recruitment methods for qualitative research

How to Recruit Participants for Qualitative Research (2022 Edition)

We explain best practices for recruiting participants for qualitative research that will help you save time and money.

Qualitative research, when executed correctly, explores and uncovers the emotional and cognitive motivations behind your target audience’s actions, behaviors, and opinions relative to your research objectives and goals. 

So, the success of a qualitative research project depends on engaging the “right” participants—highly qualified, fitting the profile, enthusiastic and articulate. But research participant recruitment can be a resource “suck”, devouring time and money that could be used for the actual research, analysis and report writing. Let’s explore how to recruit the best, most qualified participants while saving both time and money.

6 Steps to Recruiting Quality Participants

From defining the objectives of your project to clarifying the factors and qualities of the participants you’ll need to meet those objectives, to creating the questions for the initial screening survey and follow up conversational screener that will identify qualified participants to setting a motivating incentive, the steps to a successful qualitative research project can be a lot. Let’s break it all down. 

1. Hold a Stakeholder Meeting to Define Research Objectives

Before you begin the process to recruit participants for qualitative research , you need to define precisely what you're trying to achieve with the research. This information will be useful when crafting your screener questions, securing participants that fit the profile and even setting the incentive amount. 

If you collaborate with other teams on a research project, the critical first step is to hold a stakeholders’ meeting to determine research objectives and ensure all stakeholders agree on those objectives.

Asking the questions that concisely define the purpose of your research project will also provide the parameters for exactly who the study should focus on. This will become your participant profile.

5 Sample Questions for a Stakeholder’s Meeting

• What’s the objective of this project e.g., what do you want to learn?
• What audience has the demographics, background, education, experience, skill, information you need to meet those objectives?
• What do you already know in relation to the objectives?
• How will your organization use the results of the research/What will your organization do with the learnings?
• What are your concerns, if any, regarding this project? How will those concerns be met and managed?

Once you have the answers to these questions, you can move on to the next step. 

2. Develop and Fine Tune Screener Survey Questions 

Your screener survey allows you to cull potential participants quickly. This means the most important criteria for qualification/disqualification need to be at the beginning of the survey—both your non-negotiables (immediate disqualifiers) and your negotiables (subject-to-approval and/or less rigid disqualifiers). 

In most cases, non-negotiables are concrete questions related to demographics, such as a candidate’s business, location, age, gender, ethnicity and past research participation. However, screening questions can also be identifying behaviors and/or opinions. For example, if you're looking for marketing professionals that use a specific type of software, use of this software and even use of this software over a specified amount of time might be a must to qualify.

Leading questions with transparent choices for response should be avoided. This can be achieved by offering some options in multiple-choice response lists that will mis-direct unqualified potential participants. 

3. Assess For Articulateness and Enthusiasm in the Conversational Screen

When conducting a qualitative study, you are exploring the motivations behind behaviors and opinions . For example, if you're testing a website, you’re learning about participants’ journeys through the site and striving to understand what exactly drove their navigation choices. 

Participants that are articulate and outgoing enough to examine and explain the logical process and emotional triggers that caused them to choose one path over the other are a must. 

Finding these participants is one of the greatest challenges of a successful recruitment. Asking “Articulation Questions” that require time, thought and putting feelings into words, will help identify these participants. 

Sample Articulation Questions 

• Think about the last book you read. Describe it and how it made you feel. 
• What is your thought process when you go shopping for groceries? How does that differ for different types of foods?
• Describe the next vacation you want to take and why you want to go there. 

Note that Articulation Questions in no way relate to the research topic. They are questions anyone can answer and will determine whether a candidate is more likely to answer with thought, in detail and openly sharing emotions versus only responding with the bare minimum.

4. Consider Using Advanced Screening 

Speak directly with candidates : At  Respondent , we provide the ability to conduct unique and advanced screening. One feature allows you to speak directly with candidates. Speaking directly with candidates will help determine if a candidate can elaborate in their answers and offer the detail needed.

Avoid imposters : Because of the incentives offered for research participation, there are people who attempt to participate in any and all research projects whether they qualify or not. Some will create fake email accounts and lie in their screener responses to qualify. Having one of these imposters slip through and take the place of a qualified participant can skew research results. Respondent pre-vets candidates through their social media accounts and the requirement of having a valid business email. This guards against any posers slipping through. 

Participant Ratings : Another Respondent safeguard encourages researchers to rate participants. After a study, a survey is sent out to rate the effectiveness of each of your participants as:  

• Poor (did not meet expectations) 
• Good (met expectations) 
• Great (exceeded expectations)

For Respondent researchers, participant rating is a unique and an important element in the recruiting process. 

5. The Importance of Over-Recruiting

No matter how diligent you are in your recruiting, there will likely be no-shows. So, it's a good idea to always over-recruit. 

For focus groups it’s common practice to recruit two additional participants per group e.g., recruit 10 to seat 8 per group. If 9 or even 10 show up, it’s up to the moderator and client if all participants will be included in the focus group or not. Keep in mind that all participants who show up, whether they are asked to participate or not must be paid their incentive. 

For I-D-Is (one-on-one interviews), recruit several back-up participants that can be contacted and scheduled to replace any no-shows. Again, it’s up to the moderator and client if all who have been recruited will be interviewed or not. 

Respondent makes no-show and replacement management easy. If you have an I-D-I participant that doesn't show up, mark them as "no-show." Respondent will immediately contact you, asking if you want us to identify a replacement from your previously vetted participant pool. The replacement participant will be scheduled as a make up for your no-show. Respondent will not charge for the recruiting of no-shows.

6. Offer Fair & Quick Compensation 

Determining what type and the amount of the incentive for participants can be a challenge.  The amount needs to be motivating for participants to first agree to participate and then to actually show-up. The amount offered must also fit within the research budget. This can be a balancing act. 

Typically, the longer a participant is needed, the larger your incentive needs to be. Additionally, the location of the study must be considered. Higher compensation will be necessary for an in-person study versus a remote one. 

Individuals in certain professions and at higher income levels will not be as motivated by an incentive. Larger incentives must be offered to these participants for both a timely and successful recruit and to encourage their attendance.

Respondent handles the payment of participant incentives which can be a hassle and time-consuming. Simply indicate that a participant has shown up and participated and Respondent takes care of payment. 

Recruiting Made Quick and Easy with Respondent

Following the steps to have a successful recruit which leads to a successful project traditionally has been difficult, time consuming and costly. Respondent offers solutions that streamlines and accelerates the process while providing the highest quality participants you can be confident in and all this at reasonable costs. Give Respondent a try.

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Chapter 29: Recruitment and sampling

Tess Tsindos

Learning outcomes

Upon completion of this chapter, you should be able to:

• Describe the main types of sampling.
• Describe recruitment approaches.
• Understand how to conduct recruitment and sampling.
• Identify the strengths and limitations of recruitment and sampling.

What is sampling?

Sampling is defined as selecting a suitable group of people (population) for a study. 1 Inviting people to the study who have the information to address the research question is a key consideration in sampling. Sampling is guided by the research question and will also influence data collection.

In qualitative research, different forms of non-random sampling, also known as non-probability sampling (not everyone has the chance of being selected), are utilised. 1 Using non-random sampling means the likelihood of a potential research participant being selected is not known in advance. This form is limited in generalisability; however, it aligns with qualitative research principles of sampling for meaning rather than frequency. Qualitative researchers tend to say that qualitative research is not generalisable, but is representative. 1  While qualitative studies often include non-random sampling, simple random sampling can be conducted when it is important to select a random set of participants from a large population, in which everyone has the same chance of being selected. This could be done by randomly selecting names from a telephone list or voter registration roll.

There are many ways to select a sample (sampling techniques). Among these are:

Snowball sampling ,   whereby study participants recruit or refer people they know to the study. This method is commonly used when potential participants can be hard to find through other means but potential participants are likely known to each other. For example, drug users or patients with rare diseases are likely to know others like themselves. This method may pose challenges for privacy because people may not want to share their contacts. 2

Convenience sampling ,   in which study participants are those most available to participate in the study. Participants may be those who are easily accessible to the researchers – such as a practitioner who is a member of a professional organisation and uses that organisation to recruit participants or patients at a hospital where the researcher works. This method can introduce bias because participants are drawn from within the researcher’s own networks or spheres of influence. 2

Purposive sampling ,   also known as purposeful sampling or selective sampling, involves the selection of participants on the basis of their ability to provide in-depth and detailed information about the phenomenon under investigation. For example, a study on the experience of working in a public hospital as a frontline emergency nurse during the COVID-19 pandemic requires participants to be nurses, working in an emergency department, having worked during the pandemic and at a public hospital. A general practitioner, for example, could not provide in-depth information on the phenomenon being investigated. This method may present challenges in locating potential participants because it can be difficult to find participants who are able to provide in-depth information about the phenomenon being studied. 2

Quota sampling   is sometimes referred to as purposive sampling with more structure. Categories that are important to the study and for which there is likely to be some variation are identified and then subgroups are identified on the basis of each category. The researcher decides how many people to include from each subgroup and collects data from that number of participants in each subgroup. This method requires the investigator to have prior information about the sample. For example, in a study researching students and their experience of attending university, many subgroups need to be considered; for example, those living on or off campus, the course of study, faculty or discipline, age, gender identity, ethnicity and more. This method can present a challenge to fill quotas for each category identified. 2

Snowball, convenience purposive and quota sampling are the most commonly used techniques for sampling in qualitative research. Other, less commonly used techniques include stratified sampling, theoretical sampling, extreme case sampling, typical case sampling, systemic sampling and intensity sampling. The technique used will depend on the research aim and questions.

Sample size in qualitative research

There are no clear guidelines for sample sizing in qualitative research. While researchers often propose a sample size, in general it is not decided on prior to data collection, but rather when data saturation occurs. Data saturation is a controversial concept because it is usually considered the point at which no new data is identified in interviews or focus groups. Some qualitative researchers, such as Braun and Clarke 4 hold that data saturation can never be fully achieved because each participant will have something new to add to the data. For other researchers, data saturation is an acceptable concept, and is often given as 8–17 participants. 1, 3 While 15 might be a proposed sample size for a study involving interviews, when the researcher has completed 10 interviews they may feel they have reached saturation as far as new themes or ideas are concerned. It is important to remember that sample size is not used to generalise and validate findings 5 , but rather to ensure in-depth understandings of the phenomenon under investigation.

Criteria for sampling

Another consideration in sampling is determining the inclusion and exclusion criteria for the study. This is a standard practice in qualitative research and is used to define who will and will not be able to participate in the study. 6 For example, inclusion criteria might include gender identity, age and health diagnosis. People who do not meet the inclusion criteria would not be eligible to participate in the study. Exclusion criteria are more than simply the opposite of inclusion criteria; they cover specific factors such as not being able to provide informed consent, using a specific type of medication, having a certain diagnosis and more. 6 Inclusion and exclusion criteria are broad, and should not be so narrow that they limit the characteristics of participants who can be recruited to the study.

