Literature - incentives

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Strategies for Motivating Latino Couples’ Participation
in Qualitative Health Research and Their Effects
on Sample Construction
| H. Mabel Preloran, PhD, Carole H. Browner, PhD, MPH, and Eli Lieber, PhD

Health researchers rarely discuss the process
of recruiting study participants. But this paucity of discussion should not be taken as a
sign that recruitment is a straightforward matter. Most investigators would agree that recruitment is often fraught with obstacles. The
amount of time needed for enrollment is usually underestimated,1–3 while the pool of potential candidates is often overestimated.4,5
Recruiting participants for qualitative research is often more challenging than recruiting for survey research, because qualitative
research can involve a long-term relationship
with investigators and may be seen as a timeconsuming endeavor. 6 Recruitment is reported to be particularly difficult when the
protocol calls for more than one member of
a family group7 or for participants from ethnic minority backgrounds.8–10 The difficulties
intensify when the potential participants are
immigrants, especially those who are newly
arrived and have yet to establish a stable residence.11,12 It is also difficult to recruit in a
medical setting for research that does not
offer therapeutic benefits.13–15
Yet a growing proportion of the US population is from immigrant backgrounds, with by
far the largest group coming from Mexico and
elsewhere in Latin America.16 This population
surge has had important consequences for the
delivery of medical services, particularly prenatal care, because immigrant birth rates tend
to be significantly higher than those of USborn women.17 An additional problem—and
one not restricted to immigrant populations—
is the failure to include male partners in most
studies of prenatal care.18,19 Men’s wishes may
be highly influential in women’s fertility decisions, particularly in families recently immigrated to the United States.
Though rarely acknowledged, the practicalities of recruitment may have an impact on
the type of research that is attempted, the

Many investigators report difficulties recruiting low-income Latinos into health research projects,
especially when they seek to enroll more than one family member. We developed a series of strategies
that proved effective in motivating candidates who were initially reluctant to enroll.
There is a possibility that these strategies biased the composition of the sample. Predictably, the reasons participants gave for enrolling were correlated with the recruitment strategy that had brought
them into the study. Furthermore, we found statistically significant associations between recruitment
technique and key study variables (e.g., the domestic stability of the couple).
By increasing investigators’ ability to recruit Latinos, however, the strategies outlined should help to
ensure that Latinos’ experiences are given due weight in the deliberations of medical professionals and
policymakers. (Am J Public Health. 2001;91:1832–1841)
data that are analyzed, and the theories and
policy recommendations that result. But because immigrants are hard to recruit, they are
underrepresented in health research. And because couples are hard to recruit, male partners are woefully underrepresented in research on prenatal care. Needless to say,
when recruitment difficulties are combined,
as is the case with immigrant male partners,
the research literature is thinner still.
Researchers make use of a variety of techniques for overcoming these recruitment problems. Most previous accounts of recruiting
study participants from ethnically diverse populations come from clinical trials.2,7,8,10,20–25 Investigators have found that using recruiters
from the same ethnic background as the study
population, or using community leaders as intermediaries, can help. Instilling trust is important. Offering monetary compensation can
also be effective.8,9,15,26,27
Of course, raising the recruitment rate is
not the only problem researchers must overcome. They must also confront the issue of
sample bias. Recruitment strategies work better for some people than for others, and the
measures taken to raise the recruitment rate
might also skew it, attracting some types of
people at the expense of others. This may be
inevitable in all studies, but it is incumbent on

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researchers to be aware of how the recruitment strategy influences sample composition.
The goal of this article is 2-fold. First, we
wish to present and evaluate the strategies
that we developed to overcome the problems
of recruiting immigrant Latino couples for a
qualitative health-related study. Second, we
want to work through one suggestive example
of how recruitment strategies can affect the
composition of the study sample and therefore affect the study findings.

