Susceptibility of elderly Asian immigrants to persuasion with respect to participation in research

Familism, respect for authority, and a sense of shame/pride are cultural characteristics that might influence research participation of Asian Americans. We compared 79 elderly Asian immigrants, most of whom immigrated from China or Hong Kong, with 58 elders who were not Asian and mostly not immigrants. Responding to hypothetical situations presented on a self-administered questionnaire, the Asian group professed to be more likely to be influenced by a request from a son/daughter, landlord, physician, or advertisement (p < 0.001) and by a monetary incentive (p = 0.05). Multivariate adjustment for potential confounders attenuated the strength of these relations, but except in the case of the monetary offer, differences remained statistically significant. Within the Asian group, multivariate logistic regression modeling indicated that years lived in the US was associated with more likelihood of refusing requests to participate in research. We conclude that acculturation or assimilation into American society may build resistance to pressure to participate in research. Our findings also suggest that elderly Asian immigrants may need additional protections to achieve truly informed consent.     

Optimal Design of Population-Level Financial Incentives of Influenza Vaccination for the Elderly

ObjectivesTo identify how monetary incentives affect influenza vaccination uptake rate using a randomized control experiment and to subsequently design an optimal incentive program in Singapore, a high-income country with a market-based healthcare system.Methods4000 people aged ≥65 were randomly assigned to 4 treatment groups (1000 each) and were offered a monetary incentive (in shopping vouchers) if they chose to participate. The baseline group was invited to complete a questionnaire with incentives of 10 Singapore dollars (SGD; where 1 SGD ≈ 0.73 USD), whereas the other three groups were invited to complete the questionnaire and be vaccinated against influenza at their own cost of around 32 SGD, in return for incentives of 10, 20, or 30 SGD.ResultsIncreasing the total incentive for vaccination and reporting from 10 to 20 SGD increased participation in vaccination from 4.5% to 7.5% (P < .001). Increasing the total incentive from 20 to 30 SGD increased the participation rate to 9.2%, but this was not statistically significantly different from a 20-SGD incentive. The group of nonworking elderly were more sensitive to changes in incentives than those who worked. In addition to working status, the effects of increasing incentives on influenza vaccination rates differed by ethnicity, socio-economic status, household size, and a measure of social resilience. There were no significant differential effects by age group, gender, or education, however. The cost of the program per completed vaccination under a 20-SGD incentive is 36.80 SGD, which was the lowest among the three intervention arms. For a hypothetical population-level financial incentive program to promote influenza vaccination among the elderly, accounting for transmission dynamics, an incentive between 10 and 20 SGD minimizes the cost per completed vaccination from both governmental and health system perspectives.ConclusionsAppropriate monetary incentives can boost influenza vaccination rates. Increasing monetary incentives for vaccination from 10 to 20 SGD can improve the influenza vaccination uptake rate, but further increasing the monetary incentive to 30 SGD results in no additional gains. A partial incentive may therefore be considered to improve vaccination coverage in this high-risk group.     

Self‐selection bias in eating disorders outcomes research: Does treatment response of underweight research participants and non‐participants differ?

Observational treatment studies provide a valuable alternative to RCTs but are often criticized due to potential self‐selection biases. Studies comparing those who do and do not participate in research on eating disorder treatment are scarce, but necessary to evaluate the impact of self‐selection bias on outcomes. All consecutive underweight adult first admissions (N = 392) to an integrated inpatient (IP)‐partial hospital (PH) behavioral specialty program were invited to participate in a longitudinal study of eating disorder treatment. Demographic and hospital course data were collected on participants (n = 234) and non‐participants (n = 158). Participants and non‐participants had similar BMI at admission, lengths of stay, and weight gain rates. Participants were less likely than non‐participants to end treatment prematurely from IP and were discharged at a higher BMI; the effect size was small. Few differences in hospital course were observed between participants and non‐participants. Although participants were more likely to transition to PH and were discharged at a higher BMI, completion of step‐down to PH within this integrated IP‐PH program rather than research participation status at admission was a better indicator of discharge BMI, which remains the strongest predictor of long‐term weight‐maintenance in eating disorders.     