Well-developed inclusion and exclusion criteria and well-considered sampling methods will assist researchers with the next step, recruitment to the study.

W hat is recruitment ?

Broadly speaking, recruitment to a research study involves presenting potential participants with detailed information about the research to help them decide on whether to participate in the study. The information presented during recruitment contributes to the consent process. Researchers who initiate participant recruitment should have a basic knowledge about the research and be part of the study team.

Before any research is to commence, the study must have ethical approval from a human research ethics committee. For academic researchers, this is the university’s human research ethics committee. For researchers outside the academic setting, it is the organisation that has been identified as the review agency. For example, research conducted within a hospital setting is reviewed by the hospital’s research ethics committee or panel. Research ethics committees review applications against the benchmarks set out in the National Statement on Ethical Conduct in Human Research .

As part of their data collection activities, researchers need to consider how they will invite research participants (recruitment) and the process of consent (see Chapter 30).

Recruitment methods need to take account of whether participant contact information is available and if there is permission to use it for the purpose of the research. Having email, phone or in-person (e.g. at a clinic) information will enable the researchers to correspond directly with potential participants, to invite them to participate in the research. Most researchers do not have the contact information of potential participants or are not able to contact them for the purpose of the research. In this instance, more passive methods of recruitment are needed and need to take into account settings frequented by potential participants, in-person or online. Passive methods of recruitment include advertising on social media, posting flyers on clinic noticeboards to advertise the research, asking clinics, sporting clubs, social clubs, schools, professional organisations, patient groups and other agencies to distrubute printed newsletters or to send emails on behalf of the researcher. The author has been involved in many studies in which contact details were not available. In a hospital study examining staff perceptions of how well a program was implemented, the hospital sent out invitations to potential participants (hospital staff) on behalf of the researcher. Staff who wished to participate were able to contact the investigators independently. In other instances where no contact details were available, the author advertised for participants with the assistance of peak bodies and community networks.

Recruiting participants through social media is increasingly common, but researchers need to be mindful about privacy and public availability of information. For example, potential participants may believe their comments in response to a recruitment advertisement on a social media platform are private, when in fact the information they share is available or visible to all users on that platform, or to the public.

Problems that may be encountered during recruitment include (but are not limited to) participants who are not fluent in English, participants who are hard to find and participants who do not trust research. Researchers need to consider these challenges in their recruitment activities and adjust them as necessary. Adjustments may include providing documents translated into the preferred language(s) of potential participants, recruiting research staff who speak the language, being mindful of the gender identity of research staff (e.g. women participants from some cultural backgrounds may prefer to deal with women researchers) and ensuring the research purpose is clearly communicated.

Incentives for research participants

Sometimes recruitment can be enhanced by providing an incentive for participants. This approach must be approved by the human research ethics committee before being offered to participants. Examples of reasonable incentives include providing reimbursement for parking at a hospital, offering a gift/shopping card or a coffee voucher for a nearby café, in recognition of time spent participating in the study. Incentives should not be excessive and therefore potentially coercive. The National Health and Medical Research Council (NHMRC) provides guidance on incentives in research.

Examples of s ampling and recruitment methods are presented in T able 29 .1. Notice how often multiple recruitment methods are used.

Table 29.1: Examples of sampling and recruitment

Strengths and challenges.

Each sampling and recruitment method has strengths and challenges. The one chosen depends on the study’s research question(s) and aim(s). Choosing the appropriate methods will bring rigour to the research, while choosing inappropriate methods will reduce rigour and affect the research results. Consider a study in which women’s experience of episiotomy is being sought. 7 It may be possible to recruit many women based on how relatively easy the birth was, or only a few women based on how willing the women are to talk about the use of forceps during delivery. Or consider a descriptive qualitative study in which up to 40 participants are recruited to provide slightly more generalisable results about an experience with a health service. 8 Each sampling and recruitment method is valid, depending on what is being researched.

Sampling refers to the selection of a suitable group of people from a broader population, to participate in a study. Selecting the people suitable for the research study is important because that will affect the study’s findings. There are many ways to sample, and these depend on the research being undertaken as well as the availability of participants. Recruitment refers to providing potential participants with information about the research and gaining their agreement to participate. There are many recruitment methods, and the one(s) chosen depend on the research being undertaken as well as participant agreement to become involved. Issues of privacy, confidentiality and consent need to be fully considered when sampling and recruiting participants to a research study.

• Lopez V, Whitehead D. Sampling data and data collection in qualitative research . In Schneider Z, Whitehead D, LoBiondo-Wood G, Haber J. Nursing & Midwifery Research: Methods and Appraisal for Evidence-Based Practice (4th ed). Elsevier Mosby; 2013:123-140.
• DeCarlo M, Cummings C, Agnelli K. Graduate R esearch M ethods in S ocial W ork : A P roject-based A pproach ; 2020.   Accessed September 26, 2023. https://viva.pressbooks.pub/mswresearch/
• Hennink M & Kaiser B. Sample sizes for saturation in qualitative research: a systematic review of empirical tests . Soc Sci Med . 2022;292:114523. doi.org/10.1016/j.socscimed.2021.114523
• Braun V & Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qual Res Sport, Exerc Health . 2019;13(2):1-16. doi:10.1080/2159676X.2019.1704846
• Vasileiou K, Barnett J, Thorpe S et al Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol  2018;18:148. doi:10.1186/s12874-018-0594-7
• ICORD, Vancouver Coastal Health Research Institute. Inclusion & exclusion criteria explained. Accessed May 28 th 2023. https://icord.org/research/studycriteria/
• He S, Jiang H, Qian X et al Women’s experience of episiotomy: a qualitative study from China BMJ Open  2020;10:e033354. doi:10.1136/bmjopen-2019-033354
• Williams M, Jordan A, Scott J et al Service users’ experiences of contacting NHS patient medicines helpline services: a qualitative study. BMJ Open  2020;10:e036326. doi:10.1136/bmjopen-2019-036326
• Gabriel P, Kaczorowski J, Berry N. Recruitment of refugees for health research: a qualitative study to add refugees’ perspectives . Int J Environ Res Public Health . 2017;14:125. Doi:10.3390/ijerph14020125
• Jola C, Sundström M, McLeod J. Benefits of dance for Parkinson’s: the music, the moves, and the company. PLoS ONE . 2022;17(11): e0265921. doi:10.1371/journal.pone.02659214
• Gauche C, de Beer L & Lizelle Brink L. Managing employee well-being: a qualitative study exploring job and personal resources of at-risk employees. SA Journal of Human Resource Management/SA Tydskrif vir Menslikehulpbronbestuur . 2017;15:a957. doi:10.4102/sajhrm. v15i0.957
• Hoernke K, Djellouli N, Andrews L et al Frontline healthcare workers’ experiences with personal protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal. BMJ Open .   2021;11:e046199. doi: 10.1136/bmjopen-2020-046199

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Tess Tsindos is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Open access
• Published: 25 October 2018

Improving trial recruitment processes: how qualitative methodologies can be used to address the top 10 research priorities identified within the PRioRiTy study

• Marita Hennessy   ORCID: orcid.org/0000-0001-7742-8118 1 , 2 ,
• Andrew Hunter 1 , 3 ,
• Patricia Healy 3 , 4 ,
• Sandra Galvin 3 , 4 &
• Catherine Houghton 1 , 4  

Trials volume  19 , Article number:  584 ( 2018 ) Cite this article

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A Methodology to this article was published on 01 March 2018

How can we improve recruitment to trials? In their recently published paper, Healy et al. outline the top 10 prioritised questions for trial recruitment research identified by the PRioRiTy study. The challenge now is for researchers to answer these questions; but how best can these be answered? In this commentary, we illustrate how qualitative research can be utilised to generate in-depth insight into trial recruitment issues, either as a stand-alone methodology, or through a mixed-methods approach. Consideration is given to how different forms of qualitative research can be used to address these priorities and to help researchers set out an agenda to optimise its value.

Peer Review reports

In their recently published paper, Healy et al. outline the top 10 prioritised questions for trial recruitment research identified by the Prioritising Recruitment in Randomised Trials (PRioRiTy) study (Table  1 ) [ 1 ]. The challenge now is for researchers to answer these questions. We believe that there are significant opportunities for qualitative methodologies to contribute to better understanding of trial recruitment issues and that the true value of such methodologies has not been fully recognised, or realised, to date. By working together, all key stakeholders—including trialists, researchers, clinicians, practitioners, commissioners, managers, policy makers, and members of the public—can find answers to the various recruitment issues by embedding qualitative designs in trials, or vice versa (i.e. embedding trials within qualitative designs) [ 2 ]. To this end, this paper will present a number of examples where qualitative research has been used to improve the conduct of trials, and specifically recruitment.

What is the value of qualitative methods in trial recruitment research?

Qualitative research can address questions in trial recruitment that are not easily addressed by quantitative methods, by providing in-depth information on the experiences of participants and recruiters. It can also help contribute to trial design, including the development of effective recruitment strategies. Qualitative research methods have been used to address various aspects of randomised trials; these include developing and understanding the acceptability of the intervention being trialled, the trial design, process and conduct (including recruitment and retention), explaining trial outcomes, and providing contextual understanding of the target condition for the trial [ 3 ]. Increasingly, more focus is being placed on the pre-trial stage [ 3 ]. Qualitative research can potentially improve the efficiency of trials by identifying problems with recruitment. This enables the trialists to address those problems and increase or optimise recruitment [ 3 ]. Common qualitative research methods include interviews, focus groups, and observations. Other methods include analysis of trial documents, and audio recordings of trial recruitment interactions. While the integration of qualitative methods within randomised trials is recognised as important, in practice, fully embedded/integrated designs are rarely realised and methodological concerns persist [ 3 , 4 , 5 ]. It is imperative that researchers in primary qualitative research fully report and justify their methodological approach to ensure the rigor of their methods and maintain the credibility of qualitative research in trials. A range of potential weaknesses have been identified, including lack of clarity regarding methods, sample and data collection, limited explanation of context, poor description of data analysis, and failure to account for the impact, if any, of the qualitative researcher [ 6 , 7 ] There is also a need for those undertaking qualitative evidence synthesis to address the confidence in their findings using GRADE CERQual [ 8 ]. In addition, there are reporting guidelines on the EQUATOR network ( https://www.equator-network.org/ ) specifically aimed at qualitative research and evidence synthesis.

How can questions be answered by qualitative methods?

We will now outline how different qualitative methodologies can be used to address the top 10 priorities. We have grouped the approaches into three categories: 1) interviews and focus groups; 2) observation, audio recording and documentary analysis; and (3) qualitative evidence synthesis. Each of the methods can also be used within mixed-methods approaches; however, we will not specifically address such approaches within this commentary. In mixed-methods research, the researcher collects and analyses both qualitative and quantitative data rigorously, integrates the two forms of data and their results, organizes these procedures into specific research designs, and frames these procedures within theory and philosophy ([ 9 ]: page 5).