THE STUDY
Our study of the amniocentesis decisions of
Latino couples28 makes a revealing test case
because it posed a combination of obstacles
to recruitment. We were trying to enroll an
immigrant group that customarily has low
participation rates in social research; we were
trying to recruit couples, not just individuals;
and we were approaching them at a sensitive
time, in a medical setting, without offering
any medical benefits.
The investigation focused on a group of
Mexican-origin women in Southern California
who were offered amniocentesis because they
had screened positive on an α-fetoprotein
(AFP) test, a routinely offered prenatal blood
test.29 Approximately 8% to 13% of US

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women screen AFP-positive.30–33 A positive
AFP result indicates an increased risk of fetal
anomaly, including neural tube defects; intestinal, kidney, liver, or placental problems; and
Down syndrome and other chromosomal
anomalies.34
The AFP test is only a screening test and
provides no diagnostic information. In California, women who screen AFP-positive are
offered genetic counseling and a highresolution ultrasound in an effort to establish a definitive diagnosis. In about half the
cases, the ultrasound reveals the reason for
the positive result, the most common reason
being that the pregnancy was either more or
less advanced than had been thought. However, should the sonogram fail to provide an
explanation, the woman is generally offered
amniocentesis—an invasive procedure that
carries a small risk of miscarriage.35,36 (Miscarriage rates following amniocentesis in
California hospitals can range from 1/500
to 1/200 [H. M. Preloran, C. H. Browner,
and E. Lieber, unpublished field notes,
1996].) This risk, and the fact that most
anomalies detected by fetal diagnosis have
neither treatment nor cure, often leads pregnant women to experience intense anxiety if
they screen AFP-positive. It was during the
period when couples were deciding whether
to undergo amniocentesis or waiting for
their results that we had our first recruitment contacts.
Participation in our study required one
face-to-face interview, lasting a little more
than an hour, with each member of the couple, as well as a willingness to respond to one
or more phone requests for additional information should the need arise. Although the
original design called for separate interviews,
some candidates would agree to participate
only if they and their partner could be interviewed together; thus, 45% of the study participants were interviewed jointly.
We wanted to include male partners in our
study of amniocentesis decisions to redress a
significant lacuna in most existing work on
the subject, which focuses almost exclusively
on women. As a result of this research gap,
we know little about men’s values, attitudes,
and needs in relation to fetal diagnosis or
how they might affect women’s decisions. We
wanted to test our hypothesis that male part-

ners’ roles in Latinas’ reproductive decisions
are often underestimated.37 Anecdotal accounts reveal that couples often differ in their
views about prenatal testing,38,39 but we
know little about how differences within couples are resolved.40 These issues promised to
be particularly salient in Latino populations,
where evidence suggests that men’s wishes
can be decisive in women’s fertility
decisions.41–43
The woman and her male partner remained the analytical unit throughout our
investigation, but our conception of “couple”
changed as the study advanced. In our initial
conception, a couple was defined as 2 people who shared the biological parenthood of
the fetus, constituted a social and economic
unit (with a shared residence and family
budget),44–46 and intended to provide emotional and material support to the child after
its birth. But early on we found that in the
greater Los Angeles area, couples with these
characteristics were not easy to find or enroll. Some couples shared social and economic responsibilities and made joint reproductive decisions even though they lived
apart. In other cases, men might appear
prominently in women’s accounts of their
amniocentesis decisions while the men themselves were seemingly uninvolved.47,48 Accordingly, we made an extra effort to include
such male partners in our investigation.

THE RECRUITMENT STRATEGIES
Over the course of our recruitment efforts,
we employed 4 distinct strategies. In the
“standard” approach, one of the partners,
usually the woman, would first be contacted
in person, and then the researcher would follow up by telephone with both partners. On
occasion, both partners were recruited “on
the spot” at the genetic clinic, without the
need for follow-up calls. However, on occasion we were forced by circumstance to resort to 2 other approaches. In the case of
“co-recruitment,” we would first recruit the
woman, she would broach the issue of participating with her male partner, and the researcher would complete the process. Under
the “brokering” strategy, the female partner
would independently recruit the male partner without further help from us.

