Strategies for Recruiting African American Men into Prostate Cancer Screening Studies

Abstract

Background

Recruitment for research and clinical trials continues to be challenging. Prostate cancer is the most commonly diagnosed cancer in men and disproportionately affects African American men; thus, effective recruitment strategies are essential for this population.

Objectives

To focus on innovative and effective recruitment strategies for research on prostate cancer with minorities.

Methods

A systematic description is provided of the recruitment efforts for a hermeneutic phenomenological qualitative study of African American men's experiences in decision-making on whether or not to have a prostate cancer screening.

Results

Seventeen African American men were enrolled from rural Central Virginia. Recruiting strategies were targeted on places where African American men usually are found, but that are rarely used for recruitment: barbershops, community health centers, and churches. Word-of-mouth was used also, and the majority of the participants (n = 11) were reached through this method.

Discussion

Recruitment efforts have been noted to be particularly challenging among minorities, for numerous reasons. Making minority recruitment a priority in any research or clinical trial is essential in gaining a representative sample. Word-of-mouth is a powerful tool that is often forgotten, but should be looked at in further detail.

Several researchers (Britton et al., 1999; Heiat, Gross, & Krumholz, 2002) have noted that minorities and individuals from vulnerable populations (e.g., low-income, low-literacy, chronically disabled, and lacking or with limited community resources) have been underrepresented in clinical trials. However, although the 1993 National Institutes of Health (NIH) Revitalization Act mandated the inclusion of minorities in clinical trials and there have been attempts to enhance minority participation, there are still disparities in participant recruitment (National Institutes of Health, 1994).

Little is found within the literature on strategies for recruiting African Americans into research. Participation of African American people in clinical trials and research is limited, particularly among men. There is significant need for the placement of enhanced research recruitment strategies to obtain adequate health data from this vulnerable population. Minorities can be recruited successfully with planning and open communication. Different recruitment venues were used in this study, and planning was focused on recruiting African American men into research on the meaning of prostate cancer screening. Thus, this report is focused on the successful recruitment strategies of a study examining rural African American men in their decision whether or not to have a prostate cancer screening.

Involving minorities is particularly important in research on prostate cancer, which affects African American men more than other ethnic groups (Jones, Underwood, & Rivers, 2007). The incidence rate of prostate cancer in African American men is 239.8 per 100,000 compared to 153 per 100,000 for White men, 133.4 per 100,000 for Hispanic men, 91.1 per 100,000 for Asian/Pacific Islander men, and 76.1 per 100,000 for American Indian/Alaska Native men (Horner et al., 2008). Although incidence is high in African American men, a limited number of these men are enrolled in studies related to prostate cancer screening due to the recruitment barriers (Coleman et al., 1997; Royal et al., 2000). The significance of the problem with African American recruitment as it pertains to research, particularly prostate cancer research, is evident from the increased incidence rate within this population. While prostate cancer screening is fairly effective at early detection, screening is controversial and it has not been shown that prostate cancer screening decreases mortality rates in randomized controlled clinical trials. As a result, the United States Preventive Services Task Force concluded that the evidence is insufficient to recommend for or against routine prostate cancer screening. Nevertheless, screening offers the only possibility for early detection of prostate cancer, which is very important, particularly in high-risk individuals, such as African American men and persons with a first-degree relative (i.e., father, brother) who has been diagnosed with prostate cancer.

Background

There are numerous barriers to minorities' participation in research and clinical trials. Previous researchers have noted that minorities distrust researchers and medical institutions (Alvidrez & Arean, 2002; McCaskill-Stevens et al., 1999) as a result of decades of being coerced into participating in studies that did not have participants' well-being as a priority. Other barriers include lack of researchers' cultural sensitivity (Choi & Smith, 2004), lack of transportation (Brown, Fouad, Basen-Engquist, & Tortolero-Luna, 2000), lack of understanding of clinical trials (Ford et al., 2008), and inadequate incentives (Ashing-Giwa & Ganz, 2000).

Two major barriers are unique to recruiting for randomized clinical trials (RCTs) and, although true for all participants, may have particular cogency for minorities. The first is the impression that participants are being experimented on. This comes from a lack of trust that researchers are interested in the welfare of the participants. To be recruited, participants have to be convinced that they are individually more important than the data that the research will yield. The second barrier is that an RCT means that one group will receive the experimental treatment (drug, teaching, device, or personal care) and another will not. In order to recruit participants, researchers need to deal directly with the fact that a new treatment that may have benefits will be withheld from about half of the participants.

