Lessons learned in recruiting and retaining Black men in behavioral diabetes intervention research

Abstract

Black men experience disproportionately high rates of type 2 diabetes (T2D) and its complications, yet remain underrepresented in diabetes intervention research. Culturally tailored, community-based interventions that prioritize trust and address structural barriers are essential for improving recruitment and retention in this population. This article provides insights from the Michigan Men's Diabetes (MenD I and II) Projects, a peer-led diabetes self-management intervention tailored to Black men with T2D. MenD I and MenD II used Diabetes Self-Management Education (DSME) and Peer-Led Diabetes Self-Management Support (PLDSMS) sessions delivered virtually to meet participants' needs. Recruitment efforts engaged trusted community organizations, healthcare providers, and targeted outreach. Retention strategies emphasized trust-building, flexible scheduling, and culturally resonant support mechanisms, such as fostering a sense of community, providing personalized check-ins, and incorporating time for informal interactions and relationship-building. Data collected from pre- and post-intervention assessments and participant feedback illustrate the effectiveness of these approaches in addressing barriers and sustaining engagement. Despite challenges like medical mistrust, systemic inequities, and competing responsibilities, the MenD studies demonstrate that well-designed peer-led interventions can effectively engage Black men. These findings highlight the importance of culturally tailored adaptations and strong community partnerships in overcoming barriers to participation. Insights from MenD I and II offer valuable guidance for reducing health disparities and improving diabetes outcomes for Black men.

Highlights

• •Materials were created to reflect Black men's T2D experiences in SE Michigan, using accessible language and cultural relevance.

1. Introduction

Black men experience disproportionately high rates of type 2 diabetes (T2D) and its complications, which contribute to significant health disparities in morbidity and mortality. National statistics indicate that Black men are more than twice as likely as their non-Hispanic White counterparts to develop T2D and suffer from its long-term consequences, including cardiovascular disease, kidney failure, and lower limb [1,2]. Despite these alarming statistics, Black men remain significantly underrepresented in diabetes intervention research. Several factors contribute to this underrepresentation, including historical mistrust of medical institutions, systemic racism in healthcare, and culturally specific barriers related to masculinity and self-reliance [3]. Addressing these disparities requires targeted strategies that consider both the structural and sociocultural factors influencing Black men's engagement in diabetes self-management programs.

The National Standards for Diabetes Self-Management Education (DSME) and Support (DSMS) emphasize the importance of ongoing DSMS delivered by healthcare professionals or trained non-professional peer leaders to effectively improve health outcomes for individuals with T2D [4]. Of additional importance, interventions led by peer leaders have demonstrated significant improvements in glycemic stability and self-management behaviors [5,6]. Black men have preferred peer-led interventions facilitated by others who have shared lived experiences [7,8]. This preference aligns with research on gender and health behavior change, which suggests that male interventionists are often more effective in engaging men in chronic disease self-management programs [9].

Despite the potential benefits, most peer-led diabetes self-management support (PLDSMS) studies predominantly recruit women, with Black men making up, on average, 15 % of participants [10]. Given the significant burden of T2D among Black men and their underrepresentation in intervention research, it is critical to develop and evaluate recruitment and retention strategies tailored specifically to this population. This paper examines lessons learned from the Michigan Men's Diabetes Projects (MenD I and II), a peer-led intervention designed to address the unique needs of Black men with T2D. We detail the recruitment and retention strategies employed in MenD I and MenD II and discuss their implications for future research to improve diabetes-related health outcomes in Black men.

2. Study description

The Michigan Men's Diabetes Project (MenD) was a two-phase randomized controlled trial evaluating the feasibility and effectiveness of a PLDSMS intervention. Participants were Black men aged 55 and older residing in Metro Detroit with a confirmed T2D diagnosis. Primary and secondary outcomes (self-management behaviors, HbA1c levels, self-efficacy, and diabetes distress) were assessed pre- and post-intervention in the first phase (MenD I). The 12-week intervention was delivered virtually via Zoom for Health to enhance accessibility.

In MenD I, we initially recruited 35 potential participants, of whom 28 consented to participate (80 % consent rate). Of these, 24 participants (86 %) completed the 12-week intervention and post-intervention assessments. Building on this foundation, MenD II successfully recruited 65 potential participants, enrolling 48 (74 % consent rate). Retention rates remained strong throughout the extended follow-up periods, with 43 participants (90 %) completing the three-month assessment, 40 (83 %) completing the nine-month assessment, and 38 (79 %) completing the final 15-month assessment. These retention rates compare favorably to previous health promotion intervention studies focused on Black men, which typically report retention rates of 85 % [7].

