Merran Toerien

Clear obstacles and hidden challenges: understanding recruiter perspectives in six pragmatic randomised controlled trials

BackgroundRecruitment of sufficient participants in an efficient manner is still widely acknowledged to be a major challenge to the mounting and completion of randomised controlled trials (RCTs). Few recruitment interventions have involved staff undertaking recruitment. This study aimed i) to understand the recruitment process from the perspective of recruiters actively recruiting RCT participants in six pragmatic RCTs, and ii) to identify opportunities for interventions to improve recruitment.MethodsInterviews were undertaken with 72 individuals (32 doctors or RCT Chief investigators (CIs); 40 nurses/other health professionals) who were actively recruiting participants in six RCTs to explore their experiences of recruitment. The RCTs varied in scale, duration, and clinical contexts. Interviews were fully transcribed and analysed using qualitative content and thematic analytic methods derived from grounded theory. For this analysis, data were systematically extracted from each RCT and synthesised across all six RCTs to produce a detailed and nuanced understanding of the recruitment process from the perspectives of the recruiters.ResultsRecruiters readily identified organisational difficulties, fewer than expected eligible patients, and patients’ treatment preferences as the key barriers to recruitment. As they described their experiences of recruitment, several previously hidden issues related to their roles as researchers and clinicians emerged, imbued with discomfort and emotion. The synthesis across the RCTs showed that doctors were uncomfortable about aspects of patient eligibility and the effectiveness of interventions, whereas nurses were anxious about approaching potential RCT participants and conflicts between the research and their clinical responsibilities. Recruiters seemed unaware that their views contributed to recruitment difficulties. Their views were not known to RCT CIs. Training and support needs were identified for both groups of staff.ConclusionsThe synthesis showed that recruitment to these RCTs was a complex and fragile process. Clear obstacles were identified but hidden challenges related to recruiters’ roles undermined recruitment, unbeknown to RCT CIs. Qualitative research can elicit and identify the hidden challenges. Training and support are then needed for recruiters to become more comfortable with the design and principles of RCTs, so that they can engage more openly with potentially eligible participants and create a more resilient recruitment process.

Exploring the depilation norm: a qualitative questionnaire study of women's body hair removal

Womens body hair removal is highly normative across contemporary western cultures. Nevertheless, little is known about the production and maintenance of this norm. Drawing on qualitative survey data from 678 women in the UK, this study offers two explanations: First, hairlessness and hairiness are predominantly constructed as positive and negative alternatives, respectively. Consequently, the ‘options’ to depilate, or not, are unequally weighted. Second, should a woman fail to depilate, she is likely to be subject to interactional sanctions. These exact a social price for being hairy, and serve to ‘enforce’ the depilation norm. Depilation is, then, shown to be a matter not merely of personal preference, but of conforming to a social norm reflecting an imperative to ‘improve’ the body. Taking a feminist perspective, this study understands the depilation norm as an instance of the ‘policing’ of womens bodies within a narrow ideal of social acceptability.

Gender and body hair: constructing the feminine woman

Abstract Womens body hair removal is strongly normative within contemporary Western culture. Although often trivialised, and seldom the subject of academic study, the hairlessness norm powerfully endorses the assumption that a womans body is unacceptable if unaltered; its very normativity points to a socio-cultural presumption that hairlessness is the appropriate condition for the feminine body. This paper explores biological/medical, historical and mythological literature pertaining to body hair and gender, as well as feminist analyses of the norm for feminine hairlessness. Much of this literature both reflects and constructs an understanding of hairlessness as ‘just the way things are’. Taken-for-granted, hairlessness serves, this paper argues, both to demarcate the masculine from the feminine, and to construct the ‘appropriately’ feminine woman as primarily concerned with her appearance, as ‘tamed’, and as less than fully adult.

The intellectual challenges and emotional consequences of equipoise contributed to the fragility of recruitment in six randomized controlled trials

Objective The aim of the study was to investigate how doctors considered and experienced the concept of equipoise while recruiting patients to randomized controlled trials (RCTs). Study Design and Setting In-depth interviews with 32 doctors in six publicly funded pragmatic RCTs explored their perceptions of equipoise as they undertook RCT recruitment. The RCTs varied in size, duration, type of complex intervention, and clinical specialties. Interview data were analyzed using qualitative content and thematic analytical methods derived from grounded theory and synthesized across six RCTs. Results All six RCTs suffered from poor recruitment. Doctors wanted to gather robust evidence but experienced considerable discomfort and emotion in relation to their clinical instincts and concerns about patient eligibility and safety. Although they relied on a sense of community equipoise to justify participation, most acknowledged having “hunches” about particular treatments and patients, some of which undermined recruitment. Surgeons experienced these issues most intensely. Training and support promoted greater confidence in equipoise and improved engagement and recruitment. Conclusion Recruitment to RCTs is a fragile process and difficult for doctors intellectually and emotionally. Training and support can enable most doctors to become comfortable with key RCT concepts including equipoise, uncertainty, patient eligibility, and randomization, promoting a more resilient recruitment process in partnership with patients.

