A Personal Touch: The Most Important Strategy for Recruiting Latino Research Participants

Abstract

People from non-White racial groups and other underserved populations, including Latinos, are frequently reluctant to participate in research. Yet their participation into research is foundational to producing information that researchers and health care providers need to address health disparities. The purpose of this article is to describe challenges we have encountered along with culturally relevant strategies we used in five research studies to recruit Mexican American participants from community settings, some of whom were also of low socioeconomic status. We found that the most effective recruitment strategies reflect the common cultural values of personalismo, simpátia, confianza, respeto, and familismo.

Twenty years after the National Institutes of Health issued guidelines to increase representation of underserved people, including those of minority races and ethnicities and people of low socioeconomic status (SES) in health research, researchers still strive to recruit and enroll diverse research samples (Freedman et al., 1995; Nicholson, Schwirian, & Groner, 2015). Participation of underserved groups in health research is extremely important because people of non- White race, Latino ethnicity, and low SES are more likely to experience worse health status (Nelson, 2002). When more people from underserved groups participate in research, studies can generate information about the causes of health disparities and the best ways to ameliorate them. Equal in importance to these scientific reasons for samples to reflect the general population in terms of race, ethnicity, and SES are the ethical considerations. For example, adherence to principles of social and distributive justice can be demonstrated by providing access to clinical trials that test culturally relevant and innovative health improvement interventions for people of all races, ethnicities, and income groups. Therefore, research participation can benefit vulnerable individuals and their communities who are at higher risk of morbidity and mortality (Clark, 2012; Ford et al., 2013; Hébert et al., 2015; Nelson, 2002; Rogers & Lange, 2013; Yancey, Ortega, & Kumanyika, 2006).

In this article, we describe challenges encountered along with culturally relevant strategies used in five research studies to recruit Mexican American participants from community settings, some of whom were also of low SES. The five studies were conducted in central and south Texas (Table 1) and targeted nonhospitalized, community-dwelling Mexican American adults with type 2 diabetes or tuberculosis. The university’s institutional review board approved all study protocols.

Table 1.

Description of Five Studies That Serve as Examples of Recruitment Practices.

Study	Description	Reference
1	Focus groups and survey of Mexican   Americans’ (n = 125) diabetes   symptoms conducted in central   and south Texas. Recruitment via   registry, a listserv for Hispanic   women, and flyers in community   settings, workplaces, and clinic.	García, 2011
2	Case study of a Hispanic university   student with type 1 diabetes   (n = 1) in central Texas about   her transition from home life to   university living. Recruitment via   flyers in community settings and   an endocrinology clinic; e-mails   to student organization leaders,   and in-person presentations to   student groups.	Lagon, 2011
3	Pilot test of a symptom-focused   home-based intervention for   Mexican Americans with type   2 diabetes (n = 72) conducted   in Travis County, Texas.   Recruitment via health fairs and   clinic waiting areas, listserv, flyers   in clinics, word of mouth.	García et al., 2015
4	Survey of Mexican Americans’   (n = 150) diabetes health literacy   and knowledge conducted in   Austin, Texas. Recruitment from   clinic waiting rooms and referrals   from clinic personnel.	García, 2015
5	Qualitative study of Mexican   Americans with tuberculosis   conducted in Cameron and   Hidalgo Counties, Texas.   Recruitment at county clinics by   nursing staff and the researcher.	Zuniga et al., 2014

Barriers to Participation

People of low SES, non-White racial, and Latino ethnic groups are less likely to be recruited into research studies as non-Hispanic White participants with middle SES (Wendler et al., 2006). Potential Latino participants might distrust the research process; fear discrimination, loss of confidentiality, or other harms; or lack information about the research process and its value—and as a result they may be reluctant or completely unwilling to participate (Ceballos et al., 2014; Crist, Ruiz, Torres-Urquidy, Pasvogel, & Hepworth, 2013; Jacobs et al., 2011). Moreover, many people, regardless of ethnicity or SES, might not wish to participate in research because they do not recognize the importance or extent of the health problem under study, are uncertain about what the research entails, have competing demands and preferences, or anticipate unreasonable burdens of participating in research (Ceballos et al., 2014; Jacobs et al., 2011).