Interviews and focus groups

The use of individual interviews or focus groups within randomised trials facilitates understanding from the viewpoint of those experiencing phenomena (in this instance, recruitment to trials), and can be conducted with patient participants, recruiters, health professionals, or others. Individual interviews provide the opportunity for in-depth discussion of individuals’ personal insights and lived experiences, particularly when the topic is potentially sensitive [ 10 , 11 ]. Alternatively, the strengths of focus groups lie in group dynamics and the interactive nature of the unfolding discussions. Focus groups allow discussion in a more relaxed atmosphere to explore shared experiences and develop understanding from their interaction [ 12 ].

Donovan et al. provide a detailed example of how interviews can provide a rich understanding of the complexities and hidden challenges underlying recruitment to randomised trials from the perspectives of recruiters [ 13 ]. Similarly, Oakley et al. provide an example of the use of focus groups to support process evaluation within a trial [ 14 ]. They argue that the science of a randomised trial is enhanced by ongoing high-quality evaluation which considers the context in which the intervention is delivered, helping to explain outcomes. Analysis of focus group data provides insight into acceptability and delivery of interventions from the perspective of participants [ 5 ]; interviews can also facilitate such insights. O’Cathain et al. identify the increasing use of focus groups and individual interviews within trials, suggesting that incorporating these methods at feasibility and pilot stages of trials can enhance the leaning about trials for trialists and researchers, and contribute to the overall trial endeavour [ 5 ].

Dormandy et al. conducted interviews with general practitioners to seek their views on effective ways of recruiting and retaining practices to clinical trials [ 15 ]. This study found that interviews with general practitioners allowed identification of key strategies for communication, data collection, and payment to support retention and recruitment.

Donovan et al. synthesised findings from interviews with recruiters in a number of trials, providing improved understanding of the complexity and fragile nature of recruitment practices [ 13 ]. Interviews elicited detailed information from recruiters regarding their tendency to undermine recruitment practices, specifically randomisation for clinical and equipoise reasons [ 13 ]. Importantly, these findings were elicited in individual interviews, with responses being fed into efforts to improve recruitment practices. In an earlier study, Donovan et al. conducted in-depth interviews with men in the Prostate testing for cancer and Treatment (ProtecT) study to establish interpretation of study information by participants [ 2 ]. Subsequent changes to the content and delivery of study information within this trial, incorporating findings from these interviews amongst other data, increased recruitment rates from 40% to 70% [ 2 ]. The examples presented show that interviews and focus groups would be appropriate qualitative methods for most of the PRioRiTy questions, conscious of the group versus individual dynamic for some sensitive questions. Individual interviews would be more suitable for question nine (‘What are the best approaches to optimise the informed consent process when recruiting participants to randomised trials?’), however, where the process of informed consent would perhaps be better discussed individually.

Observation, audio recording, and documentary analysis

While the strengths of interviews and focus groups are to capture perspectives and experiences, there can sometimes be conflict between what people say happens and what actually happens. There are times when qualitative methods that capture interactions and events would be more suitable for answering questions about trial processes. These methods can include observations, audio recordings, and documentary analysis of trial processes. For example, Healy et al. conducted a mixed-methods process evaluation of the OptiBIRTH trial (a pan-European cluster randomised controlled trial (RCT)) [ 16 ]. An ethnographic study conducted by Maguire was embedded within this study to explore the implementation of the intervention in practice [ 17 ]. Qualitative observations and interviews uncovered the impact of the intervention on culture and rituals within the practice setting.

An example of the use of audio recording was presented by Donovan and colleagues [ 2 ]. Analysis of audiotape recordings of recruitment appointments in the ProtecT study revealed how the language used when presenting trial information could impact on recruitment [ 2 ]. This innovative qualitative approach became the cornerstone of QuinteT Recruitment Intervention (QRI) developed by Donovan and colleagues [ 18 ]. The QRI involves understanding the process of recruitment in real time and then developing an action plan to address the identified difficulties in collaboration with the RCT Chief Investigator, Trial Management Group, and Clinical Trials Unit [ 18 ].

Documentary analysis examines anything written or produced about a context and how it has evolved [ 19 ]. This can include formal and informal sources which may contain clues as to how a phenomenon has evolved [ 19 ]. This is an important method to understand what is happening and the context from which the phenomenon has grown. Documentary sources, unlike interviews, are not the result of a somewhat artificial process of interaction and, therefore, the process by which they are produced cannot be ignored [ 20 ]. Content analysis of trial documents was conducted in the Selective bladder Preservation Against Radical Excision (SPARE) feasibility study (along with analysis of interview data and audio recordings of recruitment appointments) to explore reasons for low recruitment and to attempt to improve recruitment rates [ 21 ]. Trial documents examined included the SPARE trial Patient Information Sheet and trial protocol. Findings contributed to revisions to trial processes that were acceptable to trialists and recruiters.

In recruitment research, these qualitative methods, alone or in combination (as utilized for example in the QRI), could be used to answer the “what is happening?” component of the PRioRiTy questions. For instance, using observation or audio recording, the best approaches for including under-represented or vulnerable populations (question seven) could be explored. Similarly, informed consent processes (question nine: ‘What are the best approaches to optimise the informed consent process when recruiting participants to randomised trials?’) could be examined using observations, audio recording, or documentary analysis. Researchers could also use observational techniques to explore the role of technology in recruitment processes outlined in question ten. In the context of the PRioRiTy questions, documents would be important for augmenting evidence from interviews and observations [ 22 ], to develop a better understanding about recruitment processes and outcomes.

• Qualitative evidence synthesis

In addition to emphasising the importance of primary qualitative studies in trial research, there is now recognition of the contribution to be made by qualitative evidence synthesis (QES). QES is a valuable way of synthesising primary qualitative research to capture experiences, perceptions, and factors that impact on certain components of the trial process. QES is rigorous and provides meaningful conclusions that can inform policy and practice [ 23 , 24 ].

As outlined in the PRioRiTy paper, a number of qualitative syntheses have already been conducted that address questions six and nine [ 25 , 26 , 27 , 28 ]. It should be noted that all of the questions identified in the PRioRiTy paper were deemed “unanswered” if there was no up-to-date systematic review (< 3 years old). Houghton et al. have also published a Cochrane Protocol exploring the factors that impact on recruitment to trials [ 29 ]. This ongoing qualitative review will be integrated with the findings of a Cochrane review [ 30 ] that aimed to identify interventions designed to improve recruitment to RCTs, which in turn will inform PRioRiTy questions two and six. QES has great potential for guiding further recommendations for most of the PRioRiTy questions.

Conclusions: where do we go from here?

The PRioRiTy study identified and prioritised important unanswered questions on how to improve the process of recruiting people to randomised trials. Further research is now required to address those prioritised questions. We propose that qualitative research approaches have a crucial role in providing answers to the questions posed. Similar to the examples provided, qualitative research could be conducted as a stand-alone study embedded as a study within a trial (SWAT), or as part of mixed-methods research. Failure to integrate findings and variations in quality are ongoing issues [ 31 ]. Trialists and qualitative researchers need to collaborate and work together to ensure qualitative work is done appropriately, ethically, and rigorously.

As described above, there is ample opportunity for qualitative methodologies to address the top ten priorities identified for trial recruitment research. Organisations such as QUESTS, the HRB-TMRN, Trial Forge, and QuinteT can bridge links between trialists and researchers to better inform trial recruitment.

Some key considerations for moving this agenda forward are:

Qualitative research needs to be integral, and not considered an optional add-on.

There needs to be a common language supporting communication between trialists and researchers.

Qualitative methodologies should be embedded at the design phase (including costings) and fully reported on completion. This includes pre-trial, pilot, and feasibility stages of the trial [ 3 , 4 ].

The potential positive impact of qualitative research in trial recruitment and other trial methodology research needs to be rigorously researched, articulated, and disseminated.

Qualitative research can help provide the necessary evidence to guide researchers on how to improve the process of how people are recruited to randomised trials; an issue which persists as a challenge to trialists.

Abbreviations

Prioritising Recruitment in Randomised Trials

Prostate testing for cancer and Treatment

Qualitative Evidence Synthesis

QuinteT Recruitment Intervention

Qualitative Research in Trials Centre

Qualitative Research Integrated within Trials

Randomised Controlled Trial

Selective bladder Preservation Against Radical Excision

Study Within A Trial

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Hennessy, M., Hunter, A., Healy, P. et al. Improving trial recruitment processes: how qualitative methodologies can be used to address the top 10 research priorities identified within the PRioRiTy study. Trials 19 , 584 (2018). https://doi.org/10.1186/s13063-018-2964-1

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Revising Recruitment for Focus Groups to Meet Shifting Needs during COVID-19

Pearman d. parker.

University of Arkansas for Medical Sciences College of Nursing, Little Rock, Arkansas

Jean C. McSweeney

Kristie b. hadden.

University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas

Kaycee G. Hess

Pearman D. Parker, PhD, MPH, PMH-BC is a Clinical Assistant Professor, and Jean C. McSweeney, PhD, RN, FAAN, FAHA is a Professor Emeritus, University of Arkansas for Medical Sciences, College of Nursing, Little Rock, AR.

Kristie B. Hadden, PhD, is an Associate Professor in the Department of Medical Humanities and Bioethics in the College of Medicine at the University of Arkansas for Medical Sciences, Little Rock, AR.

Kaycee Hess, BSN, RN is a graduate student, University of Arkansas for Medical Sciences, College of Nursing, Little Rock, AR.

Background:

The COVID-19 pandemic forced researchers to modify recruitment strategies to meet accrual goals for qualitative studies. Traditional methods of in-person recruiting and using paper marketing material were eliminated almost overnight at the onset of the pandemic. Researchers quickly adapted their recruitment strategies, but researchers had to shift local, in-person recruitment efforts to solely using online platforms. The shifting recruitment strategies were accompanied with unexpected challenges, but we were able to meet our accrual goal for focus groups.

Objectives:

The objective of this brief report is to explore new recruitment strategies that developed during the COVID-19 pandemic and offer suggestions for future online-based qualitative studies.

Prior to COVID-19, we designed four main strategies (research registry, marketing material, social media, and provider endorsement) to recruit potential participants for focus groups as part of a qualitative, descriptive study involving young women breast cancer survivors. After the onset of COVID-19, we successfully adapted each of our initial four strategies to recruit potential participants in an incremental process. Using these adapted strategies, a total of 62 young women completed the first part of the data collection process prior to participating in a focus group. Thirty-three women participated in the focus groups and the remaining 29 participants were lost to follow-up. The vast majority of participants were recruited through marketing material and social media after making strategic changes to recruitment.