Barriers to Cancer Clinical Trial Participation Among American Indian and Alaska Native Tribal College Students

Purpose: American Indians and Alaska Natives (AIs/ANs) have some of the highest cancer‐related mortality rates of all US racial and ethnic groups, but they are underrepresented in clinical trials. We sought to identify factors that influence willingness to participate in cancer clinical trials among AI/AN tribal college students, and to compare attitudes toward clinical trial participation among these students with attitudes among older AI/AN adults. Methods: Questionnaire data from 489 AI/AN tribal college students were collected and analyzed along with previously collected data from 112 older AI/AN adults. We examined 10 factors that influenced participation in the tribal college sample, and using chi‐square analysis and these 10 factors, we compared attitudes toward research participation among 3 groups defined by age: students younger than 40, students 40 and older, and nonstudent adults 40 and older. Findings: About 80% of students were willing to participate if the study would lead to new treatments or help others with cancer in their community, the study doctor had experience treating AI/AN patients, and they received payment. Older nonstudent adults were less likely to participate on the basis of the doctor's expertise than were students (73% vs 84%, P = .007), or if the study was conducted 50 miles away (24% vs 41%, P= .001). Conclusions: Finding high rates of willingness to participate is an important first step in increasing participation of AIs/ANs in clinical trials. More information is needed on whether these attitudes influence actual behavior when opportunities to participate become available.     

Volunteer bias in medical education research: an empirical study of over three decades of longitudinal data

CONTEXT: The issue of whether medical education research outcomes can be biased by students' refusal to allow their data to be used in outcomes research should be empirically addressed to assure the validity of research findings. Given that institutions are expected to document the outcomes of their educational programmes, evaluations of clinical performance subsequent to medical school are crucial, but are often incomplete when graduates decline to permit data collection. OBJECTIVES: This study aimed to examine the demographic and performance differences between research volunteers and others. METHODS: A total of 7415 doctors graduated from Jefferson Medical College between 1970 and 2004; 75% (n = 5575) agreed to participate in medical education research by granting written permission for the collection of data from their postgraduate training directors on their behalf (research volunteers); 20% (n = 1489) refused to grant such permission (non-volunteers), and 5% (n = 351) did not return the permission form (non-respondents). This prospective longitudinal study compared research volunteers, non-volunteers and non-respondents on gender, ethnicity, performance measures prior to, during and after medical school, scores on medical licensing examinations, and board certification status. RESULTS: Doctors who granted permission (volunteers) generally performed better during and after medical school. In addition, they scored higher on medical licensing examinations and had a higher certification rate. Women and members of ethnic minority groups were less likely to grant permission. CONCLUSIONS: The study raises questions about the validity of research findings as a result of volunteerism in medical education research. The implications for guidelines regarding the protection of human subjects in medical education research, and for educational outcomes, are discussed.     

The effects of cash and lottery incentives on mailed surveys to physicians: a randomized trial

Low response rates, especially among physicians, are a common problem in mailed survey research. We conducted a randomized trial to examine the effects of cash and lottery incentives on response rates. A total of 4,850 subjects were randomized to one of three interventions accompanying a mailed survey-no incentive (n = 1,700), cash payment [three levels of Hong Kong dollars (HKD) $10, $20, and $40; N = 50 in each subgroup], or entry into a lottery (three levels of HKD$1,000, $2,000, and $4,000; N = 1,000 in each subgroup) on receipt of the completed questionnaire. The response rates were higher among those offered incentives than those without (19.8% vs. 16.8%, P =.012). Cash was the more effective incentive compared to lottery (27.3% vs. 19.4%, P =.017). Response also increased substantially between the first and second mailings (14.2% vs. 18.8%, P >.001). In addition, those with specialist qualifications were more willing to participate in mailed surveys. We found no significant differences in response outcomes among the various incentive arms. Cash reward at the $20 level was the most cost-effective intervention, in terms of cost per responder. Further systematic examination of the effects of different incentive strategies in epidemiologic studies should be encouraged.     