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During a period of approximately 24
months, the recruitment coordinator (H.M.P.),
who is Latina, and 3 assistants, all of whom
are Latina, attempted to contact the 1305
Spanish-surnamed women who were offered
amniocentesis at 6 genetic clinics in southern
California. From the initial pool, 783 (60.0%)
did not meet our enrollment criteria for a variety of reasons (e.g., they were Latino but not
of Mexican origin, the AFP result was falsepositive, they were being offered amniocentesis for other reasons). Another 132 (10.1%)
could not be recruited for other reasons (e.g.,
separation or divorce; phone disconnected;
failed to answer phone calls; woman told recruiter that partner would not be interested;
partner deported, imprisoned, or working outside the area).
Three hundred and ninety (29.9%) eligible
women remained. Of these, 243 (62.3%) declined participation, either actively—by openly
stating they were not interested—or passively—
by avoiding phone contact or canceling more
than 5 appointments. While we were obligated to respect the candidates’ right to refuse,
we were concerned that our sample might be
biased if the refusals followed a systematic pattern. We could obtain only limited information
from candidates about their reasons for declining to participate in our research. The most
common explanation was the wish to be left
alone. Anecdotal evidence also suggests that
fear was a significant factor in refusal. For example, some women were unwilling to give us
their home address; others said they could not
receive visitors or leave the house. Some men
said they feared that participating in the study
would only add to the upset their partners felt
after the positive screening test result. Although these explanations are informative, the
number of candidates who provided such explanations is too low to permit generalization.
In recruiters’ daily field notes, information
about each contact with a potential participant and the participant’s reasons for accepting or declining were recorded. For successfully recruited candidates, reasons for
participation were coded inductively. Answers such as “I don’t know,” “Because I
want to” (without specifying why), and “No
particular reason” were categorized as “No
particular reason.” When respondents expressed appreciation for the interest the re-

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TABLE 1—Characteristics of the Study Population: Mexican-Origin Women and Their
Partners Recruited From Southern California Genetic Clinics, 1995–1997
Women (n = 147)

Ethnicity
Mexican Americana
Mexican immigrantb
Other Latinoc
Education
Primary or less
Secondary or less
More than secondary
Annual household income, $
<10 000
10 001–20 000
≥20 001
Unknown
Religion
Catholic
Other
None

Men (n = 120)

No.

%

No.

%

45
102
...

30.6
69.4
...

34
76
10

28.3
63.3
8.3

37
72
37

25.3
49.3
25.3

31
60
25

26.7
51.7
21.6

49
42
39
12

34.5
29.6
27.4
8.5

34
43
34
7

28.8
36.4
28.8
5.9

125
15
7

85.0
10.2
4.8

96
10
14

80.0
8.3
11.7

Note. Numbers add up to fewer than 147 (women) and 120 (men) because of missing data.
a
Born in the United States or immigrated before completing primary school.
b
Immigrated after completing primary school.
c
From a Hispanic background other than Mexican.

searcher had shown in them and wanted to
reciprocate by helping (e.g.,“una mano lava la
otra” [“one hand washes the other”]), responses were coded as “Helping researcher.”
The responses of candidates who said they
were interested in learning more about the
implications of their own test results or about
genetic testing in general were classified as
“Gaining knowledge.”
Finally, 122 couples were successfully recruited (although only 120 couples actually
completed the study). They provide the basis
for the following analysis of successful recruitment approaches. In addition, we included 27
women who were part of a couple when they
agreed to enroll in the research but became
single before we could interview their partners. (See Table 1 for general characteristics
of the study population.) We retained these
27 newly single women in part to examine
the effect of marital status on recruitment efforts and study variables, which would have
been impossible had the sample consisted
only of couples. Among these 27 were 6 who
by circumstance happened not to be living

with their partners at the time of the interview, for instance, if the partner had had to
make an unexpected trip to Mexico. The relationships of the other 21 were genuinely unstable in that the men had practically disappeared or were otherwise indifferent to the
pregnancy. This fact had a significant effect
on our ability to recruit those men.

ENROLLMENT RATES
Enrollment rates varied at different stages
of our research. During the pilot phase, they
were extremely low, at 3.3%. At that time we
were bound to and restricted by an approach
that made direct contact with candidates difficult. Our clinic sponsors insisted that candidates be formally introduced to us by medical
personnel, who would also explain the aims
and benefits of our study and ask for the
client’s collaboration. The slow pace of recruitment prompted us to request more direct
contact with candidates. Our request was
eventually granted on the condition that candidates be approached in the presence of