Discussion:

The most effective method of recruitment was the strategic use of marketing material and social media, and we offer suggestions for researchers considering online recruitment methods. We recommend that researchers use various social media platforms, specific hashtags, and target their sample population at the onset of the study. The data collection changes initiated by the effects of COVID-19 may remain, and researchers can consider implementing permanent recruitment strategies to best meet the needs of this new landscape of conducing online focus groups.

The COVID-19 pandemic created a series of unpredictable effects for nearly 16 months in health systems and across Academia. Major funding agencies such as the National Institutes of Health and the Food and Drug Administration encouraged researchers to follow their local Institutional Review Boards and university regulations while keeping participant safety paramount ( Food and Drug Administration, 2020 ; National Institutes of Health, 2020 ). Following the recommendation and guidance from numerous universities across the country, qualitative researchers were affected as many studies were halted in the middle of recruitment, especially at the beginning of the pandemic. Traditional approaches to recruitment, such as in-person recruiting in waiting rooms and posting paper fliers, were eliminated almost overnight. After the initial pause in recruitment was lifted, researchers had to quickly adapt strategies to accommodate the new landscape created by COVID-19.

The traditional recruitment methods for qualitative, descriptive studies include a mixture of in-person and online strategies. The strategies used for recruiting in-person focus groups traditionally include local advertisements, provider endorsements, and marketing outreach efforts to members in the community ( Marshall & Rossman, 2011 ). Within focus groups for women with breast cancer, traditionally groups range from five to nine participants per group ( Ceballos et al., 2021 ; Currin-McCulloch et al., 2021 ; Yelton et al., 2021 ). Though qualitative studies have no set sample goal equivalent to quantitative studies, researchers generally stop recruiting once they reach data saturation (meaning no new data emerges; Creswell, 2013 ). These traditional strategies have generally been successful to meet data saturation and accrual goals for in-person focus groups ( Rogers et al., 2021 ), but when the pandemic forced non-essential, in-person gatherings to halt, researchers had to shift local, in-person recruitment efforts to solely using online platforms. The shifting recruitment strategies were accompanied with unexpected challenges, but we were able to meet our accrual goal for focus groups. We consulted the literature ( Quach et al., 2013 ; Topolovec-Vranic & Natarajan, 2016 ) and met with communication specialists to revise our recruitment plan. However, we moved forward carefully as we had no published guidance on how to navigate stress and emotional turmoil of potential participants caused by the unprecedented pandemic. Thus, the purpose of this article is to discuss the recruitment strategy changes as a response to COVID-19. We conclude by offering suggestions for researchers in navigating this new qualitative research landscape in similar virtual settings.

Overview of Study

The purpose of the descriptive, qualitative study was to explore perceptions of cancer educational material for young women breast cancer survivors who completed active treatment within the last five years. We sought to recruit 32 – 40 young women breast cancer survivors to participate in focus groups. Young women were asked to consent and complete a demographic questionnaire and the Newest Vital Sign (NVS; Pfizer, 2011 ) health literacy instrument prior to participating in a focus group. The consent, questionnaire, and health literacy instrument were administered through REDCap – an electronic data capturing tool housed at our institution ( Harris et al., 2009 ).

All research was conducted ethically, received IRB approval, and operated in accordance with all applicable government regulations and University of Arkansas for Medical Sciences (UAMS) research policies and procedures. All participants completed consents via REDCap ( Harris et al., 2009 ) and emphasis was placed that participation in focus groups was confidential and voluntary due to the sensitive nature of the study.

Prior to COVID-19, we designed our recruitment protocol to include four major recruitment approaches to meet the accrual goal for this study: 1) AResearch Registry – a statewide research registry; 2) marketing materials; 3) social media promotion; and 4) provider endorsement in local clinical settings. After the onset of COVID-19, we adapted each of our initial four strategies to recruit potential participants ( Table 1 ).

Overview of Recruitment Changes related to COVID-19

ARresearch Registry

The ARresearch Registry is a voluntary participant research registry of more than 7,500 men and women of different ethnic and racial backgrounds living primarily in Arkansas ( UAMS Translational Research Institute, 2021 ). The registry consists of mix of healthy volunteers (n = 3088; 40.7%) and those who may have a history of a chronic illness. Participants sign up through a REDCap portal link, answer demographic questions, and indicate which type of research they are interested in ( Harris et al., 2009 ; McSweeney et al., 2019 ). Most of the participants indicate they are interested in weight management (n = 3732, 49.2%), mental health (n = 3250, 42.8%), heart disease (n = 2800, 36.9%), and women’s health (n = 2739, 36.1%; UAMS Translational Research Institute, 2021 ).

Before COVID-19

We planned to use the ARresearch Registry to identify and recruit young women between the ages 18 – 45 with a history of breast cancer. We originally planned to implement a direct mailing campaign which included a personalized letter and colorful recruitment flier. The letter included purpose of the study, focus group details, time commitments, and compensation information, which was all delivered in a warm, friendly tone. The flier adhered to plain language guidelines ( Plain Language Action and Information Network, n.d. ) and included graphics representing young women with diverse backgrounds.

During COVID-19

Following the COVID-19 restrictions, we were unexpectedly unable to send out direct mailings due to the contact precautions to reduce the transmission of COVID-19. To accommodate this unanticipated change, we then created an e-mail campaign. We eliminated the personalized letter and replaced with a two step-process. First, an initial e-mail was sent out to all of the potential participants notifying them of a potential match for a study. Potential participants then had the option to opt-in enrollment by clicking an “I’m interested” link. Second, once participants opted in, a follow-up e-mail was sent with more information about the study (written out details, IRB approval, principal investigator information) and an accompanying IRB-approved flier embedded as a picture in the text. Potential participants would then click an embedded link which was directly connected to the consent, demographic questionnaire, and NVS instrument housed in a REDCap portal ( Harris et al., 2009 ). A participant was considered ‘enrolled’ upon completing all three portions.

Marketing Materials

We originally planned on strategically placing print marketing materials (recruitment fliers) throughout a local survivorship clinic. The fliers were designed to be placed in elevators and in waiting rooms where potential participants could see the study information and then opt-in by e-mailing a study coordinator for enrollment or further information.

At the onset of the pandemic, all print materials were removed from elevators and patient care areas per the contact precaution guidelines to reduce transmission of COVID-19. We quickly adapted and turned the printed flier into a digital copy with the intention to distribute electronically, if needed. We also added a QR code which linked directly to the consent, demographic questionnaire, and NVS instrument. The QR code was added in anticipation of when print materials would be allowed in patient care areas so potential participants could have direct access. After six months into the pandemic, we were able to replace the revised print materials with QR codes in elevators and patient care areas.

Social Media

We originally planned on using social media as a platform to advertise recruitment for the study within the state. We solicited recommendations from a communications specialist with a history of working with community-based cancer organizations throughout Arkansas. We also followed recommendations mentioned in the literature surrounding social media as a recruitment tool ( Quach et al., 2013 ; Topolovec-Vranic & Natarajan, 2016 ). The major platforms we originally intended to use were Facebook and Instagram. We planned to share a stock image with a link to the recruitment website where potential participants could learn about the study and enroll across all three major platforms. We also planned to purchase a ‘boosted post’ through Facebook which increased visibility of a post by reaching a broader audience ( Facebook, 2021 ) within a predetermined timeframe for three months to the audience following our main University of Arkansas for Medical Sciences (UAMS) page. The purpose of ‘boosting’ a post was to reach a larger audience beyond the immediate followers ( Facebook, 2021 ). Additionally, ‘boosting’ a post purchased access to metrics about the post such as link clicks, sharing, and engagement.

Our original social media plan continued through COVID-19 initially. We purchased a ‘boosted ad’ for our main UAMS Facebook page and ran for three months from November 2020 – January 2021. Initially we had low accrual and planned on purchasing more time for a boosted post. However, our institution’s Facebook page was unexpectedly restricted due to a billing issue, and our Office of Communications could not purchase more time.

Due to the unexpected page restriction and consistently low accrual numbers, we had to add additional recruitment tactics using social media and personal endorsements from community organizations. We then expanded our sampling beyond the state and reached out to national organizations to ask if they could share the study’s website link and digital flier with their followers. We asked for assistance through the Young Survival Coalition, Moffitt Cancer Center’s Adolescent and Young Adult (AYA) program, and the Tampa Bay Community Cancer Network (TBCCN) to share the study flier and accompanying website to their supporters.

Provider Endorsements

The final recruitment strategy we employed was provider endorsement of our study. Providers (breast oncologists and nurse practitioners) allowed for us to strategically place fliers in the waiting room of a local survivorship clinic detailing the study (length of time required, incentives, focus group format). Providers also were given additional copies of the fliers and could directly refer a patient to the study (if they fit the inclusion criteria listed on the flier).

Due to the changes accompanying with COVID-19 protocols, patients were encouraged to partake in telehealth visits for their survivorship visits. Providers had the option to mention and reference the study at their discretion.

Using the search functions within ARresearch Registry, we identified 256 potential participants between the ages of 18 and 45 with an interest in breast cancer. The initial e-mail was sent to 256 potential participants. Fourteen women immediately declined (5.4%), and 38 women confirmed their interest (14.8%) by clicking an embedded link to receive more information. Of those 38, we lost 30 to follow up (78.9%) and seven (18.4%) were ineligible (had no history of breast cancer). We were able to recruit and enroll one participant using the ARresearch Registry.

Marketing Materials & Social Media

Our ‘boosted post’ ran initially for 50 days from November 2020 to January 2021 on the main UAMS Facebook page. The page had a reach of more than 39,152 people at the time. Over the course of 50 days, the post received 504 post engagements, 399 clicks so viewers could visit the outsourced link to the study’s main recruitment website, 64 post reactions (like, love, care, laugh, wow, sad, or angry), 23 shares to other pages, and 17 comments.

The Young Survival Coalition, Moffitt Cancer Center’s AYA program, and the TBCCN graciously agreed to share the digital fliers and link to the study’s website via an e-mail blast sent out to a pre-determined audience within list servs. These organizations helped expand our reach from statewide to national sampling. All but one of our participants were recruited using a combination of marketing materials (digital fliers) and social media.

Provider Endorsement

Providers continued to have the option to endorse the study during their clinic hours for telehealth visits at the initial onset of the pandemic and also after some in-person visits resumed approximately six months into the pandemic. However, no participants were recruited through providers’ direct endorsement of the study.

All of our recruitment strategies resulted in 128 REDCap entries. We received 66 (51.5%) entries with incomplete data. We had 62 (48.4%) potential participants who completed all three portions (consent, demographic questionnaire, and health literacy instrument). Thirty-three young women participated in the focus groups and the remaining participants ( n = 29, 46.8%) were lost to follow-up.

We adapted each of our four major recruitment strategies during COVID-19 to meet accrual goals for our qualitative, descriptive study. While most of our successful recruitment occurred using marketing materials and social media, we developed recommendations for researchers conducting qualitative studies.