Motivations for,and perceptions and experiences of participating in,a cluster randomised controlled trial of a HIV-behavioural intervention in rural South Africa

Empirical research on ethical issues in HIV-prevention and gender-based violence research, critical for honing ethical and safety guidelines, is limited. In this paper we describe South African young people's motivations for participating in randomised controlled trial, the prevalence of negative occurrences, participation regrets and associated factors. This trial partly followed, but also deviated from, the WHO safety guidelines for research on violence against women. A total of 1085 women and 985 men provided information two years after the trial start. Most participated for HIV testing and to help their community. Fewer reported motivation by the financial incentive. Minor adverse events included upset from questions on childhood experiences and arguments at home with siblings. Just under 1 in 10 (8.1% women, 9.8% men) regretted participation. Factors were associated with this were keeping some questions secret from their partners, feeling sad about questions on childhood, quarrelling at home and, for women, being motivated by the incentive. Men who had been physically violent to a partner were twice as likely to regret participation. There were no recorded adverse effects from the deviations from the ethical guidelines. Participation regrets mostly stemmed from problems in participants’ families preceding the research. There was no evidence that the research had been unsafe.     

The effect of participation in an incentive-based wellness program on self-reported exercise

Employers are increasingly trying to promote healthy behaviors, including regular exercise, through wellness programs that offer financial incentives. However, there is limited evidence that these types of programs affect exercise habits within employee populations. In this study, we estimate the effect of participation in an incentive-based wellness program on self-reported exercise. Since 2008, the University of Minnesota's Fitness Rewards Program has offered a $20 monthly incentive to encourage fitness center utilization among its employees. Using 2006 to 2010 health risk assessments and university administrative files for 2972 employees, we conducted a retrospective cohort study utilizing propensity score methods to estimate the effect of participation in the Fitness Rewards Program on self-reported exercise days per week from 2008 to 2010. On average, participation in the program led to an increase of 0.59 vigorous exercise days per week (95% Confidence Interval: 0.42, 0.78) and 0.43 strength-building exercise days per week (95% Confidence Interval: 0.31, 0.58) in 2008 for participants relative to non-participants. Increases in exercise persisted through 2010. Employees reporting less frequent exercise prior to the program were least likely to participate in the program, but when they participated they had the largest increases in exercise compared to non-participants. Offering an incentive for fitness center utilization encourages higher levels of exercise. Future policies may want to concentrate on how to motivate participation among individuals who are less frequently physically active.     

Colorectal Cancer Screening Adherence in African–American Men and Women 50 Years of Age and Older Living in Maryland

African Americans experience disproportionate incidence and mortality rates from colorectal cancer (CRC). This health disparity is partially explained by low participation in screening. This study aimed to identify factors influencing adherence to colorectal cancer screening among African Americans. Telephone interviews were conducted with African Americans living in Maryland (57% response rate). A total of 504 respondents agreed to participate. The survey primarily assessed participation in CRC screening, health beliefs and attitudes about CRC screening, and demographics. Nearly 77% of respondents reported being adherent to CRC screening guidelines. Of those not adherent, nearly 50% reported not ever receiving a physician recommendation to be screened. Having health insurance was a strong correlate of adherence. Study participants with greater perceived CRC risk were more likely to be adherent. Further, those who reported that they were caregivers were less likely to be adherent to screening. Findings indicate that those who were the primary care takers of children or disabled persons were less likely to participate in CRC screening. Efforts are needed to ensure that caregivers do not neglect their own preventive health, including CRC screening. Further, access to care and health insurance coverage also appear to be an important factor for participation in CRC screening. Ensuring that those who do not have adequate healthcare coverage are not excluded from participation in CRC screening due to cost should be an important priority if reduction in CRC health disparity is to be achieved.     

Impact of a financial incentive on case and control participation in a telephone interview

The authors investigated the effect of a 5.00 dollars incentive on participation in a telephone interview among cases and controls in an ongoing study of colorectal cancer. Cases and matched community controls were sent a letter introducing the study. One week later, a nurse called to invite the person to participate in a 30-minute telephone interview. After 1 year of data collection (which began in June 2001), the authors began enclosing a 5.00 dollars bill in the initial letter as an incentive. Incentives were mailed to all potential controls. The authors randomized 50% of a subset of cases to receive the incentive. In the year prior to institution of the incentive, 44.2% of 851 controls participated in the interview, as compared with 56.2% of 1,043 controls in the year after the incentive was instituted (p < 0.001). Among cases randomized to receive the incentive (n = 199), 63.8% participated as compared with 68.4% in the nonincentive group (n = 193) (p > 0.05). Among cases aged 60-69 years, the response rate in the incentive group was reduced by 17% (p = 0.03). Thus, among controls, a small monetary incentive appears to promote a feeling of goodwill toward the research. It does not seem to have an equivalent effect among cases, and in the worst case it may insult or annoy some cases who may otherwise have participated.     