Some of these barriers may be even greater for people of low SES who have fewer resources, less education, multiple jobs, or limited access to health care. They may also be deterred from participating in research by their perceptions of cultural differences between their own experiences and researchers’ expectations of participants’ knowledge, skill, or attitudes (Medina, 2013). In addition, Latinos might not participate because of language barriers and concerns about undocumented immigration status (Bull, Boaz, & Sjostedt, 2014; Crist et al., 2013; Ejiogu et al., 2011; Ford et al., 2013).

It is often more difficult to identify and recruit eligible participants from the general public for community-based research than it is to identify eligible participants from acute care or clinic-based settings. Without a registry or database of eligible potential participants, researchers must search the larger community to attract eligible participants (Bishop, Tiro, Sanders, Craddock Lee, & Skinner, 2015; Ford et al., 2013; Workman, 2013).

Strategies and Challenges

There are many effective methods to recruit Latinos and persons of low SES into research studies but all have challenges in terms of cost, effort, extent of reach, or lack of focus that must be balanced with researchers’ resources.

Mass Media

The broadest and least direct method is to place advertisements in newspapers and on the radio. Advertisements in the mass media have the advantage of reaching many potential participants. Some of the community newspapers are free, so there would be no cost to the participant to obtain the newspaper. Radio stations can create advertisements that match the radio genre, for example, in style of music or talk programming, to the researcher’s targeted audience and in the target population’s preferred language. Some radio stations regard the research recruitment announcement as a public service announcement, and will air the advertisement for little to no charge; otherwise, advertising can be expensive.

Mass media advertising often results in a large volume of calls, many from ineligible people. The response to mass media advertisements usually peaks immediately following release of the advertisement and requires the researcher to have staff available to respond to calls at sporadic times (Lora et al., 2012; Vincent, McEwen, Hepworth, & Stump, 2013). Without staff to answer the call during evenings and weekends, potential recruits would often not leave a voice message and could be lost to the study. Therefore, mass media advertisements can be costly in staff time without yielding an adequate sample of participants (Gilliss et al., 2001; Yancey et al., 2006).

In our study conducted along the U.S. border with Mexico (Zuñiga, Muñoz, Johnson, & García, 2014), not a single participant indicated that they responded to the daily advertisements in a bilingual newspaper or to radio spots that were run several times a day for several weeks. For another of our studies (García, Brown, Horner, Zuñiga, & Arheart, 2015), which did not use radio advertisements, a few participants reported they had enrolled in the study after hearing about it on the radio. From that experience, we can assume that some participants do not always remember where they first heard about the study, which makes recruiting methods challenging to evaluate.

Flyers

Posting or distributing flyers is another useful indirect recruiting tool; the flyers can be placed in locations with high numbers of potentially eligible recruits, such as in clinic exam rooms or waiting areas, community gathering places, workplace break rooms, and schools. We used flyers written at a reading level appropriate for the target population in both English and Spanish. Readability testing statistics for English-language materials are based on the number of syllables per word and words per sentence (Doak, Doak, & Root, 1996); however, these principles are less applicable to Spanish-language readability. We aimed for a Flesch Kincaid Grade-Level score of fifth grade or lower for flyers in most studies and allowed the reading difficulty to be at the ninth-grade level for recruiting a sample of university students.

For all five of our studies, we achieved mixed success from using flyers. For instance, one participant stated that he had noticed the flyer every time he was in the clinic and wanted to be in the study but that he was nervous to call without assistance, concerned that he would be bothering the researcher. He needed and got help from the clinic nurse to call the researcher. Thus, it is quite likely that many potential participants do not respond to flyers because they need assistance or lack a sense of efficacy that they can complete that first step to enrolling in the study. Our use of flyers was more successful when participants were allowed to use the clinic phone to call the researcher, or when the nurse assisted the patient to call the research office. While overall response to our flyers was low compared with the number of flyers we distributed, we found that it was helpful to have a flyer available to hand to participants to read during the recruitment conversation or to take with them to pass on to friends or family members.

