BRIEF REPORT: If You Build It, They Will Come

Abstract

BACKGROUND

Latinos have low representation in cancer prevention trials and intervention studies. Culturally appropriate recruitment strategies are needed to address this issue.

OBJECTIVE

To describe and summarize the effectiveness of recruitment strategies used by the Latin American Cancer Research Coalition (LACRC).

DESIGN

Descriptive report of recruitment methods.

PARTICIPANTS

Uninsured Latino immigrants (N=1,170; 77% female, 23% male) from Central and South America recruited to 7 cancer control studies.

APPROACH

The LACRC recruitment model involved inclusion of Latino researchers and providers, and use of culturally acceptable materials released through culturally appropriate outlets such as Latino radio stations.

RESULTS

The overall participation rate was high—96% of patients identified as eligible agreed to participate. Women were excellent referrals for recruiting men to research studies. Additionally, a local Latino radio program was used to efficiently recruit eligible study participants.

CONCLUSIONS

Latinos are interested and willing to participate in cancer control studies when culturally relevant approaches are used. Research teams that partner with Latino researchers and with Latino service providers are important in educating Latinos about cancer control and encouraging participation in research.

Approximately 35.7 million Latinos live in the United States, making them the largest and fastest growing minority group.¹ While Latinos have lower cancer incidences than non-Hispanic whites for most leading cancer sites, they are more likely to be diagnosed with nonlocalized disease.^2–4 While cancer control and clinical translational trials may reduce cancer morbidity and mortality, Latino representation in these studies is low. In prior breast cancer prevention trials,<4% of women recruited were Latinas despite targeted mass media approaches, and only 3% of men in the Southwest Oncology Group's prostate cancer prevention trial were Latino.^5,6 Factors such as low literacy, limited knowledge about cancer prevention, insurance status, and low self-efficacy have been noted as barriers to clinical trial participation for Latinos.⁷

The underrepresentation of Latinos in cancer research may be, in part, due to lack of culturally appropriate strategies.^8,9 Participatory and community models that incorporate members from the same cultural group and use culturally adapted materials have been effective in recruiting Latinos and other minorities into health studies.^9–11 This paper describes recruitment methods used by the Latin American Cancer Research Coalition (LACRC), summarizes their effectiveness, and proposes a research development model for recruiting Latinos into cancer control studies.

METHOD

The LACRC model to conduct cancer control studies includes a dynamic coalition of primary care partners, interdisciplinary researchers, and advisors. The LACRC is comprised of a hospital-based cancer screening clinic, a university-based comprehensive cancer center, several primary care clinics, university-based schools of business and nursing, cancer advocates, survivors, community organizations, and the National Cancer Institute's (NCI) Cancer Information Service.

The Latino population in the mid-Atlantic region is demographically different from most previously studied Latino groups. Most of the estimated 436,238 Latinos in this region are recent immigrants from Central and South America, with the greatest numbers from El Salvador. Many are uninsured, poorly educated, lack legal resident status, do not speak English, and at least 20% live in poverty.^1,12–15 Fifty-two percent to 64% are recently immigrated (<5 years) to the United States, compared to a national average of 29%.

Since 2001, the LACRC has completed 7 studies that use both qualitative and quantitative approaches (see Table 1). The LACRC model for research, TRUST, is based on the inclusion of trained multicultural staff, Latino media, social networks, Latino spokespersons to facilitate community entrée, and culturally tailored messages. Table 2 presents the main components of the TRUST model. The first 2 components of the TRUST model reflect the development of a culturally appropriate infrastructure. The last 3 are specific to study recruitment activities. Aspects of our TRUST recruitment model are described below.

Table 1.

