Reconceptualizing Recruitment in Qualitative Research

Abstract

Adequate participant recruitment is critical for any qualitative research project. Our research team experienced numerous difficulties when attempting to recruit young adults with type 1 diabetes to discuss their transition from pediatric to adult-focused care. Using our experience as a case study, we identify the activities involved in four phases of participant recruitment: (1) development of a recruitment plan, (2) implementation, (3) participant engagement post-data collection, and (4) post-recruitment assessment. We present a new definition of participant recruitment which better captures the range of activities involved. We discuss aspects impacting recruitment in our case: the influence of other stakeholders, the dynamic nature of recruitment, recruitment of specific populations, and the challenges of recruiting within a healthcare environment. Finally, we identify and consider four factors that impact participant recruitment: communication, participant interest/value, participant trust in the research project, and participant availability and consider potential strategies for overcoming barriers related to each factor. In the end, our case underscores the centrality and potential fluidity of participant recruitment within qualitative research.

Keywords

Qualitative research recruitment health services research young adults type 1 diabetes mellitus

What is Known?

Participant recruitment is an issue faced by all qualitative researchers, but it is a topic often not covered explicitly or in depth in qualitative methodological texts. There are few detailed cases available of the issues that can arise in recruiting participants for qualitative research, particularly with young adults in a health services research context.

What the Article Adds?

The article offers a new definition and presents the activities involved in four phases of participant recruitment. It provides a detailed account of some of the issues involved in recruiting young adults in qualitative research, including the impact of other stakeholders (e.g., funders and ethics boards) and the requirement to recruit through medical clinics can have on recruitment efforts. Finally, we present four factors for analyzing issues related to inadequate recruitment and highlight the critical role of participant recruitment within qualitative research.

Introduction

Many qualitative researchers have struggled with issues related to participant recruitment (Hudson et al., 2017; James et al., 2014; Jessiman, 2013). Failure to recruit study participants can increase costs, create barriers to timely completion, and even threaten the viability of an entire project (Adams et al., 2015; James et al., 2014; Lovato et al., 1997; Tan et al., 2016). Issues with recruitment often only become apparent after considerable effort has already gone into planning a study. While recruitment is widely acknowledged as being critical for the success of research (Hendricks-Ferguson et al., 2013; James et al., 2014; McDonagh & Kelly, 2010; Poole & Peyton, 2013; Tan et al., 2016), it is often not directly or extensively discussed in many qualitative research methodology texts, which usually focus more on the issues of sampling and determining data saturation when discussing participant engagement (Creswell, 2012; Green & Thorogood, 2009; Morse, 2012; Patton, 2015). This omission may be due to earlier attempts to distinguish qualitative research from quantitative research and its concern with getting ample numbers of participants to improve statistical power. Recruitment may be seen as merely a procedure part of conducting research and be of less interest to academics focused on learning about a particular topic. Regardless, omitting recruitment from methodological discussions obscures the potential complexity and centrality of participant recruitment within qualitative research design.

In this article, we use a recent experience of attempting to recruit young adults with type 1 diabetes to explore the issue of participant recruitment. We present this examination for several reasons. First, we want to share the specific strategies we used in our recruitment plan and how we adjusted our approach to recruitment during the study. We hope that sharing our approach and difficulties in detail will foster greater discussion around how to ultimately improve participation in qualitative research. Given that we were unsuccessful in recruiting a sufficient number of participants, we reflect on how we may have been able to improve our recruitment efforts. In assessing our experience, we identify four phases of participant recruitment and the activities involved in each phase for our project. We then present a new definition of participant recruitment that better captures the range of activities involved and identify some of the lessons learned from our case. Finally, we use this case to conceptualize some of the dynamics of participant recruitment—which includes the elements of communication, participant interest/value, participant trust in the research project, and participant availability—and consider strategies for overcoming potential barriers.

