# NCI Division of Cancer Prevention

# Recruitment Manual 

# (Template)

**Introduction and Acknowledgements**

**Recruitment**

General Eligibility Criteria

Adherence and Retention

Flow of Recruitment

> General Planning Guidelines
>
> Understand the Study Population
>
> Draw from a Known Pool of Resources and Contracts within the Community
> Recruitment Referral Sources
>
> Use Available Recruitment Materials to Plan and Conduct Informational
> Sessions
>
> Establish Explicit Goals
>
> Specific Recruitment Strategies
>
> Identifying Referral Sources
>
> Community Activities
>
> Mass Media and Press Releases
>
> Targeted Mass Mailings
>
> Word of Mouth
>
> Participant Advocates
>
> Partnering with Other Studies
>
> Spokespersons
>
> Volunteers
>
> Interpreters
>
> Sharing Ideas and Problem Solving
>
> Important Points to Remember

**Recruitment Strategies for Special Populations**

African-American Recruitment Strategies

Group Strategies

Individual Strategies

Hispanic Recruitment Strategies

Recruiting Other Minorities, Ethnicities

Asians and Pacific Islanders

Native Americans

Medically Under-Served

The Elderly

Use of Recruitment Materials

**Handling Special Issues**

Low Literacy

Hearing/Vision Impairments

Learning Disabilities

Mobility Impairments

Cultural Norms

General Points to Remember

**Monitoring Responses to Recruitment**

Recruitment Strategies Log

Phone Calls

**Appendix**

Recruiting Tools: Recruiting with Powerful Presentations

### Introduction and Acknowledgements

Recruitment to cancer prevention clinical trials involves the
identification and screening of potential participants. This template
defines recruitment goals and timelines, and outlines possible
strategies, procedures, and materials that can be used for contacting
and screening potential participants.

Special thanks go to the Southwest Oncology Group for allowing the use
of original material from its Selenium and Vitamin E Prostate Cancer
Prevention Trial (SELECT) study manual.

### Recruitment

Recruitment of healthy participants to cancer prevention trials is
challenging. The objectives of recruitment are to:

-   Identify sources of potential study participants.

-   Introduce the study to physicians and community leaders having
    access to potential participants.

-   Introduce the study to potential participants who express
    preliminary interest.

-   Complete the initial screening of potential participants.

######### **General Eligibility Criteria**

It is necessary to be aware of eligibility criteria when recruiting due
to age specifications and other health requirements for participation in
a trial. Each potential participant must satisfy all eligibility
criteria. (If conducting more than one study, being aware of eligibility
criteria for all studies is useful since a patient may fit one, but not
another study.)

######### **Adherence and Retention**

Adherence means maintaining the schedule of the trial. Study retention
is keeping the participant interested in and committed to the study.
While it is very important to meet the recruitment goals, it is also
important to assess the potential participant\'s likelihood of adequate
adherence and retention.

Adherence and retention efforts begin at the outset of recruitment and
are an ongoing process. The more attention you give to recruiting a
healthy, committed participant, the less effort you should need to put
in later for adherence and retention.

######### **Flow of Recruitment**

Recruitment of study participants begins with the identification of
sources of potential participants and ends when the participant is
randomized to the study.

Potential participants will be screened at the Initial Visit to meet
specific eligibility criteria and may fall into one of three categories:

-   possibly eligible

-   possibly eligible in the future

-   ineligible

######### **General Planning Guidelines**

Review of clinical trials methodology indicates that the major reasons
for recruitment problems are inadequate planning at all levels of the
trial, overestimation of the yield from a particular source, and the
inability to alter existing plans rapidly and implement other recruiting
strategies if recruitment is lagging.

Designation of individual staff responsibilities for all aspects of
recruitment is essential for successful recruitment. If possible, employ
an experienced well-trained recruitment coordinator to have overall
responsibility for the local effort. Track recruitment efforts and the
success of each.

The following are general guidelines to consider when planning outreach
to and recruitment of a specific population.

######### **Understand the Study Population**

This may require assessment of the following characteristics:
individual, family, employment and community/culture. Use this
demographic information to tailor your message so that it is appropriate
for the group you are interested in reaching.

######### **Draw from a Known Pool of Resources and Contacts within the Community**

Establish lines of communication within the community to promote trust
and awareness of the study. You can accomplish this by identifying
contacts and points of access such as:

-   Healthcare decision makers, physicians, health writers

-   Community leaders such as clergy, politicians, radio and television
    personalities

-   Locally owned community businesses and organizations

-   Resources with which your organization has an already established
    relationship, such as labs, physicians offices, volunteers

######### **Recruitment Referral Sources**

Potential participants can be identified in a variety of ways, the
nature of which depends on the target populations of the study site. The
procedures for identifying potential participants will also vary by
referral source and study site. In the beginning, you should plan to
target sources with which you have previously established a
relationship. Also, begin with sources that have a high percentage of
potentially eligible participants.

Medical Referral Sources:

-   Physician groups such as medical and dental associations

-   Screening programs and health fairs

-   Other medical groups such as Grand Rounds

-   Minority based community clinics

Clubs/Social Groups/Organizations:

-   Social Clubs and community centers

-   Churches and temples

-   Senior citizen centers

-   Chambers of Commerce

-   Educational alumni associations

-   Health clubs

-   Local major employers and their retired associations

-   The American Association of Retired People (AARP)

-   The National Association for the Advancement of Colored People
    (NAACP)

-   Golf clubs/resorts

-   Bowling leagues

-   Fraternal Organizations such as the Masons, Elks, Nile Shrine,
    Veterans of Foreign Wars

-   Unions

-   Tribal Councils

-   Other community resources such as barber shops

-   Other organizations such as The Links, The Urban League, and
    National Associations such as Bar Associations, 100 Black Men

-   Mass media campaigns

-   Relatives of cancer patients

-   Spouses of people participating in other studies at your site

The groups listed above can be identified via the yellow pages, the
Internet, discussion groups, and through participant advocates.

