SEVERAL OF THE AUTHORS REPLY

Anna M. Nápoles-Springer1, Margaret R. Wrensch2, Daramöla N. Cabral3 and John K. Wiencke2

1 Center for Aging in Diverse Communities, Medical Effectiveness Research Center for Diverse Populations, Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA 94143
2 Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143
3 Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94143

We thank Ambrosone et al. (1) for their comments on our article (2). The Witness Project employs a valuable strategy to overcome distrust of researchers among ethnic minority communities, the use of lay health workers as role models. Using breast and cervical cancer survivors as role models of important prevention and cancer screening behaviors to be emulated has proven effective in a number of cancer control studies (35). Employing lay health workers to serve their own communities can be especially effective because it enhances the likelihood that interventions will be well suited to the sociocultural context. The Witness Project investigators deserve to be lauded for their innovative extension of these methods to recruit persons into population-based studies of cancer risk factors. We encourage Ambrosone et al. to publish their methods and recruitment results in detail so that other investigators may gain from their expertise and experience. More importantly, doing so will contribute to an evidence base of effective recruitment methods among ethnic minority groups so that disparities in research participation can be eliminated.

However, we would like to point out some unique factors in our study of lung cancer that might render a cancer survivor recruiter strategy less effective. First, one of the primary challenges in our study was the lack of race/ethnicity data in the cancer tumor registry listings of cases. Thus, we were unable to match recruiters to potential participants on ethnicity at the time of initial contact. In many instances, the initial contact to screen potential respondents for eligibility (including race/ethnicity criteria) was made by an interviewer of a discordant ethnic group. Second, lung cancer is characterized by a more accelerated disease progression and a much higher age-adjusted mortality rate than that of breast or cervical cancer. These two factors meant that, for a significant fraction of the study population (38.5 percent of African Americans and 43.1 percent of Latinos) (2), initial contact was made when respondents were too ill to participate or had died. However, it is possible that a survivor recruiter strategy may have enhanced participation rates in the remainder of the population who could be reached by telephone or in person. Nonetheless, the high mortality associated with lung cancer would have impeded the ability to identify survivor recruiters as well. Another strategy is to use cancer survivor recruiters who have had other types of cancer (not to match on cancer type), although the effectiveness of this approach needs to be evaluated systematically. Finally, since lung cancer tends to occur in older persons, a major challenge was finding age-gender-race/ethnicity-specific controls for the cases among African- American and Latino populations of a younger median age than the general population. The use of a cancer survivor recruiter may have had less of an impact on recruitment of disease-free controls.

In the original article (2), our aim was to raise awareness among researchers and funding agencies about the challenges associated with recruiting ethnic minorities as participants in research studies. Evidence is accumulating that community-wide recruitment strategies may offer potential for overcoming some of these challenges and may be more effective than traditional methods. However, our understanding of the implications of using these innovative recruitment methods for internal and external validity of our studies is much more limited. Only by publishing articles that describe systematically the methods and outcomes of various recruitment strategies can we improve our ability to include ethnic minorities in studies that seek to eliminate health disparities.

REFERENCES

  1. Ambrosone CB, Jandorf L, Furberg H, et al. Re: "Population- and community-based recruitment of African Americans and Latinos: the San Francisco Bay Area Lung Cancer Study." (Letter). Am J Epidemiol 2004;159:620.[Free Full Text]
  2. Cabral DN, Nápoles-Springer AM, Miike R, et al. Population- and community-based recruitment of African Americans and Latinos: the San Francisco Bay Area Lung Cancer Study. Am J Epidemiol 2003;158:272–9.[Abstract/Free Full Text]
  3. Lam TK, McPhee SJ, Mock J, et al. Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education. J Gen Intern Med 2003;18:516–24. [CrossRef][ISI][Medline]
  4. Navarro AM, Senn KL, McNicholas LJ, et al. Por La Vida model intervention enhances use of cancer screening tests among Latinas. Am J Prev Med 1998;15:32–41.[CrossRef][ISI][Medline]
  5. Perez-Stable EJ, Otero-Sabogal R, Sabogal F, et al. Pathways to early cancer detection for Latinas: En Accion Contra el Cancer. Health Educ Q 1996;23(suppl):S41–S59.




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