnic groups. The purpose of this descriptive analysis is to detail recruitment and retention efforts of Project ECHO Diabetes clinical sites affiliated with Stanford University and University of Florida.

DESIGN

Prospective collection of participant engagement and qualitative analysis of barriers and facilitators of research engagement within Project ECHO Diabetes, a virtual tele-education programme for healthcare providers in the management of individuals with insulin-requiring diabetes.

SETTING

Data were collected at the patient level, provider level and clinic level between 1 May 2021 and 31 July 2022.

PARTICIPANTS

Participants and study personnel were recruited from 33 Project ECHO Diabetes sites in California and Florida.

OUTCOMES

We report study completion rates for participants recruited into 33 Project ECHO Diabetes sites. Using barrier analysis, a methodology designed for the real-time assessment of interventions and system processes to identify barriers and facilitators, study personnel identified significant barriers to recruitment and retention and mapped them to actionable solutions.

RESULTS

In total, 872 participants (California n=495, Florida n=377) were recruited with differing recruitment rates by site (California=52.7%, Florida=21.5%). Barrier analysis identified lack of trust, unreliable contact information, communication issues and institutional review board (IRB) requirements as key recruitment barriers. Culturally congruent staff, community health centre (CHC) support, adequate funding and consent process flexibility were solutions to address recruitment challenges. Barriers to retention were inconsistent postal access, haemoglobin A1c kit collection challenges, COVID-19 pandemic and broadband/connectivity issues. Additional funding supporting research staff and analogue communication methods were identified as solutions address barriers to retention.

CONCLUSIONS

Funded partnerships with CHCs, trusted by their local communities, were key in our recruitment and retention strategies. IRB consent process flexibility reduced barriers to recruitment. Recruiting historically under-represented populations is feasible with funding aimed to address structural barriers to research participation.

Psychosocial functioning in pediatric food allergies: A scoping review

The psychosocial burden of food allergy (FA) can significantly affect the lives of pediatric patients and their families. A comprehensive understanding of the state of the literature on psychosocial functioning is imperative to identify gaps that may affect clinical care and future research. This review characterizes the current literature on psychosocial functioning in pediatric patients with FA and their caregivers, siblings, and families. A literature search of 5 databases (PubMed, Ovid MEDLINE, PsycINFO, Web of Science, and Embase) was conducted to identify original research articles and abstracts on psychosocial functioning of patients with FA who were aged 0 to 18 years and their caregivers, siblings, and families. A total of 257 studies met the inclusion criteria. The majority of studies examined child or caregiver psychosocial functioning, with child and caregiver quality of life examined most frequently. Most studies utilized quantitative and cross-sectional methods and inconsistently reported participant race and ethnicity. Existing research on psychosocial functioning in pediatric FA may not be generalizable to patients of color and families and siblings. Future research should diversify recruited samples regarding race, ethnicity, and country of origin; examine psychosocial functioning longitudinally; examine constructs beyond quality of life; and adopt a biopsychosocial approach by considering the interplay among psychosocial functioning, disease burden, and social contexts.

Diversity, Equity, and Inclusion within Pediatric Adherence Science

Given the long-standing history of systemic racism in psychological science, diversity, equity, and inclusion (DEI) efforts are increasingly vital to the advancement and improvement of the field. This commentary extends the seminal work of the article Upending Racism in Psychological Science: Strategies to Change How Our Science is Conducted, Reported, Reviewed, and Disseminated (Buchanan et al., Am Psychol, https://doi.org/10.31234/osf.io/6nk4x , 2020) by providing tangible applications and recommendations to improve DEI integration into pediatric adherence science. Real-world adherence examples are discussed regarding the challenges faced in systematically integrating DEI principles, potential solutions to overcoming barriers, and the implications of these efforts on scientific advancement in an effort to address and dismantle research practices that perpetuate inequity and White supremacy. Specifically, we provide discourse and practical guidance related to the conduct, reporting, reviewing, and dissemination of pediatric adherence science to promote dialog and produce actionable change toward the promotion of health equity and social justice.

A perspective on enhancing representative samples in developmental human neuroscience: Connecting science to society

Marginalized groups are often underrepresented in human developmental neuroscientific studies. This is problematic for the generalizability of findings about brain-behavior mechanisms, as well as for the validity, reliability, and reproducibility of results. In the present paper we discuss selection bias in cohort studies, which is known to contribute to the underrepresentation of marginalized groups. First, we address the issue of exclusion bias, as marginalized groups are sometimes excluded from studies because they do not fit the inclusion criteria. Second, we highlight examples of sampling bias. Recruitment strategies are not always designed to reach and attract a diverse group of youth. Third, we explain how diversity can be lost due to attrition of marginalized groups in longitudinal cohort studies. We provide experience- and evidence-based recommendations to stimulate neuroscientists to enhance study population representativeness via science communication and citizen science with youth. By connecting science to society, researchers have the opportunity to establish sustainable and equal researcher-community relationships, which can positively contribute to tackling selection biases.

Achieving Equity in Diabetes Research: Borrowing From the Field of Quality Improvement Using a Practical Framework and Improvement Tools

There are limited tools to address equity in diabetes research and clinical trials. The T1D Exchange has established a 10-step equity framework to advance equity in diabetes research. Herein, the authors outline this approach and expand on its practical application.

Pivoting during a pandemic: lessons learned from transitioning a multisite randomized controlled trial to a remote protocol in response to COVID-19

THR1VE! is an ongoing multisite randomized clinical trial of a positive psychology intervention designed to treat diabetes distress and improve glycemic outcomes in teens with type 1 diabetes. Due to the COVID-19 pandemic restrictions on clinical research and changes in diabetes clinical care, THR1VE! was adapted from an in-person enrollment protocol to a remote protocol through a series of development and testing strategies. We discuss the process of transitioning the protocol and the demonstrated feasibility of ongoing recruitment, enrollment, and retention outcomes. These findings offer support for a remotely transitioned protocol that has larger applications for ongoing and future clinical research.