First, the ARresearch Registry was not the most beneficial tool to use in recruiting despite the ‘opt-in’ method and user-friendly features of the tailored e-mails. We suspect this may have been due to the factors that many register users were local to Arkansas, a largely rural state with known connectivity issues ( Warren et al., 2019 ). Potential participants may have not had solid, reliable connections to participate in online focus groups. Additionally, the timing of the e-mail campaign may have directly affected the number of responses from the registry. The e-mail campaign was initiated in September 2020 and many participants may have been too overwhelmed with the increasing stress of balancing work-from-home life, childcare, and emotional turmoil of the pandemic to participate in a research study ( Freisthler et al., 2021 ; Miaskowski et al., 2020 ). The ARresearch Registry is documented to be a successful recruitment tool ( Gladden et al., 2020 ; McElfish et al., 2021 ; McSweeney et al., 2019 ) thus we suspect that the stress and burden of the pandemic ( Savard et al., 2021 ) largely influenced our potential participants and contributed to our lower accrual rates using the registry.

Even though researchers may not have to navigate through another pandemic in the immediate future, they will need to accommodate to unpredictable environmental stressors. For example, if a registry samples from largely one area of the country or state, unforeseen obstacles (such as natural disasters) can negatively affect recruitment. We suggest that researchers use ready-made registries with an established outreach spanning across the country to account for any unforeseen obstacles in one central location. Also, using such registries may allow researchers to oversample to reach accrual goals for more specific populations. Examples of established registries for young women breast cancer survivors include the Love Research Army ( Dr. Susan Love Foundation, 2021 ) and Young Survival Coalition ( Young Survival Coalition, 2021 ). Both of these research registries already have established networks and successful history of recruitment methods ( Su et al., 2019 ; Williamson et al., 2018 ).

Second, social media was beneficial in that all but one of our participants were recruited through Facebook ads and internal organizational promotion using list servs (weekly, bimonthly, and monthly e-mail blasts to pre-determined audiences) for the Young Survival Collation, Moffitt Cancer Center’s AYA program, and the TBCCN. However, we were missing specific data in terms of reach, thus we had no way to monitor the origins of the traffic or evaluate if we were oversampling in one particular area of the country. We also did not identify which social media platform would be the most useful prior to starting the study. This oversight may have reduced our reach to potential participants. Additionally, we used a well-designed web page promoting our study. This allowed for easy access and sharing across all platforms. Finally, we were unexpectedly promoted through personal endorsement to list servs through contacts with another large cancer institute in the Southeast. This personal touch provided a sense of security for participants ( Luck et al., 2017 ) and may have been one of the critical factors into our successful recruitment during the stressful and burdensome pandemic. We encourage researchers to continue to use such personalization regardless of any environmental factors like a national crisis or pandemic.

As researchers plan recruitment protocols, we recommend using specific survey software such as Qualtrics which can track location of respondents known as geolocation ( Qualtrics, 2021 ). Researchers can identify location of site traffic and then will be able to implement tailored strategies to reach a different population for more generalizable results, if needed. We also recommend that researchers identify which social media platforms are most successfully used by the researchers’ home institutions. Specific strategies per platform can produce favorable results if used carefully and with consideration such as using research-specific hashtags with heavy site traffic ( Arigo et al., 2018 ). Next, we cannot understate the significance of having a well-designed web page detailing the study. Researchers will want to ensure plain language principles are used and incorporate appropriate images consistent with their target population ( Vollenwyder et al., 2018 ). Lastly, the importance of maintaining relationships to assist with recruitment is critical to any successful research project.

Third, our strategy of using provider endorsements was practically eliminated as most of the clinical care shifted to telehealth due to the COVID-19 restrictions. Patients were not given fliers by providers, nor did they see many advertisements in the waiting room of the clinics since most of the appointments were online and fliers were not allowed to be posted until about six months into the study. Also, we did not implement any fidelity checks to evaluate whether study endorsements were being conducted in the telehealth sessions.

We recommend that researchers consider implementing a slide show or preview of a study during the telehealth waiting room time if they are recruiting from a clinical setting. Often patients will have to log on to the telehealth session and then wait for a provider while looking at a blank screen. This may be an opportune time to promote a study and describe essential details. Also, researchers may consider adding in an “I’m interested” button in the virtual waiting room which could prompt the provider to give more details at the conclusion of the telehealth session. Lastly, we recommend that researchers consider implementing random fidelity checks to ensure specific recruitment strategies are occurring as designed and at the rate intended ( Proctor et al., 2011 ).

The COVID-19 pandemic forced many researchers to rely on innovative data collection methods and accompanying recruitment strategies to meet accrual goals. While the long-term effects of COVID-19 on qualitative research have not yet been identified, we can expect that the success of these new methods and recruitment strategies will encourage researchers to continue using online data collection platforms and strategic social media recruitment methods. We particularly recommend using national and statewide registries like ARresearch Registry, utilizing social media strategically, and employing telehealth-based methods alongside provider endorsement after the stress and burden from the pandemic resolves. The success of these new adapted methods may usher in more research and give researchers more access to participants across the country.

Acknowledgement:

Dr. Parker is currently supported by the University of Arkansas for Medical Sciences Translational Research Institute (TRI) grants KL2TR003108 and UL1TR003107 through the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) and Arkansas Breast Cancer Research Program. The authors would like to thank Heidi Charton, BA, for her assistance in coordinating the focus groups.

The authors have no conflicts of interest to report.

Ethical Conduct of Research: All research was conducted ethically and received IRB approval for study protocol #239621.

Contributor Information

Pearman D. Parker, University of Arkansas for Medical Sciences College of Nursing, Little Rock, Arkansas.

Jean C. McSweeney, University of Arkansas for Medical Sciences College of Nursing, Little Rock, Arkansas.

Kristie B. Hadden, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas.

Kaycee G. Hess, University of Arkansas for Medical Sciences College of Nursing, Little Rock, Arkansas.

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Recruitment for qualitative research

You’ll find a lot of information and debate about sampling issues in qualitative research: discussions over ‘random’ or ‘purposeful’ sampling, the merits and pitfalls of ubiquitous ‘snowball’ sampling, and unending questions about sample size and saturation

Daniel Turner

You’ll find a lot of information and debate about sampling issues in qualitative research: discussions over ‘random’ or ‘purposeful’ sampling, the merits and pitfalls of ubiquitous ‘snowball’ sampling, and unending questions about sample size and saturation. I’m actually going to address most of these in the next blog post, but wanted to paradoxically start by looking at recruitment. What’s the difference, and why think about recruitment strategies before sampling?

Well, I’d argue that the two have to be considered together, but recruitment tends to be a bit of an afterthought and is so rarely detailed in journal articles ( Arcury and Quandt 1999 ) I feel it merits its own post. In fact, there is a great ONS document about sampling , but it only has one sentence on advice for respondent recruitment: “The method of respondent recruitment and its effectiveness is also an important part of the sampling strategy”. Indeed!

When we talk about recruitment, we are considering the way we actually go out and ask people to take part in a research study. The sample frame is how we choose what groups of people and how many to approach, but there are huge practical problems in implementing our chosen sampling method that can be dealt with by writing a comprehensive recruitment strategy.

This might sound a bit dull, but it’s actually kind of fun – and the creation of such a strategy for your qualitative research project is a really good thought exercise, helping you plan and later acknowledge shortcomings in what actually happened. Essentially, think of this process as how you will market and advertise your research project to potential participants.

Sometimes there is a shifting dynamic between sampling and recruitment. Say we are doing random sampling from numbers in a phone book, a classic ‘random’ technique. The sampling process is the selection of x number of phone numbers to call. The recruitment is the actually calling and asking someone to take part in the research. Now, obviously not everyone is going to answer the phone, or want to answer any questions. So you then have a list of recruited people, which you might actually want to sample from again to make a representative sample. If you found out everyone that answered the phone was retired and over 60, but you wanted a wider age profile, you will need to refactor from your recruited sample.

But let’s think about this again. Why could it be that everyone who consented to take part in our study was retired? Well, we used numbers from the phone book, and called during the day. What effect might this have? Numbers in the phone book tend to be people who have been resident in one place for a long time, many students and young people just have mobiles, and if we call during the day, we will not get answers from most people who work. This illustrates the importance of carefully considering the recruitment strategy: although we chose a good random sampling technique, our strategy of making phone calls during the day has already scuppered our plans.

How about another example: recruitment through a poster advertising the study. Many qualitative studies aren’t looking for very large number of respondents, but are targeting a very specific sample. In this example, maybe it’s people who have visited their doctor in the last 6 months. Sounds like a poster in the waiting room of the local GP surgery would work well. What are the obvious limitations here?

First of all, people who see the poster will probably have visited the GP (since they are in that location), however, it actually only would recruit people who are currently receiving treatment. People who had been in the previous 6 months but didn’t need to go back again, or had such a horrible experience they never returned, will not see our poster and don’t have a chance to be recruited. Both of these will skew the sample of respondents in different ways.

In some ways this is inevitable. Whichever sampling technique and recruitment strategy we adopt, some people will not hear about the study or want to take part. However, it is important to be conscious of not just who is being sampled, but who is left out, and the likely effect this has on our sample and consequently our findings. For example our approach here probably means we oversample people who have chronic conditions requiring frequent treatment, and undersample people who hate their doctor. It’s not necessarily a disaster, but just like making a reflexivity statement about our own biases, we must be forthright about the sampling limitations and consider them when analysing and writing conclusions.

For these reasons, it’s often desirable to have multiple and complementary recruitment strategies, so that one makes up for deficiencies in the other. So a poster in the waiting room is great, but maybe we can get a list of everyone registered at the surgery, so we can also contact people not currently seeking treatment. This would be wonderful, but in the real world, we might hit problems with the surgery not being interested in the study, not able to release that information for confidentiality reasons, and the huge extra time such a process would require.

That’s why I see a recruitment strategy as a practical battle plan that tries to consider the limitations and realities of engaging with the real world. You can also start considering seemingly small things that can have a huge impact on successful recruitment:

• The design of the poster • The wording of invitation letters • The time of day you make contact (not just by phone, but don’t e-mail first thing on a Monday morning!) • Any incentives, and how appropriate they are • Data protection issues • Winning the support of ‘gatekeepers’ who control access to your sample • Timescales • Cost (especially if you are printing hundreds of letters of flyers) • Time and effort required to find each respondent • And many more…

For a more detailed discussion, there’s a great article by Newington and Metcalfe (2014) specifically on influencing factors for recruitment in qualitative research.

Finally, I want to reiterate the importance of trying to record who has not been recruited and why. If you are directly contacting a few dozen respondents by phone or e-mail, this is easy to keep track of: you know exactly who has declined or not responded, likely reasons why and probably some demographic details.

However, think about the poster example. Here, we will be lucky if 1% of people that come through the surgery contact us to take part in the study. Think through these classic marketing stages: they have to see the poster, think it’s relevant to them, want to engage, and then reach out to contact you. There will be huge losses at each of those stages, and you don’t know who these people are or why they didn’t take part. This makes it very difficult in this kind of study to know the bias of your final sample: we can guess (busy people, those who aren’t interested in research) but we don’t know for sure.

