Recruitment and Retention of Healthy Minority ...

JOURNAL OF WOMEN’S HEALTH & GENDER-BASED MEDICINE Volume 10, Number 1, 2001 Mary Ann Liebert, Inc.

Recruitment and Retention of Healthy Minority Women into Community-Based Longitudinal Research CATHERINE L. GILLISS, D.N.Sc., R.N., F.A.A.N.,1 KATHRYN A. LEE, Ph.D., R.N., F.A.A.N.,2 YOLANDA GUTIERREZ, Ph.D., R.D.,2 DIANA TAYLOR, Ph.D., R.N., F.A.A.N.,2 YEWOUBDAR BEYENE, Ph.D.,2 JOHN NEUHAUS, Ph.D.,2 and NANNY MURRELL, Ph.D., R.N.3

ABSTRACT This report examines the impact of individualized, population-based recruitment and retention approaches on the development of a subject pool, enrollment, and retention at 12 months of healthy, community-based women in three ethnic groups: African Americans, non-Hispanic European Americans, and Mexicans/Central Americans. Of 722 women contacted and screened, 346 (48%) were eligible and consented to participate. Attrition at 12 months was low (10%) compared with other published reports. The largest group of potential subjects was identified through broadcast media approaches, but this method produced the highest number of ineligible women and highest rate of attrition. Printed matter produced the next largest group of potential subjects, but ineligibility was high (53%). Face-to-face interactions enrolled the highest proportion of eligible women (84%) and lowest overall attrition (7%). Direct referral yielded fairly efficient enrollments (57%) and average attrition. Multiple approaches for recruitment can produce a diverse sample of healthy, community-based women. Face-toface recruitment results in the highest yield of participants with the lowest attribution but is presumed to require more resources.

studies. The purpose of this article is to examine whether the use of individualized, populationbased recruitment and retention approaches improves the efficiency of subjects screened and retained and improves retention at 12 months of healthy, community-based women in three groups: African Americans, non-Hispanic European Americans, and Mexicans/Central Americans.

INTRODUCTION

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as well as a federal requirement that funded science address broad populations, including women and minorities, a body of literature has developed on effective strategies for the recruitment and retention of women and minorities in community-based ITH GROWING SCIENTIFIC INTEREST

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Yale University School of Nursing, New Haven, Connecticut. University of California, San Francisco, California. 3 University of Texas, Galveston, Texas. This research is supported in part by a grant from the National Institute of Nursing Research (1 R01 NR04259) at the NIH. 2

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GILLISS ET AL.

MATERIALS AND METHODS What does the National Institutes of Health (NIH) require? In 1990, Section 492B of the Public Health Service Act issued new guidelines to promote the inclusion of women and minorities in research. These guidelines were strengthened with the passage of the NIH Reauthorization Act of 1993, Public Law 103-43 (Federal Register, March 28, 1994). Currently, all applications for federal support are required to be peer reviewed for the scientific acceptability of representation for gender and minority inclusion* and, more recently, the inclusion of children. (Recently, the NIH instituted a policy requiring scientific justification for the inclusion/exclusion of children, which is beyond the scope of this report.) These NIH guidelines require that (1) women and members of minority groups and their subpopulations be included in all human subject research, (2) in phase III clinical trials, women and minorities and their subpopulations be included so that valid analyses of differences in intervention effect can be accomplished, (3) cost not be used as justification for exclusion of these groups, and (4) programs be initiated for outreach to recruit these groups into clinical studies. The initial review group assigned to evaluate the research proposal is required to assess the scientific and human subject considerations related to inclusion/exclusion, to determine the appropriateness of a design to measure differences, and to evaluate the plans for recruitment and outreach to the study populations. Each of these considerations should influence scientific merit. Based on the recent experience of two authors in reviewing federal applications (C.L.G. and K.A.L.), recruitment strategies are not adequately described by many investigators, and often those that are described are not based on specific approaches that have been evaluated and reported in the research literature. Therefore, this report provides data for strengthening the recruitment and retention strategies designed by future in-

*A guide for investigators preparing applications, NIH Outreach on the Inclusion of Women and Minorities in Biomedical and Biobehavioral Research, is available from the NIH through the Office of Research on Women’s Health, NIH, Building 10, Room 21, 9000 Rockville Pike, Bethesda, MD 20892.

vestigators who desire to conduct communitybased research with minority women.