######### **Use Available Recruitment Materials to Plan and Conduct Informational Sessions**

When possible, pretest selected recruitment and screening strategies,
especially if they have not been previously used in your clinical
center. A variety of recruitment materials are available that can be
used alone or in combination depending on the group being targeted for
recruitment:

-   Slide presentation

-   Written materials developed for a variety of lay audiences,
    including the general population, cancer patients, minorities, and
    people with limited literacy skills

-   Public education programs and materials

-   Free Cancer Information Service educational materials that contain
    useful, relevant, and empowering information (1-800-4-CANCER)

######### **Establish Explicit Goals**

Establish specific short- and long-term goals for recruiting and
retaining study participants, and be prepared to evaluate your
recruitment plans. Set realistic and obtainable goals. Make a calendar
for the entire recruitment period. One short-term goal may be to
increase minority enrollment at your site by ten percent over the next
two months. A long-term goal may be to develop a newsletter that
provides feedback on the status of the study to a particular community
referral source to keep them involved and supportive of the study.

It is important to evaluate participant accrual, adherence and retention
on a frequent basis. These evaluations can help monitor how well your
site is achieving its established recruitment goals and identify reasons
for participant withdrawal. Periodic monitoring will also ensure that
the strategies being implemented conform to the needs and values of
research participants and their communities. Develop contingency plans
and use multiple varied recruitment strategies. At least three
recruitment strategies should be employed at all times. Be prepared to
initiate recruitment on the target date.

The following is an example of an action plan to help you plan your
approach to a specific source or group that can be used as a model once
you have followed the steps above.

######### **Figure 1: Example of a Recruitment Action Plan for a Specific Study**

A. Community Assessment

> A prelude to developing a recruitment plan, conducting a community
> assessment, helps identify critical partners and sources of
> participants and shows the bigger picture. Questions to be addressed:

-   Where are you able to reach those who will participate?

-   Where have participants come from in previous trials of this type?

-   Where have you been unsuccessful?

-   What new sources have you been able to identify?

-   What is the level of preexisting collaboration around health?

-   How much access would these preexisting linkages have to special
    populations?

-   Who are the leaders that would be able to influence people's
    decisions to participate?

-   To what extent are local membership groups concerned about family
    health and can they be recruited to promote the trial?

B. Focused Site Specific Plan

> 1\. Who is your population? (e.g., geographic location, eligibility
> criteria) Example: Men aged 55 and older who reside in Western North
> Carolina.
>
> 2\. Where are you going to locate these participants? (e.g., clinics,
> community organizations, lists, ads, etc.)
>
> 3\. How are you going to recruit these participants?

4\. What special plans are being used to recruit minorities?

> 5\. Your local IRB needs to approve the materials used for
> recruitment.

C. Environment and Norms

-   What is the level of knowledge about cancer prevention among
    targeted groups?

-   How much concern is there or how much interest in prevention?

-   Are there local figures who have had cancer who could and would
    promote prevention?

-   Do any of the television/radio outlets have a particular focus or
    interest in health?

-   What about Unions?

-   What other cancer control activities are underway in the community?

D. Relevant Articles

> Consider doing your own literature searches for relevant information
> based on your target population.

### Specific Recruitment Strategies

######### **Identifying Referral Sources**

The procedure for identifying potential participants varies by the type
of referral source. The nature of these referral sources depends on the
target population for recruitment. In each case, negotiations should be
made with the individual referral source. Some sources will provide
mailing labels, while others require the study site to furnish
recruitment materials for distribution by the source.

Developing positive relationships with community leaders is an essential
part of the recruitment process. These community leaders, sometimes
referred to as gatekeepers, can provide and enhance access to a certain
community.

It is best to target groups with whom there is an existing relationship.
It is a mistake to assume that the negotiations will be completed
quickly. Experience suggests that some negotiations may take months to
finalize. It is best to develop the relationships many months in advance
of planned initial mailings or other activities in order to avoid delays
in the recruitment schedule.

######### **Community Activities**

Approach leaders of organizations with potential participants and
attempt to gain their interest and support for the study. For instance,
approach the head of a local pipe-fitters union and present him or her
with a verbal overview of the study, and provide study materials such as
a study flier or brochures. Ask that these materials be posted in union
halls and anywhere else identified as a good source for potential
participants. Ask the union leader (if potentially eligible) to consider
joining the study. If he joins, then ask him if he is willing to voice
his support. If appropriate, ask if someone from the study can visit the
work site and explain the study.

Hand deliver letters and a study brochure describing the study to
physicians and medical societies in the local area. Provide them with
the appropriate recruitment materials for their patients, as well as the
Professional Flier and background materials about your institution.
Request referrals and give assurances that the study protocol does not
conflict with the mission of primary care physicians, or supplant them
as their patients\' primary caregivers. This is important because
physicians serve as gatekeepers by alerting and helping their patients
gain access to research trials. Return to these officers monthly to
reinforce and refresh supplies.

The leaders of medical societies (and leaders of other organizations)
may also offer support, including putting information about the study in
their local and/or national newsletter.

######### **Mass Media and Press Releases**

Recruitment can be promoted through various marketing and publicity
ventures. They can include newspaper articles, newspaper and radio
interviews, and television reports. Consider meeting with the public
relations officer or the marketing director at your institution for
guidance on approaching the media. Ask your public relations office to
provide an established contact person from the media, or to give advice
on how to contact the local media.

