This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This paper examines lessons learned from recruitment strategies utilized in enrolling participants between and for a randomized controlled trial to test a culturally specific HIV risk-reduction intervention for Black MSMW.
Methods Interested respondents completed a brief screener and participants completed surveys at baseline and at post, 3 and 6 months follow-up. Recruitment patterns were assessed by examining the source of study information reported when respondents were asked how they learned about the study. Chi-square tests were then conducted to examine differences in the distribution of participants by self-reported HIV status, age group and socio-economic status SES for each type of study information source.
Results Regardless of HIV or SES, study respondents were more likely to have received information about the study through a service agency than from other sources. Conclusions While agencies and referrals from personal networks appear to be the most significant recruitment source for potential HIV research participants, there is evidence that Internet based tools may enhance recruitment, particularly among younger Black MSMW.
Fear and distrust towards medical research has been fostered by studies in which minorities were deceived or taken advantage of, [ 4 — 7 ] and by individual and community experiences of poor or discriminatory healthcare encounters. This distrust, together with lack of reading level appropriate and language-specific information, complex informed consent processes, [ 8 ] and limited access to healthcare and transportation [ 9 ] has contributed to low research participation rates [ 2 , 10 ].
The situation becomes even more challenging when research is focused on sensitive and traditionally stigmatized sexual behaviors in minorities. In response to the Federal requirements designed to foster equitable selection of research participants, many researchers have implemented culturally, linguistically and socially relevant recruitment strategies [ 11 ].
Despite these efforts, recruiting specific subgroups such as minorities from large metropolitan areas remains challenging [ 12 ]. For example, low-income urban neighborhoods present additional challenges of increased resident turnover and reduced interest in prevention interventions, particularly when individuals lead a day-to-day existence with regard to food and shelter [ 12 ].
For example, in African American communities, churches often serve as a recruitment resource for research participants [ 14 ]; yet there is limited support when studies target risky sexual behavior and sexual minority populations [ 15 , 16 ].
Fear of ostracism, ridicule and alienation from within the Black community [ 17 , 18 ] complicates efforts to seek Black MSM from general community networks and social settings [ 19 ]. Conspiracy beliefs about HIV being a man-made disease to harm people of African descent also dissuade some Black men from engaging in HIV research [ 20 , 21 ].
The high HIV incidence among Black MSM [ 22 — 26 ], surveillance data indicating that they compose nearly half of all cases of HIV among Black people, and their potential role in a substantial but unknown number of cases among Black women [ 25 , 26 ] have brought attention to the need for better engagement of these men in HIV risk-reduction and treatment efforts. Furthermore, because many Black MSMW do not construct their personal identities around their same-sex behavior [ 34 , 35 ] and reside within communities with few gay venues, [ 36 ] the above-mentioned strategies may have limited success or yield non-representative samples.
A few researchers have implemented ethnographic mapping techniques in order to conduct targeted sampling in social and sexual spaces where MSMW congregate [ 37 , 38 ].
To date, however, we are not aware of a published comparative analysis of the relative effectiveness of various recruitment venues and methods.
We also analyzed data on those screened by HIV status, strata of socioeconomic status SES , and age group in order to assess what outreach venues and approaches might be best for reaching Black MSMW within these specific sub-groups.
This analysis was a tertiary objective of the study — one not originally proposed but conceived early in the implementation phase. Briefly, the three-week, six-session 12 hours total small-group intervention was developed with the collaborating agencies and informed by community advisory board members and extensive formative research.
Intervention objectives, format, and activities were guided by the Theory of Reasoned Action and Planned Behavior, Empowerment Theory, and the Critical Thinking and Cultural Affirmation Model — an Afrocentric model developed by one of our community collaborators and based on the Social Cognitive Theory [ 40 ].
To best mirror eventual intervention dissemination, many of the intervention sessions were held at the partner agencies. A more detailed description of the intervention and the theory on which it is based can be found in the article by Harawa et al. Assessments were conducted at baseline, immediately post intervention and at 3 and 6 months post intervention.
HIV-positive, HIV-negative, and unknown status men were all eligible to participate and HIV testing was encouraged but not required for study participation. Hence, eligibility was open to men who identified as Black or African American. Methods Outreach and recruitment strategies During the initial study development phase in , a Community Advisory Board CAB with 7 members selected for their expertise and knowledge about the life, culture and practices of African American men living in Los Angeles was created.
Additional CAB members were recruited by the investigators and by other CAB members through their own professional and personal networks. All CAB members were Black men and most self-identified as gay, bisexual or same gender loving. CAB members provided input on the content and format of recruitment materials and curriculum and advised on locations and events for reaching BMSMW. Later, they were encouraged to share study information with potential participants.
Our community partners -- three local community based organizations CBOs that offered a range of HIV and non-HIV-related services -- also provided extensive input on all aspects of the study development. We asked participants about barriers for Black MSMW to participate in a small-group HIV risk-reduction intervention and their suggestions about recruitment approaches and locations. Details of the focus group findings can be found elsewhere [ 40 , 41 ] and further information on the intervention development and content can be found in Williams et al.
Conducting outreach and recruitment All recruiters were selected based on their ability to both interact and do outreach with Black MSMW. In addition, most recruiters had prior prevention or outreach experience with this population.