What is generally believed? Although investigators are motivated to include and retain healthy women and minorities in ongoing longitudinal studies in the community, common wisdom and reported experience suggest that successful strategies may differ from those used for people who are not healthy, for members of majority groups, and for men. Generally speaking, those who are ill and agree to participate in an ongoing clinical trial are recruited from hospitals and clinics and motivated to participate in the treatment, whether in an experimental or control group. This differs from healthy community-based groups, who are generally well and difficult to access, may be under surveillance for the possible development of a specific problem, or may be participating in an actual prevention program. The direct personal benefit is not evident for those who are healthy, making recruitment and retention less likely. With regard to race, African Americans have been described as “suspicious” of clinical research, and Hispanic populations have been described as unaware of the possible benefits of clinical research participation.1 Recruitment of minorities into clinical trials has been consistently described as rarely successful, taking longer than expected, and being based on hypothesized pools of eligible persons that rarely materialize.2 The recruitment of women into research studies has been described as requiring special approaches as well. Kelly and Cordell3 identified overt and covert societal and institutional sexism in recruitment plans, noting that women often face the barrier of poverty as an added strain to research participation. Women may require child care, gender-specific incentives, and patient-centered approaches to support their participation.

What is known about the recruitment and retention of minorities? Ness et al.4 published a review of 65 clinical studies that included detailed data on recruitment of subjects. Surprisingly, the reports included very few data on the ethnic/racial composition of potential, eligible, or refusing subjects. Ness et al. concluded that the published evidence was insufficient to either support or refute the possibility of differential recruitment rates for whites and minorities.

RECRUITMENT/RETENTION OF HEALTHY MINORITY WOMEN

Holcombe et al.1 reported that communitybased networks were successfully used to recruit African Americans to prostate cancer prevention trials. In response to barriers (e.g., time required of M.D.s to explain the protocols, access of minorities to healthcare, illiteracy, transportation, cultural concerns about clinical research, suspicion/distrust, complexity of consents), they implemented corresponding solutions (e.g., additional staff to explain protocols, use of charity hospital systems, alternatives to written information, education or peer groups about clinical research, community outreach, and simplified consent forms). Despite these steps, problems in recruitment continued, possibly because of lack of access to care or hidden illiteracy. In addressing recruitment of African Americans for a secondary prevention trial, Gorelick et al.5 reported the need for a community network to aid in planning access to community groups. They proposed establishing a community advisory board, appointing a community service coordinator, and organizing a community network to include volunteers to create public awareness about the study in churches, the media, community organizations, and through the mail. They advocated establishment of a speaker’s bureau to extend the message and offer a service to the community in general exchange for their support and participation. Stoy et al.6 provided data on recruitment from their community-based prevention trial aimed at reducing cholesterol in elderly African Americans, most of whom were female. Whereas media strategies successfully recruited white subjects, African American subjects were more successfully recruited through churches. In a population-based lung cancer prevention trial, Goodman et al.7 recruited subjects through mailing to health insurance subscribers, a strategy that produced a very small pool of minorities. Phonathon approaches were used by Coleman et al.8 to recruit African American seniors into a health promotion trial with a 6-month exercise component. When direct dial calls placed by leaders in a community-based senior center recruited only 33% of the needed sample, other strategies were added. An additional 33% of the sample was recruited via printed media (newsletters and flyers), 26% by word of mouth, and 8% through “other approaches,” which included Public Service Announcements, community presentations, or seeing the exercise intervention group in ac-