Based on participant feedback from MenD I, MenD II expanded recruitment, enrolling 48 participants and increasing follow-up duration. Data were collected at three, nine, and 15 months to examine intervention durability and retention. Expanded recruitment strategies include healthcare system registries, community-based partnerships, and social media outreach. Participants were randomized into one of two groups. The intervention arm received three months of DSME and six months of DSMS, followed by an additional six months of ongoing support. Peer leaders facilitated DSMS sessions and co-facilitated DSME with a Certified Diabetes Care and Education Specialist (CDCES). The Enhanced Usual Care (EUC) arm received six months of virtual DSME facilitated solely by the CDCES.

3. Lessons learned

3.1. Developing and maintaining effective academic-community partnerships

Strong community ties were essential for recruitment and retention. Partnering with trusted organizations, including a local church, a senior center, the Michigan Men's Health Foundation, and the Michigan Center for Urban African American Aging Research (MCUAAAR), provided access to established networks trusted by Black men.

MCUAAAR, a National Institute on Aging-funded collaborative center led by three major research universities, focuses on reducing health disparities among older African Americans through research, training, and community engagement [11]. A key MCUAAAR initiative, the Healthier Black Elders Center (HBEC), facilitates community-based research participation and provides health education resources for older Black adults in Detroit, Michigan and surrounding areas [12]. HBEC also manages the Participant Resource Pool (PRP), a registry of older Black adults interested in aging-related research, connecting researchers with a diverse and engaged study population [13].

The Michigan Men's Health Foundation (MMHF), a 501(c) (3) non-profit dedicated to men's health advocacy with a focus on education, research, and prostate cancer treatment, also contributed to recruitment efforts [14]. These efforts were centered on the annual MMHF Men's Health Fair, which, since 2009, has provided health screenings to approximately 1400 predominantly Black men each year [14]. The event incorporates family-friendly activities, appearances by local athletes, and culturally resonant messaging that emphasizes camaraderie and health improvement. These strategic partnerships fostered culturally relevant engagement and provided accessible locations for study assessments.

While we benefited from existing community infrastructure through MCUAAAR, HBEC, and MMHF, establishing and nurturing these partnerships required deliberate strategies that other researchers can implement.

• 1.Reciprocal Value Creation: Rather than viewing community organizations solely as recruitment channels, we engaged them as full research partners. This included acknowledging their expertise through co-authorship on publications and formally including them as partners in grant development and submission efforts. Specifically, we co-wrote and received a grant with the MMHF and succfully published a manuscript [15].
• 2.Relationship-Building Before Recruitment: Collectively, our team brought over 20 years of experience working in the community. We collaborated with HBEC through lunch-and-learn sessions and obtained study approval from HBEC, prioritizing meaningful engagement over simply utilizing existing research infrastructure. Our team volunteered to deliver presentations on the importance of participating in research and provided workshops and toolkits to support ongoing programming. We invested in relationship-building prior to initiating recruitment by attending community events, meeting with organizational leaders, and volunteering at partner-led activities. This approach established trust and demonstrated a commitment beyond data collection.
• 3.Shared Decision-Making: In our prior studies, study approval required formal presentations and report reviews to gather community feedback. For instance, in order to gain access to the PRP, we presented our study to the HBEC composed of organizational community members, which met quarterly to provide approval of and feedback on the study.
• 4.Sustainable Engagement: To ensure sustained engagement, we developed capacity-building opportunities for partner organizations, including workshops on the value of research participation and diabetes education, that extended beyond our specific study goals. The research team also engaged in non-research-related activities, such as assisting with health screening data entry from the MMHF annual men's health fair and volunteering at fundraising events. Our peer leaders also participated in recording videos for the MMHF to demonstrate to funders and potential participants the impact of our peer leader support program.

These strategies transformed conventional recruitment relationships into true research partnerships, increasing both recruitment effectiveness and program sustainability.

