Our success recruiting our target population (lower SES, minority, or Spanish-speaking adults at risk of developing diabetes) suggests that our overall strategy may be a model for other studies trying to reach vulnerable and underserved groups. Indeed, about 80% of our final sample is either ethnic minority or had less than or equal to a high school education. Based on Census 2000 and American Community Survey 2006–2008 data for the City of Berkeley (U.S. Census Bureau, 2000
), we overrepresented Latinos and African Americans as well as individuals with a high school or less education. Given difficulties recruiting minority and underserved populations, our approach may offer new ideas for recruiting these population groups into research pertaining to chronic diseases or randomized trials.
We designed outreach and recruitment to utilize existing community resources, to address as many known barriers to recruitment as possible for our targeted groups, and to take advantage of cultural factors supporting participation in research. Most of our methods, delivered in a variety of community settings, are commonly used to recruit vulnerable populations. The uniqueness is that we used these approaches to recruit people to a screening event to assess diabetes risk, not to recruit people directly into the study.
Because outreach and screening were conducted “in-person” by our diverse staff and held at familiar community venues, once a person was deemed “likely at risk of developing diabetes” and recruitment efforts initiated, familiarity with the staff and the setting may have overcome lack of trust, a common barrier (Escobar-Chaves, Tortolero, Masse, Watson, & Fulton, 2002
; Stewart et al., 2006
; Warren-Findlow et al., 2003
). Holding study and program components in local venues and offering to help with transportation and childcare made it more convenient to participate (Escobar-Chaves et al., 2002
; UyBico et al., 2007
; Warren-Findlow et al., 2003
; Yancey et al., 2006
). Explaining the research process using a simple systematic approach may have helped overcome lack of familiarity with research, aversion to randomization, and concern about low literacy (Escobar-Chaves et al., 2002
; Fisher et al., 2002
; Warren-Findlow et al., 2003
; Yancey et al., 2006
). Although others have suggested doing this (Dennis & Neese, 2000
), few studies have done so systematically.
We considered possible reasons why people decided to enroll. First, in Phase II, we were working within a “window of opportunity” in which people had just learned they were “at risk,” thus the study and program were offered as a potential action that could be taken. Consistent with the Health Belief Model (Janz, Champion, & Strecher, 2002
), this “perception of risk” may have helped people decide to do something. Second, once people invest time in something, they are more likely to continue (Rubin et al., 2002
); the fact that individuals had received diabetes education, completed a DRA, and attended a screening event may have influenced their decision to enroll. This is supported by our finding that 90% of those invited to hear more about the study were interested in having the study explained. Last, many people in our targeted neighborhoods had limited access to health care, precluding opportunities for education and lifestyle programs. The “opportunity” of this lifestyle program may have helped people decide to enroll. Despite our successes, we are concerned that almost 30% of those “at risk” and potentially eligible were not interested at the outset.
This project adhered to several principles of Community-Based Participatory Research (Israel et al., 1998
) including building on community strengths and resources, facilitating collaborative partnerships, and integrating knowledge and action for the mutual benefit of all partners. By joining with a health department that already served our target population, we built on community resources, enabling us to conduct a large health education and screening effort modeled after the health department's usual programs. We had two types of collaborative partnership—with the health department to conduct outreach, recruitment, and deliver the lifestyle program and with the four community centers that provided space throughout the entire project. Finally, this project was mutually beneficial: to the university to complete the randomized trial, to the health department because the program was designed to be theirs and remained so at the end of the study, and to the community centers that received several benefits described in our methods. In addition, all outreach and screening took place in the communities in which our target population lived, thus people never had to travel outside of their neighborhood.
Although we could not assess the relative efficiency of the different methods of outreach, our results have implications for future recruitment efforts. To get people to attend a screening event, we invested the most time and staffing in outreach events involving project staff, for example, presentations and tabling. However, results showed that nearly half of those attending a screening event had heard about the screenings through professionals and community partners, which was clearly less expensive. It must be kept in mind, however, that these professionals were inviting people to a diabetes screening, not to a research study. Thus, effort by these community professionals may have been because the diabetes education and screenings provided a unique resource to otherwise underserved communities. Referral by friends or family members also had minimal associated study costs but yielded about 15% of those screened.
Efforts by professionals and community organizations to invite people to a screening had almost no associated cost. Thus, engaging professionals in getting the word out about a study (or screening) clearly is a benefit. Indirectly, organizations that allowed us to conduct outreach and screening at their sites served as “gatekeepers” known to be influential in recruitment (Sinclair et al., 2000
). Several Latino community organizations made considerable effort to recruit people to the screenings, which was important in recruiting Spanish-speaking Latinos. Although we informed professionals in all communities about the screenings and study, professionals in the Latino community made primarily “person-to-person” contacts. For example, an adult school director invited us to discuss diabetes and the screening events to English as Second Language teachers, many of whom invited us to speak to their students. One school implemented an automated “phone tree” informing parents about the screenings, and several principals sent flyers home to parents. These extra efforts by professionals in the Latino community suggest that we filled a need for bilingual health education and screening.
Although our use of community-based diabetes education and screening as a first step was unique at the time we designed the study, several recent lifestyle intervention studies have used community-based approaches. One focusing on young African American women offered community-based blood pressure screening and recruited those at risk (Staffileno & Coke, 2006
). Ackermann, Finch, Brizendine, Zhou, and Marrero (2008)
used a self-report screening tool and non-fasting capillary glucose testing in community settings to identify people at risk of developing diabetes for their YMCA-based lifestyle program. However, only people with one of several listed diabetes risk factors were eligible to attend the screenings. Others have used community-based screening; however, it was to determine study eligibility rather than to screen for risk as a community service (Seidel, Powell, Zgibor, Siminerio, & Piatt, 2008
). Given the substantial differences in the target population and the sequence of offering screening as a first step, it is not useful to compare our response rate to these studies.