Be prepared to handle by letter or telephone the response from the
public immediately after the media publicity goes out. Do not send out
an announcement until you are organized and ready to respond. Also, do
not be too optimistic that the responses will continue. It is surprising
how quickly the calls stop after a media feature story has run. You may
need to plan a follow-up press release in a month.

### Targeted Mass Mailings

You can employ a variety of direct mail campaigns to potential
participants in the targeted age group. These people can be identified
through a variety of sources: motor vehicle registration lists,
drivers\' license lists, voter registration tapes, Medicare enrollee
lists, and commercial mailing list brokers.

These mailing lists may not be directly available to you; however, the
organization may be willing to put their own mailing labels on a mailing
of materials provided by you to a specified target population. They may
be able to define the printing of the mailing labels based on criteria
such as males, a specific age group, and ethnicity. This would protect
their need for confidentiality. In addition to these general sources of
age-eligible people, many sites will have identified several other
enriched sources of potential participants. Previous experience suggests
that second and even third mailings using the same list give excellent
results.

Mailings usually consist of a letter inviting participants who are
age-eligible to return an Interest Survey or post card indicating their
potential interest. A flier describing the study should be included as
well as a postage-paid return envelope or postcard. A potential
participant could either call or mail in his or her response.

######### **Word of Mouth**

Potential participants and participants who ask how they can be of help
or whom you think are very supportive of the study can also be good
recruiters. Encourage them to share study information with other
friends, family members, clubs, or organizations they have contact with
or belong to as a member. You can provide them with participant fliers,
or business cards, and encourage them to have interested participants
call your study site for more information.

######### **Participant Advocates**

Participant advocates can help bridge the research gap by suggesting
ways to help eliminate recruitment barriers. They bring their voice and
experience into the research dialogue and help explain the value of
cancer research to the public. They can facilitate communication, help
interpret study information and help you focus on potential participant
needs and motivations. They help with \"what\'s in it for me\" concerns
and to focus attention on the ultimate goal.

######### **Partnering with Other Studies**

Study sites are encouraged to keep abreast of other studies being
conducted within their geographic area. By doing so, you can explore
opportunities for sharing recruitment strategies with other studies. For
instance, a study may be recruiting women in the same age group as your
study. It might improve this study\'s adherence if the women brought
their husbands with them to the study visits and at that time the
husband could be screened as a participant in your study. This may
require coordinating the scheduling of appointments between studies, but
this extra effort may enhance recruitment.

######### **Spokespersons**

Individuals other than your own Investigators and study staff may
communicate information about your study to the public. Identifying
local celebrities or spokespersons may be beneficial. You may also want
to consider a 'peer\' spokesperson. This may be someone like the most
respected member of the local union but not necessarily someone who
holds an office or has appeared in ad campaigns.

Spokespersons can serve as popular and positive advocates, but their
credibility and effectiveness may have limits. Spokespersons can assist
in making contacts and spreading the word about the study to specific
ethnic groups or social circles. Spokespersons can have a great impact
when used to create Public Service Announcements (PSAs). Local
television and radio stations are required by law to provide airtime
free of charge, but competition for this time is fierce. Spokespersons
should be kept abreast of study updates and status. This will allow
spokespersons to appear knowledgeable and up to date when discussing the
study with current participants, thus promoting adherence.

Some literature suggests that a familiar spokesperson, such as a
celebrity or a peer, is perceived as more credible than one who is
unknown. If you were to use advertising strategies to select a
spokesperson, you would want to match your spokesperson with the topic
you are promoting. For instance, identifying a woman in the eligibility
age range, and perhaps in the ethnic group you want to target, who
either has had the type of cancer you are studying or is willing to join
may prove beneficial.

Current participants also often work well as spokespersons. Local cancer
advocacy groups can often provide names of local celebrities willing to
act as spokespersons. You may want to contact your institution\'s media
relations specialists, administrators, directors, and Investigators to
see if they know of local celebrities who fit the profile and are
willing to be contacted.

If you do use a spokesperson, strategize with your Investigator and
media staff about how a spokesperson can present study information in an
appealing and provocative manner to both the media and the general
public. Also, check with your IRB as to whether outreach activities need
to be reviewed and approved.

######### **Volunteers**

Seeking volunteers from the community or from your institution to assist
with recruitment can help alleviate some staffing and workload issues.
Volunteers can assist with stuffing envelopes, sorting surveys,
answering phones, scheduling appointments, and documenting information.
Some volunteers prefer one-time activities or events, while others
prefer a more structured commitment. Consult your institution\'s policy
on the use of volunteers and any associated confidentiality issues.

Consider asking for volunteers from the nursing community, medical
schools, or college campuses to assist at screenings or information
sessions in the community. For example, the volunteers could provide
free blood pressure screening at a group meeting to enhance public
participation. Students can sometimes get continuing education credits
for their assistance in these events.

######### **Interpreters**

To assist with minority recruitment, study sites may need to use
interpreters. Check within your institution to see if language
interpreters are available. You may also want to consider using a
full-service language interpretation and translation company. Some
services offer over-the-phone interpretation, electronic mail and short
message translations, visual translation (reading a document you
received in another language to you over the phone in English), plus
in-language telemarketing and teleservicing. There is a fee for these
services.

######### **Sharing Ideas and Problem Solving**

Share ideas and problem solve with other study personnel in your
institution who are recruiting, or have recruited, from a similar
population base.

######### **Important Points to Remember**

The following are a variety of points to consider when recruiting from
the general population:

-   Always be very respectful; be available to talk and answer
    questions; always maintain confidentiality.

