A collaborative approach to the recruitment and retention of minority patients with diabetes in rural community health centers

doi:10.1016/j.cct.2008.09.007

Contemporary Clinical Trials

Volume 30, Issue 1, January 2009, Pages 63-70

https://doi.org/10.1016/j.cct.2008.09.007 Get rights and content

Abstract

Context

Recruiting and retaining minorities from rural, community health centers is a challenge. Collaboration between the researchers and health center personnel and activities to enhance trust may improve results.

Purpose

To describe recruitment and retention strategies and report results of a 12-month clinical trial of a telemedicine-based diabetes self-management intervention, conducted within a rural community health center.

Methods

Multi-level, multi-staged recruitment process including collaborative planning, data extraction, medical record review, telephone screen, 2 in-person enrollment visits and randomization. Target sample was adults ≥ 35 years of age with type 2 diabetes, glycated hemoglobin (GHb) > 7% with no significant comorbidities to prevent safe participation. Follow-up visits occurred at 6 and 12 months post-randomization.

Findings

Of those eligible from medical record review, 65% were African-American(AA)/other and female. Approximately 33% of those successfully contacted by telephone were randomized (n = 165), yielding a predominately AA/other (73.9%) and female (74.5%) sample. Among those eligible at the Telephone Screen, a greater percentage of Non-Hispanic Whites (NHW) refused participation than AA/other (54.2% vs 45.8%), while a greater percentage of women refused compared to men (64.4% vs 35.6%). Significant baseline differences were found by ethnicity for education, insurance, transportation and diastolic blood pressure; by gender for income, transportation, weight, and home monitoring of blood glucose. Overall 6 and 12 month retention rates were 90.9% and 82.4%, respectively, with a greater percentage of AA/Other and female participants retained.

Conclusions

Our collaborative approach was successful in recruiting and retaining ethnically diverse study participants who reside in a rural underserved area of South Carolina. Differences in baseline characteristics and retention by ethnicity and gender were found. Successful translational research must allow for a collaborative approach addressing factors at the level of the community health center, key personnel, and patients in an effort to build trust for the purpose of advancing the science of translating research to practice.

Introduction

While federal requirements for inclusion of minorities and women in federally funded research [1], [2] has resulted in increased representation of these groups, there is still room for additional improvement [3]. Recruitment from within the community health center setting may be ideal, as the population served, particularly in rural areas, is predominately women [4]. Yet this environment can be challenging due to numerous factors including Health Information Portability and Accountability Act (HIPAA) regulations [5], organizational readiness [6], [7], trust, and participant and physician interest and motivation [8], [9], [10], [11]. A relationship between the academic institution and the community health center based on mutual respect is critical to facilitate translational research [12], [13], [14], [15]. Furthermore, involvement by community health center personnel and health system infrastructure may be vitally important to efficiently conduct research in terms of the successful recruitment and retention of subjects.

The American Diabetes Association (ADA) has advanced evidence-based clinical practice guidelines [16]; however these guidelines are often unmet [17], [18], [19], particularly in medically underserved communities [20], [21]. Telemedicine technologies exist that may enhance adherence to clinical practice guidelines [22], [23], [24], [25]. We are conducting translational research to evaluate telemedicine using interactive videoconferencing to increase the availability of health professionals in rural underserved communities for the effective delivery of a diabetes self management education program (Diabetes TeleCare or DTC) and as a means to provide retinal assessments in the primary care setting. Key study outcomes include metabolic status (glycated hemoglobin (GHb), lipids, blood pressure, frequency of retinal examinations), self-management behaviors, quality of life and cost effectiveness. The study is set in a Public Health Service-designated medically underserved community with a relatively high proportion of African American residents, a population in which the prevalence of diabetes is higher, and metabolic control is worse, compared to non-Hispanic white populations [26], [27].

We describe herein our translational research experience with community health centers in rural medically underserved areas. Our goal is to share strategies that led to a productive collaborative research environment between the health centers in South Carolina and the academic research institution located more than 100 miles away. Planned activities that were designed to establish relationships, foster ownership of the research process, and build trust ultimately resulted in the successful recruitment, randomization and retention of ethnically diverse participants. Specifically, participants were randomized to either: 1) a 13 session self-management intervention conducted by a nurse/certified diabetes educator and dietitian using videoconferencing, and an ophthalmologist via remote retinal interpretation or 2) usual care. Our research methods may be of interest to the reader who desires to establish a collaborative research environment with community health centers in rural underserved communities for the purpose of conducting translational research.

Section snippets

Setting

The South Carolina Primary Health Care Association (SCPHCA) is a consortium of federally qualified health centers (FQHCs) across the state. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors [28]. Our prior work with the SCPHCA has led to the identification of FQHCs in which we successfully conducted research resulting in positive working relationships

Collaboration and trust

Of paramount importance was the development of strategies that fostered collaborative relationships and trust before translational research activities began. For example, in-person visits to the community health centers were organized to assess organizational resources, barriers, interest and needs prior to initiating the research. These visits took the form of meetings with key staff identified by the upper management at the community health centers. Overall, 90% of the community health center

Discussion

We report our recruitment and retention strategies and the baseline characteristics of participants in a randomized clinical trial designed to evaluate the effectiveness of a telemedicine-facilitated diabetes self-management intervention, which included a retinal assessment and was implemented in a rural, medically underserved community. Diabetes TeleCare Study planning from the earliest inception involved community health center personnel to understand and communicate the needs of the

Acknowledgement

Supported by the National Institutes of Health through the National Institute of Diabetes and Digestive and Kidney Diseases (1R18DK067312). We would like to thank Ann Lewis, CEO, providers, staff and patients at CareSouth Carolina, Inc. for their participation, without which we could not have completed the work.

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