Personal Contacts

We were more successful in recruiting when we could make information known about the study through people likely to be in contact with eligible participants. We encouraged participants to refer people they knew to the study; the “snowball” sampling (Polit & Beck, 2010) resulted in a small but meaningful number of participants. Researchers can often partner with key members of the community to contact potential participants directly or send their messages via trusted proxies. For example, health ministers and clergy assisted in recruitment for García’s (2011) studies by posting notices about the study in church newsletters and on bulletin boards and reading announcements at the end of religious services. Engaging physicians, nurses, community health workers, laboratory technicians, or receptionists; librarians, business owners, or clerks; community leaders and group or neighborhood e-mail listservs, to deliver the recruitment message, builds on the trust between community gatekeepers and community members and enhances credibility of the researchers (Reidy, Orpinas, & Davis, 2012; Vincent et al., 2013).

We have had the most success in recruitment when researchers themselves or their staff were in direct contact with members of the target population. For instance, to reach people with diabetes in two studies (García, 2011; García et al., 2015), we set up a booth at several health fairs sponsored by community groups, health care organizations, church groups, and the Mexican consulate. An effective but also resource-intensive strategy was to position a researcher in an available room in a clinic. The clinic nurse would tell patients about the study and if patients were interested, the nurse would escort and introduce them to the researcher. Researchers also directly approached patients in waiting rooms to explain the study and invite them to participate.

In fact, direct contact with the potential participants was the only successful method for Zuñiga et al.’s (2014) study that recruited low-income and predominantly Spanish-speaking outpatients on the Texas–Mexico border. When the researcher was not physically present at the clinic, no participants were recruited, despite staff’s efforts. One explanation came from a participant who said he did not want to bother the researcher, who would have to travel from a different city to interview him. When the researcher was already on site, participants were more inclined to enroll and schedule interviews.

Even so, direct recruitment methods are not always successful. We were surprised that Lagon’s (unpublished manuscript) efforts to recruit university students with diabetes by speaking before students’ professional, service, and social organizations and soliciting referrals from endocrinologists, university health clinic staff, and nearby coffee shop employees yielded little response. Because she targeted a fairly uncommon population, she found she needed to broaden the study’s inclusion criteria (larger range of ages and universities), accept a reduced number of participants for the case study, and rely on social media and word of mouth from friends and family.

Communication Strategies

We erred in assuming that potential participants had access to telephones or that they would be familiar with our usual patterns of communication. For instance, we found that participants recruited near the U.S.–Mexico border were not accustomed to the practice of using business cards. During the recruitment phase, prospective participants were given the researcher’s business card so they could contact her about the study. Later, when the researcher met with the participants, several handed the business card back to the researcher as if it was a ticket or authorization to participate, apparently not familiar with the practice of keeping the card on hand to make contact should they so desire. We also found that several potential participants did not own a telephone or lacked a permanent phone number where they could be reached. Many reported that they used someone else’s phone when they needed to make calls. This was a major barrier to recruitment and maintaining contact throughout the study because it was not possible to call participants or leave detailed messages for them.

Using onsite recruitment efforts offset the need for the participant to have a phone or e-mail address when the researcher could schedule an interview with the participant during the in person screening process. Since no follow-up call could be made, participants, who were often unable to read in Spanish or English, needed to remember the time and location of the interview.

Research Staff Practices

We always used Spanish-speaking team members and, to build trust, we did not try to capture any data about citizenship or country of origin, although many participants freely shared their origin or immigration status. We also employed research staff (office workers, recruiters, data collectors, and interventionists) who closely matched the target population’s culture.

Discussion

We used a variety of methods to recruit participants with varying degrees of success. The benefits and challenges of each method are summarized in Table 2.

Table 2.

Recruitment Methods, Their Benefits, and Potential Challenges.

