Racial and ethnic minority patient participation in N-of-1 trials: perspectives of healthcare providers and patients

A mixed-methods study on the recruitment of patients from ethnic minority groups to clinical trials in a central London teaching hospital

Background/aims

Additional research is needed to fully understand barriers in recruitment to clinical trials and how these might affect different ethnic groups. The aim of this study was to explore the factors acting as barriers and facilitators in the process of recruiting patients to clinical trials in a UK (central London) teaching hospital, with a particular focus on patients from ethnic minority groups, and on areas where action could be taken.

Methods

The study was designed as a mixed-methods study comprised of: 1) a quantitative workstream which explored variations in the ethnic and gender breakdown of people admitted to hospital relative to the demographic characteristics of patients enrolled into research studies at the hospital, and 2) a qualitative workstream which explored staff experiences of recruiting patients to clinical trials and patients' experiences of being approached to take part in a clinical trial. The quantitative workstream provided the necessary context for the design of the qualitative workstream.

Results

We found that the chances of being involved in research at the hospital were lower in all ethnic minority groups and lower amongst female patients. Some of the factors acting as barriers in trial participation included patients' perceptions of clinical research as a form of experimental medicine that might have high risks, the role of family members in decision-making processes, and language barriers (where patients might not be fluent in English and the study information is not communicated in other languages). Potential strategies to address underrepresentation included the development of accessible information about research and how patient data are used, development of study materials in multiple languages and use of interpreters during the recruitment process, support for staff in involving family members in decision-making and a greater ethnic diversity within study teams.

Conclusions

The under-representation of people from minority ethnic populations in clinical research remains a major challenge, impacting on the rigour and applicability of findings as well as implying some populations are missing out on the benefits of research. Study design needs to place greater emphasis on patient need and convenience and therefore to take greater account of the deterrent effect of financial and time burdens on trial participants. Recruiting sites and sponsors need to review the provision of interpreting and translation support for trials, including availability and cost to individual studies and staff confidence in reliability.

Breaking barriers: fostering equitable access to pediatric genomics through innovative care models and technologies

The integration of genomic medicine into pediatric clinical practice is a critical need that remains largely unmet, especially in socioeconomically challenged and rural areas where healthcare disparities are most pronounced. This review seeks to summarize the barriers responsible for delayed diagnosis and treatment, and examines diverse care models, technological innovations, and strategies for dissemination and implementation aimed at addressing the evolving genomic needs of pediatric populations. Through a comprehensive review of the literature, we explore proposed methodologies to bridge this gap in pediatric healthcare, with a specific emphasis on understanding and speeding implementation approaches and technologies to mitigate disparities in underserved populations, including rural and marginalized communities. There are both external and internal factors to consider in demographic and social determinants when evaluating patient access. To address these barriers, potential solutions include telegenetic services, alternative care delivery models, pediatric subspecialist expansion, and non-genetic provider education. By improving access to pediatric genomic services, therapeutic interventions will also be more available to all pediatric patients. IMPACT STATEMENT: Genomic testing has clinical utility in pediatric populations but access for people from diverse demographic and social-economic groups is problematic. Understanding barriers responsible for delayed genetic diagnosis and treatment in pediatric populations will improve reach, adoption, implementation, and maintenance of genomic medicine in pediatric healthcare context. Innovative care models, adaptation of appropriate technologies, and strategies aimed at addressing pediatric genomic needs are needed.

Enablers and barriers of clinical trial participation in adult patients from minority ethnic groups: a systematic review

BACKGROUND

Clinical trials are essential to the development of healthcare innovations that advance life expectancy and improve quality of life. However, there exists a pronounced disparity in ethnic representation among trial participants. This imbalance, particularly in relation to minority ethnic groups, can lead to a limited understanding of how therapies affect diverse populations. The present systematic literature review (SLR) aims to identify the factors that both hinder and facilitate the participation of minority ethnic groups in clinical trials.

METHODS

This review involved a systematic search of keywords across four databases: Web of Science, PubMed, CINAHL Plus and The Cochrane Library. The review was not restricted by language or study site; however, the date of publication was limited between 1st January 2017 and 1st October 2022. Studies discussing or outlining the involvement of minority ethnic groups in clinical trials, and those outlining inclusive recruitment and participation procedures were targeted.

RESULTS

A total of 43 articles were included in the review. Of these, 36 articles were from the United States (US), 20 articles reported on oncology trials and 39 articles reported information from the patient's perspective. Reported barriers included a lack of researchers from minority ethnic groups implementing and conducting clinical research, inadequate funding for clinical trial efforts in geographical areas serving minority populations and a lack of awareness and education among research staff regarding which underrepresented groups to target for recruitment and the strategies to employ in reaching out to them. Several recommendations were suggested by the articles included in the review to address these barriers. Prominently, the use of patient navigators or community liaison roles was highly recommended as a way of supporting patients through the research recruitment process. The articles also highlighted the benefits of translating study materials and interventions into multiple languages and actively involving diverse communities in the development of health education materials. Lastly, leveraging technologies to address socioeconomic barriers, such as the use of virtual approaches to avoid lengthy travel, may also help to improve diversity in trials.

CONCLUSIONS

Ensuring representation of minority ethnic groups in clinical trials is critical to developing therapies with generalisable efficacies. While progress has been made in enhancing outreach of wider racial groups and fortifying educational resources, there remains a pressing need to delve deeper into the obstacles impeding the recruitment of a diverse participant base, particularly in regions outside the US, where relevant studies are scarce.

REGISTRATION

The review protocol was registered on PROSPERO (CRD42022368106) (1).

N-of-1 trials: The epitome of personalized medicine?

Observational studies are notoriously susceptible to bias, and parallel-group randomized trials are important to identify the best overall treatment for eligible patients. Yet, such trials can be expected to be a misleading indicator of the best treatment for some subgroups or individual patients. In selected circumstances, patients can be treated in n-of-1 trials to address the inherent heterogeneity of treatment response in clinical populations. Such trials help to accomplish the ultimate goal of all biomedical research, to optimize the care of individual patients.