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tion. The authors concluded that the use of multiple methods was required but that a strong link to the community was conducive to recruitment of the prospective African American study participant. In a comprehensive review of strategies for recruitment of minorities into clinical trials, Swanson and Ward2 detailed recruitment barriers related to physician participation and patient recruitment and the studies in which the barriers were identified. They listed ineffective methods and effective methods, with citations for these methods. Their summary suggested equivocal results in that many of the approaches cited as effective were also cited as ineffective. In another review, Arean and GallagherThompson9 identified barriers to the recruitment of older minority adults into clinical research and the effective approaches employed in their work to address these barriers. The identified problems included (1) overcoming fear and mistrust, (2) overcoming transportation and outreach barriers, (3) education about the disorder under study and the benefits of participating, (4) understanding cultural barriers, (5) feedback to the community, (6) dealing with perceived and actual poor health, and (7) providing incentives. These problems tended to be identified by many authors, but few systematic reports of attempts to remedy these problems were cited. The authors offered their own anecdotal insights. Marin and Marin10 identified approaches to enhance recruitment and retention of Hispanic participants. They proposed establishing legitimacy by using community consultation and key informants, forming a community advisory board, and matching the ethnicity of the interviewer/ data collector to the subject. For retention, they advised offering compensation, assuring privacy, developing an expectation of long-term contact, collecting the names and contact information of relatives and others who can help to locate subjects, and maintaining contact with greeting cards and newsletters. They reported that a San Francisco-based study of Hispanics lost 45% of the subjects to follow-up in 12 months and that a rural Texas study lost 65% of the subjects after 3 years. In two other studies, Miami-based Cubans were retained at a rate of 72% at 3 years, and 53% of Mexicans were retained at 3 years. They explain the differences in attrition by the stability of the Miami-based Cuban population. In a description of retention efforts and results

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in an innercity study of Hispanic and African American families with young children who had asthma, Senturia et al.11 reported that retention was improved with flexible staff, computer tracking, and face-to-face approaches to recruitment. They noted that the families who were retained tended to have provided more contact names and reported less family stress and more social support than those lost to follow-up. Although the cited literature offered some direction for recruitment and retention of healthy midlife women in the current longitudinal study, results were definitely conflicting. Further, the literature did not explicitly identify ethnic/racial characteristics as distinct from socioeconomic characteristics. This lack of clarity may continue to confound our understanding of appropriate strategies for recruitment and retention of minorities.

What is known about the recruitment and retention of minority women? Although some data suggest that women are retained in studies at a higher rate than men,6 most authors identify a set of barriers faced when recruiting and retaining minority women in community-based clinical studies. Mouton et al.12 examined the beliefs of women who did not respond to an invitation to join a cancer prevention trial. Although most of the women held positive attitudes toward cancer trials and agreed that such trials benefited society, white and African American women were distinguished by their beliefs about the trustworthiness of scientists, the ethics of clinical science, and the preference to be treated by someone of the same race. For African Americans, these beliefs/preferences were reported with much greater frequency. These two subject subgroups did not differ from one another in income level or education, suggesting that the significant difference associated with these beliefs may relate to ethnicity or race rather than socioeconomic status. Gavalier et al.13 attempted to sample postmenopausal women self-identified as American Indian, Asian, African American, Hispanic, and Caucasian. After a slow start to enrollment, they introduced new recruitment strategies, including the use of culturally matched research staff, networking in community groups, and direct recruitment. This approach resulted in a significantly increased pool of interested subjects between years 1 and 2 of the project.

GILLISS ET AL.