3.2. Adapting research procedures

Flexibility and adaptability in research procedures were essential in addressing the unique needs of Black men with T2D. Scheduling intervention sessions during evenings and weekends allowed participants to balance work and family responsibilities while engaging in the program. Our study also utilized a virtual platform, Zoom for Health, for all intervention sessions, further enhancing accessibility by eliminating transportation challenges and accommodating participants' preferences for remote engagement [16]. It is also important to note that sessions initially were in person for MenD I. However, Covid-19 and social distancing requirements led to a pivot to Zoom for Health.

During MenD II, we incorporated a flexible ongoing support phase, allowing peer leaders and participants to decide the frequency and format of their meetings. This adaptation acknowledged participants' busy schedules while maintaining the intervention's focus on sustained peer support.

3.3. Role of peer leaders

Peer leaders were a cornerstone of both MenD I and MenD II. As Black men with lived experiences of managing T2D, they provided relatable support, fostering trust and camaraderie among participants. Their involvement was instrumental in addressing cultural stigmas associated with seeking help and discussing health challenges. Peer leaders participated in DSME sessions under the supervision of the CDCES and independently led DSMS sessions, providing guidance and encouragement rooted in shared experiences. Our CDCES was available for one-on-one check-ins as needed with participants and peer leaders were encouraged to communicate and support one another outside of study sessions, indeed, they reported establishing a support group via text and arranging meetups between sessions and after the study concluded.

The peer leader training program emphasized cultural humility, active listening, and strategies for fostering group cohesion. This training prepared them to address participants' concerns and promote meaningful discussions. The peer-led model enhanced the intervention's cultural relevance and created a supportive environment where participants felt heard and valued. Additionally, training incorporated examples reflecting Black men's lived experiences, and all materials, including the diabetes self-management guidebook, were developed by experts in the field and written at an eighth grade reading level. Notably, peer leaders previously participated in a PLDSMS program and were thus acutely more cognizant of participant needs.

3.4. Retention strategies

Participant feedback led to changes in retention efforts, primarily the need to foster a sense of community. Social support and brotherhood were integral to the study's design, with sessions incorporating time for informal interactions and relationship-building. Personalized check-ins, conducted regularly by research staff, helped participants feel valued and supported throughout their involvement in the study.

Incentives also played a role in retention, with participants receiving compensation for completing health assessments and program milestones. Beyond financial incentives, participants appreciated the program's tangible benefits, such as receiving culturally relevant DSME and developing connections with peers facing similar challenges.

3.5. Building trust and addressing mistrust

Overcoming historical mistrust required intentional efforts to establish and maintain trust with participants. These efforts included 1) emphasizing transparency about the study's purpose, processes, and benefits at every stage and 2) engaging Black men in recruitment and intervention delivery to bridge trust gaps and demonstrate commitment to their needs. For example, Black men who completed initial MenD I and II assessments were encouraged to recruit others from their social networks who met eligibility criteria.

Addressing participants' concerns about research participation was essential, including ensuring confidentiality and de-identifying personal information in study findings. Open discussions about the study's goals and their contributions to improving health outcomes fostered a sense of shared purpose and empowerment. Regular follow-ups, including reminder calls and text messages, reinforced participation and reduced attrition. Lastly, conducting health assessments in trusted community locations, such as churches and senior centers, helped alleviate discomfort associated with traditional clinical settings.

3.6. Expanded recruitment strategies in MenD II

Building on lessons from MenD I, we implemented additional recruitment approaches in MenD II.

• 1.Healthcare System Registries: We partnered with a local healthcare system to identify potential participants through their electronic health records. As part of this process, we obtained appropriate human subjects approval, followed by researcher contact if patients expressed interest.
• 2.Social Media Outreach: We developed culturally tailored recruitment materials for Facebook targeting men aged 55+ in the Metro Detroit area with interests related to health, diabetes, or community events. These advertisements highlighted peer support aspects and featured images of Black men similar in age to our target population.

Each strategy's effectiveness varied, with electronic health records yielding the highest consent rate, followed by social media recruitment.

3.7. Addressing structural and sociocultural barriers

Our intervention specifically addressed several key structural and sociocultural barriers that affect Black men's participation in health research.