-   Talk with potential participants about their concerns; identify and
    address any perceived barriers to participation with the potential
    participant.

-   Offer flexible schedules so potential participants won\'t have to
    take time off work to come to appointments.

-   When possible, offer free parking, transportation, and medical
    exams. (Seek IRB approval first.)

-   Help potential participants requiring financial or other assistance
    get in contact with available social services or community
    resources.

-   Enhance your study site\'s community referral network by linking
    with churches, adult day care centers, support groups, etc.

### Recruitment Strategies for Special Populations

The NCI is committed to working towards increasing the overall accrual
of special populations to clinical trials as detailed in the NCI
Initiatives for Special Populations (1998). The appropriate
participation of ethnic/racial minority populations in clinical trials
has been a specific goal. Participation of diverse populations is
desired because it may provide more generalizable results.

######### **African-American Recruitment Strategies**

The following strategies are recommended to assist in the recruitment of
African-American men:

-   Develop concise educational messages targeted for lay readers
    regarding increased incidence of and mortality from your study's
    type of cancer in the African-American community. Include the
    benefits and limitations of early detection methods, and the need
    for research on how to prevent cancer in the messages. Radio is
    often the most cost-effective way to communicate, but if possible,
    use television and the print media.

-   Ask African-American study participants to present their experience
    to others in their community.

-   Ask African-American cancer survivors and their spouses and family
    to be advocates for your study.

-   Include African-American participants or cancer survivors in
    advertisements for the trial.

-   Ask African-American participants to be available to \"mentor\"
    another African­-American considering participation in the study.

-   Target local radio programs with stories or messages or to arrange
    interviews, focusing on those with a large African-American
    audience.

-   Use materials that are culturally appropriate.

-   Prepare special materials for those with literacy problems.

-   Use videos to convey the message, focusing on African-American men
    and their spouses who can tell their stories.

-   Look for contacts in retirement organizations, fraternities,
    sororities and advisory boards.

-   Don\'t imitate an ethnic communication style which is not naturally
    your own. For example, using African-American communication style or
    buzzwords or phrases when you are not African-­American may be
    interpreted as ridicule.

-   Show that you view the community as a safe environment by conducting
    recruitment at the referral source such as going into the church,
    social center, or union hall to do a presentation or attend an
    organization\'s meeting.

-   Explain the benefits of participation for the participant, and for
    future generations.

-   Seek African-American community leaders to work with you in planning
    popular events.

-   Provide incentives such as free blood pressure screening to draw
    attention to your presentation.

######### **Group Strategies**

Within the African-American community you may encounter resistance to
participation in a clinical trial. Other study population groups will
likely voice these concerns as well. The following are some strategies
to prepare you for approaching a referral source in group settings:

-   Seek screening opportunities in the community such as health fairs,
    screening, and

-   Checking for upcoming meetings where fliers can be distributed.

-   Develop trust with the community by being open and honest.

-   Consider including physicians, nurses, and educators on your team
    that reflect the ethnicity of the target group.

-   Work with African-American ministers and church representatives.

######### **Individual Strategies**

The following are suggestions for approaching an individual:

-   Create an environment that is conducive to building trust by being
    available to talk and answer questions.

-   Be honest and admit when you don\'t know something, and promptly
    provide follow-up responses.

-   Keep interactions informal, cite personal examples, and allow for
    interruptions and free expression of opinions.

-   Assign one primary staff member (preferably a staff member of the
    same race/ethnicity) to facilitate continuity with the potential
    participant.

-   Make regular contact so as to maintain an ongoing dialogue.

-   Involve family members by providing them with information to support
    the participant. Engage participants in peer counseling.

######### **Hispanic Recruitment Strategies**

Successful recruitment within the Hispanic community requires an
understanding of Hispanic culture, and in particular, Hispanic
perceptions of the medical community, disease and communication styles.

Consider establishing communication with health care leaders at
community health clinics that serve a large proportion of Hispanic
patients. Trusted members of the health care team may be very effective
at distributing recruitment materials and communicating with potentially
eligible participants. These local community health care leaders may
also have ideas to assist you in your efforts at reaching the Hispanic
community.

If you have a large Hispanic population, consider having a separate
Community Advisory Board for Hispanic recruitment. Representatives
should include physicians, other trusted health care leaders, clergy,
community leaders, and lay advisors - both male and female is desirable.

The following strategies and methods to enhance communication are
recommended when recruiting within the Hispanic community:

-   Present information in non-technical terms and in a linguistically
    accurate format. Materials written in Spanish that are literally
    translated to English are often stilted and should be avoided. Use
    an experienced translator when doing language translations. For
    other materials, consider using a local interpreter or interpreter
    service.

-   Hispanics often show more concern about the impact of potential
    disease on their families and close friends than on themselves.
    Therefore, messages are best framed in terms of the family, and the
    implications of a particular health-related behavior for the family
    unit.

-   Cultural considerations are extremely important in the development
    of messages and materials. For example, the prevalence of the
    attitudes of \"fatalismo\" (fatalism) and \"resignacion\"
    (acceptance) regarding illness, and the aversion of males to seeking
    care due to the \"machismo\" attitude.

-   Hispanics often prefer getting health-related information from other
    individuals (doctors, family, close friends) rather than from
    printed material. Whenever possible, use videos, speakers,
    health­care professionals and participant testimonials in recruiting.

-   Testimonials from cancer patients, or from Hispanic celebrities or
    doctors who have experienced cancer themselves or in their families,
    are considered most desirable.

-   There is a strong preference for Spanish-language media in the
    Hispanic community, especially radio and television.