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medical personnel. Enrollment rates rose to
8.0% once this change was implemented.
Over time we gained greater trust from our
medical sponsors, and we were eventually allowed to recruit more independently. Yet although we now had the visible support of
clinic staff, for the most part we were left to
recruit on our own. We found that the key to
achieving this level of staff cooperation was to
follow the rules of each field site but to as be
invisible as possible. When we were given the
freedom to use all 4 of our recruitment strategies, we were able to achieve an enrollment
rate of 37.7%.
It is important to note that our greater success at recruiting did not necessarily mean that
our new strategies were cost-effective.49 Our
procedures were often very time-consuming
for both researchers and participants, since
motivation to participate was usually low, and
the need to enroll both partners made the effort more difficult.7 On-the-spot recruiting was
the least labor-intensive strategy, while brokering proved to be the most demanding. Corecruitment was somewhat less labor-intensive
than our standard approach.
Given that most of our candidates were not
particularly interested in participating in our
investigation, we needed to find ways to motivate them. Assigning bilingual, bicultural recruiters was very helpful in building trust, as
other researchers working with ethnic minority groups have found.9,27,50,51 But our research went a step further. Taking a cue from
the candidates themselves, we found we
could motivate them by appealing through aspects of the “traditional” gender roles found
in Latino culture.

CULTURAL SCRIPTS FOR
MOTIVATING FEMALE
PARTICIPATION
Couples were our target population, but
most of our initial contacts were made with
women—not least because nearly half of the
female candidates came for genetic counseling
alone or with partners who were occupied
elsewhere watching their children. In the clinic
waiting rooms, it quickly became clear to us
that many of the women we sought to recruit
for our sample, especially those who were relatively new immigrants, were anxious, ill at

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ease, or reluctant to ask questions of clinic
staff, especially if the staff member did not appear to speak Spanish. In addition, many had
brought young children with them.
We offered to perform small favors, such as
helping the women communicate with clinic
staff, complete hospital or insurance forms, or
find a pay phone, or watching their children
while they were attending to medical or administrative matters. We listened sympathetically to complaints about the long hours of
waiting and occasionally offered emotional
support to women who were upset about the
prenatal genetic testing decisions they were
facing. Sometimes we sought to establish
friendly ties by providing information or offering help even before introducing ourselves
as researchers.
Some may question whether the approach
to recruitment used here was ethical, because
we began to develop friendly relationships
with potential participants before completely
disclosing the details of our research.52 However, it is safe to assume that potential study
participants would not mistake us for clients
or staff. Although we were present in the
waiting room for several hours at a time, it
was clear we were not waiting to be seen by
a clinician. We did not dress like clinicians or
perform formal clinical responsibilities. Moreover, in compliance with institutional review
board ethical requirements, any interested
candidates were given a comprehensive explanation of all aspects of the project before
any participation began. That is, we explained that their prenatal care was in no
way connected with participation in our
study, that they could decline to answer
questions that made them uncomfortable,
and that they could withdraw from participation at any time.
We did make minor modifications in the
sequence of our recruitment protocol from
time to time. For example, we brought up
with the women earlier than we did with the
men the $40 monetary incentive and the fact
that the interview would give them a chance
to discuss their feelings about amniocentesis.
But in all cases, we fully disclosed the research goals and procedures. Participants always read and signed the consent form detailing the study’s objectives and what
participation would involve prior to any for-

mal interview. These measures minimized
the possibilities for misunderstanding between researchers and candidates and provided an environment in which participants
could freely raise their concerns.
Regarding to our recruitment approaches,
2 conversational topics that often helped
“break the ice” were the women’s children
(who were sometimes playing near their
mothers while we were chatting) and the
women’s hopes and beliefs about the sex of
the fetus. Although conversations could be
helpful in establishing rapport, offering small
services was more effective. These interactions followed a “cultural script” that we
came to call comadrismo, a term derived
from madre or (mother) that is commonly
used by Latinas to describe relationships of
trust and mutual support among women. In
employing comadrismo, we employed the
classical anthropological approach of participant observation.
The participant observation approach involves engaging in the same activities as
study participants, or coming as close as it is
possible for an outsider to do.53,54 Sometimes
nurses, rushing to fulfill multiple demands,
asked us to show patients how to fill out
forms or walk them to the room where they
would have their next appointment. On other
occasions, patients who had already seen us
doing those tasks similarly requested our
help, or we offered it to them. Occasionally,
in the course of chatting with candidates who
found themselves with an unusually long wait
at the hospital or clinic, we indicated that we
were involved in a research study that might
interest them. In other cases, we introduced
ourselves in the waiting room and asked if we
might talk more with them after they finished
their medical appointment. We believe these
diverse approaches did not obscure our intentions, but rather were used to sensitively discover the time at which the candidate would
be most sympathetic to the request to participate in our research.
Usually after we had established an initial
rapport with a woman, we introduced ourselves as social researchers interested in talking with her at greater length about her pregnancy. While we alluded to our interest in
issues surrounding prenatal diagnosis, we
placed more emphasis on wanting to talk with