Rationale for the use of passive consent in smoking prevention research: politics, policy, and pragmatics

The empirical evaluation of school-based smoking prevention programs requires a broad sampling of subjects who are exposed to treatment or control conditions. The low base rate of ongoing smoking among young adolescents, the slow increase in smoking rates, and concerns about the representativeness of samples make it imperative that assessment of smoking and drug use include almost all students. Positive consent procedures outlined by regulations for the protection of human subjects (Department of Health and Human Services. Code of Federal Regulations, Part 46: Protection of Human Subjects. #45 CFR 46, 1983) require parental permission for minors to participate in a research project. However, those subjects who are at highest risk to smoke are least likely to have parental consent for such a project. Low participation rates and subject selection bias are serious threats to the external validity of studies that use a positive consent procedure. With passive consent, parents respond only if they wish to withhold consent; a nonresponse is interpreted as approval of their child's participation. The subject retains the right to consent or decline participation. Four criteria must be met to waive the requirement of positive parental consent. The passive consent procedure, as used in smoking prevention research, meets those criteria. Data are presented that support the use of this procedure. Research is recommended to examine how consent procedures can affect the results of prevention studies.     

Physician participation in a Medicaid managed care program, the Kansas Primary Care Network

This study was designed to identify the factors that enhance and impede physician participation in a Medicaid managed care program, the Kansas Primary Care Network (PCN). The data for the study were collected in the summer of 1993 through a mail survey of primary care physicians in the PCN service area. Logistic regression and cross tabular analytic techniques were employed for data analysis. The results indicate that physicians who are not receptive to capitation-based reimbursement practices, those who practice in the higher per capita income counties, those who do not compare the PCN reimbursement rates favorably with private insurance rates, and physicians who think that untimely payment and the requirement to document patient referrals for specialty treatment pose problems for them are less likely to participate in the PCN program. Further, the study shows that institutional physicians have larger Medicaid caseloads than solo practitioners, who have larger Medicaid caseloads than single-specialty and multi-specialty group practitioners. Since most of the variables that attain statistical significance in explaining physician participation in the PCN program have to do with money, the study reaffirms the two market theory of the United States' health care delivery system.     

Tobacco use among immigrant and nonimmigrant adolescents: individual and family level influences

PurposeTo identify individual and family level characteristics that might explain differences in rates of tobacco use among immigrant and nonimmigrant adolescents.MethodsData for analysis come from a probability sample of 5401 adolescents aged 12–18 years participating in the Ontario Health Survey (OHS). Three groups were compared: (a) adolescents born in Canada to Canadian-born parents (n = 3886), (b) adolescents born in Canada to immigrant parents (n = 1233), and (c) adolescents born outside of Canada (n = 282). Discrete, multilevel logistic regression was used in the analysis.ResultsAdolescents born outside of Canada report the lowest rates of tobacco use, despite greater economic hardship. A negative association emerges between family socioeconomic status and tobacco use among adolescents born in Canada but not among adolescents born outside of Canada. Immigrant youth are less likely to affiliate with peers who smoke and are more likely to come from families where parents do not smoke: these differences partially explain the decreased rates of tobacco use among immigrant adolescents.ConclusionsAlthough subject to greater economic hardship, immigrant youth are less likely to engage in tobacco use. Protective factors associated with immigrant family life, such as lower rates of parental tobacco use and less exposure among immigrant adolescents to peers who smoke, may counteract some of the negative effects of poverty and social hardship. Future research should begin to address the processes that lead to adaptive outcomes among adolescents from immigrant families, despite greater exposure to social disadvantage.     