• 1.Economic and Logistical Barriers: Our shift to virtual delivery eliminated transportation barriers while maintaining engagement in the initial study. Additionally, we offered flexible scheduling options including early morning to evenings to accommodate participants' work schedules.
• 2.Masculinity and Help-Seeking Behaviors: Program materials and recruitment messaging were framed around strength, self-reliance, and brotherhood rather than vulnerability or dependency. Peer leaders were trained to facilitate discussions that acknowledged traditional masculine norms while encouraging health-promoting behaviors within this framework.
• 3.Healthcare Access Limitations: Peer leaders were trained to support participants in discussing their roles with healthcare providers. Given the variability and local nature of community resources, peer leaders referred participants to study staff or the CDCES when specific issues arose. The diabetes guidebook included updated links to credible sources for medication and diabetes-related information.
• 4.Digital Divide Considerations: To address potential technology barriers, we offered tablets with cellular data plans to participants without internet and staff participated in one-on-one technology assistance with technology use, such as help logging into zoom, when needed.
• 5.Health Literacy Concerns: Educational materials and resources were developed to reflect the experiences of Black men with T2D in Southeast Michigan, ensuring cultural relevance and accessibility by using an eighth-grade reading level and incorporating culturally resonant examples and imagery.

These targeted approaches directly addressed the structural and sociocultural factors identified in our introduction, resulting in higher engagement among a population traditionally underrepresented in diabetes intervention research.

4. Conclusion

Building trust and fostering community connections were critical to recruiting and retaining Black men in the MenD studies. Despite historical mistrust and structural barriers, our findings indicate that culturally tailored, peer-led interventions can effectively engage Black men in diabetes self-management programs. Enrollment and retention improved significantly in MenD II by introducing flexible schedules, virtual delivery, and ongoing support, demonstrating the value of adapting interventions to meet participants' needs.

Data suggest that Black men benefit significantly from peer-led diabetes support models, particularly when those models incorporate culturally relevant strategies and address barriers to participation. Our findings emphasize the need for researchers to remain vigilant in addressing systemic inequities and continue refining recruitment and retention approaches. By leveraging adaptable, community-driven strategies, future interventions can better support Black men in managing their health. Our experiences highlight the importance of strong community partnerships to overcome challenges and meet participants' immediate needs. Although these partnerships allowed us to align intervention goals with community priorities and foster trust among participants, one limitation of this study is that the lessons learned solely rely on qualitative observations.

Recruiting and retaining Black men in diabetes research requires a commitment to culturally tailored, community-focused strategies prioritizing trust-building and flexibility. While challenges remain, the insights gained from MenD I and MenD II provide a foundation for reimagining how diabetes interventions can be implemented and scaled in diverse community settings to address health disparities and improve outcomes for Black men.

CRediT authorship contribution statement

Jaclynn M. Hawkins: Writing – review & editing, Writing – original draft, Methodology, Conceptualization. Alana M. Ewen: Writing – review & editing, Writing – original draft. Martha Funnell: Writing – review & editing, Conceptualization. Robin Nwankwo: Writing – review & editing, Conceptualization. Gretchen Piatt: Writing – review & editing, Conceptualization.

Informed consent

All participants provided written informed consent prior to their participation in the study. The consent process included a detailed explanation of the study's purpose, procedures, risks, and benefits, ensuring participants understood their rights, including their right to withdraw at any time.

Glossary

• •Recruitment: The process of identifying, approaching, and enrolling participants into a research study.
• •Retention: Strategies and efforts used to maintain participant engagement and ensure continued involvement in a research study.
• •Community-Based Participatory Research (CBPR): A collaborative research approach that actively involves community members in the research process to enhance the relevance and impact of the study.
• •Culturally Tailored Interventions: Research-based strategies that consider the cultural beliefs, values, and practices of a specific population to improve engagement and effectiveness.
• •Health Disparities: Differences in health outcomes and access to healthcare services among different population groups, often due to social, economic, and environmental factors.
• •Diabetes Self-Management Education (DSME): Structured programs that provide individuals with diabetes the knowledge, skills, and support needed to manage their condition effectively.

Ethics approval

This study was approved by the Institutional Review Board (IRB) at the University of Michigan (IRB #HUM00200496.). All research activities were conducted in accordance with ethical guidelines and principles outlined in the Declaration of Helsinki.

Funding

The Michigan Men's Diabetes Project is supported by the National Institute on Aging (2P30AG024824–16), Blue Cross Blue Shield Foundation of Michigan (003063.MG), and the Michigan Center for Diabetes Translational Research (NIDDK P30DK092926).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request.