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her about her feelings rather than her decision about amniocentesis. When a woman
seemed receptive but noncommittal (i.e., responding with, “I’d prefer to think about it”)
we waited until she had completed her genetic
consultation and ultrasound testing before
continuing our recruitment efforts. At that
point, we explained that we could conduct the
interview in a more relaxed environment,
such as the woman’s home, and emphasized
that we did not intend to be a burden. This
was sufficiently reassuring for several women,
who then agreed to enroll in the investigation.
We also introduced the incentive of financial compensation, characterizing it as a “small
amount” offered as a token of our appreciation for the participant’s time. (The amount
was $20 per person, $40 per couple; all participants were compensated at the conclusion
of their interviews). Some who had initially
hesitated expressed more interest once they
learned of this incentive. At this point, we explained that participation in the study would
also require an interview with the male partner. A number of women continued to show
interest but said they were still undecided. We
therefore asked permission to call them at
home, reminding them that they were under
no obligation and that their refusal would in
no way jeopardize their prenatal care.
Becoming comadres (i.e., offering resources
and services, including the monetary compensation) appears to have been significant in
motivating some women who had been otherwise reluctant to enroll. The financial incentive was not the decisive factor in most cases,
but it did make a difference for women who
seemed less inclined to participate and who
may have been politely trying to refuse by
saying they would think about it or call back.
After learning that they would be compensated for their time, several women responded more positively, giving more precise
instructions, such as, “Call me tomorrow after
9 AM, or better, after dinner if you also want
to speak to my husband.”

INVISIBLE MEN
Once women agreed to participate, we
turned to the task of recruiting their partners.
In about 12% (17 of 147) of cases, this was
an easy task; both partners attended the ge-

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netic consultation and both agreed on the
spot to be part of our investigation. In an additional 58 cases, the woman said she was interested and agreed to let us call her partner
at home. All men contacted under these circumstances, which we called our standard
procedure, agreed to enroll in the research. In
the remaining cases, however, we found we
needed the woman to collaborate in recruiting her partner. To facilitate these efforts, we
developed the strategies of co-recruitment
and brokering, which we describe below.
Our hopes of recruiting most men on the
spot, at the genetic clinics, went unfulfilled.
About half the men did not attend their partners’ prenatal genetic consultation, and a
large proportion of those present tended to be
physically separated from their partners, taking care of their children, pacing in the corridors, or outside in the parking lot checking
on their automobiles. As a result, most male
recruitment was done by telephone. Unfortunately, however, the men were usually not
available when we called, and many did not
return our phone calls. (We had planned on
making a maximum of 6 follow-up calls but
chose to increase this to 10.)
The difficulty we had recruiting men for
our study was in itself instructive, casting a revealing light on some of the attitudes we
hoped to investigate in the study proper. The
men’s failure to attend their partners’ prenatal
genetic consultation and their reluctance to
communicate with us may have indicated a
more general disengagement from their partners’ amniocentesis decisions. Since men’s
roles in such decisions were central to our research, we became even more concerned to
recruit men to explore the meaning of their
apparent lack of interest and distance from
the process. We also faced an obvious danger
of sample bias, if the only men who agreed to
participate in the study were those who were
involved in the amniocentesis decision to an
unusual degree.
In comparison with the face-to-face relationship of comadrismo, which proved effective in recruiting women, indirect contacts
worked better with most men. This led us to
develop the co-recruitment and brokering approaches. In co-recruitment, the researcher
and the female candidate, sometimes with the
help of other family members, shared respon-

sibility for motivating the man to participate.
We recruited 29 couples in this manner. This
recruitment strategy was, in fact, first suggested to us by several women who offered to
“soften up” their partners prior to our contacting them.
Co-recruitment was also used as a secondary strategy when a woman realized that her
own efforts to recruit her male partner were
not enough. On one such occasion, a woman
helped us to recruit her reluctant husband by
instructing her mother-in-law to leave the
house at the time of our call so that her husband would be forced to answer the phone.
Another woman offered to “kidnap” her husband by having her eldest son ask him to stay
home to work on the family car until we
could meet him at home to request his participation. In a third instance, the sister-in-law of
a female candidate agreed to organize a
meeting between us and her brother. These
examples illustrate how the female candidates
enlisted other members of their families in
the co-recruitment process.
Brokering was the other strategy successful
in recruiting male partners. In these cases, the
women offered to recruit their partners themselves, and our own role was a passive one.
Forty-five female candidates offered to act as
brokers, and 43 of these women completed
the study. Initially, this approach seemed costeffective, as it involved no additional time investment on our part. Unfortunately, however, brokering also had the highest male
withdrawal rate (22/45, or 48.9%), far exceeding the rates of the other 3 approaches
(7/104, or 6.7%). Nevertheless, our experiences observing women acting as recruitment
brokers with their male partners were instructive, in that they helped us develop a cultural
script that proved fruitful in our own attempts
to recruit men.