Lewis et al.14 sought to study communitybased postmenopausal women of African American, Hispanic, and non-Hispanic white descent. Strategies included mass mailings, community outreach (including presentations to churches and community groups), personal referrals, television and radio ads, paid and unpaid public service announcements, fliers, and face-to-face community recruitment at meetings. The greatest number was recruited via mass mailings (52%), followed by media (e.g., ads in newspapers or news stories and then television) (34%). Radio, newsletters, and news magazines were poor sources for recruitment. Reported yields did not vary by ethnic group. The overall yield from basic eligibility screening was approximately 11.5%. Yields were consistently lower for women with less education and women of low or unknown socioeconomic status. Blumenthal et al.15 addressed recruitment and retention in a community-based sample of innercity African American women for an educational intervention for cancer screening. Using two contact methods yielded 39% of those contacted. A face-to-face approach was more successful (49%) than mail and phone contacts (20%). Retention at 18 months was 60% in the experimental group and 65% in the control group; 30% were lost to follow-up in both groups. Those retained through the 18-month point were more likely to be wealthier, married or living as married, better educated, and employed. Refusals were associated with the perception that the study would be burdensome. Loss to follow-up was associated with younger age. Only 38% of the contacted women were successfully recruited. Face-to-face communication was found to be more successful than telephone communication. This review suggests that few researchers have systematically evaluated the results of their approaches to recruitment and retention for their effectiveness. In those instances where systematic reviews of the strategies for recruitment and retention have been presented, the results do not provide clear support for strategies worth employing.

The Midlife Women’s Health Study:16 A look at recruitment and retention in the San Francisco Bay area The purpose of our 5-year longitudinal study was to describe changes in the biopsychosocial

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health of midlife women through the menopausal transition. Recruitment began in January 1996, and enrollment was complete by November 1997. From 1011 responses, 722 women were screened for eligibility. There were 275 women ineligible because of age, ethnicity, or chronic health problems and 100 eligible women who refused prior to enrollment after learning that this was not an intervention study that would include free healthcare. After the study was explained there were 347 (78%) who consented, enrolled, and completed the initial visit and data collection. This initial data collection included 89 African American, 164 European American, and 94 Mexican/Central American women between the ages of 40 and 48 years who were healthy, not taking hormones, and still experiencing regular menstrual cycles. The research team dropped 1 additional European American woman because of an undisclosed mental health diagnosis, leaving a total of 346 who consented, enrolled, completed the first data collection interval, and were eligible to continue. The convenience recruitment approaches employed produced a sample profile that reflects published profiles of California’s population of women (Table 1). African American women were less likely to be married or in permanent relationships than their European American or Mexican/Central American counterparts (chisquare 5 13.1, p 5 0.002). European Americans were less likely to have children (chi-square 5 9.1, p 5 0.01) than the other two groups, and Mexican/Central Americans reported less formal edTABLE 1.

Age (mean 6 SD) Birthplace (%) United States California Mexico Central American English as a second language (%) Completed high school (%) Not currently employed (%) Married/partner (%) Have one or more children (%) Median household income/year Mean household income/year , $30,000 (%) . $60,000 (%)

ucation than African Americans and European Americans (F2,337 5 23.1, p , 0.0001). European Americans had higher incomes (F2,335 5 16.9, p , 0.0001). The groups were not statistically different on self-reported adequacy of income for housing, food, healthcare, or essential daily needs. After reviewing the literature, we employed a variety of approaches to create a pool of African American and Mexican/Central American women to screen for study eligibility and possible enrollment. These included strategies mentioned by other researchers: (1) using age, gender, and culturally/racially matched persons to collect the data and maintain continuity of relationship with the subjects they screened and eventually visited, (2) placing advertisements in newsletters and newspapers, (3) posting fliers in community libraries and other public places, (4) placing public service announcements with Spanish-language television and radio stations as well as media known to be popular among African Americans, (5) visiting ethnic-specific churches and street fairs to speak about the study, and (6) visiting community-based support/social groups with culturally specific membership.

RESULTS Enrollment Of the 722 women contacted and screened, 346 were eligible and consented to participate (48%). This rate varied slightly across the three sub-

DEMOGRAPHIC VARIABLES

BY

ETHNIC GROUP (n 5 346)

African American (n 5 89)

European American (n 5 163)

Mexican/Central American (n 5 94)

43.1 6 2.5

43.5 6 2.2

43.6 6 2.6

95 44

95 44

93 13 41 73 $40,000 $38,000 32 18

96 15 64 59 $70,000 $55,900 15 55

58 38 21 19 58 72 15 72 76 $50,000 $42,125 32 22

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GILLISS ET AL. TABLE 2.