Case: Type 1 Diabetes Transition Study

Our research study, Improving Outcomes for Youth with Type 1 Diabetes in Transition to Adult Care Through Strengthening Integration with Primary Care, was a multi-phase project that included both quantitative and qualitative components. The project explored ways to improve the experience of young adults with type 1 diabetes as they leave pediatric care and move into the adult-focused healthcare system. One component of the project was to have focus groups with young adults who recently transitioned into adult-focused care. The option of participating in a one-on-one interview was later added at the request of one of the ethics boards reviewing our project. We invited young adults who were (1) diagnosed with type 1 diabetes before 18 years of age and (2) their pediatric provider identified as having transferred to adult care in the last 5 years at one of the three pediatric diabetes programs in the Canadian provinces of Newfoundland and Labrador (NL) and Ontario (ON) to participate. Our recruitment plan used a combination of mailed invitation packages and telephone calls to potential participants who had been identified by the diabetes programs as eligible for the project.

Our recruitment plan had numerous strengths, including having been previously used successfully by members of the research team and being conducted by experienced researchers. Before we stated recruitment, our full plan was reviewed by a patient advisory committee, three different research ethics boards, and providers involved in the care of the patients we were trying to recruit. The research team included members who cared for patients at each of the clinics from which we tried to recruit participants (Sullivan-Bolyai et al., 2007). Contact with potential participants was made by a research nurse. This nurse had knowledge of all aspects of the project and previous experience interviewing young adults (Houghton et al., 2020). Our recruitment plan also allowed for multiple attempts to contact participants and was adjusted to try and improve recruitment during the process. Despite these efforts, we were only able to recruit 3 of the 48 people invited to participate in ON and none of the 40 people invited in NL after months of effort. Because of the low number of participants, the inability to get participants at all the sites after numerous attempts, difficulties in continuing recruitment, and the timeline for completing the entire project, we ultimately closed this component of the research project without completing it. In Appendix A, we provide a detailed description of the development of our entire recruitment plan and the changes we made to it over our research project.

What is Participant Recruitment?

Reflecting on our experience, we first recognized that participant recruitment can be seen as occurring over four phases. The first phase is the development of a recruitment plan. This phase includes everything from the initial planning of the project to the securing of the ethical and institutional approvals needed for the researchers to begin contacting potential participants. The second phase is the implementation of the recruitment plan. This phase includes everything from training recruiters to the decision to end recruitment. These first two phases encompass most of what people think of when they consider recruitment. But there are two other phases that should be included when considering participant recruitment. The third phase of participant recruitment is maintaining participant engagement post-data collection, which should occur, even though we did not do it for our project. Given that participants have given their time and may have a direct interest in the results of a study, it is important to maintain contact with participants even after data collection is complete (Berger et al., 2009). This continued engagement will also allow researchers to communicate any issues with the study to participants if they arise post-data collection. A fourth phase is assessing the overall recruitment activities after they are completed to see what lessons can be learned. In most qualitative research studies, this fourth phase rarely explicitly occurs, but it is a useful practice to adopt so that recruitment can be improved and lessons about recruitment can be shared amongst researchers.

In analyzing recruitment in our study, we developed a detailed description of our recruitment activities (Appendix A). We then identified the specific activities and decisions we took during each of the four phases of recruitment for our project. We also include aspects of our project that impacted or influenced our recruitment efforts. Some of these activities are clearly part of what researchers consider as part of the recruitment process, for example, identifying eligible participants and contacting them to invite them to participate. Other authors have included activities such as consenting, screening participants, enrollment, and retention in their recruitment models (Berger et al., 2009). As we assessed our poor recruitment results, we realized that a wider range of study activities had implications for our participant recruitment, including even selecting the original research objectives for the study. The list of activities involved in participant recruitment was also more extensive than has been presented by other authors (Table 1).

Table 1.

Activities in four phases of participant recruitment.