-   Cancer is viewed as a devastating and incurable disease among
    Hispanics of low socioeconomic status, and therefore often has a
    stigma of social disgrace attached to it. Efforts to reach this
    audience should stress basic cancer facts, e.g., that it is not
    contagious; that cancer affects those who have no family history of
    the disease; and that community resources exist to help
    Hispanics/Latinos cope with the disease.

-   Address the Hispanic population as a whole, instead of by specific
    ethnic groups within the population.

-   Messages must be sensitive to financial constraints. For example,
    offer free prostate cancer screening. When possible, always spell
    out the cost, or lack thereof, of services offered.

-   Religion plays a prominent role in the Hispanic community, even when
    members of that community are not actively practicing their
    religion. Getting cancer and other diseases is often viewed as
    \"God\'s decision\" so communication should counter possible
    pessimism with accurate information.

######### **Recruiting Other Minorities/Ethnicities**

Keep in mind that diversity exists *within* all minority populations.
For instance, Native Americans are not a homogeneous population and what
works for one tribe may not work for another. Review literature - census
data, medical journals and articles, cancer statistics, community
newspapers, books, and minority health Web sites to obtain knowledge
about other cultures to guide you in contacting and talking with other
minority groups.

######### **Asians and Pacific Islanders**

Cultural themes to keep in mind when dealing with Asian and Pacific
Islanders are:

-   Concept of losing-face based on the idea that an individual\'s
    disgrace or credit is shared by his family and community

-   Concern and respect for parents

-   Importance of family honor

-   Respect for authority

-   Reliance on home remedies

-   Endurance of pain/suffering without complaint

-   Belief that negative thoughts become reality

######### **Native Americans**

Cultural themes to keep in mind when talking with Native Americans are:

-   Respect for the individual\'s right to freedom

-   Respect for all living things

-   Respect for the land

-   Group consensus in decisions regarding the tribe

-   Respect and honor for the tribe/village

-   Religion - belief in a supreme being and life after death

-   Belief that saying the word \"cancer\" would bring it upon oneself

-   Traditional healing practices of folk medicine and herbal medicines

######### **Medically Under-Served**

The medically under-served are those who have limited access to health
care due to many factors. These include those living significant
distances from medical settings and having inadequate income and
transportation. Consulting with the staff of local free clinics is
recommended for advice on approaching and communicating with this
population.

The following are suggestions for addressing concerns of the medically
under-served:

-   Verify that any services or income they receive will not be affected
    by study participation; check with social services.

-   Offer free parking, transportation, and exams when possible.

-   Do not show excessive prosperity in your attire or demeanor.

-   Keep communications simple and genuine

You can partner with local county and/or city health clinics to provide
a recruitment and/or referral site for the medically under-served.
Request funding from foundations and local community service programs to
provide transportation, parking, and other forms of assistance.

######### **The Elderly**

An elderly person who meets your judgment of physically and
psychologically fit to participate at randomization may later develop
health and/or cognitive impairments or a change in living conditions
that hinder adherence and retention. This is not meant to discourage
recruitment of elderly individuals but to alert staff that recruitment
of the elderly may require a special sensitivity to their needs and to
the process of informed consent.

Research reveals that recruitment among elderly populations appears to
be no more difficult than among individuals of other age groups. Tips
for recruiting the elderly include:

-   Use in-person contacts as opposed to written materials.

-   Availability of transportation is often a major barrier to
    participation, so provide updated bus route information and free
    transportation if possible.

-   Remember that inadequate literacy rates are high among this
    population.

######### **Use of Recruitment Materials**

-   Use appropriate informational pamphlets; for example, if English is
    the second language of the potential participant you are seeking to
    recruit, use and present materials in their first language.

-   Use materials that contain concise, short sentences with a
    conversational tone.

### 

### Handling Special Issues

######### **Low Literacy**

The 1992 National Adult Literacy Survey (NALS), the most accurate
portrait of English-language literacy in the United States, found that
40 to 44 million Americans, or approximately one quarter of the U.S.
population, are functionally illiterate, and another 50 million have
marginal literacy skills. This means that almost half of our adult
population has deficiencies in reading or computational skills. Of
these, 5% have learning disabilities and 15% were born outside the
United States. However, the vast majority of adults with poor literacy
are white, native-born Americans. Ethnic minorities and medically
under-served are disproportionately represented among people with low
literacy skills. Inadequate literacy is especially prevalent among the
elderly.

Low-literacy issues raise serious concerns about the ability of many
Americans to function adequately in health care settings. An
individual\'s functional health literacy-the ability to read and
comprehend prescription bottles, appointment slips, and other essential
health-related materials required to successfully function as a
participant may be significantly worse than their general literacy,
because functional literacy is context specific. That is, an individual
may be able to read and understand materials with familiar content but
struggles to comprehend materials written at the same level of
complexity if that material contains unfamiliar vocabulary and concepts,
especially those related to health care.

Overall, the average reading skills of adult Americans is between the
skill levels of grade 8 and grade 9, and the reading skills of Medicaid
participants are at about 5^t^\' grade level. It is important for staff
not to assume that they can recognize individuals with poor literacy
skills, because most individuals with limited literacy try to hide the
fact due to the shame they feel about their reading deficiencies.

Some methods to enhance communication while presenting materials to
those with inadequate literacy are:

-   Choose a speech rate and style that promotes understanding and
    demonstrates respect for the potential participant.

-   Don\'t ask directly whether or not a person can read the informed
    consent.

-   Encourage questions and tell the participant it is OK to interrupt
    your presentation of the materials if there are any questions.

-   Elicit interaction by going through study materials or the informed
    consent point by point, allowing for repeats of the important parts
    and time for questions.