Parental consent for abortion and the judicial bypass option in Arkansas: effects and correlates

CONTEXT: In 2005, Arkansas changed its parental notification requirement for minors seeking an abortion to a parental consent law, under which a minor can obtain an abortion without consent after obtaining a judicial waiver. METHODS: Using state health department data on 7,463 abortions among 15–19‐year‐olds over the period 2001–2007, an analysis of abortion and second‐trimester abortion rates among Arkansas minors relative to rates among older teenagers evaluated the influence of the 2005 change in the law. Linear and logistic regression analyses estimated the changes in rates among different age‐groups, and assessed the likelihood of minors’ using the bypass procedure or having a second‐trimester abortion. RESULTS: No association was found between the change in the law and either the abortion rate or the second‐trimester abortion rate among minors in the state. Ten percent of all abortions among minors were obtained through the judicial bypass procedure, and minors aged 15 or younger who had an abortion were less likely than those aged 17 to get a waiver (odds ratio, 0.2). Minors who used the bypass option were less likely than those who obtained parental consent to have a second‐trimester abortion (0.5), and they terminated the pregnancy 1.1 weeks earlier, on average, than did minors who had gotten such consent. CONCLUSIONS: States that convert a parental notification statute to a parental consent statute are unlikely to experience a decrease in abortions among minors.     

Willingness to participate in biomedical research. African-americans vs whites

PURPOSE: The overall goals of this study were: 1) to determine whether (and if so, the extent to which) African-Americans differed in their willingness to participate in biomedical studies as compared to non-Hispanic Whites, and 2) to determine the influence that a range of demographic, psycho-social and medico-historical variables had on the comparative willingness of these groups to participate in biomedical research. This report will present preliminary findings on the first goal.METHODS: The Tuskegee Legacy Project (TLP) Questionnaire, a 60 item instrument developed within the Northeastern Minority Oral Health Research Center (a P50 Center supported by the National Institute of Dental and Craniofacial Research at NIH), was administered via a random-digit dial telephone interview by the University of Alabama at Birmingham Survey Research Unit to 840 adult African-Americans and Whites in three city/county areas: Birmingham/Jefferson Cty, AL; Hartford/Hartford Cty, CT and Tuskegee/Macon Cty, AL.RESULTS: The response rates were 70%, 65% and 49% for Birmingham, Tuskegee and Hartford, respectively. A lower percentage of African-Americans (21%) reported that they were either somewhat or very likely to participate as biomedical research subjects than did Whites (29%) (p < 0.0001). In response to 7 prompts on 'who' was conducting a study, African-Americans indicated they were less likely to participate than Whites on 4 specific prompts and more likely to participate on only 1 prompt (p < 0.006 for each). In response to 9 prompts on 'what' a study asked participants to do, African-Americans indicated they were less likely to participate than Whites on only 2 specific prompts (p < 0.001 for each), more likely to participate on 2 prompts (p < 0.001), and were equally or near equally likely to participate on 5 prompts.CONCLUSIONS: The findings from this study show that African-Americans self-reported a lower willingness to participate in biomedical studies than did non-Hispanic Whites, and that African-American subjects were more influenced by the factor of 'who' was running the study than by the factor of 'what' they might have to do as study subjects. Study supported by grant P 50 DE10592 from the NIDCR at NIH.     

Receipt of cancer screening services: surprising results for some rural minorities

Background: Evidence suggests that rural minority populations experience disparities in cancer screening, treatment, and outcomes. It is unknown how race/ethnicity and rurality intersect in these disparities. The purpose of this analysis is to examine the cancer screening rates among minorities in rural areas. Methods: We utilized the 2008 Behavioral Risk Factor Surveillance System (BRFSS) to examine rates of screening for breast, cervical, and colorectal cancer. Bivariate analysis estimated screening rates by rurality and sociodemographics. Multivariate analysis estimated the factors that contributed to the odds of screening. Results: Rural residents were less likely to obtain screenings than urban residents. African Americans were more likely to be screened than whites or Hispanics. Race/ethnicity and rurality interacted, showing that African American women continued to be more likely than whites to be screened for breast or cervical cancer, but the odds decreased with rurality. Conclusions: This analysis confirmed previous research which found that rural residents were less likely to obtain cancer screenings than other residents. We further found that the pattern of disparity differed according to race/ethnicity, with African Americans having favorable odds of receipt of service regardless of rurality. These results have the potential to create better targeted interventions to those groups that continue to be underserved.     