Phases of Recruitment	Activities
Phase 1: Development of the recruitment plan	Identifying study objectives Meeting funding requirements Involving patient advisors and incorporating their feedback Identifying eligible participants Determining the method of data collection Identifying data collection sites Considering participation of distinct populations Considering eligible participant population size Determining when to contact participants and when data collection would occur Determining what would be asked of participants Determining what participants would receive for their participation Determining how to contact participants, including the number of attempted contacts Determining who will contact participants Determining who would pay any costs involved in contacting participants Developing of recruitment instruments Planning in case there were too many potential participants Reviewing the appropriateness of the recruitment plan Applying for ethical and institutional approvals Adjusting the recruitment plan to meet ethics board requirements Securing ethical and institutional approvals to contact eligible participants
Phase 2: Implementing the recruitment plan	Training recruiters Reconsidering the timing for implementing the recruitment plan Negotiating with providers/clinic staff to carry out recruitment plan Securing contact information for potential participants Contacting potential participants Screening participants for eligibility Dealing with issues arising from contacting people not eligible for the study Arranging for data collection Explaining study aims, risks, and benefits Obtaining informed consent Monitoring recruitment Adjusting recruitment plan Submitting protocol amendments to ethic boards Conducting activities to further enhance recruitment Determining the end of recruitment
Phase 3: Maintaining participant engagement	Communicating any issues with the study to participants Providing updates to study participants Disseminating findings to participants
Phase 4: Post-recruitment assessment	Assessing recruitment process Disseminating lessons learned from recruitment assessment to the research community

Surprisingly, we found few definitions of participant recruitment provided in the academic literature. Given defines participant recruitment as “the process whereby the researcher identifies and invites (recruits) participants to join the study” (Given, 2012). Based on the range of activities we identify in our case, we propose a wider definition of participant recruitment as including all the activities that impact the planning and engagement of participants in and after data collection, including any assessment of a study’s recruitment activities. In short, participant recruitment includes most of what you plan and do with participants next to data collection. Our definition is even more broad because it includes the phases of the study that impact on participant recruitment that may be often seen as distinct from recruitment, for example, identifying research objectives. As we discuss below, it is not that these activities are solely about recruitment, but they do impact how recruitment will occur and their potential impact on recruitment should be considered when these activities are being carried out. Looking at participant recruitment from the perspective of all the activities involved highlights its central role in any research project. It should also not be surprising given the list above that researchers may spent as much time on recruitment than they do on data collection and analysis.

Aspects of Recruitment

Our analysis identified some aspects that may be useful for researchers to consider when planning their own recruitment activities. We discuss four of them here: the influence of other stakeholders on recruitment, the dynamic nature of recruitment, recruiting specific populations, and the challenges of recruiting within a healthcare environment.

Stakeholders’ Influence on Recruitment

Researchers may think of a recruitment plan as something the research team develops on its own as part of its original research protocol. We found numerous stakeholders influenced our recruitment efforts and that a recruitment plan involves a level of negotiation with other stakeholders, especially in contexts where implementation is dependent on other professionals. The conditions set by the research funders led to the project being conducted in multiple centers. This multi-center approach resulted in the project going through three different ethics reviews, with the ethics review boards influencing the timing of recruitment, the level of information about potential participants that was shared with the research team, and the methods of data collection. The funding requirement that there be a patient advisory committee led to its creation and it also provided input on our recruitment efforts. Because the participants were being identified through healthcare programs, the research team had to negotiate its recruitment plans with providers and clinical administrative staff at different centers. It is not that any of these stakeholders are responsible for the poor results of our recruitment efforts. In fact, it is likely that their input helped our overall recruitment plan. Researchers should be cognizant, however, of the extent to which other stakeholders are involved and can influence their participant recruitment.

The Dynamic Nature of Recruitment

Researchers may also think of a recruitment plan as something that they develop only at the beginning of a research project. But recruitment is dynamic and recruitment plans often have to evolve throughout a research study. Over our project, we made changes to the timing of recruitment and data collection, the methods of data collection used, how participants were to be contacted, and their level of compensation. Changes to our recruitment plan continued to occur almost to the end of data collection. These changes were either requested by stakeholders or adjustments made given the context and our low levels of recruitment. Our recruitment plans for NL and ON were the same at the beginning of the project. By the end, given the changes made, recruitment was being carried out differently between the two provinces.

