Summary of our actual experience of recruitment
Recruitment to PODOSA commenced in July 2007 and closed in October 2009. Although we introduced all strategies from the outset of recruitment, we initially focussed on the health service approach as directed by the ethics committee. As detailed below, we promoted the trial widely. As in the preparatory phase, we found there was widespread approval of, and support for, the aims of the trial amongst both health care professionals and community leaders. However it quickly became apparent that the level of recruitment via NHS channels, was going to be much lower than the rate originally hoped for. In response, we increased direct promotional and recruitment efforts within the South Asian communities. After the initial nine months of recruitment we had screened around 400 people compared to the target of 1600. Experience from the research team's promotional talks and visits within the community showed that face-to-face recruitment either individually or with small groups was relatively successful. However we found that the goodwill of local community groups and organisations to help with recruitment was insufficient for a project of this scale. Several organisations were keen to assist, but had limited resources to allow staff to spend time actively recruiting for PODOSA.
Therefore in March 2008, we sought and acquired new funding and subsequently partnered with five local organisations and 10 individuals to recruit for us. Our agreement with these groups and individuals was to pay £15 per person referred who was subsequently screened. At this time we also initiated a similar payment scheme for general practitioners who referred patients to the study. Towards the end of 2008 we contracted with a marketing and consultancy company, specialised in working with the South Asian community, to adapt our materials and to market PODOSA.
Table
2 summarises the source and numbers of referrals achieved in relation to initial targets. The main criteria for referrals were South Asians of Indian- or Pakistani-origin, aged 35 years or over and without diabetes. The dietitans then had to assess potential participants for eligibility to be screened, including waist size, availability for the three year intervention period, and clinical exclusion criteria. The approaches are set out below, with numbering corresponding to that in Table
2. (We did not record the total number of contacts made informally with potential recruits by our research dietitians or by the community recruiters.)
Table 2
Recruitment strategies to identify participants for screening stage of PODOSA
1. NHS
| | | | |
1 (a) Direct referrals from health care professionals | 55 (3) | 25 | 1 | Largely unsuccessful |
1 (b) Written invitations via GPs to potential participants | 265 (13) | 25 | 11 | Low (5.2%) response rate to letters was resource intensive |
1 (c) Written invitation via diabetes register to diabetes patients (to target their relatives) | 16 | | 0 | Unsuccessful |
1 (d) Search of practice lists for IGT/IFG | 4 | | 0 | Unsuccessful |
Subtotal
|
336 (16)
|
50
|
12
|
Limited success
|
2. Community
| | | | |
2 (a) Via research team contacts, self referrals and 'snowball' effect | > 630 (30) | | 47 | Successful particularly in Glasgow, at minimal cost |
2 (b) Community organisations and recruiters, assisting with recruitment for small payment | 618 (29) | (a), (b) and (c) 50 | 26 | Initially unsuccessful when relying on goodwill, moderately successful when payment offered |
2 (c) Research team recruitment via visits/talks | 480 (23) | | 14 | Moderately successful but labour intensive |
Subtotal
|
1728 (82)
|
50
|
87
|
Successful
|
3. Media techniques
| | | | |
3 (a) Written articles in the press, radio interviews, leaflet and poster distribution, website and e-mail distribution lists | Exact number not known, but few | Mainly to raise awareness with the expectation of some self-referrals | 0 | Not successful in directly enrolling participants |
3 (b) Ethnic marketing and consultancy company | 25 (1) | | 1 | Limited success achieved by fieldwork, not mass marketing |
Subtotal
|
> 25 (2)
|
-
|
1
|
Unsuccessful
|
Totals
|
> 2089 (100)
|
100%
|
100% (1319)
| |
1 (a) Direct NHS referrals
Before and during recruitment, we promoted PODOSA to professionals in both primary and secondary care via presentations and face-to-face discussions. Study information leaflets in English, Punjabi and Urdu, posters and referral forms were distributed to general practices and secondary care diabetes clinics in each city. The aim was to raise awareness of the study with the expectation that health care professionals would refer potentially eligible patients to the research team.
