Inclusive recruitment in (qualitative) research

Aim

To provide practical guidance to qualitative researchers concerning the effective engagement and inclusion of ‘differently reached populations’ which are often underrepresented in research. Such underrepresented populations may include people of ethnic minority groups (here, we refer to a broad definition of people with a migration background, including (children of) diverse subgroups of migrants, e.g. labor migrants, people from former colonies, refugees, people with a mixed ethnicity, but also people with other shared characteristics, such as country of origin, culture, religion, language, or skin color, that differ from the majority population), people with a middle- or lower socioeconomic status (SES), members of the LGBTQIA+ community, and neurodivergent people. It is important to note the large heterogeneity both between and within these populations, and therefore, that there is not a ‘one size fits all’ solution. These guidelines are based on researchers’ experiences with recruiting people from ethnic minority groups, a middle- or lower SES, and members of the LQBTQIA+ community for research; to some degree, these guidelines might also apply to other underrepresented populations. Note that the tips provided in this appendix should be taken as general statements, which you may apply to your target population.

Why

Despite the positive trend among researchers, who increasingly aim to include diverse minority groups in their research, they still face barriers to effectively do so. More information and practical tips on how to reach and engage all kinds of specific and minority groups is important for promoting equity, reducing disparities, improving healthcare outcomes, and ensuring representativeness of health research findings in diverse populations.

How to
Planning

Take into account that including a heterogenous population may require additional time and effort compared to majority group individuals, such as people of native Dutch origin and higher educated people. Consequently, it is important to adopt tailored approaches and engagement strategies which should be considered early on in your data collection. It is therefore strongly advised to reserve more time for sampling in the research planning to ensure a smoother data collection process. Additionally, you may contact colleagues who are more experienced in reaching and recruiting diverse minority populations for research, and ask them for tips and tricks.

Locating your study population

It is important to start with a clear idea of who you want to include in your studies, and then consider where you might find individuals who meet your inclusion criteria. This will depend on whether you aim to include patients or ‘civilians’, age-criteria, ethnicity, religion, socioeconomic position, sexual identity and orientation, and any other inclusion criteria. For example, some individuals can be more readily engaged within natural settings such as community centers, prayer rooms (churches, mosques), and civil and social organizations such as schools.

It is important to be well prepared and get to know the study population prior to your recruitment. By talking to people from the community you want to recruit, you can learn how you can best reach out to them, what their preferences and needs are, whether topics are considered sensitive or taboo, etc. Also consider heterogeneity amongst your target population, and attempt to recruit people with various different perspectives into your studies, to better reflect your target population.

Getting in touch with your study population

Key figures and existing networks

Recruitment via key figures from communities is an effective way of including people from your target population. We refer to key figures in a broad sense: this may include community leaders from ethnic or religious communities (for instance within religious subgroups, e.g., Pastors, Imams, or group leaders of community centers), influential people who belong to your target population (including, for instance, (health) influencers on (social) media, well-known figures in the community, experts by experience), colleagues who share characteristics with the target population, or group moderators on online platforms and social media. In essence, key figures may be anyone with a large network of people who belong to your target population, who may take on the role of an ‘ambassador’ to help you reach people. Working together with these key figures and recruiting via their networks may require building a ‘warm connection’, with them. If they recognize the relevance of your work, and you are building meaningful relations with them, they are more likely to provide access to their network.

With respect to getting in touch with key figures, e-mailing may not always work. In some instances, calling them or sending a message on a medium they use frequently (e.g. WhatsApp), may be more likely to give you a response. If no contact information for a key figure or an organization is available, you could consider visiting them at the location of their organization to get in touch. However, these ways of getting in touch should be done in a respectful manner, so you should consider how you present yourself and how to approach them beforehand. A few things to consider may be the timing of your visit, how you dress, how to approach people, and whether you should visit the community as an outsider. Make sure your visit does this not coincide with community holidays or activities such as prayers, dress appropriately, greet and address people in a sensitive manner (e.g. shaking hands between women and men), and if an organization is considered a safe space for members, consider whether you should be visiting them in person. Finally, these key figures are helping you voluntarily: consider giving them a gift card as a token of appreciation when their input is relatively small, and when you are collaborating more intensively, you may consider paying them for their work.