Difficulties in Engaging in Young Adults

Different populations raise unique issues for participant recruitment. In our case, engaging young adults with type 1 diabetes raised issues related to their moving back and forth to university/training programs and the contact information on their medical file still being for their parents. One of the main difficulties related to the transition of young adults into the adult-focused health care is that this is a period of flux in many young adults’ lives, which makes it difficult for them to maintain a connection to the healthcare system. These factors can also make recruitment difficult and add addition time to the recruitment period. Sequeira et al. (2015) were unable to analyze the control arm of their trial of a structured transition program for young adults with type 1 diabetes because a large number of people had either changed contact information or lost interest in participating in the study within a 12-month period. Some of the issues identified in our study may be, therefore, an indicator of suboptimal transition experiences, including the lack of accurate contact information and the overall poor response rates. Our research team considered when to start recruitment and data collection given the timeline of university semesters. Because we were focused on a small population who attended specific diabetes programs and we had their contact information, we did not feel that a wider engagement through social media was required, which may have been a mistake. Regardless, further examination and sharing of research experiences to determine best practices for recruiting distinct populations, like young adults, would be helpful to qualitative researchers (Ellard-Gray et al., 2015; Spratling, 2013). Special attention must also be given to ensuring unique populations are also not biased against during recruitment (Bamidele et al., 2019; Banas et al., 2019).

Unique Issues for Qualitative Health Services Researchers

Health services research examines ways to improve the effectiveness and efficiency of our health systems by analyzing the numerous factors that impact care delivery (Canadian Institutes of Health Research, 2014). Because it is often conducted within hospitals and other healthcare institutions, qualitative health services researchers can face additional challenges regarding participant recruitment (Broyles et al., 2011). As we found, ethical concerns and legal restrictions surrounding confidentiality meant that potential participants had to be invited to participate directly by their care providers, limiting the possible recruitment strategies open to researchers who are outside patients’ circles of care (Nguyen et al., 2014; Sullivan-Bolyai et al., 2007). Studies that focus on exploring patient experience with a specific medical program have a restricted patient pool from which to recruit (James et al., 2014; Poole & Peyton, 2013) and a limited number of providers and clinic staff to help recruit participants (Ellard-Grey et al., 2015). There are other logistic barriers to participating in interviews and focus groups within the healthcare setting that can hamper recruitment efforts, such as arranging a suitable time to conduct interviews and finding a suitable location (Hendricks-Ferguson et al., 2013; Lovato et al., 1997; Walders-Abramson & Larkin, 2017; Wdowik et al., 1997). More research and guidance around how to address specific issues of qualitative recruitment in specialized contexts, for example, within a healthcare context, would also be helpful to qualitative health researchers.

Assessing Participant Recruitment

Participant recruitment is, at its core, about reaching outside the research team and making a connection with a person who has a relevant experience and them agreeing to share their experience. When we reflect on the actions we took to try to bring about this connection, we found that there was four factors that we tried to influence. First, we enacted a communication strategy to let potential participants know about the study and how they could become involved. The communication back from potential participants showed us the extent to which our efforts were being successful. But potential participants do not only need to know about a study in order to participate. They must be interested or see value in participating (Kristensen & Ravn, 2015). Potential participants also need to be able to trust that the study is credible (Ellard-Grey et al., 2015). Finally, they need to be available or able to participate. These elements can all influence the success of the recruitment plan. We found it useful to assess what we did and potential issues that may have arose in terms of these four factors (Table 2).

Table 2.

Advantages and potential issues with recruitment plan and implementation across four factors.