The best way to address the first barrier, the idea that one is being experimented on, is through establishing trust. Assurances, in writing, that danger to the participant will be addressed immediately and personal welfare will always outweigh data collection are important, but trust in the researcher or team of researchers on a personal level is of the upmost importance. The best way to deal with the second problem is to use a crossover design if possible. In that way the experimental treatment will not be withheld from any group. Groups will receive the treatment at different times. The advantage of being in the control group the first time is that if any risks appear in the treatment in the first round, the control group will be spared the risks. The advantage of being in the experimental group in the first round is that the benefits of the treatment (if there are any) will be enjoyed by the participants sooner.

Methods

The purpose of this hermeneutic phenomenological (Cohen, Kahn, & Steeves, 2000) qualitative study was to explore the experiences of rural African American men in decision-making regarding prostate cancer screening. The study was conducted in central Virginia. Narratives about deciding to have or not to have a prostate cancer screening were analyzed in a three-step process. First individual units of meaning or strips (Agar, 1986) having to do with screening decisions were identified. Second, the strips were grouped into categories based on similarities of meaning. Finally, the categories were arranged to form themes expressing the participants' experiences.

Study participants met the following criteria: (a) at least 40 years old; (b) self-reported African American male; (c) never been diagnosed with prostate cancer; (d) and able to provide informed consent. Interested men contacted the first author, and a time and location convenient for the participant were established to check eligibility and conduct an interview. The Institutional Review Board at the University of Virginia approved the study.

Recruitment Strategies

It has been noted that investigators who value the importance of minorities in research have more success with minority recruitment (Williams & Corbie-Smith, 2006). The authors of this study took special care in deciding where to recruit these rural participants. Their previous experiences (Jones, Taylor, et al., 2007) in recruiting research participants from a variety of sources aided in the decision of where to recruit. The authors first discussed venues where African American men were likely to be found. Once a list of potential places was created, a plan to recruit participants was initiated. Flyers, local newspaper announcements, and public service announcements were used to disseminate information at the beginning of the study. African American men were recruited through announcements on television and radio stations that African Americans listen to, in community health centers, and in recreational centers in rural areas. In addition, the first author made a point of not only sending out announcements to businesses in the rural localities, but actually visiting and creating a trusting relationship with the proprietors of barbershops, churches, and convenience stores where African American men often were found. Developing these trusting relationships was important, because they not only gave direct access to potential participants who came into those places, but also created future relationships.

One venue that was particularly important in recruitment efforts was barbershops. For African American men, barbershops are more than a place to get a shave and haircut; they are places for social networking (Murphy, 1998). For decades, there were only a few places where African American men, regardless of their education, socioeconomic status, or occupation, could congregate and voice their opinions about various topics, and one of those places was in Black-owned barbershops (Harris-Lacewell, 2004). Further, there have been successes in health promotion and treatment for African American men in such nonconventional areas as barbershops (Hart et al., 2008). For instance, Hess et al. (2007) found that a blood pressure intervention implemented in barbershops lowered blood pressure significantly more than standard screening and health education.

In this study of prostate cancer screening, a list of the Charlottesville area Black-owned barbershops was created by searching the business advertisement section of the phone book and obtaining barbershop names from minority leaders. Once the list was created with telephone numbers, the first author (an African American himself) called proprietors of the barbershops to ask for an estimate of who they primarily had as clients. He then set up meetings to talk about the study's aims with each proprietor. This allowed him to confirm whether the majority of the barbers' clientele were African American men. The proprietors thought the study would be well-received by clients, and they were pleased there were studies focused on the health of African American men. They agreed to allow the investigators to place flyers in their establishments and to sit in their waiting rooms in case there were any clients interested in the study. Often, the proprietor would mention the study to a client who seemed to meet the eligibility criteria, and if he wanted more information, the potential participant could call the investigator or talk directly to the investigator if the investigator was present that day. At the time of the study, there were four Black-owned barbershops in Charlottesville that had a majority of African American clients.

Another important recruitment tactic was word-of-mouth communication about the study from men who were planning to participate or had participated already. Word-of-mouth was defined as someone hearing about the study from a family member, friend, coworker, study participant, or another source trusted by that particular individual. The effectiveness of word-of-mouth has been underrated, though several researchers (Lee et al., 1997; Peck, Sharpe, Burroughs, & Granner, 2008) noted that word-of-mouth is often more effective than other strategies in recruiting individuals, particularly minorities. Word-of-mouth and snowball sampling are similar strategies that can be used to locate a hidden population to whom it may be challenging to gain access. However, the difference between the two recruitment strategies is that true snowball sampling would begin with a randomized selected sample from a population, and then each participant would be asked to give a reference of someone who meets the eligibility criteria (Goodman, 1961; Sudman, 1976). Conversely, the word-of-mouth strategy that was used in this study started with community gatekeepers and those who participated in the study to communicate the details of the study to others.