ONE -YEAR ATTRITION RATES

Broadcast media Not eligible, refused Attrition at 1 year Printed matter Not eligible, refused Attrition at 1 year Face-to-face Not eligible, refused Attrition at 1 year Direct referral Not eligible, refused Attrition at 1 year Internet website Not eligible, refused Attrition at 1 year

BY

RECRUITMENT SOURCE

AND

ETHNIC GROUP (n 5 722)

African American (n 5 193)

European American (n 5 317)

Mexican/Central American (n 5 212)

Total screened (n 5 722)

3357 (58%) 3/24 (13%)

58/94 (62%) 6/36 (17%)

61/90 (68%) 3/29 (10%)

152/241 (63%) 12/89 (13%)

39/61 (64%) 2/22 (9%)

54/109 (50%) 4/55 (7%)

25/53 (47%) 4/28 (14%)

118/223 (53%) 10/105 (10%)

6/29 (21%) 1/23 (4%)

19/69 (28%) 2/50 (4%)

7/26 (27%) 3/19 (16%)

32/124 (26%) 6/92 (7%)

13/32 (41%) 1/19 (5%)

11/26 (42%) 1/15 (7%)

15/33 (45%) 3/18 (17%)

39/91 (43%) 5/52 (10%)

11/14 (79%) 0/3 (0%)

14/19 (74%) 0/5 (0%)

9/10 (90%) 0/1 (0%)

34/43 (79%) 0/9 (0%)

groups. African Americans were enrolled at a rate of 46% (89 of 193), European Americans were enrolled at a rate of 51% (163 of 317), and Mexican/Central Americans were enrolled at a rate of 44% (94 of 212) (Table 2). The largest group (n 5 241) of possible subjects was identified through broadcast media approaches (e.g., radio and television public service announcements and special news features). Although this approach was successful in locating potential subjects, it found the highest number of ineligible women (152 of 241, 63%) and the highest rate of attrition (12 of 89, 13%) across all groups. This approach found more potential subjects in the Mexican/Central American subgroup than any other method, but their rate of refusal/ ineligibility was also highest (61 of 90, 68%). Printed matter (e.g., brochures, fliers, or advertisements) produced the next largest group of potential subjects (n 5 223). European Americans were identified at a rate of almost twice that of other groups, but ineligibility was high (54 of 109, 50%). African Americans had an even higher rate of ineligibility (39 of 64, 64%). Face-to-face interactions (e.g., street fairs, church coffee hours, and parent-teacher meetings) resulted in the highest proportion of eligible women (74%), and about two and a half times more European American women as members of the other two ethnic groups. Direct referrals produced smaller but similar numbers of potential subjects across all ethnic groups (range of 26 to 33) and similar levels of enrollment (range of 55% to 59%). Internet website recruitment produced

few potential participants and an especially low level of enrollment (21%).

Recruitment of eligible participants by subgroup Face-to-face recruitment was the most effective strategy for African American women, with the lowest proportion of ineligible cases (21%). The association of eligibility with source of recruitment was significant: chi-square 5 17.1, p 5 0.001. Direct referral was the second most effective strategy for this group (59% recruited). Printed material and broadcast media were the least effective recruitment strategies (36% and 42%, respectively) for obtaining eligible and willing African American participants. The most effective method for locating eligible European American women involved face-toface approaches (72%), followed by direct referral (58%). Printed matter was successful only half the time, and broadcast methods resulted in only a 38% recruitment rate. Attrition was high for broadcast media (17%) and low for face-to-face methods (4%). The recruitment method was also statistically significant in recruitment of eligible Mexican/ Central American women (chi-square 5 16.4, p 5 0.001). The most successful strategy for eligible Mexican/Central American women was face-toface recruitment (73%), although the frequencies were small. There was little difference between printed matter and direct referral (53% and 55%, respectively) in enrollment rates, and broadcast methods were significantly less effective (32%).