LACRC Recruitment Methods and Characteristics of Study Samples (N=1,170)

Study	Participation Rates	Sources	Recruitment Methods					Consent Type	Country of Origin	Gender	Education (≤High School)	Age, y
			Posters	Flyers	Radio	Referral2	Incentive
Cancer prevention priorities (N=88)	93%	Clinic, community sites	–	X	–	X	$50 Cash	Written	United States 8% Mexico 10% Central America 60% South America 16% Other 7%	Male 56%	51%	13–60
RCT feasibility (N=79)	96%	Clinic	–	X	–	–	–	Verbal	N/D	Female 100%	N/D	36–91
Breast cancer prevention* (N=450)	95%	Clinic	X	X	–	X	$15 Gift card	Written	Central America 51.42% South America 27.36% Other 21.22%	Female 100%	70%	33–81
Latina trust (N=178)	95%	Clinic, community sites	X	X	X	–	$10 Gift card	Verbal	Central America 31% South America 57% North America 8% Other 4%	Female 100%	55%	21–90
Tobacco use (N=305)	97%	Clinic and ancillary services, health fair, community sites	X	X	X	X	$10 Gift card	Written	United States 2.3% Mexico 9.2% Central America Caribbean 51.5% South America 30.9% Other 5.25%	Male 65%	66%	18–76
Colorectal screening (N=70)	98%	Clinic, food program, community sites, female focus groups.	X	X	X	X	$50 Cash	Written	Mexico 2% Central America 39% South America 55% Other 2%	Male 28%	43%	50–80

^*Combined two studies of breast cancer risk and STAR enrollment intervention from family members, or social network.

LACRC, Latin American Cancer Research Coalition; N/D, not determined; RCT, randomized clinical trial; STAR, Study of Tamoxifen and Raloxifene.

Table 2.

The LACRC Method for Study Recruitment: TRUST

Approach	Example
Teams are interdisciplinary and include Latino researchers	Latino primary investigators, junior faculty, interviewers
Recruit and train bilingual and bicultural staff	Research training for clinic staff, internships for Latino students, training and mentorship for Latino and non-Latino researchers
Use recruitment strategies that include Latino mass media and places of social interactions	Latino radio programs, community clinics, community radio, community locations
Spokesperson(s) facilitate access into the community and provide feedback to research teams	Partner with trusted media personality and safety net providers
Tailor strategies for literacy, linguistic, and cultural appropriateness	Messages incorporate Latino culture and are specific to group targeted

Teams Are Interdisciplinary and Include Latino Researchers

Central to overcoming barriers to research participation among Latinos is maintaining bilingual multiethnic interdisciplinary research teams. The LACRC developed an initiative to engage Latino researchers and medical professionals in the research process. The LACRC provided training opportunities for junior faculty, health care professionals, and graduate students from various disciplines and paired non-Latino investigators with Latino researchers and medical professionals. The interdisciplinary research team has expertise in oncology, geriatrics, epidemiology, primary care, psychology, cancer control, social marketing, community-based research, anthropology, and minority health. A community advisory group provides input, creating appropriate recruitment approaches and better understanding of Latinos' priorities.

Recruit and Train Bilingual and Bicultural Staff

Key to the LACRC's success is its partnership with 5 primary care clinics. These clinic partners are nonfederally funded, community based, and specialize in serving uninsured Latinos, many of whom are recent immigrants. Clinics are funded by the NCI to dedicate a bilingual staff member trained in cancer control, as well as for percent time for a primary investigator (generally the medical director) in each clinic.

Use Recruitment Strategies that Include Latino Places of Social Interactions

Recruitment approaches combined resources and activities of the partner clinics and Latino service providers (e.g., English as second language classes) to facilitate reach of messages into the community. Posters and flyers were placed in the clinics. The LACRC distributed cancer education materials and recruited subjects at various health fairs in the Latino community.