Our CBO partner sites were the focus of some of our recruitment efforts. Some other recruitment sites provided services unrelated to HIV, health, or sexual orientation e. To minimize study associated risks and maximize privacy, outreach was often conducted at these sites without the agency staff members being told that our target population was MSMW.
Recruitment for the intervention phase started in July and ended in May Representatives from two academic institutions and our three CBO partners formed the field team. Because the intervention was designed to be facilitated by ethnically matched men, most of the recruiters were themselves self-identified African American men.
However, not all were MSMW. Over the course of the project, we had male recruiters who identified as homosexual, bisexual and heterosexual. We also had two women, one African American and one African-born who carried out a significant amount of recruitment. Occasionally, the female Indian-born Project Director conducted outreach and recruitment as well. Female recruiters have been successful in other research with Black MSM [ 28 ] and our focus group participants reported that some Black MSMW might prefer to interact with a female than a male recruiter in public places.
They and CAB members further indicated that some MSMW might be uncomfortable if approached in such settings by male recruiters who they perceived to be effeminate. Our community-partnered research approach was helpful for negotiating such gender stereotypes and concerns regarding emasculinization while working to recruit this population, as many field staffs were CBO members who had successfully engaged MSMW in the past.
A recruitment goal of at least 8 new enrollees per month was established early in the study. Recruiters generally worked in teams to maintain morale and mitigate rejection fatigue and boredom in the field. They completed weekly recruitment logs that included information on recruitment dates, times and locations with an estimate of the number of potentially eligible men present and contacted at each.
This information was used to plan future recruitment activities. Recruitment materials and methods We used a wide range of recruitment materials including flyers, postcards, tri-fold brochures, matchbox style condom packets, bus placards, social media and the internet. Language and content i. The recruitment scripts and all recruitment materials used also emphasized confidentiality and the potential for cash compensation.
Following CDU IRB regulations, incentive amounts were not printed on recruitment materials but were provided during the screening process or discussions with recruiters.
All materials used by our research team were approved by the institutional review boards IRBs within the two collaborating academic institutions. Most also included a black and red color scheme and the Adinkra West African symbols used in the intervention and photographs of Black men. Distribution of promotional materials involved both active and passive approaches.
During active recruitment, recruiters handed out flyers to Black men and explained the project to those indicating interest. During passive recruitment, recruiters displayed materials in our collaborating agencies, and in other venues that were frequented by African American men.
Locations are described in Table 1. Staff also distributed small packets that included two condoms, lubricant, a mint candy and a small flyer or left them in jars at Black barbershops.
The packets left in the barbershops did not include lubricant packets, as experienced staff members indicated that the presence of lubricant may generate homophobic discourse among customers. We ran weekly advertisements in a small number of Black community newspapers. Advertisements were also run inside of public buses with high African American ridership for 2. Study staff created a website and a Facebook page for the study and weekly announcements were placed on craigslist.
It consistently yielded a few calls per month at minimal cost i. Attempts were also made to recruit participants through messaging in online chat rooms and dating websites; however, site-specific restrictions and limited response led to our discontinuing this approach. Paid banner advertisements on a major newspaper and a black gay dating site also yielded fewer than five calls over a couple of months and were discontinued.
We sought referrals from our collaborators and various community based agencies and health clinics. We contacted providers and staff directly via regular and electronic mail, telephone, and through presentations.
We also provided a brief training on how to make such referrals. As part of the recruitment drive, study staff also hosted four events and participated in a variety of community events.
In Year 1, we organized a kick-off party at a local club to introduce the project to the target population and an informational breakfast at the lead university to introduce it to providers. In later years, we also conducted two one-day HIV testing events targeting the clientele of several local barbershops serving African American men.
These events provided opportunities to reach potential participants and build positive relationships with the barbers themselves. Screening and enrollment Interested individuals were screened by a recruiter in the field or over the telephone.
In addition to determining eligibility, potential participants were also asked how they found out about the project.
Once respondents were screened eligible, they were scheduled for the informed consent process and baseline interview. Data were collected using an audio computer-assisted self-interview ACASI that assessed socio-demographics, HIV testing, sexual- and drug-risk behaviors, and other covariates.
Cross tabulations were calculated to examine recruitment patterns by how those screened found out about the study and to examine differences in information source by age group, HIV status, and socioeconomic status SES among study participants.
Fisher exact tests were reported for cross tabulations with cells less than 6. Income was based on individual income from all sources including public assistance , before taxes. The sum of these scores for each participant was then used to categorize him into 3 SES strata: Results Table 1 provides the total number and relative distribution of the logged field-based outreach activities. The study recruitment target of 8 eligible participants per month was on average exceeded. In Year 1, which included only 6 months of recruitment, 46 participants were enrolled, while , and participants were enrolled in years 2—4, respectively.
In year 5, which included the last 5 months of the study, only 24 participants were enrolled. Thus, for the 47 months of recruitment, men were recruited and enrolled, which exceeded our original target of Throughout the years, enrollment tended to be low in November and December. This periodic drop in enrollment may be related to waning interest from potential participants and staff vacation time during the holidays. A total of interested respondents completed the screening.
Hence, nearly twice as many individuals were screened as were enrolled and three times as many were screened as were retained over the study course. Outcome analyses were based on whichever follow-up assessment was completed last, the 3 or 6 months [ 39 ]; therefore, we base our overall retention on those completing either of these post assessments.