-   Avoid slang, technical jargon and complex sentences; use lay terms
    as much as possible.

-   Use open-ended questions or questions phrased in several ways to
    obtain information.

-   Confirm the individual\'s knowledge about the study. For example,
    ask him to tell you in his own words what the study is about; let
    him know that you are trying to make sure he knows exactly what he
    is signing up to do.

-   Remind the potential participant he can share information about the
    study with family members and friends who are familiar with his
    needs and may be able to help him better understand.

-   Emphasize the importance of the study and the need for questions and
    procedures.

-   Inform the potential participant that he will never be referred to
    by name or by any other identifying information in any reports,
    emphasizing that information about the men in the study as an entire
    group will be reported.

-   Always be respectful and non judgmental by listening and not making
    judgmental statements.

-   Allow potential participants to take materials home to review with
    their family. It is acceptable and encouraged to have a family
    member join the potential participant at the visits. The family
    members\' support of the participant should be encouraged at all
    times.

######### **Hearing/Vision Impairments**

Carefully observe the potential participant. He may have health and
functional impairments such as hearing and vision impairment. If he
leans toward you as you talk, this is an indicator you may need to speak
in a slightly louder voice (don\'t shout) to compensate for what appears
to be a hearing deficiency. Look at the person as you speak because he
may depend on lip reading to compensate for his hearing deficit.

Often the best way to communicate with those with severe hearing
impairments is through a qualified Sign Language interpreter. Your
institution\'s social services department may have a list of locally
available interpreters.

Vision problems can be addressed by offering reading glasses and by
using pictures, diagrams, and large print written materials appropriate
for the disability.

######### **Learning Disabilities**

If it appears the potential participant is not responding to you and not
paying attention, it may indicate a learning disability. Speak slowly to
ensure information is being communicated.

Messages are communicated by facial expressions and body movements
specific to each culture. You should be aware of variations in nonverbal
communication to avoid misunderstandings or inappropriate movements that
may unintentionally offend potential participants. Use pictures and
diagrams to enhance understanding.

######### **Mobility Impairments**

Based on the age group being recruited, you may run into systemic
diseases such as arthritis or other conditions that may affect mobility.
Remember that they may not be debilitating enough to affect the
individual\'s performance status, but still may make an individual
sensitive to strong handshakes or sitting for long periods of time.
Also, a firm handshake may be a positive gesture of goodwill in the
Anglo-American culture, but some other cultures prefer only a light
touch. Be aware of the walking pace of the participant, and match your
own pace accordingly so as to not leave him walking behind you.

######### 

######### **Cultural Norms**

To help alleviate barriers (such as lack of trust, differences in age,
education level, or racial differences) that may cause a potential
participant to give inadequate information to a staff member, try the
following:

-   Ask questions in several different ways to double-check information.

-   Adjust style of interaction to compensate for differences in age
    between you and the potential participant.

-   Use open-ended questions.

-   Be aware of your own cultural values and biases, and don\'t let them
    interfere with interactions with the potential participant.

-   Acquire basic knowledge of cultural values and health beliefs for
    the population groups that you routinely serve.

-   Explain that the study will provide important information for men of
    all ethnic and racial backgrounds.

-   Explain that researchers from all ethnic and racial groups from
    across the country are involved in conducting the study.

######### **General Points to Remember**

Conservative use of body language is wise when you are uncertain as to
what is appropriate within a cultural group. Asking general questions
about body language can also help if you have doubts about appropriate
behavior. Watch a prospective participant for hints of what is
appropriate body language. Does he use gestures freely or sparingly,
extend his hand for shaking, and keep his hands and arms close to the
body?

### 

### Monitoring Responses to Recruitment

Using multiple recruitment strategies, coupled with a monitoring system
that provides rapid feedback regarding the efficacy and costs of each,
maximizes effectiveness. Monitoring of recruitment progress weekly,
preferably through computerized tracking systems, is a key to meeting
recruitment goals, in that it identifies recruitment problems and
successes. Based on this information, recruiting strategies can be
modified.

A suggestion for monitoring recruitment is to assign a number to each
referral source. If using more than one recruitment strategy for a
single source, assign each strategy a unique number. For example, assign
two referral source numbers to a referral source to which you do two
mailings, one for the first mailing and a different number for the
second mailing.

######### **Recruitment Strategies Log**

The purpose of the Strategies Log is to document the effectiveness of
your recruitment methods. Strategies Logs should be completed by the end
of each month, and the information recorded should reflect recruitment
efforts from the first to the last day of the month. (See Figure 2.)

The following describes how each of the log\'s sections should be
completed:

[Recruitment Strategies]{.underline}

In this section, summarize in a few short words the type of recruitment
strategies implemented. This description should be general; for example,
if someone at your site is speaking with church groups, then you might
write, \"meet with church groups.\"

[Try Strategy Again?]{.underline}

The purpose of this section is to state whether or not your site would
try the strategy listed in the previous column again. Think about how
successful this strategy was in your community and how feasible it was
to implement. A yes or no in this column is all that is necessary.

[Number Contacted]{.underline}

In this column, record the actual number or an estimate of were
initially introduced to the trial by the strategy implemented.

[Number Who Visited the Clinic Site]{.underline}

In this column, record the number of potential participants who visited
a clinic site as a result of the strategy implemented.

[Number Randomized]{.underline}

In this column, record the actual number of individuals randomized to
the study.

[Site Name, Staff Member Name, Phone #, and Date]{.underline}

Record site information and the name of the person completing the form
should questions arise in the future.

