Recruiting Community Health Centers for Implementation Research: Challenges, Implications, and Potential Solutions

Contributions to the Literature Under-resourced clinics (e.g., community health centers) wishing to participate in implementation research may be unable to do so because of financial and staffing resource limitations, and thus may be under-represented in implementation science results. This may introduce bias that limits study findings' generalizability, impacts evidence-based intervention adoption in similar care settings, and exacerbates health inequities. Recruitment bias is well studied in patient-randomized trials but not in clinic-randomized trials. This article presents two examples of studies seeking to recruit under-resourced clinics and highlights challenges inherent to recruiting such clinics in implementation science trials, and potential ramifications for study generalizability and health equity. Editorial Implementation science generates knowledge about effective approaches for supporting the adoption and sustainment of evidence-based interventions (EBIs).1 Maximizing the external validity (and generalizability) of randomized trials' findings in implementation research requires recruiting study sites that represent the settings where adoption of a given EBI is desired.2 Recruitment to clinic-randomized trials may be challenging, however, when the care settings of interest are under-resourced clinics such as community health centers (CHCs), with the potential to exacerbate health inequities. As the nation's health care safety net, CHCs serve >30 million socioeconomically vulnerable patients regardless of ability to pay, often operating with very limited financial and staffing resources.3 Achieving health equity will require optimizing EBI implementation in this setting.4 Yet although CHCs may recognize the value of taking part in EBI implementation trials, their resource limitations may prohibit study participation.5 This may result in such settings' under-representation in implementation research, introducing potential recruitment bias, weak evidence on EBI implementation in under-resourced settings,6 study findings that are not generalizable to the under-represented populations served by CHCs, and a threat that health inequities will be perpetuated.6?8 Recruitment bias in patient-randomized trials is well studied and known to adversely impact study findings' generalizability.7 As far less is known about recruitment bias in clinic-randomized trials, we present insights from two recent implementation studies targeting evidence-based perinatal