How to Recruit a Patient

2 03 2011

By Paul Sonenthal

Without patients, there would be no clinical research. Obvious as that statement may be, I am reminded of its implications every day. We just enrolled the 50th patient in the Coping, Symptoms & Adherence Project and to mark the occasion of being 33% done, I want to take a moment to consider what it has taken to get this far.

One of the more basic skills required to enroll a patient is the ability to communicate with them. And since my Setswana is pretty terrible, I depend almost completely on our study nurses to get the job done. For all their hard work and assistance, I am deeply grateful.

Each day, our first step is to identify potential patients. These are people over the age of 21 and starting efavirenz-based antiretroviral therapy (ART) within two weeks of their enrollment. Plus, they cannot be pregnant. Unfortunately, patients that fit all these criteria are not always easily identifiable.

The six clinics where we recruit patients are all constructed the same way—a large waiting room ringed by six or seven small consultation rooms. As we walk in the door at around 8am, we are typically greeted by at least 30 patients sitting in the waiting room, some have been there for two and half hours or more. Most of those waiting they have been on ART for months or even years (the government’s MASA program has been providing free ART to Batswana since 2002) and are ineligible. In order to find the patients to approach, we try to gather as much information from as many sources as possible. Our methods include sitting in on counseling sessions for new enrollees, checking appointment books, giving speeches to the entire waiting room and reviewing charts. But none of these methods are comprehensive, and we are constantly trying to develop new approaches.

It is often said that all work in Botswana is relationship based. This certainly rings true for recruitment. Hands down, our best source of information is the staff at the IDCCs. However, they are often very busy and sometimes uninterested. Bit by bit, we have developed the trust of a handful of nurses, adherence counselors and doctors. When we do recruit, it is often because of them. They point out eligible patients and perhaps more importantly, advocate on our behalf. Their advocacy helps overcome one of our biggest barriers to enrollment: lack of trust. Botswana is a country that has seen a lot of researchers come and go—and the results have been mixed—so it is understandable that many people are wary when they see us walk into the clinic.

Finally, no matter how carefully we plan our approach, we have to accept that some things are simply beyond our control. Last week we enrolled 13 patients, by far our best week ever. But at the time of writing this post, we have gone three straight days without a single enrollment.

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