######### **Figure 2: Recruitment Strategies Log** 

***Date of Project (*mo.\_\_\_ yr.\_\_\_)**

+-------------------+--------+------------+------------+-------------+
| **Recruitment     | *      | **Number   |            |             |
| Strategy**        | *Try** | of         |            |             |
|                   |        | Potential  |            |             |
| **(list           | **Stra | Part       |            |             |
| activity)**       | tegy** | icipants** |            |             |
|                   |        |            |            |             |
|                   | **Ag   |            |            |             |
|                   | ain?** |            |            |             |
|                   |        |            |            |             |
|                   | **(    |            |            |             |
|                   | Y/N)** |            |            |             |
+-------------------+--------+------------+------------+-------------+
|                   |        | **         | **Visited  | **Ra        |
|                   |        | Contacted? | Clin       | ndomized?** |
|                   |        | actual/es  | ic/Site?** |             |
|                   |        | ti-mated** |            |             |
+-------------------+--------+------------+------------+-------------+
| Month /Week 1     |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 1\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 2\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 3\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 4\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| Month /Week 2     |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 1\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 2\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 3\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 4\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| Month /Week 3     |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 1\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 2\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 3\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 4\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| Month /Week 4     |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 1\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 2\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 3\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+
| 4\.               |        |            |            |             |
+-------------------+--------+------------+------------+-------------+

**Site
name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Staff member name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone
#\_\_\_\_\_\_\_\_\_\_\_\_**

######### **Phone Calls**

When potential participants, or their family members, call the study
site in response to a presentation or a mailing, a preliminary screening
for age and health status can be done over the phone. If speaking with a
family member, be sure to ask him/her whether the potential participant
gave verbal consent allowing the family member to supply the screening
information.

Record the potential participant\'s name, address, and phone number.
Mail him or her literature on the study. Follow up with a phone call in
a few days. Thank the inquiring party for his/her interest in the study,
and say a staff member will call the potential participant after he/she
returns the Interest Survey. Document the phone call.

### Appendix

### Recruiting Tools: Recruiting With Powerful Presentations

######### 

### Messages and Memories

Most research shows that audiences pay less attention to your message
than to your tone of voice and body language.

Of your total communication (content, voice and body language), the
audience will assign the following values to your presentation:

-   7 percent - content, or the information you provide.

-   38 percent - voice, or how you deliver the information.

-   55 percent - non-verbal, or the messages you convey with your body.

When you do not reinforce the information you have presented (with a
handout or some kind of follow-up) people tend to forget it.

40 percent - after 20 minutes 60 percent - after a half day 90 percent -
after a week

Source: Donald J. Moine and John H. Herd, citing resL-archer Albert
Mehrabian and others in *Modem Persuasion Strategies: The
Hidden-Advantage in Selling* (Prentice­

Hall).

### Guidelines for a Successful Presentation

######### **Take Command of the Room**

1.  Command the attention of your listeners.

2.  Arouse their interest in you and in your message.

3.  Get the audience to believe what you say.

######### **Direct Your Fire**

1.  Target your subject matter for this audience.

2.  Show this audience why this topic is important to each person.

3.  Describe how this topic affects each one personally.

######### **Say What You Mean**

1.  State clearly the subject or theme of your presentation.

2.  State clearly what you are going to prove, explain, or describe

3.  Make clear your stand on the topic.

######### **Sell your idea**

1.  Expand on your central theme to help your audience understand the
    subject

2.  Prove the point you have made with strong and appropriate examples;
    make the audience agree with your position.

3.  Persuade your audience to abandon their individual beliefs and join
    in accepting your point of view.

######### **Get Action**

1.  State clearly how the information you have presented will benefit
    them.

2.  Tell your audience what you want them to do.

3.  Encourage your audience to act!

### 

### Hints for Formal Presentations 

######### **Do:**

-   Allow enough time to prepare your material.

-   Expect to do well!

-   Know your audience.

-   Use a strong \"grabber\" to establish a purpose, provide continuity,
    and reinforce your points.

-   Prepare your speech for ease of reading.

-   Use loose 8 1/2 x 11 inch sheets for your text, and number them.

-   Check out the facilities beforehand.

-   Mark your visuals at the correct points on your script.

-   Maintain eye contact with one person at a time.

-   Make all body movements and gestures work for you

-   Keep your hands out of your pockets.

-   Vary your volume and rate of speaking appropriately.

-   Use short sentences with action verbs.

-   Emphasize words that convey your meaning.

-   Insert pauses between sentences.

######### **Don't:**

-   Don\'t reintroduce yourself.

-   Don\'t begin by saying, "I'm going to talk about,\" \"My topic is,\"
    or \"I\'ve been asked to talk about...\'\'

-   Don\'t make apologies or excuses.

-   Don\'t be argumentative or antagonistic.

-   Don\'t speak too quietly, loudly, slowly, or quickly. Don\'t use
    tentative phrases such as, \"I think,\" \"I believe,\" or \"It seems
    to me that.\" Do say, \"I know,\" \"I\'m convinced,\" or \"There\'s
    no question that.\"

-   Don\'t say, \"in conclusion,\" or \"in summary.\"

-   Don\'t use verbal fillers such as \"um,\" \"uh,\" \"you know,\" and
    \"okay.\"

### Tips for Running Successful Question-and-Answer Sessions

1.  Be aware of your posture and body language. Although the formal
    presentation may have concluded, you are still \"on stage.\"

2.  When asked a question, pay attention to the person asking the
    question. Don\'t do anything distracting such as drinking water or
    writing a note.

3.  When a person asks a question, maintain eye contact until that
    person completes the question. Then shift and maintain eye contact
    with the entire audience.

