Expert offers specific strategies for improving recruitment in rural areas

Key is to use influential locals

Recruiting clinical trial participants is rarely easy, but finding subjects in rural areas where transportation and trust are big obstacles can be particularly challenging.

"You need to be really familiar at the community level to understand the population you're seeking knowledge about," says Shannon Golden, MA, a research associate at Wake Forest University Health Sciences in Winston-Salem, NC.

Golden has worked on a Centers for Disease Control and Prevention grant that had researchers conduct focus groups throughout West Virginia to get people with diabetes to talk about their self care.

"I can't think of a more rural place than West Virginia to get this experience of recruiting rural volunteers," Golden says.

"Because of the rural environment, there were geographical barriers where people didn't have access to health care," Golden explains. "They didn't have access to people they felt were approachable, such as doctors they could trust."

Also, there were few specialists in these rural regions, so the rural populations were underserved for their medical needs, she adds.

Finding people to participate in the focus groups was a similar process to finding patients to screen for clinical trial enrollment, and Golden developed some specific enrollment strategies as a result. Here are her suggestions for improving enrollment in rural areas:

• Find central gathering places and gatekeepers: "We spent a lot of time in the community, finding the central gathering places," Golden says. "It might be a local convenience store that draws a crowd, or it could be a fast food restaurant."

The key is to find areas where CT marketing processionals or recruiters can hang fliers or schedule a town meeting to discuss an upcoming trial, she adds.

"The bottom line is that you're an outsider," Golden says.

So when CT professionals meet with people at the common watering hole, they'll gain a better understanding of the trust issues and priorities of the community.

And this is also the way to identify gatekeepers. Gatekeepers are the well-trusted people who have influence over others in the community, Golden says.

"Gatekeepers sometimes are professionals, but often they are not," she says. "A gatekeeper could be a local nurse or a librarian, or it could be the old lady in the corner house, who has lived there since she was born."

"These are the trusted members of the community, who will help you promote your study," Golden says. "By working with them, you gain legitimacy and acceptance."

• Approach the community's professionals first: "You start with the professionals because you talk the same language, and you can promote your purpose with more clarity there," Golden says. "So when you're conducting health research, start with the diabetes educators, nurses, or home health aides."

These professionals will help CT staff identify community-level gatekeepers and people who might be willing to enroll in a study.

"They're your avenue to that person's doorstep," Golden says. "There are two tiers of gatekeepers: the ones at the professional level who speak the same language as you, and they're the ones who can point you in the right direction for the community folks, who are not necessarily professionals."

Community gatekeepers might help CT professionals gain access to the local church group or knitting circle, she adds.

This process can take time, particularly when a rural community is self-sufficient and not as interested in the benefits of participation in research.

"If you're writing a grant, you should budget six months for really good community entry work," Golden suggests. "You'll attend local events, attend town meetings and show up for stuff without always promoting your study."

One CT professional could handle this community introduction work for many studies.

"But if you will have a group of clinical research people descend on the community, then you will want all of their faces and names around the area before the study begins," Golden says. "If there are town meetings and group activities, then you will want to attend those."

• Hire local people on the research team: "If your research team is not made up of local people, then you should hire from the community for your team," Golden suggests.

"The CR team can place ads in local papers, describing the job," Golden says. "We try to get the point across [in the ads] that people have to be flexible and approachable."

Once applicants respond, it's good to screen them for basic job-holding skills, but the resume takes backseat to the interview.

"To find someone local, we interviewed in the community," she says. "And the funny thing is that the interview is more important than anything on their resume."

Through a job interview, investigators will learn how well the person presents himself or herself, and there will be clues to how well the potential employee is accepted in the community.

"They might have suggestions at the interview about what might work and not work in the recruitment efforts," Golden says. "They know the local politics."

A CR team member from the community will understand the nuances of connections in the community as recruitment begins.

For instance, it's possible that the CR team has been listening to a very vocal community member who happens to be disliked in many circles. Just having an association with this person might dampen enrollment, Golden says.

The local member should help the team steer clear of these problems.

It's these people savvy and political skills that are more important than experience in finding the right person for the job, Golden notes.

"Some of the best people we've hired in communities had no health training at all," she says. "We trained them to do data collection and finger pricks."

• Have local CR workers be the project's front: "We want the community hire to lead the research team by being a face on the project," Golden says. "This is the contact person who becomes our key gatekeeper."

The local folks are invaluable to the project.

"You invest a lot of trust in your new research team member, who will give you wise advice on how to maneuver the community successfully," Golden says. "We've had some projects where we allow the local person to perform the interviews rather than the principal investigator because she's the one who the community will relate to."

The PI's academic credentials might intimidate potential participants, she adds.

• Recruit community gatekeepers to help with recruitment: "You can place newspaper advertisements, announcements in church bulletins, and buy radio spots," Golden says. "But truly and honestly, these are all less effective than having a really good gatekeeper."

The community CR team member can assist with recruiting community gatekeepers who will talk positively about the study at their PTA meetings and sewing circles, Golden says.

"More often than not they are not compensated and do the work all for good will," Golden says.

But there are ways to pay back these recruitment volunteers.

"For example, in a study with focus groups, we were able to recruit volunteers for a gatekeeper pool," Golden says. "And after the focus group we had medical students on rotation answer questions by the focus group about diabetes."

Although the volunteers weren't paid, they did receive an incentive of having access to medical experts.

"If we were in touch with a certified diabetes educator, we might promote her availability to a local diabetes support group," Golden says.

If a CR team is holding a group meeting for local residents, then it's a good idea to provide daycare services, she notes.

"If your grant presents a problem, then you could always find a Girl Scout troop that would benefit from community service," Golden says. "Find a location that's neutral and accessible and that has facilities conducive to what you're trying to achieve."

Other incentives include providing snacks and beverages at group meetings.

"We always offer refreshments," Golden says. "In the past, what we have also done is if we work closely with senior centers, we'll reward them by donating a large bushel of apples or other fruit."

The important thing is that community gatekeepers and local organizations remember the CR team and realize that researchers thought they were important to the project, she adds.

Rewarding organizations that assist in recruitment is a good way to ensure future assistance.

"We've given senior centers gift baskets for letting us do a recruitment session at their facility, or we might have a raffle where we give out tickets and pull out names for individual baskets," Golden says. "That way the senior center feels thanked and appreciated for their efforts to get their clients there for us."