Live recruitment

Another option to get in touch with your study population is live recruitment, i.e. approaching people in public spaces. This means the researcher(s) may proactively visit communities in order to establish personal connections and introduce one's project. It is recommended to approach communities without any ulterior motives (hidden agenda) and to demonstrate genuine interest in the community. Please also check whether this strategy  is in line with the guidelines of the local medical ethical review committee for your specific type of study, population and context, and be respectful of people’s spaces. Whether live recruitment will work, will depend on your target population, as well as the public space you choose. For instance, this will work better for the general public, than for those with a specific diagnosis (for tips on recruiting patients, see Healthcare setting) or other specific inclusion criteria. With respect to public spaces, you could consider recruitment in a community center, market, school, church, mosque, or other public setting: however, you should first discuss this with someone from the organization (see Key figures and existing networks) and ask for formal permission.

Healthcare setting

For recruiting patients, or those with a specific diagnosis, recruitment in healthcare settings (general practice offices, hospitals, pharmacy) may be the most efficient recruitment strategy. Here too, you should collaborate closely with the professionals working there, and you need permission to recruit individuals in these settings. Depending on your study population and the workload of the healthcare professional, you should decide together whether you will contact patients yourself, or the healthcare professional may contact their patients for you. Whereas healthcare professionals may be too busy to contact patients themselves, this does have the added advantage of a familiar face, which can facilitate participation. This strategy may be particularly effective when the healthcare professional shares characteristics with your target population (such as a similar ethnic background, language, or religion). 

Online

Online recruitment may work for some populations, however, not everyone is active online. You may be more successful in using social media to recruit younger individuals, whereas this may not be very useful to reach middle aged and older individuals. Also recognize that different social media platforms have different target populations, i.e. LinkedIn for professionals, Facebook for older generations, and Instagram and TikTok for younger generations. Additionally, some population subgroups have extensive WhatsApp networks, through which your recruitment materials may be spread. For more targeted recruitment, look up online communities that you could contact, such as networks for patients, people of certain ethnic groups, LGBTQIA+ individuals, or other networks depending on your inclusion criteria. Online recruitment strategies may include an online flyer or picture, but for some communities, a short video explaining the research might be more appealing.

Flyers

When used well, flyers may work for recruiting some individuals, yet these are not the most effective way. If you choose to use flyers, it works best to have someone actively hand them out and provide some information about the study, versus simply placing flyers on a table. Please be aware of (municipal) legislature concerning distributing flyers in public spaces, such as markets, as you may need permission to do so. It is important that the flyer is easy to understand (see Language difficulties) to include those with lower literacy levels. For those with a migration background, you may also consider translating a flyer to reduce language barriers, yet not all migrant populations may have a shared written language. Moreover, low literacy and reading abilities may still play a role in people’s native tongue, thus, it may also help to create a more ‘visual’ flyer, with images that appeal to the people you are trying to recruit. You may additionally consider adding a picture of the researchers in the flyer, as familiar faces may foster trust amongst potential participants, yet we advise you to consider whether this is appropriate, and consider your own safety and wellbeing (see Safety considerations).

Facilitators
Barriers
Flexibility and accessibility Language difficulties
Be relevant and convincing Mistrust
Prolonged engagement Privacy regulations
Giving back to communities  
Facilitators for recruitment

Flexibility and accessibility

These recruitment strategies require you to be flexible and accessible in your role as a researcher. You may not always be able to stick to 9-to-5, but instead, occasionally work in evenings or weekends, and sudden changes in your planning may occur. Moreover, you are likely to be expected to travel to your participants, instead of your participants travelling to you.

Another facilitator is accessible communication. E-mail may be a less accessible means of communication versus phone calls or WhatsApp. Ask participants what their preferred means of communication is, and if you have a work phone (see Safety considerations), allow participants to call you or message you via WhatsApp if they prefer. Using their preferred channel, it may also help to send participants a conformation message including date, time and location of your appointment, and you can consider sending them a reminder a day before the appointment.

Be relevant and convincing

In order for people to participate in your study, the topic of your study needs to be relevant to them. Therefore, it is important to frame and phrase the aim of your study in a way that makes clear what the target population might gain from participating in the study. For instance, if your study population is at increased risk of disease, or if your results may be used to inform policy or have other implications, this will show the target population what they, or their community, might gain from participating. You should also clearly state what participating in your study entails: people may be scared of the term ‘medical research’, and may therefore be hesitant to participate.