Method	Benefit	Potential challenges
Mass media:   Advertisements   in newspapers,   radio, television,a   Internet,a   billboarda	Reach many people	Requires staff to   respond to callers   when advertisement   is run, perhaps   during nonusual   work hours
		Often prompt   responses from   many people who   are not eligible for   the study
		Can be costly
		May require media   specialist to create   advertisements
Flyers and   pamphlets	Have something   written for people   to see	Reading level and   language should be   appropriate
		Should be visually   appealinga
	Can be linked to   websitea	May prompt   responses from   many people who   are not eligible for   the study
Researchers and   research staff	Face-to-face   interactions provide   opportunities   to develop   relationships and   communicate   directly with   members of the   target population	Might not be   perceived as   trustworthy or   familiar
Gatekeepers:   Health care staff   and community   members	Trusted professionals   and community   leaders are more   likely to create trust   (confianza), respect   (respeto), personal   relationships   (personalismo),   pleasant interactions   (simpátia) than   indirect methods	Staff or community   members may   be too busy to   recruit patients   consistently
Promotoras	Can often build   rapport with   participants quickly,   bridge the gap   between research   and the community	May need training   to maintain   confidentiality and   avoid pressuring to   participate
Participants:   Snowball   sampling	Participants may   know people who   also have the health   condition who   might otherwise be   difficult to reach	Participants might be   biased about study
	Builds on preexisting   confianza, respeto,   personalismo,   simpátia	Snowball sampling   alone might not be   sufficient to attain   desired sample size

^aNot described in this article.

Direct Contact by Researchers Is Consistent With Cultural Values

Of all the methods, we found that our recruiting efforts were far more successful when we relied on methods of direct contact with potential recruits. This is because developing relationships with recruits expressed shared Hispanic cultural values of personalismo (preference for warm relationships that convey care and acceptance of the patient and her or his circumstances), simpátia (preference for smooth relationships that are free of criticism and confrontation as well as finding someone likeable, sharing common interests), confianza (trust), respeto (respect in all interactions with special consideration afforded the elderly, the educated, and people in authority) and familismo (emphasis on family, loyalty, cooperation, and interdependence; Guillet & Echavarría, 2015; Padilla & Villalobos, 2007). Other researchers have reported that talking directly with patients was necessary for recruitment and resulted in participants’ good feelings about the research (Barnett, Aguilar, Brittner, & Bonuck, 2012; Bonevski et al., 2014, Ibrahim & Sidani, 2014). In other words, direct contact between the researchers and their staff with participants created confianza, respeto, simpátia, and personalismo.

Contact by Health Care Providers and Community Leaders

Researchers often need help from health care providers, clinic staff, community leaders, and liaisons (Reidy et al., 2012). We found community liaisons were essential, in part due to the confianza community members had in the liaison. Health care referrals were an effective method of recruitment because health care providers often have established good relationships (emphasizing personalismo, simpátia, and respeto) with their patients, making their endorsements of a research project a highly effective means of recruitment.

Technological Substitute for Direct Contact

If it is not possible to have direct contact with potential recruits, researchers can still employ practices that are consistent with Latino cultural values via the use of technology. Hendrickson (2007) recommended making a video to explain the study. This strategy has been effective for recruitment when research sites have the necessary means to show a video in a repeating loop to patients in a clinic waiting room or for people at a health fair. The video has the benefit of showing potential participants who the members of the research team are, which builds on the value of personalismo and simpátia. However, as with any nondirect method of recruiting, the video loop might not be effective in the general community, where potential participants are not the majority of the audience.

Promotoras

Our studies used bilingual and bicultural nurses, nursing students, and medical assistants to recruit and enroll participants. However, members of the community might have seen them as outsiders because of their affiliation with university and health care systems. Therefore, researchers should consider employing promotoras, members of the targeted population who are trained as health promoters. Promotoras are recommended by researchers to recruit Latinos because they are typically more successful in establishing trust with community members than research staff members (Vincent et al., 2013).

Conclusion

In five research studies with Mexican American participants, we learned that recruitment was more successful when conducted in person compared with indirect methods such as radio, newspaper, or flyers. The researcher or an assistant and key personnel at the research site or members of the community (e.g., health care workers, community activists, teachers, librarians, and business owners) were invaluable for recruiting because of their help in establishing relationships, trust, respect, and kinship with researchers and for their assistance to recruits in overcoming the unfamiliarity of becoming a research participant.