Communication	Participant interest/value	Participant trust in research project	Participant availability
Advantages
Invitation packages Calls to participants Recruitment calls made at various times a day Toll-free phone number provided to contact research team Project described by nurse practitioner (NL) Research coordinator attending clinics (NL)	Project reviewed by young adults with type 1 diabetes and diabetes providers Offered gift card (NL)	Information packages sent from clinic they attended Invitation packages addressed directly to participants Contact information for a research team provided Communication on University letterhead Research ethics board approvals communicated to potential participants	Flexibility in timing of focus groups Availability of telephone interviews Recruitment calls made at various times a day
Potential issues
Uncertain whether potential participants received invitation package or telephone call	Patient advisory committee not large or diverse enough Research topic chosen before involvement of the patient advisory committee Participants have competing life commitments Potential participants not interested in research topic Not enough emphasis on the benefits of the project to diabetes care	Telephone calls came from NL, which may have been unfamiliar number for participants in ON Participants unfamiliar with members of the research team Young adults may not be comfortable with participating in health research	Competing life commitments Relatively small population from which to recruit

Assessing recruitment from these four perspectives can also highlight issues that should be addressed. Future recruitment may improve by emphasizing the benefits of research to diabetes care (Hendricks-Ferguson et al., 2013; Poole & Peyton, 2013). McDonagh and Kelly have noted that involving young people in study design helps ensure study relevance and achievable outcomes (McDonagh & Kelly, 2010); this begins with the identification of a research question that will engage the population needed for successful recruitment. While the patient advisory committee was involved in the recruitment strategy, they could have been consulted on the research topic using their experience to assess its relevance to emerging adults living with diabetes. The panel could have been more involved in the development of the information material communicated to potential participants, rather than just being requested to review the completed material.

While we discuss four key factors that we saw as impacting our recruitment issues, there are clearly other factors that should be considered when developing a recruitment plan for a qualitative research study. Houghton et al. (2020) recently completed a comprehensive review of the factors that impact recruitment within randomized healthcare trials. Although the context is different, many of the factors that they identified—for example, the level of perceived risk and gain to participants, study features, the type of communication, and encouragement of other people—are also relevant to recruitment in the qualitative research context. Their review also highlights the fact that there is no perfect recruitment strategy and that making the decision to include certain features may be viewed positively by some potential participants and negatively by others. Lessons from other reviews of interventions to improve randomized trials could also be tried and evaluated by qualitative researchers (Gardner et al., 2020; Treweek et al., 2018; van den Brink et al., 2020).

Our case study and assessment have several limitations. First, it was not initially planned as a case study. We also did not conduct a formal evaluation of our recruitment strategy nor were we able to interview any of the people who did not participate in the study. In another part of our study, we were conducting interviews with healthcare providers. For that part of the study, our study coordinator completed 9 interviews out of the 17 people asked to participate, using a similar recruitment approach. Because it was beyond the scope of our project, we did not follow up with participants to evaluate why our recruitment in one part of the study appeared to work much better than the other.

Conclusion

Our study highlights the problems that can arise for recruitment in qualitative research. Participant recruitment is not just something researchers need to consider when developing their research protocol but includes all the activities required to get participants to participate in data collection. It is clear then that recruitment can be, as it was with our study, a central and dynamic aspect of qualitative research design. While we devoted a lot of attention to our recruitment strategy, we ultimately failed to recruit enough participants for our project in two different jurisdictions. We identify four factors from which to assess potential issues with recruitment. Researchers need to carefully consider the design of their recruitment plan but should also be prepared to revise it during the study if necessary. We hope that other researchers can learn from our experience when recruiting participants in future qualitative research projects and that this case will help foster greater discussion around this topic.

Footnotes

Acknowledgments

Thank you to the diabetes clinics at the Janeway Children’s Health and Rehabilitation Centre (St. John’s, NL), Major’s Path (St. John’s, NL), Markham Stouffville Hospital (Markham, ON), and SickKids Hospital (Toronto, ON) for their assistance in recruiting the patients for this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Canadian Institutes for Health Research (CIHR) Operating Grant: Pan-Canadian SPOR Network in Primary and Integrated Health Care Innovations—Quick Strikes (funding reference number SQS-145186); the Janeway Children’s Health Foundation; and internal funding for Dr. Guttmann from the Hospital for Sick Children Research Institute.

Ethical approval

Ethics Approvals for this study were granted by the Newfoundland and Labrador Health Research Ethics Authority and the hospital research ethics board of the Hospital for Sick Children and of Markham Stouffville Hospital (Markham, Ontario).

ORCID iD

Roger Chafe

Appendix A

Appendix B

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