Response rates vary greatly by method: by post 25% is really good, direct contact much higher, posters and flyers below 10%. However, you can improve these rates with careful planning, by considering carefully who will engage and why, and making it a good prospect to take part: describe the aims of the research, compensate time, and explain the proposed benefits. But you also need to take an ethical approach, don’t coerce, and make promises you can’t keep. Check out the recruitment guidelines drawn up by the Association for Qualitative Research.

My personal experience tells me that most people who engage with qualitative research are lovely! They want to help if they can, and love an opportunity to talk about themselves and have their voice heard. Just be aware of what kinds of people end up being your respondents, and make sure you acknowledge the possibility of hidden voices from people who don’t engage for their own reasons.

Once you get to your analysis, don't forget to try Quirkos for free , and see how our easy-to-use software can make a real qualitative difference to your research project! To keep up to date with new blog articles on this, and other qualitative research topics, follow our Twitter feed: twitter.com/quirkossoftware .

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• Research article
• Open access
• Published: 23 January 2014

Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams

• Lisa Newington 1 &
• Alison Metcalfe 2  

BMC Medical Research Methodology volume  14 , Article number:  10 ( 2014 ) Cite this article

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Recruiting the required number of participants is vital to the success of clinical research and yet many studies fail to achieve their expected recruitment rate. Increasing research participation is a key agenda within the NHS and elsewhere, but the optimal methods of improving recruitment to clinical research remain elusive. The aim of this study was to identify the factors that researchers perceive as influential in the recruitment of participants to clinically focused research.

Semi-structured interviews were conducted with 11 individuals from three clinical research teams based in London. Sampling was a combination of convenience and purposive. The interviews were audio recorded, transcribed verbatim and analysed using the framework method to identify key themes.

Four themes were identified as influential to recruitment: infrastructure, nature of the research, recruiter characteristics and participant characteristics. The main reason individuals participate in clinical research was believed to be altruism, while logistical issues were considered important for those who declined. Suggestions to improve recruitment included reducing participant burden, providing support for individuals who do not speak English, and forming collaborations with primary care to improve the identification of, and access to, potentially eligible participants.

Conclusions

Recruiting the target number of research participants was perceived as difficult, especially for clinical trials. New and diverse strategies to ensure that all potentially eligible patients are invited to participate may be beneficial and require further exploration in different settings. Establishing integrated clinical and academic teams with shared responsibilities for recruitment may also facilitate this process. Language barriers and long journey times were considered negative influences to recruitment; although more prominent, these issues are not unique to London and are likely to be important influences in other locations.

Peer Review reports

Participant recruitment is vital to the success of a research study, and yet many research projects fail to recruit a sufficient number of participants [ 1 ]. Increasing participation in clinical research has become a key area of focus within the NHS, with the aim of facilitating evidence-based policy, improving health outcomes and reducing health inequality [ 2 ]. The identification of optimal recruitment methods is gaining interest and a recent systematic review of strategies aimed at improving recruitment to randomised controlled trials (RCTs) identified 45 relevant studies and categorised six types of intervention: trial design, obtaining consent, approach to participants, financial incentives, training for recruiters and trial coordination [ 3 ]. Overall, the general strategies found to be effective in improving recruitment included: making telephone reminders to non-responders, having opt-out procedures where potential participants are required to contact the trial team if they do not want to be contacted about a trial, and having open rather than blinded trial designs [ 3 ]. It is not known whether more trialists are now adopting these strategies, or if they are proving successful in other settings or for other research methodologies.

Attempts to optimise recruitment and retention for non-interventional research studies include a range of techniques, such as using large sampling frames, sending reminders, running wide-scale publicity campaigns, providing free helplines and providing material in the respondents’ own languages [ 4 ]. While there may be universal elements to improving clinical research recruitment, reports of successful recruitment strategies for non-intervention studies are often directed at the particular target demographic group, for example: African American Elders [ 5 ], palliative care patients and their carers [ 6 ], adolescent mothers [ 7 ] and individuals from minority groups [ 8 ]. It is clear that recruitment and retention strategies need to be relevant to the target population and the research methodology used, and therefore the optimum strategy is likely to vary. However, further investigation of research recruitment according to different study designs is required to enable an evidence-based approach to recruitment.

The views of the researchers and clinicians involved in participant recruitment are beginning to be explored. We recently conducted a systematic review and thematic meta-synthesis to investigate this subject and found that the recruitment process could be defined by five key themes: building a research community, securing resources, the nature of the research, professional identities, and recruitment strategies [ 9 ]. Across all five themes there were reports of competition and compromise. Competition arose over funding, staffing and participants, and between clinical and research responsibilities; whilst compromise was needed to create study designs that were acceptable to patients, clinicians and researchers. Overall the views of researchers and clinicians were similar, which was partly explained by the overlapping elements of their roles.

The factors and situations that prompt some individuals to agree to participate in clinical research when others decline have also received attention, with the hope of informing new recruitment practices. However, to date, this work has been predominantly directed at a single medical condition and there have been varied findings [ 10 – 14 ].

Geographical location has been shown to influence recruitment rates to RCTs, with large cities such as London associated with poorer recruitment [ 15 , 16 ]. Possible suggestions for lower recruitment rates in London are the more varied ethnic population (individuals who are traditionally more difficult to engage in medical research), higher population mobility (individuals potentially missing invitations or reminders to participate), and more university hospitals (creating research fatigue as individuals are repeatedly approached to participate in research) [ 15 ]. Research teams in London therefore not only have to contend with the recruitment issues faced elsewhere, but may face an additional set of issues associated with their location.

The aim of the current study was to identify and understand the factors affecting recruitment to clinically focused research in London, UK, with the aim of mapping the existing strategies and informing new approaches. This study adds to existing work by exploring pertinent themes that arose across different clinical areas, study designs and researcher roles, providing a broad view of the factors that researchers consider important for the recruitment of clinical research participants. The following questions were explored:

What do researchers perceive to be the influential factors in recruiting participants to their clinically focused research?

What steps do research teams take to optimise recruitment to their studies?

What are researchers’ perceptions of why potential participants consent or decline to participate in their research?

Does being located in London create any additional issues with recruitment?

A convenience sample of three research leads involved in clinically focused research and based in teaching hospitals in South London were identified and invited to participate in a one-off interview to discuss their experiences and perceptions of recruiting participants for their studies. The phrase clinically focused research was defined as any medical research requiring an individual’s consent to participate, including donation of tissue samples, observational studies and RCTs, and the discussion was limited to recruiting adult patients able to give informed consent. The interviews were semi-structured and used non-directive, open-ended questions based on topics identified from preliminary discussions with clinical researchers and from the existing literature; the topic guide is listed in Table  1 . Each participant was asked to identify other members of their team with differing roles and responsibilities, and a purposive sample of these individuals was also invited to participate in the study. The same topic guide was used throughout and additional individuals were identified as necessary to ensure a broad mix of research professions were included, and to enable interviewing to continue until saturation was reached. All interviews were conducted face-to-face by the primary author in early 2013 at locations chosen by the participants. The interviews were audio recorded and transcribed verbatim.

The interview data was analysed using the framework method established by Ritchie and Spencer [ 17 ]. The framework matrix was developed using NVivo 10 software (QSR) and incorporated the interview topic guide, ideas from the existing literature and prominent themes identified from a preliminary review of the transcripts. The transcripts were coded line by line and additional themes were entered into the matrix where necessary. The matrix was populated with summarised data according to participant and theme, and used to identify common and divergent issues in answer to the study research questions.

Ethical approval

This study was approved by the King’s College London, College Research Ethics Committee (Reference PNM/12/13-106). All participants gave informed consent to be interviewed. All but one participant also consented to anonymous quotes from their interviews being used in the resulting reports and publications.

A total of 15 individuals were invited to participate in the study, of which 11 agreed to be interviewed. Participant demographics are shown in Table  2 . One speciality registrar declined to be interviewed, citing that his role was predominantly clinical not research-based, and three speciality registrars did not reply to their invitations. The mean interview duration was 28 minutes, ranging from 19 to 48 minutes.

Interviewees were involved in a range of studies, all outpatient-based and run as part of three research teams (A, B and C) in three tertiary care hospital sites in South London. Study designs included a first-in-man drug trial, longitudinal observational studies, laboratory studies requiring one-off anonymous tissue samples, genetics studies, trials of therapy interventions, and physiological studies. All research teams carried out research with patients and healthy volunteers, and most interviewees had volunteered themselves as study participants at some stage. With the exception of the two clinical research scientists and the clinical research associate, all participants were also involved in clinical activities as part of their role. When asked why they became involved in clinical research, all participants reported having an interest in research at an earlier point in their career and acting upon this for a variety of reasons including: an extension of a previous role, the desire for more control over their work, part of their current training, to learn more about evidence-based medicine, to do something worthwhile, to improve job satisfaction and to ensure more sociable working hours. All interviewees were educated to degree level, four had gained a PhD and two were working towards a PhD or MD. All participants acknowledged difficultly in recruiting research participants and mentioned particular strategies or modifications that were made to improve recruitment within their teams. The general perception of recruitment was that it is hard to recruit the desired numbers in the allocated time and that more often than not, extensions to the recruitment period are required.

Influential factors in the recruitment of participants

Numerous factors were identified by the interviewees as influential in the recruitment of research participants and these were categorised into four main themes: infrastructure, nature of the research, recruiter characteristics and participant characteristics.

Infrastructure

The need for access to potentially eligible participants was emphasised throughout. Collaboration between hospital clinicians, GPs and researchers were viewed as essential for the identification of eligible patients and to avoid clinician gatekeeping. All research teams had established systems to facilitate the identification of patients, but there was awareness that potentially eligible patients seen in other departments or hospitals were frequently inaccessible.

“There will be a lot of patients going to [smaller hospitals], who could be enrolled in studies, but they’re not available there. They are available here. If they knew that we were doing it, and there was a mechanism for moving those patients for the duration of the trial here, I would think everyone would be happy. But there isn’t” . (Consultant, team A)

One team had developed a strategy where local hospitals were encouraged to identify eligible patients and refer them to the participating site for the duration of the trial. Whilst this was seen as a positive step, it was also acknowledged that greater recognition for the referring sites, in terms of funding and co-authorship, would be required to improve uptake.

The preparatory work carried out by research teams was considered highly influential in the success of recruitment. Screening patient records, identifying eligible patients, preparing appropriate recruitment material and ensuring that the relevant clinicians and researchers were fully informed about the study, were all recommended. These tasks were primarily the responsibility of the research nurses and research associates.

