Clinical research has long struggled with diversity, equity, inclusion, and access (DEIA). Despite the increasing diversity of the U.S. population, marginalized groups continue to be underrepresented in clinical trials. The lack of representation in clinical trials has impeded innovation, compromised generalizability of evidence, and may undermine trust in the clinical trials enterprise [1] – conclusions that FDA echoes in its guidance on diversity plans [2]. DEIA must inform clinical trials from design to dissemination to generate valid, generalizable evidence that meets the needs of an increasingly diverse population and addresses health inequities.
In this commentary, we discuss select site readiness practices, outlined in a companion article [Reference Buse, Austin and Johnston3], which are particularly relevant to promoting DEIA in clinical trials. This perspective focuses on race and ethnicity, though other aspects of diversity, such as ability, sex, gender, sexual orientation, and others, also are underrepresented in clinical research [1,4]. Addressing race and ethnicity is an opportunity to intentionally focus efforts on a long-standing area of exclusion in clinical trials. The companion article includes the full set of site readiness practices, methods for their selection, and a rationale for their use by clinical trial sites. Site readiness practices must include DEIA considerations to avoid perpetuating existing inequities and to help address known or suspected barriers to clinical trials access – such as language, transportation, or dependent care [Reference Mapes, Foster and Kusnoor5]. Additionally, site readiness practices should seek to address structural constructs perpetuated within the medical and clinical trial enterprise that impede progress on these issues – through insurance coverage, hiring practices, partnership with communities, and mentorship opportunities. To this point, improving DEIA should specifically and explicitly be expressed as both goals and metrics for progress. Effective DEIA efforts in research participation should begin early, during the design and budgeting stages. Site readiness often involves actions taken even before the project’s conceptualization, such as modifying existing systems or policies. We believe that the site readiness practices discussed in this article (Table 1) support the development of a clinical research system that is intentionally inclusive, and therefore more closely aligned with the needs of patients.
Table 1. Site readiness practices that promote clinical trial site readiness through diversity, equity, inclusion, and access
Diversifying Participants
Ensure that research teams can enroll diverse trial participants by engaging communities early and incorporating community members to serve as advisors [Reference Andrasik, Broder and Wallace6]. For example, to recruit diverse participants, a research team should include individuals who are proficient in languages commonly spoken by populations of interest and/or represent the community experience via race, ethnicity, or culture. Research team diversity can improve trust, particularly for populations that may justifiably associate white authority figures with oppression based on historical and current events. Further, community members or advisory boards can help the research teams ensure that the trials conducted will have an authentic, viable connection to the communities being asked to participate [Reference Minkler, Salvatore and Chang7]. For example, they can assist in providing a clear understanding of the purpose and goals of the clinical trials in a respectful and culturally appropriate manner and develop effective solutions not based on stereotypes when unanticipated challenges arise. Ultimately, institutional infrastructure and leadership that prioritizes DEIA are crucial for ensuring the diversity of research teams and trial participants.
Diversifying and Sustaining Research Teams and Workforce
Improve diversity and retention in the clinical trial workforce. This effort is a strong emphasis for the Clinical and Translational Science Award program [Reference Locklear, Lewis and Calhoun8]. While acknowledging the challenges of recruiting a representative workforce, it is essential to prioritize diverse participant recruitment for more impactful and generalizable scientific outcomes [Reference Locklear, Lewis and Calhoun8]. Institutions that have difficulty recruiting and retaining diverse workers will likely have trouble recruiting diverse participants. The ability to work with diverse participants should be evaluated as a core job responsibility during hiring and employment. It is more efficient to train diverse candidates in research methods than to train nondiverse candidates in language and cultural skills. A diverse research team is not just a strength but a necessity. Members should be fully engaged and empowered, not merely serving as tokens to demonstrate a commitment to diversity. Partnering with and hiring from minority-serving institutions, and diverse community organizations, and their networks can help expand the pool of candidates and build capacity to train diverse personnel [9]. Building community capacity through strategic partnerships can prepare the future clinical trials workforce, promote bidirectional knowledge sharing, and ensure the sustainability of DEIA efforts [10].