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Retention of participants after 1 year Table 3 shows the study attrition at 6 months and 12 months. The attrition rate across the sample was 9.5% (33 women). There were 7 (8%) African Americans, 13 (8%) European Americans, and 13 (14%) Mexican/Central Americans who withdrew from the study because of “burden.” Onset of health problems and relocation to another state caused 2 additional dropouts. As an extra component of the study, 53 women also volunteered for an intensive 1–2-hour interview. To our surprise, there was no increased rate of attrition among these 17 African American, 19 European American, and 17 Mexican/Central American women. Only 1 European American of the 13 who withdrew was part of the additional interview study. In yet another component of the study, 70 women volunteered for a more complete assessment of longitudinal sleep changes, which required 48 hours of extra commitment and the burden of using monitoring equipment during sleep. Only 2 of the women who withdrew were participants in the intensive interview component. Study attrition across all groups and methods of recruitment was low at month 12 of the study (10%). This rate was identical for African Americans and European Americans (7 of 89, 8% and 13 of 163, 8%, respectively) and higher for Mexican/Central Americans (13 of 94, 14%). There was no significant difference in retention by type of recruitment strategy for either the African American women or the Mexican/ Central American women. The lack of statistically significant differences may be a result of the low attrition rate. However, there were some interesting trends in the data that should be explored further. The African American women had somewhat better retention from face-to-face methods (4% attrition) and direct referral (5% attrition) compared with printed matter (9% attrition) and

TABLE 3.

Time 1 (initial visit) Time 2 (6-month visit) Time 3 (12-month visit) Total

broadcast media (13% attrition). This was not the case for the Mexican/Central American women, whose overall rate of attrition was higher (14%). The higher attrition rate for this group may be related to a change in personnel, although both the initial and subsequent data collectors were Hispanic. Printed matter and broadcast media resulted in less attrition (14% and 10%, respectively) than face-to-face (16%) and direct referral (17%). Attrition among the European American women was generally lower (range 4%–7%) except for those recruited by broadcast media, for which the attrition rate was 17%.

DISCUSSION AND CONCLUSIONS Printed matter and broadcast media reached larger numbers of women than face-to-face and direct referrals, but the expected yield of eligible participants was lower (between 37% and 47% of the contacts). The more labor-intensive approach of face-to-face personal contacts reached fewer subjects but yielded a higher percentage of eligible participants (74%). These results are consistent with the reports of Goodman et al.,7 who found that mailings produced a very small pool of minority participants. In our study, the expressed interest resulting from printed matter was twice as high in European American as in African American and Mexican/Central American participants. Lewis et al.14 reported that mass mailings were the most successful strategy for recruitment of a group of European American, African American, and Hispanic American women and that equal numbers of each group were identified. However, eligibility rates were much lower (around 10%) than for our participants (around 47%). Both African American women and Mexican/ Central American women were enrolled in greater

ATTRITIO N RATE AND NUMBER REMAINING AFTER 1 YEAR (THREE VISITS ) Attrition rate

Sample completed (n)

(n)

(%)

346 322 313 313

24 9 33/346

6.9 2.6 9.5

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GILLISS ET AL.

numbers from the recruitment approaches of faceto-face meeting and direct referrals. However, the attrition rates associated with these two approaches were higher for Mexican/Central American women, suggesting that retention-enhancing approaches may be needed for the Mexican/ Central American group. Our low attrition rate in this longitudinal study is evidence of the success of using other researchers’ experience from the reported studies cited. Unfortunately, there are few published reports of the results of use of these individualized strategies. Thus, integrating these results with others is difficult. We conclude, however, that use of multiple methods allows the researcher to reach a diverse ethnic and socioeconomic sample. Rates of enrollment and attrition vary by subgroup for each approach. Thus, the selection of a recruitment approach will depend on the available time and resources. Face-to-face recruitment will be more costly but, based on our own work, will result in higher overall levels of enrollment and less attrition. A change in personnel, even when allowing for a smooth transition, may affect retention, particularly in Mexican/Central American women.