1 (b) NHS: written invitations via General Practices
Fifteen practices in Glasgow and 18 in Edinburgh were identified as having the largest number of South Asian patients. Practice lists were searched for patients aged 35 years or older without a diagnosis of diabetes and then scanned for common South Asian surnames. The ensuing lists were checked by practice staff prior to these patients being invited. Personally addressed invitation letters with study information leaflets in three languages and reply forms were sent from the practice. Interested participants were given the option to respond by pre-paid mail, phone or email.
1 (c) Written invitations via the diabetes register
NHS Lothian and Greater Glasgow & Clyde have diabetes registers with levels of ethnicity coding exceeding 60%. In Lothian, we approached South Asians already diagnosed with diabetes to seek participation of their relatives, who might be especially receptive to the idea of a prevention programme. General practices, as the owners of the diabetes register data, agreed to their patients being sent a recruitment pack to pass onto family members and friends.
1 (d) Search of practice lists for IGT/IFG
We piloted an electronic search of the practice lists of six general practices using READ codes (the coding system used in UK general practice) to identify potentially eligible patients who already had a recorded diagnosis of IGT or IFG. The aim was to target our specific study population as outlined in Table
1.
All patient searches described above were carried out by either primary care or diabetes network staff who had the authority and relevant approvals to access patient records.
2 (a) Community recruitment: research team contacts and the snowball effect
Personal contacts provided us with links to numerous local community leaders and groups. During the initial recruitment period one dietitian in Glasgow enrolled three individuals into the screening stage, one from each of the Sikh, Hindu and Muslim faiths. During the first nine months, 140 further participants were screened for the study (34% of the total screened at that point) as a result of snowballing via these three initial contacts. The dietitians asked all those attending the screening visit if they had family or friends who might be interested in participating and if appropriate gave them a supply of study information leaflets to pass on.
2 (b) Community recruitment: using community and faith organisations
We had support from community leaders, including many of the faith organisations in both cities, and other influential people, e.g. the Indian and Pakistani Consuls, a Member of Parliament, and other leaders. Many community and religious organisations were approached by the research team, the intention being to carry out initial promotional talks ourselves, then to ask these groups to pass on information to their clients and members.
After securing additional funding, we set up formal partnerships with five local organisations, including: NHS or community health initiatives, a women and children's Islamic teaching organisation and, the Muslim Council for Scotland, a national body to promote Muslim affairs in Scotland. We also identified 10 individual recruiters who were well known within their local communities. Contracts were agreed with the groups and individuals, based on a payment of £15 per referral actually screened. All the paid recruiters were given materials and training about diabetes, the risk for South Asians, the trial eligibility criteria and the importance of confidentiality.
2 (c) Research team's visits/talks
During the 27 month recruitment period, the research team gave over 60 talks in a range of community organisations including many temples and mosques and at local South Asian events. The talks focussed on South Asians' risk of developing type 2 diabetes, how it can be prevented and what trial participation would involve. We also attended melas (South Asian fairs) and other such gatherings.
3 Media promotion
3(a) PODOSA published in NHS, local and South Asian specific newspapers. The trial was promoted in the Indian and Pakistani communities through poster and leaflet distribution. Our information leaflet used simple language to describe the study, explain that South Asians are at high risk of developing diabetes, and provide the research team's contact details. It was translated into Urdu and Punjabi and all language versions were tested for understanding within the community, using local contacts conversant in these languages. The study website contained information about the trial, prevention of diabetes, and had a simple self-referral registration facility. Other methods utilised were e-mails to distribution lists of various South Asian organisations and well connected individuals, and publicity via interviews on the Glasgow South Asian Radio station (Radio Awaz). The main aim was to raise awareness but with an expectation that this would lead to some self-referrals.
3(b) Marketing Agency
A marketing and promotions company designed an e-flyer and new promotional poster to a high professional standard, and initiated a marketing campaign. This involved regular email-shots to their large database of South Asian contacts, widespread poster distribution and access to local media, for example arranging radio interviews with the Principal Investigator.