Prolonged engagement

Many researchers will visit these communities once to get their data, and never return. This can make people more sceptic towards researchers, and create a feeling of ‘being used’. Prolonged engagement, i.e. remaining in touch with communities for an extended period of time, can foster trust and ‘warm connections’ with the community, thereby improving collaborations. In most communities, it is essential to establish a foundation of trust prior to engaging individuals or groups in a research project (see Mistrust). This process necessitates a sustained and active involvement by the executive researcher(s), such as partaking in communal activities like dancing, cooking, and attending open events. 

Giving back to communities

Consider that as researchers, we ask people to invest time and effort into our studies, without any direct gains for participants. Many researchers visit these communities for their studies, without giving back to these communities. We strongly advise you to give back something to these communities. Depending on the community’s preferences, this may include providing financial compensation for participation in your study, sharing your results, other relevant information, or your network with the community, or providing them with the opportunity to be engaged with your study for a longer period if they desire. If you are not sure what you can do in return, you may always ask them. Also note that reimbursing travel costs may actually complicate participation for your participants given that this requires them to fill in certain forms, and that other financial compensation such as a gift card may be easier.

Barriers to participating

Language difficulties

For certain groups, specifically those with lower levels of education or a migration background, language difficulties may hinder participation in research. Therefore, it is important to speak to people in easy understandable language (B1-level according to the Common European Framework of Reference for Languages, a level that is easy to understand for 90% of people), and for those who do not master the Dutch or English language well enough you could consider hiring a professional interpreter or asking someone (e.g., family member) who speaks their native language. However, never request a child under 16 years of age to interpret! Similarly, you could consider translating materials for some groups. There are several certified translation companies which are able to translate your recruitment materials, questionnaires and informed consent forms. Alternatively, for some materials (specifically materials not subject to specific ethical or legal regulations) using online translations checked by key figures fluent in both Dutch and the other language may suffice. It is important to recognize that low literacy is often not limited to the Dutch language, as some individuals may also have difficulty reading and writing in their native language as well: consider this before spending time and money translating materials. 

Mistrust

Some groups may have mistrust towards the government or the medical system, which can transfer to mistrusting you as a researcher. This mistrust can make people less willing to participate in your study. More nuanced than mistrust, perceived status differences may foster social distance between people from these communities and researchers, which could make people less likely to participate in research. In these instances, it is even more important to have these ‘warm connections’ with the community and community leaders and prolonged engagement, as these may promote trust in you as a researcher. 

Privacy regulations

Privacy regulations, including the informed consent forms (ICF) and patient information forms (PIF), may also function as a barrier to participating. These forms are often written in complex and formal language. People who have difficulty reading may not understand what is written in these forms, and may thus drop out when presented with these forms. Currently, approved new formats, which are easier to understand, are being developed. Until these become available, it is advised to verbally explain these forms to participants in easy understandable language. Pharos also has a suggested format for shorter, easier version of the informed consent available for researchers to use. If you have a clear motivation for using other forms than the standard form, you may be able to obtain approval for easier versions of the ICF and PIF, if necessary in addition to the original forms. Please check with the medical ethical committee at your institution what their regulations are prior to using these forms. You can always discuss your options as well as related questions concerning your recruitment and data with the medical ethical review committee. 

Safety considerations

In using these strategies, as in any project, it is always important to consider your own safety and wellbeing. If you are planning on recruiting participants outside of a medical setting, please consider going into the field with at least two researchers present to ensure safety. In line, we advise you to never use your own phone number when recruiting, and instead, buy or borrow a phone for the project.

Reflexivity/positionality

It is important to monitor and reflect on yourself and your intentions. In particular when you are not a member of the community you want to study, reflect on why you are doing this research. You should be able to communicate clearly your intentions and motivations to your target population. Why are ‘you’ interested in ‘them’?

Are you not successfully including your target population?  Then, please consider:

  • Asking them! Why do people not (want to) participate in the study, and is there a way in which you could motivate them to participate? This could be related to the study topic, i.e. when the target population does not have any interest in the topic, or alternatively, when there is a large taboo on the topic. Some other groups may simply feel like they are too busy, and might not have the time to participate in the study.
  • Your own identity. As a qualitative researcher, you are one of the instruments used. Consider who you are, e.g. your gender, age, ethnicity, language use, and other aspects of yourself, and how this may affect data collection. Some people may be more trusting towards people who are more similar to them with respect to gender, ethnicity, religion, sexual identity or orientation, or other characteristics. Consider these identities, and if you are in a position to choose between different researchers or have interns working on the project, you may be more successful when someone more similar to the participants you are trying to reach is working on the recruitment.
 Useful resources
 Literature on flyers