4.  Complete your response by looking at a different person.

5.  Take questions from the entire audience.

6.  Repeat or paraphrase all questions when speaking to a large
    audience.

7.  Reply simply and directly. Do not make another speech

8.  If you think a question has been answered in your presentation,
    don\'t insult the audience by saying, \" I answered that in my
    speech.\" Consider that you may not have made the point clearly
    \'and answer it.

9.  Don\'t say, \"That\'s a good question. It implies that previous
    questions were not good ones.

10. Remind the members of the audience to keep questions\' short. Don\'t
    let questions become speeches.

11. If a question reappears in a different form, do not answer it again.
    If you are not prepared with an answer to a question, don\'t get
    into troubled water. Say, *\'That\'s an interesting but complex
    question, so why don\'t we talk about it later,\" or Mr. Smith is
    our expert on that and I\'d like to check with him so that I don\'t
    give you the wrong information. I will get that information for
    you.\"*

12. As you prepare your presentation, anticipate several major questions
    and prepare answers to them.

13. Put all pertinent dates, places and names on cards for quick recall
    during the Q&A.

14. If there are no questions, or too few, express surprise, and put
    forward a question about something that you stated in the
    presentation.

15. Keep within the time limit of the Q&A session.

16. Assess the audience\'s interest level and meet it.

### Giving Persuasive Speeches

Persuasive speeches attempt to show an audience how the speaker\'s
solution to a problem (or point of view about a topic) is one that they
should adopt. Arouse the feelings of the audience to adopt your
position.

######### **Get Their Attention** 

-   Open with a startling statement, statistic, or quote related to the
    topic.

-   Use a local example of the problem.

-   Ask a rhetorical question.

**Show the Nature of the Problem**

-   Suggest various causes.

-   Give local and wide-ranging effects.

-   Show how the problem directly affects the listeners.

######### **Present a Solution**

-   Propose two approaches to solving the problem and give the reasons
    why your approach is superior.

-   Show what your approach will require in cost, time, and number of
    people.

-   Show how your solution will either, circumvent or eliminate the
    cause.

######### **Appeal for Audience Action**

-   Ask them to do what is appropriate for your topic: vote for you,
    accept the budget, or give you their business.

######### **Closing**

-   Summarize the important points.

-   Challenge the audience to act. Indicate your own intention to act.

-   Close with a strong appeal for community or personal action.

### 

### Knowing How to Use Audio-Visuals

Visuals should help the audience understand and retain the information
you are presenting. They also may highlight the key points for your
audience, but should never get in the way of delivering the message.
Here are the basics about visuals.

######### **Do:**

-   Think visually---translate data into a visual image such as a pie
    chart or bar graph.

-   Allow enough time to design, produce and test the best visuals for
    your presentation.

-   Work with a professional slide-design firm.

-   Rehearse with your visuals.

-   Keep visuals simple enough for everyone to understand and large
    enough for everyone to see.

-   Use seven lines or less per slide, including the title.

-   Use \"build\" sequences for emphasis.

-   Set copy flush with the left margin and ragged at the right margin.

-   Use the basic five colors for lettering: white, yellow, orange,
    green, and blue.

-   Use darker colors to provide a contrast for large background areas.

-   Dim the room without turning off the lights completely.

-   Use upper/lower case type (never all capital letters), and be
    consistent

-   Use normal spacing between words and captions.

-   Use a blank between slides to indicate a change of topic.

-   Place the lectern to the right of the screen.

######### **Don\'t:**

-   Crowd the screen with information.

-   Use slides of poor quality.

-   Overuse bullets, dashes, and stars.

-   Photograph from typewritten copy.

-   Use slides that have been duplicated poorly.

-   Alter the format. Stay with horizontal/vertical typeface and
    artwork.

-   Use inadequate contrast of foreground and background.

-   Use stereotyped visuals. Be imaginative in your choice of visuals.

### 

### Speaker Profile/Checklist

Here are points to consider in rating your power as a speaker, or in
rating another speaker. Tape record yourself on different occasions and
on the phone with different people. Then consider these questions about
your voice:

-   Is it pleasant?

-   Does it have any undesirable characteristics?

-   Does it reflect the thoughts and feelings you intend to convey?

-   Are changes in pitch, loudness, duration, and tone quality
    appropriate to what you are saying?

-   Would you listen to this voice in a presentation?

-   Does your voice reflect your personality?

-   Does it get your message across? If not, why?

-   How can you improve the sound of your voice?

If you have a videotape of yourself, use this checklist to evaluate your
delivery.

######### **Delivery:**

-   Inhibited

-   Well-paced

-   Shifted weight from one foot to another

-   Used space appropriately

-   Overall image

-   Locked hip

-   Was stiff/Unnatural

-   Stepped~.~ back from audience

-   Reinforcing facial expressions

-   Non-words (uh, ya know)

-   Used mini-gestures

-   Enthusiastic

-   Stood at an angle to audience

-   Used spontaneous motivated movements

-   Was sensitive to/concerned about audience

######### **Hands:**

-   In pockets

-   Arms folded

-   Unnecessary movement/gestures

-   Behind back

-   Blocking face

-   Well groomed

-   Clenched in front

-   Grasping on lectern

-   Purposeful

######### **Eye Contact:**

-   Over their heads

-   Too rapid

-   Met entire audience

-   Needs improvement

-   Head bobbed

-   Level of sincerity/credibility

######### **Voice:**

-   Rate

-   Variety

-   Clarity

-   Emphasis

-   Insufficient volume

-   Monotone

-   Too fast

-   Too slow

######### **Timing and Organization:**

-   Effective grabber

-   Too much material

-   Gained and held attention

-   Structured thought-pattern

-   Stayed in time limit

-   Clear & appropriate visual aids

-   Clarity of goal

-   Support or amplification of main points

###