“Here, we do look through the clinic list and, myself on the busiest days, will look at the past three clinic letters and see if they’re going to be suitable, or if they’re already on the study. We do recommend that’s the best way to find patients. And then we’d print the relevant paperwork and put that in the notes, so the doctors can see. So then they don’t even have to think about it, it’s just there. I think that works best. I would say that maybe about half of places do that, because they haven’t got time. They haven’t got time to do the prep” . (Clinical research associate, team A)

One suggestion to improve access to patients was the use of opt-out systems. This was mentioned with reference to patients being required to opt out of research teams contacting them about relevant research projects, but was also discussed with regard to opting in to the routine donation of anonymous tissue samples (surplus to requirements for clinical tests) for clinically focused research. Neither system was currently in place.

Issue with the regulations surrounding ethical approval and the content of participant information sheets were commonly discussed. The interviewees thought that the approval process was too slow, which created delays in starting recruitment and raised concerns that their departments would get overlooked for involvement in multi-centre studies in favour of sites with faster turnaround times.

“We certainly need to improve the speed with which we’re able to take a study from application through to actually being run. We are unbelievable slow. Unbelievable top heavy with regulation… It often means, locally, that we get bypassed in these programmes” . (Consultant, team A)

The interviewees were also concerned that the information required by ethics committees led to the participant information sheets becoming excessively long and detailed, and off-putting to patients. The researchers were aware of the conflict between ensuring patients had sufficient information about a study to make an informed decision about participation, and providing accessible study literature, however many interviewees believed that with the current format, patients did not actually read the information sheets provided, instead relying on verbal discussions to make a decision about participation.

“I get a few who will [read the patient information sheets], but nobody does. I would say 98% of people don’t read it. I do a summary of what is important to them” . (Specialty registrar, team C)

Several researchers suggested inviting patients and members of the public to sit on ethics committees to provide feedback on this issue and one research team had implemented a strategy to use more images and pictures in their participant information sheets to improve readability.

Increasing public awareness of clinically focused research was widely thought to have the potential to improve research recruitment, with the exception of one interviewee who felt that people would only be interested in research when their health was affected. Whilst there were many comments on the need to increase awareness of research within hospitals and other healthcare facilities, interviewees had few suggestions of how this could be improved. There was frustration at the lack of media coverage or celebrity endorsement within their clinical areas, compared to the numerous high-profile campaigns for areas such as cancer research. However, the media was viewed as having both positive and negative effects on recruitment, depending on the nature of the coverage.

Nature of the research

The influence of the type of research on participant recruitment was discussed by all interviewees. It was noted that clinical trials were harder to recruit for than observational studies because they require greater commitment from the participants in terms of time and risk. The interviewees also acknowledged the difficulty between designing studies that were appealing to potential participants and ensuring they were scientifically robust.

“We wanted it to be a good trial from the beginning. So it wasn’t just ‘everybody gets [the intervention] and let’s see what happens’. Although that would have been much easier and might have given us the answer quicker. So it’s placebo controlled, randomised, double blind. Not only are we asking these people to possibly risk their lives, but they might not get it anyway” . (Clinical research scientist, team B)

Some studies incorporated open label or crossover phases after the initial RCT, which was believed to make the study more acceptable to patients. Other recommendations, such as allowing patients to have their study blood tests carried out in the community and offering evening and weekend research appointments, were suggested to reduce the time burden of research participation, but these strategies had not been adopted.

“I guess the big thing would be to try and reduce the burden of commitment to patients, as much as possible. If there was any chance that they could have research bloods taken with GPs, or in their local community, or research nurses could go and take the blood in their home, to avoid this” . (Research nurse, team A)

Payment for research participation was also discussed. Research leads highlighted the ethical issues associated with paying patients for research participation, whilst others acknowledged the role of payment as a driver in recruiting people to participate in their work. The semantics of this issue were important, with one interviewee stating that while it was unethical to pay patients to participate in research, there was the need to explore “being able to financially help volunteers better” . (Consultant, team A).

Recruiter characteristics

It was widely reported that patients were more likely to agree to participate research if they were asked by a medical doctor, specifically their usual doctor. Even for observational studies, which do not require a doctor to take consent, it was noted that recruitment was more successful if the doctor mentioned the study to the patient before the research nurse provided a more detailed explanation. In this respect, successful recruitment was seen as a team effort.

“Our clinicians are so pro-research they are very good at introducing it into the clinical consultation, which really helps, because if it’s first mentioned, I think, by a clinician it’s considered just a normal part of the clinical care, then I think people are sometimes a bit more accepting of it” . (Research nurse, team A)

In addition to the recruiters’ professional roles, their personality and knowledge of the research project were also considered influential. Although all interviewees had undergone the relevant research and ethics training, none had received specific training in recruitment. There was debate on whether it was possible to teach the art of recruitment and if so whether this would be useful. The more experienced researchers felt that specific training was unnecessary as recruitment style and strategy vary depending on the clinical speciality and the particular study involved, and on-the-job experience was believed to be more important that generic recruitment training. It was also suggested that an individual’s personality was central to their recruitment success, an aspect that is difficult to teach.

“ The art of getting people in; it’s not clear. If I couldn’t recruit to trials, I wouldn’t be doing trials… some of my colleagues are good at recruiting, some aren’t quite so good. Trying to tell someone what to do is just not helpful, is it? ” (Consultant, team B)

“Then it’s also your personality. I think patients, they need to trust you. If you are a little bit unsure about something – not about the protocol itself, because that changes and you can’t expect to know a thousand pages of protocol – but that you are confident. Holding their hands all they way during the study” . (Research nurse, team B)

The less experienced researchers believed they would have benefited from additional support during the early stages to learn how to optimise their recruitment success, but acknowledged that a general training programme was unlikely to be appropriate for all recruitment situations.

Interviewer: “Did anyone talk to you about recruiting?”

Respondent: “No, but it would have been helpful… No-one spoke to me and gave me any advice… Although studies are so different and patient groups are so different, that it’s probably slightly different for everyone” . (Specialty registrar, team A)

The clinical research scientists expressed frustration at being reliant on clinicians to recruit patients for their research, especially as they had completed the prerequisite training and had recruited patients previously; however current regulations prohibit non-clinicians from recruiting patients.

“I don’t know why they don’t think [scientists] can consent people here. We used to be able to. It’s only the last few years that we’ve not been able to. We’ve done all the consent courses and everything” . (Clinical research scientist, team B)

Participant characteristics

All interviewees thought that certain patients were more likely to agree to participate in clinically focused research than others. The reported reasons for this are explored in more detail in the section “Why do some individuals consent to participate and others decline?”, however it is important to highlight that for a potential participant to either consent or decline to participate in research, they must first be invited. This links to the previous issues of identifying and accessing eligible patients, but also relates to situations where potentially eligible patients may be denied the opportunity to take part. For example, several interviewees mentioned that individuals who do not speak or understand English are unable to participate in the majority of studies due to the absence of funding for interpreter and translation services.

“…that’s actually something we really need to think of as a team going forward with recruitment, because at the moment we’ve said, for example, if patients come with interpreters or they have no English, then we haven’t included them” . (Research nurse, team A)

One interviewee recalled using interpretation services in the past, but only as a last resort due to the additional workload created.

“It did happen in the past, that for some protocol it had been waived that you can have an interpreter, which can’t be a relative. Because it needs to be an independent interpreter. It needs to be really last chance, because it’s a lot of work, extra, on top of what you have to do” . (Research nurse, team B)

Where potential participants did speak sufficient English to be eligible for participation, but it was not their first language, some interviewees reported lower recruitment rates compared with native English speakers. Suggested reasons for this included communication issues or a general increased reluctance to participate in clinical research.

“Potentially there have been times in the past where I’ve felt that this person’s not really taking in what I’m saying, for various reasons, whether that’s to do with language differences, English not as a first language” . (Research nurse, team A)

Steps taken to optimise recruitment

Table  3 shows the recruitment strategies and specific techniques employed by the research teams and the interviewees’ suggestions of techniques to further improve recruitment. The recruitment strategies were divided into three main themes: preparation and planning, engendering patient support, and collaboration with clinicians. The majority of suggestions to improve recruitment were targeted at making research participation more appealing and less time consuming for patients.

Why do some individuals consent to participate and others decline?

The interviewees believed that the main reason why patients agreed to participate in their research was altruism, including the desire to help future patients and the wish to give something back to the hospital and team that cared for them. For the latter, researchers were clear to point out their duty to ensure that research participation was truly voluntary, rather than an obligation.

“A common thing tends to be ‘you’ve done so much for me, I’m quite happy to do anything for you’. Which is a sort of double edged sword actually, because that’s very generous of them, but actually you want them to participate because they want to, and you have to say ‘well you don’t have to’, and you’ve got to think that they’ve actually understood” . (Research nurse, team A)

There was also a general consensus that many individuals who took part in clinically focused research valued the potential benefits of participation, namely the opportunity to access additional health checks, novel treatments, increased contact with clinicians and the clearly defined plan of care. For researchers who provided payment for participation in their studies, financial gain was also viewed as an important motivator.

“Some of the studies that we run here, we pay £50 a visit. So it’s also to do with people need a bit of extra cash at the moment” . (Research nurse, team C)

Furthermore, patients who were interested in the research question and believed that clinical research was worthwhile were considered more likely to accept the invitation to participate. As discussed previously, the nature of the research was also viewed as highly influential, with patients preferring to participate in non-interventional studies.

“I think it’s much easier to recruit for an observational study. Because we’re not doing anything that could harm them” . (Specialty registrar, team A)

No particular strategies were employed to recruit patients of different ethnicities or socio-demographic backgrounds, with the common belief that recruiters attempt to invite all eligible patients to participate, regardless of their background. Despite the fact that recruitment was limited to English language speakers, most researchers felt that they recruited a good spread of the local population, although this did depend on the clinical area under investigation and the time commitment involved.

“I suppose retired patients have probably said ‘yes’ more willingly. For our study, we are requiring them to have extra tests. Some of the patients have said they are worried about time. Or getting here from work earlier” . (Specialty registrar, team A)

For patients who declined to participate in clinical research, the predominant reasons were thought to be practical. Patients who were working were unable to take extra time off work for research appointments and the additional travel required to attend the hospital was also believed to be off-putting, especially for patients who did not live locally.

“I think for some, mainly it’s time I’d say. Because often they’ve been sat in the waiting room for up to an hour already. So when it gets to the point where they’ve had their appointment, they’ve been seen by a nurse… they’re just like ‘I’ve just not got time’. I think that’s the main issue” . (Clinical research associate, team A)

Fear was also considered important, mainly with respect to clinical trials. Fear of taking new drugs, fear of additional diagnoses being discovered from extra screening, fear of needles, fear of symptoms worsening and fear of the storage of tissue or genetic information were all suggested. Language was also thought to play a role. As discussed in the section “Participant characteristics”, some interviewees observed that individuals who spoke English as an additional language were more reluctant to participate compared with native English speakers.