Using qualitative research methods to improve recruitment to randomized controlled trials: the Quartet study

Objective: Randomized controlled trials (RCTs) are considered the optimum method for evaluating health care interventions, yet many fail to recruit sufficient participants in a timely manner. The ProtecT (Prostate testing for cancer and Treatment) study employed qualitative research methods as part of a complex intervention to improve recruitment to the RCT. The Quartet (Qualitative research to improve recruitment to trials) study was set up to evalute whether the ProtecT studys success in increasing randomization rates could be replicated in other trials experiencing recruitment difficulties. This paper reports on the issues that emerged from the attempts to apply qualitative research methods to improve recruitment rates in RCTs collaborating with the Quartet team. Methods: The methods used were: investigation of RCT documents; semi-structured interviews and focus groups with RCT staff; audio-recording of recruitment appointments; and individual and group feedback sessions for RCT staff. Data were analysed using content and thematic analysis. Results: Barriers arose when we attempted to establish collaborations with RCTs. Difficulties were encountered in securing the commitment of all relevant staff because of poor communication between lead investigators and other staff as well as RCT staffs concerns about having recruitment appointments audio-recorded. Recruitment processes were often more complex than anticipated. Governance procedures took considerable time and resources, limiting the time available for data collection and implementation of the intervention before recruitment closure. Conclusion: Straightforward replication of the ProtecT complex intervention was more complicated than expected. However, the study has increased understanding of RCT recruitment and identified ways to overcome barriers to collaboration. Such research is more easily undertaken in the feasibility stage of an RCT, and greater success will be achieved if the research is integrated into the everyday conduct of RCTs.

Power through Knowledge: Ignorance and the ‘Real Man’:

The aim of this article is to show that tensions between conflicting accounts of masculinity need not only be ‘resolved’ by individual men, but can have a collective ‘resolution’. We argue that the ‘real man’ - by drawing together the ‘macho’ and ‘new man’ discourses - represents one such ‘integrated’ discourse of masculinity available to men. Our argument is based on a discourse analysis of 15 editions of Men’s Health, a South African magazine predominantly aimed at white, middle- to upper-middle class, heterosexual men. We also investigate how such integrated discourses may be collectively produced, arguing that the ‘real man’ is the product of a rhetorical question-answer strategy that moves men from ignorance to knowledge. Focusing on the rhetoric of masculine ignorance, we argue that the knowledge produced in answer to this ignorance serves to ‘resolve’ a current dilemma for men: how to maintain an essential masculinity while distancing oneself from criticisms of men as traditionally macho. We conclude by exploring, from a feminist perspective, the political implications of the ‘real man’ discourse as a collective ‘resolution’.

Personal Adviser Interviews With Benefits Claimants in UK Jobcentres

We report on a study commissioned by the UK government of the ways in which advisers conduct mandatory interviews with unemployment benefits claimants. Among other results, we identified practices in soliciting claimants’ job goals and job plans that were more, or less, effective in achieving desired outcomes during these interactions. Moreover, we found that making a calculation of how much better off a claimant would be by retaining some benefit and working part-time was ineffective. Our reports, recommendations, and presentation to officials of the Department of Work & Pensions were acknowledged to have influenced policy changes concerning Jobcentre service delivery. Data are in British English.

Putting Personalisation into Practice: Work-Focused Interviews in Jobcentre Plus

The principle of personalisation is widespread across the UKs public sector, but precisely what this means is unclear. A number of theoretical typologies have been proposed but there has been little empirical study of how personalisation is translated into practice on the frontline. We address this gap through analysis of a unique dataset: over 200 audio and video recordings of work-focused interviews in Jobcentre Plus offices. Through detailed analysis of these recordings, we show that personalisation reflects two key dimensions: the substantive (what advisers do) and the procedural (how they do it). We illustrate these dimensions, showing how each represents a continuum, and propose a typology of personalisation in practice, reflecting how the dimensions interact. We conclude with some thoughts on the relevance of our findings for advisory practice in the future under the Coalition governments new Work Programme.

Patient advocacy and patient centredness in participant recruitment to randomized-controlled trials: implications for informed consent

Context  With the routinization of evidence‐based medicine and of the randomized‐controlled trial (RCT), more patients are becoming ‘sites of evidence production’ yet, little is known about how they are recruited as participants; there is some evidence that ‘substantively valid consent’ is difficult to achieve.

Referring to Persons Without Using a Full-Form Reference: Locally Initial Indexicals in Action

This article draws on naturally occurring talk-in-interaction to explore the use of unrepaired indexicals—specifically he, she, and they—to refer to third persons when there is no prior full-form reference. We show some of the local resources that participants use to understand the referent but focus predominantly on how locally initial indexicals can be used in the service of the interactional task at hand to: (a) establish continuity of focus (across sequences and across conversations) and (b) mute the relevance of a referent for the action of the turn. We discuss the implications of these findings for understanding the action of repair on locally initial indexical reference and show how our work contributes both to linguistic research on pronouns and to conversation analytic work on person reference.