Análisis del sesgo de selección en el piloto de un estudio longitudinal sobre envejecimiento en España

Objectives

To demonstrate that selection of a probabilistic sample at a national level for a study of aging in Spain is subject to selection bias. To quantify the losses produced after each phase of the administration of a questionnaire.

Methods

We performed a cross-sectional study of the Spanish community-dwelling population aged 50 years or older between 2010 and 2011. Through multivariate logistic regressions, the characteristics of the census tract of the patients’ residence were compared between those who agreed (n = 5,813) or refused (n = 7,023) to be included in the sampling frame and between those who agreed (n = 1,677) or refused (n = 2,875) to participate in the study. The individual characteristics of persons who responded (n = 1,398) or refused to respond (n = 346) to a face-to-face questionnaire administered after a telephone interview were also compared. In addition, the reasons for refusal were studied.

Results

The most frequent specific reasons for refusing to be included in the sampling frame or to participate in the study were poor health and disability (14.4% and 27.9%, respectively). In both cases, refusal was more frequent in the census tracts of districts with a lower socioeconomic level or those located in Catalonia, Guipúzcoa or Biscay. Individuals older than 81 participated less frequently in the face-to-face questionnaire. Between 8.6% and 18.4% of participants were lost at each stage of information retrieval.

Conclusion

Probabilistic sampling in sampling points chosen by the researchers would allow more resources to be devoted to increasing response rates among the groups who are less likely to participate. Questions should be concentrated in only one shorter questionnaire, administered before blood extraction.     

Frustrated demand for postpartum female sterilization in Brazil

During the last three decades, Brazilians have relied almost exclusively on two contraceptive methods, the pill and female sterilization, with sterilization use increasing over time. Until a new law was passed in 1997, sterilization was virtually illegal and not covered by either public or private health insurance. It was, however, frequently provided in public and private hospitals in conjunction with a cesarean section. The new law regulating sterilization provided for reimbursement for interval sterilizations by public health insurance, but placed restrictions on availability intended to reduce the use of cesareans. These restrictions included the prohibition of postpartum sterilizations. This paper focuses on women's sterilization intentions during pregnancy and their experiences postpartum. In a prospective study of 1612 pregnant women carried out in four Brazilian cities, there was substantial demand for postpartum sterilization in both the private and public sectors among women who wanted no more children. However, public patients were much less likely to be sterilized than private patients. Thus, the new law may not have reduced inequities in access or, paradoxically, the incentive for unnecessary cesarean sections.     

Racial and ethnic disparity in participation in DNA collection at the Atlanta site of the National Birth Defects Prevention Study

Genetic risk factors are a critical component of many epidemiologic studies; however, concerns about genetic research might affect participants' willingness to enroll. The authors assessed factors associated with completion of mailed buccal-cell collection kits following telephone interviews at the Atlanta, Georgia, study site of the National Birth Defects Prevention Study. Pregnant women who were interviewed after June 30, 1999, and had an estimated delivery date of December 31, 2002, or earlier were included (n = 1,606). For this time period, overall interview participation was 71.9%. Among those interviewed, 47.6% completed the buccal-cell collection kit (61.1% of non-Hispanic Whites, 34.9% of non-Hispanic Blacks, and 39.1% of Hispanics). Non-Hispanic White race/ethnicity, an English-language (vs. Spanish) interview, receipt of a redesigned mailing packet and an additional $20 incentive, and consumption of folic acid were associated with higher buccal-cell kit participation. Among non-Hispanic White mothers, higher education, intending to become pregnant, and having a child with a birth defect were associated with increased participation. Among non-Hispanic Black mothers, receipt of the redesigned packet and $20 incentive was associated with increased participation. Among Hispanic mothers, an English-language interview, higher education, and receipt of the redesigned packet and $20 incentive were associated with increased participation. At this study site, minority groups were less likely to participate in DNA collection. Factors associated with participation varied by race/ethnicity.