Emphasizing Engagement in Trial Recruitment and Retention
Research studies lack external validity if the research participants do not reflect the diversity of the intended patient population. Medical journals are beginning to require authors to include demographics of the study population in publications [Reference Rubin11]. Likewise, studies should have clear recruitment goals for diverse participants and a detailed plan on how to achieve them – a requirement that became law in the most recent appropriations act [12]. Economic inequalities in the United States are highly linked to race and ethnicity; economic barriers to trial participation, such as costs of transportation, living and lost wages, and caregiving, and ease of reimbursement mechanisms, should be considered when budgeting for a study that seeks to enroll diverse participants. Furthermore, researchers who recruit clinical trial participants from underrepresented communities but never return to share study outcomes with the community may drive members of these communities from participating in future clinical trials [Reference Melvin, Harvey, Pittman, Gentilin, Burshell and Kelechi13]. Efforts to improve recruitment and retention [Reference Kelsey, Patrick-Lake and Abdulai14] and follow-up [Reference Zweben, Fucito and O'Malley15] for underrepresented communities, including individuals with inconsistent access to the healthcare system, must be included in clinical trial planning.
Protecting Trial Participants
Employ privacy and security protections for research participants, accounting for the needs of diverse populations, including respect for tribal autonomy. Consent documents and discussions should be clear, culturally appropriate, and at an appropriate reading level [16]. Developing informed consent language in partnership with community members can help promote mutual understanding and trust between trial participants, researchers, and institutions [Reference Skinner, Calancie and Vu17].
Promoting Data Transparency and Unbiased Data Collection and Analysis Practices
Data sharing policies that do not examine risks that minorities face from racial profiling, or consider historical injustices and health inequities [Reference Bilheimer and Klein18] in how data are collected and shared [Reference Wolinetz and Collins19] may reduce diversity in participation. Unbiased data collection, analysis, transparency, and dissemination are key to both scientific rigor and community trust, especially for building confidence in scientific findings. Data collection practices that use standards and inclusively represent minoritized populations are critical for ensuring data can be generalizable to the populations the disease affects. Good data capture and algorithm practices can reduce bias that may otherwise be introduced in the collection and analysis of data and allow more informed research conclusions that can deliver better health outcomes. Predefined data plans should tackle key issues like the optimal data collection method for the research question and potential statistical biases, such as the implications of using a p-value of 0.05. Given that data interpretation is susceptible to researcher bias, it is vital to involve a diverse group of data interpreters.
What Can You Do?
These site readiness practices should serve as a basic DEIA roadmap and reference for every study and study site. However, we recognize that many study sites that are needed for diversity in research participation – such as non-R1 research institutions (as defined by the Carnegie Classification of Institutions of Higher Education), community-based sites, or rural sites – may not have the resources or capacity to meet all site readiness practices (Table 2). These are structural issues that need continual assessment, but there may be useful resources already within reach. For example, there may be local organizations that could help access diverse communities. In addition, there may be opportunities to partner with academic institutions, private companies, or other organizations to expand engagement with potential trial participants. Clinical and Translational Science Award (CTSA) hubs [Reference Viera, James, Shekhar, Ioachimescu and Buse20] could provide support through their integrating special population cores. Finally, recruitment methods that are cost effective, such as social media platforms, can also be effective tools for reaching diverse communities.
Table 2. List of site readiness practices for clinical trials, organized by domain
a For more information on who qualifies as a responsible party, see https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-11 (accessed August 15, 2022).
Taking steps to implement these site readiness practices or using them to improve upon existing ones is a good first step, but only a starting point. Transformation of the field is needed to significantly advance representative clinical trials. Structural barriers remain for which other solutions will be needed. It is important to consider building an ecosystem that incorporates stakeholder, specifically communities, accountability for these site readiness practices to be most effective. Implementing the site readiness practices requires engagement from all levels of leadership, with clear goals and metrics to measure progress and success, and to identify areas in need of improvement. The DEIA Learning System Framework provides institutions with a guide for developing and implementing infrastructure for supporting the types of DEIA actions that the site readiness practices promote, and operationalizing definitions for diversity, equity, inclusion, and access [Reference Carter-Edwards, Hightower and Schick21]. Through deliberate progress toward these site readiness practices, clinical trials will be better designed to recognize and address health inequities.
Acknowledgments
The authors are grateful for project management and editorial support from the National Academies of Science, Engineering and Medicine staff, Andrew N. March and Carolyn K. Shore. The authors also thank John B. Buse and the CTSA Steering Committee DEIA Task Force for their thoughtful feedback on the concept and content of this perspective.
Funding statement
There is no funding to report for this perspective.
Competing interests
The views expressed within this article do not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine, the National Research Council, or any of their constituent units. FL-H is a former member, and JLR a current member of the Forum on Drug Discovery, Development, and Translation, a standing body of the National Academies.
Open access