Word-of-mouth and social networking can decrease anxiety and distrust that may be present initially when potential participants hear of a study (Hooks et al., 1988). The strategy of word-of-mouth is particularly successful among populations with strong cultural values and for informal communication, such as with African American people (Jones, Steeves, & Williams, 2009). Not only can word-of-mouth be an effective recruitment tool, but it can also be cost-efficient, since this strategy provides practically free outreach to members of the population of interest. In the current study, the majority of participants (n =11) reported they heard about the study from someone else who was planning to be interviewed. This first author had similar experiences in previous studies (Jones et al., 2006; Jones, Taylor, et al., 2008; Jones, Utz, et al., 2008). In the current study, once an interview was complete, participants often asked for a flyer or said they knew of a person who might be willing to participate. Also, the first author consistently gave participants a flyer in case they might want to give it to someone else eligible for the study. The first author also formed a trusting relationship with one of the community gatekeepers after he enrolled in the study. After his interview, he decided that the study was important for men, particularly African Americans. The strategy of word-of-mouth became even more effective when this gatekeeper began to talk about the study to friends who might be appropriate participants.

In addition, the first author visited and spoke with administrators of clinic health departments and church ministers about the study's significance. They agreed to have flyers and announcements placed in their departments and churches, and several said that prostate cancer was an important subject that needed to be studied in more depth, particularly in the minority population.

Results

The original list of venues for recruitment included 4 Black-owned barbershops, 6 churches, 4 community health centers, 3 radio stations, and 1 recreational center. From that list, 3 participants heard about the study at the barbershop, 1 person saw a flyer in the health department, 2 persons heard about it on the radio, and the majority (n = 11) of the participants heard about the study by word-of-mouth. A total of 17 African American men were enrolled in the study. The men signed a consent form before the 1.5-hour interview began, and they each received $30 for participation. The men's ages ranged from 40 to 71 years with a mean of 52 years (SD = 10) years. Six participants had graduated from high school, and 12 were employed, with yearly incomes between $1,000 and $30,000. Seven of the men were married; only three were uninsured. All of the participants, as well as the barbershop proprietors, church leaders, and community health center leaders, gave positive feedback and expressed gratitude for the study. They stated that issues that affect minorities the most are often not addressed, and they were appreciative for the opportunity to talk about health issues that can affect African American people, particularly men.

Discussion

In this study, a trusting relationship with key people or community gatekeepers appeared to be a major factor in recruitment of participants. Given the mistrust by minority populations of healthcare providers and researchers, establishing trust between researchers and the larger community is imperative. When designing a study, researchers should place a priority on minority recruitment for their sample. Researchers who prioritize minority recruitment at the beginning of a study are more successful than those for whom minority recruitment is an afterthought (Corbie-Smith, Thomas, & St George, 2002; Durant et al., 2007).

Despite barriers to recruiting minorities in clinical trials, this study suggests some strategies that may improve enrollment. First, it is important to build trust in the community and identify gatekeepers of the community. If the community does not trust the researcher, then it is hard to gain access to potential participants. Second, it is important to rely not only on one or two methods of recruiting, but to use several. This will increase the chances that the researcher can gain access to a community gatekeeper and improve participant enrollment. Third, it is important to be willing to use unconventional methods, such as recruiting at barbershops or salons. A researcher must recruit where the population is most likely to be found. Most of all, it is important to show respect for the culture of the population and community. This show of respect along with acknowledgment of participants' time and effort (i.e., incentives and thank you cards) is important. It can keep the relationship between the researcher and the community open and allow for future research in that community.

Utilizing these strategies discussed above has the potential to lead to a sufficient sample size in larger studies. Principal investigators should take into consideration the population, geographical location, and the overall community members' previous interactions with research opportunities where the study is being conducted to determine the strategies that are appropriate. However, the fundamentals of these strategies (develop trusting community relationships, use multiple recruitment strategies, and use unconventional methods) are core to the success in recruiting study participants.

A limitation of this study is that it was focused in Charlottesville and South Central Virginia. Geographically, Virginia has a mean percentage of 19.6% African Americans compared to 12.4% for the entire US (U.S. Census Bureau, 2008). In other states that may not have as many African American people, other potential culturally tailored recruitment strategies may need to be created for specific populations.

Conclusion

Word-of-mouth was found to be an important recruitment strategy in enrolling a population that has been known to be challenging to recruit for research. It is imperative to understand the population being recruited for a study, and to know the barriers and facilitators of recruitment for this population. However, researchers can be successful in recruiting minorities if priority and planning for recruitment are dealt with at the beginning of the study by the research team.