“I have noticed sometimes, I’ve not quantified this yet, because we haven’t analysed out results, but people who maybe don’t have English as a first language are probably a bit more reluctant” . (Speciality registrar, team A)

Specific issues for London

When asked specifically about recruitment issues associated with their location in London, the researchers’ responses fell into two main themes: local research community and patient population.

Local research community

The interviewees described successful research communities within their own teams, although there was a lack of collaboration with local primary care services. It was suggested that establishing shared research databases and other systems to identify and access potentially eligible patients across different service providers would be beneficial for study recruitment, but that specific initiatives would be needed to facilitate this.

“It’s hard because, in my view, if you really want to do it, it will cost money. It will involve someone, a GP with a research interest in the catchment area. For example, they call it GPSI, which is a GP with a specialist interest in something, rheumatology or haematology et cetera, but one would have research, just purely doing research” . (Specialty registrar, team C)

In addition, researchers reported delays in the process of gaining ethical approval for their studies and a lack of financial support for in-house academic research, suggesting that local improvements could be made to these systems.

Despite these recommendations for improvement, the interviewees were generally positive about working in London and the level of research support provided.

“I think in terms of being in a big London teaching hospital, we are more geared up to research, just from personal experience having worked in district generals in [UK county], there was no set up for research and it was very much a minor thing, and if anyone was doing something, they didn’t have research nurses, it was very much clinician led. It was set up in their own interests really, their own studies. So the fact that we have a forum for research nurses here, and we are trying to actively put out the research message” . (Research nurse, team A)

Patient population

It was noted by the researchers that patients attending hospital appointments in London frequently report long travel times and this was believed to be detrimental to recruitment. This was attributed to the broad catchment area for tertiary healthcare, plus the large number of people who commute into London for work. Interviewees reported difficultly recruiting patients with long journey times, especially if research participation involved additional visits.

“There’s quite a large population of people that travel in. I guess that will affect people taking part in research. Because if they’re having to travel from Hertfordshire, that’s going to put people off, because yes, you can give them their travel expenses, but you can’t give them their three hours back” . (Research nurse, team C)

Being a tertiary care centre was also thought to have a positive effect on recruitment, with researchers commenting that patients may be more likely to trust an invitation for research participation from a specialist centre.

“So people do come in from other hospitals. Again, you have a wider group. Also, they tend to be, in a way, more sick. More likely to listen to the medic who’s telling them, ‘this isn’t a bad thing’” . (Clinical research scientist, team C)

The interviewees also discussed the diversity of the local population, and as mentioned previously, the lack of interpretation and translation services for research resulting in potentially eligible patients being excluded. However, in general it was felt that the researchers were able to recruit representative samples of their local populations.

Although all these issues were important to researchers, it was also acknowledged that most locations have problems with recruitment and that having sufficient resources and research staff should perhaps be considered more important than the location.

“I wouldn’t say there are any huge differences that I can think of. I think it really does depend on the staff and the resources that they’ve got, rather than the actual hospital and the patients coming in” . (Clinical research associate, team A)

The primary aim of this study was to identify the factors that researchers perceive as influential in the recruitment of participants to their clinically focused research. Infrastructure, the nature of the research, recruiter characteristics and participant characteristics were all deemed important. The first three themes are, in theory, more amenable to modification than the last, for example through the development of systems to improve identification and access to eligible participants [ 18 ], designing studies with reduced participant burden [ 10 ] and ensuring that recruiters have the appropriate knowledge and skills [ 19 ]. The discussion of participant characteristics focused on the concept that certain patients were thought more likely to agree to research participation than others. The danger with such an observation is the potential for recruiters to stereotype potential participants based on previous experiences, and therefore choose not to approach individuals who are otherwise eligible. As the NHS constitution pledges to inform all patients of research studies that are relevant to them and in which they may be eligible to participate [ 20 ], recruiters must be aware of the potential to deviate from this duty. In reality, the decision to participate in clinically focused research is frequently multifaceted and requires potential participants to consider the personal pros and cons of taking part at any given time [ 13 ]. The research nurses interviewed for the current study raised this point and explained their attempts to approach all eligible patients, regardless of any preconceptions about whether or not they would agree to participate.

The general perception that doctors are more successful at recruiting research participants than nurses has been explored previously. Donovan et al. [ 21 ] found no significant difference in recruitment rates between urology consultants and nurses for a prostate cancer RCT and calculated that nurses were more cost-effective recruiters, despite spending longer on average with each patient. In the current study, recruitment was viewed more as a team effort. Having the doctor mention research participation as part of the routine consultation was thought to be beneficial, as was having integrated clinical and academic teams on site. However, these strategies require sufficient staffing and resources and rely on specific funding for research posts [ 9 ]. The possible recruitment benefits of having an established therapeutic relationship with potential study participants [ 22 ], sharing similar cultural backgrounds or languages [ 23 ], and employing peer recruiters [ 24 , 25 ] have all been explored in the literature. However, the influence of the recruiter-participant relationship was not widely discussed by the interviewees, nor were the subjects of culture and ethnicity. There was a general consensus that recruiters adopted the same recruitment strategies for all demographic groups, but observational investigations of recruitment practices would be beneficial to further explore these issues. The use of eligibility criteria that include only those who speak sufficient English was attributed to a lack of resources available for interpreter services. Resource limitations would also restrict the use of peer recruitment programmes or other strategies aimed at including minority groups. As recruiting a representative sample is essential for the generalisability of research findings [ 26 ], additional investigation of this issue is required.

The research scientists interviewed were disappointed that they were no longer permitted to discuss their study directly with potential participants. This finding echoes the views of biomedical research scientists involved in placental perfusion studies [ 27 ]. The scientists raised legitimate concerns that the individuals involved in recruitment did not have sufficient knowledge of the intricacies of the study to be able to fully explain the background and rationale to potential participants, or to answer questions about particular methodologies [ 19 ]. It in current study, it was local, rather than national, policy that dictated the exclusion of research scientists from recruitment activities. The potential benefits of allowing research scientists to recruit participants to their research include reducing the workload for clinicians, providing expert knowledge of the study processes and rationale, and separating research recruitment from routine clinical care. The potential drawbacks include the research scientist having a vested interest in the research without the balance of coexisting clinical duties, and the absence of a previous therapeutic relationship with the patient. Further exploration of this issue is required, however it may be advantageous to consider including clinical research scientists as part of the recruitment team, with safeguards to guarantee that patients are not exploited.

The recommendation to use an opt-out system, where patients are required to contact the research team if they do not wish to be invited to participate in clinical research, was made in a recent systematic review [ 3 ]. Several interviewees suggested that this might be a beneficial system, however this strategy is not currently employed, and further work is required to pilot the use of opt-out within these settings. A variation of this strategy, where patients are invited to opt-in to the anonymous donation of surplus tissue after clinical tests, was also discussed. This type of tissue biobanking is available at the interviewees’ hospital sites for patients with a diagnosis of cancer, but is not routinely adopted in other clinical areas. Further research into the extension of biobanks to include other clinical specialties appears warranted [ 28 ].

The use of open, rather than blinded trial designs, and telephone reminders were also recommended by Treweek et al. [ 3 ]. There is debate over the utility of open study designs due to the potential for increased bias [ 29 ], but this methodology is gaining support [ 30 ]. The interviewees used modified versions of this strategy, such as having an open or crossover phase after the main trial, and believed this was beneficial for recruitment. None of the interviewees specifically discussed the use of telephone reminders.

The recruitment strategies employed by the interviewees were similar to those identified in our recent meta-synthesis, although there was less focus on emphasising the benefits of research participation in the current study [ 9 ]. In addition to the possible coercive aspect of emphasising the benefits , the interviewees believed that altruism was the key reason for patients accepting the invitation to participate, and therefore strategies based on highlighting potential personal benefits would not sit with this premise. The dominance of practical issues as proposed reasons for patients declining the invitation to participate in research have been documented elsewhere [ 9 , 10 ].

The key factors associated with conducting clinically focused research in London were language and travel time. Interviewees were unable to offer interpretation services to facilitate discussions about research with patients who did not speak sufficient English. The most recent government data shows that within the associated South London boroughs between 19.6-20.3 % of residents do not speak English as their primary language, compared with 15.3 % and 7.1 % in the next biggest UK cities Birmingham and Leeds, respectively [ 31 ]. The range of primary languages spoken is also greater in the interviewees’ regions, with more than 54 different languages, compared to 36 in Birmingham and 29 in Leeds [ 31 ]. Traditionally, individuals from ethnic minorities have been considered less likely to participate in clinically focused research, however studies from the USA suggest that this is not the case and recommend that more needs to be done to ensure access to research for minority groups, rather than interventions aimed at increasing willingness [ 32 – 34 ]. Strategies to aid the removal of language barriers identified in the current study would improve access to research and could potentially increase recruitment, however further investigation is required.

The interviewees also observed that patients with long travel times to the hospital were less willing to take part in research. When designing clinically focused studies, it may therefore be useful to explore the interviewees’ suggestions of increasing the use of information technology for data collection and forming collaborations with local healthcare services to minimise participant travel. As the average commuting time is 48 % longer in London than elsewhere in the country [ 35 ] this factor may be less problematic in other locations, however most tertiary and quaternary healthcare services conducting research are likely to experience similar travel issues.

Strengths and limitations

The current study adds to previous work by providing experiential reports and perceptions from research teams in three different non-cancer outpatient settings, within a specified geographical location. However, as the research teams involved were based in South London, further work is required to ascertain whether these findings translate to other regions, nationally and internationally.

Although interviewing was continued until saturation, the small sample size in the current study means it is not possible to infer any differences between the experiences and opinions of the different professions within the research teams. Furthermore, the current study relied on information collected from semi-structured interviews, and may have been subject to reporter bias. Attempts were made to minimise the degree of bias by selecting independent research teams and interviewing participants individually. Additional explorations of the researchers’ practices that include observation of the recruitment situation would be beneficial, but were beyond the scope of the current study.

Infrastructure, nature of the research, recruiter characteristics and participant characteristics were all believed to influence the success of recruitment to clinically focused research. Suggestions to improve recruitment included reducing participant burden, providing support for individuals who do not speak English and forming collaborations with primary care to improve identification of, and access to, potentially eligible patients. Despite the focus on London in the current study, the factors identified are not unique to this location and are therefore likely to be representative of other diverse cities within the UK.

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Acknowledgements

The authors would like to thank and acknowledge the contribution of the researchers who gave their time to be interviewed for this study.

This research was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

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LN and AM made substantial contributions to the design of the study. LN carried out the interviews, conducted the analysis and wrote the final manuscript. AM advised on research conduct from inception to completion, appraised the analysis process and revised the manuscript. Both authors read and approved the final manuscript.

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Newington, L., Metcalfe, A. Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams. BMC Med Res Methodol 14 , 10 (2014). https://doi.org/10.1186/1471-2288-14-10

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Received : 30 August 2013

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DOI : https://doi.org/10.1186/1471-2288-14-10

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