would produce even more subjects in the future, as it was accessible and a fairly private way to explore the study. Many heads nodded in agreement. These women and others cited a number of study features and personnel qualities that made retention possible. Among these were the fact that staff developed a continuity relationship with participants, many of whom came to our event specifically to visit with their data collector. They also indicated that the flexibility of the staff was invaluable. Participants reported that they often forgot data collection appointments or needed to reschedule at the last minute. Survey workers were accommodating to these shifts in plans, and participants felt understood and respected by the study personnel.

ACKNOWLEDGMENTS We thank Carrie Boghosian, Marjorie Cobb, Carol Duncan, Myrian Gonzales, Alice Green, Monica Miranda, and Kim Baruh for their important role in participant recruitment and retention and Nancy F. Woods, Ph.D., R.N., F.A.A.N., for consultation throughout the study.

EPILOGUE REFERENCES At a recent luncheon for study participants, the research team presented preliminary findings, including the results of this analysis. We invited participants to offer their perspectives on recruitment, and although anecdotal, their insights are valuable. Participants indicated that they were drawn to the study when it was endorsed by their churches, their children’s schools, or other agencies they trusted. Access through these institutions conveyed to them an implicit endorsement. Participants also indicated that seeing the data collectors and investigators who were recruiting and could answer their initial questions was appealing. Despite incredible barriers, a number of participants conveyed their interest in enrolling and staying in the study as “something I was doing for myself.” Others, on realizing that their ethnic group was being studied, reported, “I wanted to do this for my people.” Although the numbers of participants recruited to this study via the Internet were small, one European American woman who enrolled in the study through the Internet predicted that this method

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RECRUITMENT/RETENTION OF HEALTHY MINORITY WOMEN 8. Coleman EA, Tyll L, LaCroix AZ, et al. Recruiting African-American older adults for a communitybased health promotion intervention: Which strategies are effective? Am J Prev Med 1997;13:51. 9. Arean PA, Gallagher-Thompson D. Issues and recommendations for the recruitment and retention of older ethnic minority adults into clinical research. J Consult Clin Psychol 1996;64:875 . 10. Marin G, Marin B. Research with Hispanic populations. Newbury, Park, CA: Sage Publications, 1991:42. 11. Senturia YD, Mortimer KM, Baker D, et al. Successful techniques for retention of study participants in an inner-city population. Controlled Clin Trials 1998;19:544 . 12. Mouton CP, Harris S, Rovi S, Solorzano P, Johnson MS. Barriers to African American women’s participation in cancer clinical trials. J Natl Med Assoc 1997; 89:721. 13. Gavalier JS, Bonham-Leyba M, Castro CA, Harman SE. The Oklahoma postmenopausal women’s health study: Recruitment and characteristics of American Indian, Asian, African American, Hispanic, and Caucasian women. Alcohol Clin Exp Res 1999;23:220.

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14. Lewis CE, George V, Fouad M, Porter V, Bowen D, Urban N. Recruitment strategies in the women’s health trial: Feasibility study in minority populations. Controlled Clin Trials 1998;19:461 . 15. Blumenthal DS, Sung J, Coates R, Williams J, Liff J. Mounting research addressing issues of race/ethnicity in health care: Recruitment and retention of subjects for a longitudinal cancer prevention in an innercity African American community. Health Serv Res 1995;30:197. 16. Lee KA, Gilliss CL, et al. Bio-behavorial health in diverse midlife women. NIH, NINR (RO1-NR04259).

Address reprint requests to: Catherine L. Gilliss, D.N.Sc., R.N., F.A.A.N. Yale University School of Nursing 100 Church Street, South PO Box 9740 New Haven, CT 06536-0740