Spokesperson(s) Facilitate Access into the Community and Provide Feedback to Research Teams

To facilitate rapid access into the Latino community, the LACRC built upon the successful community connections of Dr. Elmer Huerta and safety net clinic partners. Dr. Huerta is an oncologist from Peru and is internationally known by the Latino community for his efforts in educating the community through the media.¹⁶ In a survey of 97 patients in 2 partner clinics, 70% stated that they regularly listened to Dr. Huerta's radio program (MJK, VBS, JM, and EEH, unpublished data, 2005). The LACRC's recruitment messages for breast cancer prevention and tobacco were integrated within Dr. Huerta's daily radio program Cuidando su Salud (Taking Care of Your Health). Culturally appropriate content was included by combining medical information with music, poetry, and literature from Latin America. Listeners were given instructions to call the LACRC office if they were interested in participating in the study. Participants reported that knowing that calls would be answered in Spanish made them feel more confident about calling. Within 2 days, 100 eligible women were recruited for one study. The LACRC also announced studies on the Spanish Catholic Center's weekly Latino radio program.

Tailor Strategies for Literacy, Linguistic, and Cultural Appropriateness

Needs assessment activities conducted at the onset of development of the LACRC infrastructure informed recruitment strategies. An interdisciplinary team of translators, researchers, bilingual staff, and consumers worked to tailor recruitment materials for literacy, linguistic, and cultural appropriateness.^6,7,9,17 For example, the consent process is critical to subjects' participation in research studies. The NCI has identified the need for research aimed at simplifying the informed consent process by improving comprehension and identifying methods to provide study information to diverse populations.¹⁸ The translation team worked with investigators to translate and simplify consent forms, keeping in line with Institutional Review Board and HIPAA (Health Insurance Portability and Accountability Act of 1996) guidelines.

“Community as family” was the promotional message for study recruitment—health providers and community members as one family. We included images and slogans reflecting the notion of familialism (significance of the family), simpatia (importance of friends and family in problem solving), and respeto (personal integrity). One slogan was “saber mas sobre nuestra salud es importante para nuestras familias Latinas” (knowing more about our health is important for our Latino families).^9–11 Vivid colors used in Latin folk art were used for print materials and images to reflect family unity and the multicultural composition of the Latino community.

RESULTS

The overall participation rate—which we define as number of women and men who participated in a study compared to the number of women and men approached for study participation—was 96%. Participation rates varied only slightly across studies. It should be noted, however, that when using radio it was not possible to accurately estimate the denominator.

DISCUSSION

This work demonstrates that Latinos may be more interested in participating in cancer control research if recruited using culturally appropriate methods. First, our work supports the importance of the media as a source of health information in the Latino community as demonstrated in other studies.^16,19 The LACRC found that integrating messages on Latino radio may provide an excellent way to recruit participants and test educational campaigns.

Second, we were able to successfully recruit Latino males, a traditionally hard-to-reach group. As suggested by Marin and Marin⁹ we found that gender, ethnicity, and language matching of research staff to subjects was important for aproaching Latino subjects for study participatation. Thus, using male interviewers may have increased Latino men's willingness to participate in our studies. Another key resource for recruiting men to LACRC studies were males' female family members. Future interventions can build upon this finding by promoting family- and community-centered approaches to cancer control research.

Last, our findings support the notion of the importance of partnering with Latino service providers. In our target area, safety net Latino medical providers were important resources for referrals, adding legitimacy to the research and ensuring that research was appropriate and relevant to the community.

This study has many important strengths; however, there are several caveats that should be considered in evaluating our results. This report describes data collected from a largely uninsured, Spanish-speaking group of men and women who recently emigrated from Central and South America and who are living in an urban area of the United States. Results may differ in other Latino groups. Future studies should examine costs and benefits associated with various recruitment strategies and provide detailed assessment of success by age, gender, and Latino subgroups (e.g., Mexicans, Cubans, etc.).

Central to the LACRC's success to date has been the foundation of relationships between investigators, clinicians, research staff, and the Latino community. These relationships are based on a commitment to improving cancer control and prevention within the Latino community, the provision of funding to support participation, and trust. From this experience, we have developed a model for building a successful and productive research infrastructure. Future strategies to recruit Latinos into cancer research can build upon our TRUST model, taking into account the specific needs and characteristics of the targeted population and existing community resources.