CULTURAL SCRIPTS FOR
MOTIVATING MALE PARTICIPATION
At first we thought we could “train” women
for the task of recruiting their male partners.
We suggested that they emphasize the benefits of participation, that is, that we were offering to pay them to discuss issues of interest to
them without their having to leave their
homes. For the most part, our suggestions

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were dismissed with polite smiles, but one
woman told us directly, “Don’t worry, I know
how to turn my husband around.” When
asked how she would do it, she replied, “I’m
going to tell him [the study] is for the good of
the children. . . . I know that if we want to
convince him, we should forget the talk about
money—don’t even mention it to him—he is
too proud to accept money for something like
this.” Similarly, another potential broker observed, “My husband won’t understand getting paid for answering some questions. What
I have to do is convince him that the person
who will come is working for the good of the
barrio [community]. Besides, he needs to be
sure you won’t make any trouble. He is afraid
I will open the door to strangers.”
These responses prompted us to ask other
women how they had approached their partners. Two themes recurred in the women’s
testimony—altruism, toward the child they
were expecting or toward the community,
and home security. Learning from the
women, we incorporated both of these
themes into our general approach to male recruitment. When contacting men we emphasized the altruistic aspect of “collaborating
with the research for the good of the children
and the Latino people.” We also took care to
allay men’s security concerns by explaining
that we would send an interviewer, generally
a woman, who could be trusted.
Just as we had drawn upon the culture of
Latino women to develop the comadrismo
script, we sought to couch our approaches to
Latino men in a cultural script that was familiar to them. We developed an approach that
we termed poderismo (“powerism”), in which
men were assured that they would retain control of the research process at all times, deciding when and where to meet and, should they
wish, when to withdraw from the study.
Under poderismo, men were encouraged to
express their concerns about participating and
to suggest ways to resolve these concerns. Instead of anticipating problems and offering
solutions, as we often did with women, we
would pose the question, “What should we
do about this?”
The following excerpt of a recruitment interaction between C (a male candidate) and R
(researcher) helps to illustrate central characteristics of the poderismo approach—reassuring

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men that they are in control of the situation,
acknowledging the importance of home security, and showing a concern for their partner’s
well-being.
C: I don’t think I could participate; here at
home it is always too crowded and many times
I have to work at night and I need to rest during the day.
R: I see you have these problems. . . . What
should we do?
C: Could you meet any place?
R: Yes. . .
C: I don’t know . . . it would be too difficult. . . .
And besides, I don’t want a stranger to come
. . . you know, these days. . .
R: Right. . .
C: And besides, . . . I don’t want her to be sad
talking about these things again.
R: I don’t know . . . maybe she will feel better if
she can talk.
C: I don’t know. . .
R: If you decide to give it a try and you don’t
like it, or you see she is sad, and you decide to
stop the interview, for any reason, we will stop,
no questions asked.
C: Well, I have to talk with my wife.
R: I hope you’ll join us, and remember that in
this study we will follow your commands. If
you decide to help us, we’ll appreciate it, but if
you don’t, . . . we understand your reasons.

Using this combination of co-recruitment
and brokering, together with the poderismo
script, we were able to recruit many otherwise reluctant men, who were not necessarily
present at the genetic consultation. Ultimately, our study population consisted of
nearly equal numbers of men who were present at the genetic consultation and men who
were absent, allowing us to account for the
role men play in their partners’ amniocentesis
decisions.

RECRUITMENT APPROACH,
REASONS FOR PARTICIPATING, AND
OTHER STUDY VARIABLES
When a variety of recruitment strategies
are employed, it is possible to examine statistically whether the attitudes, characteristics,
and circumstances of study participants vary
systematically with the recruitment techniques that brought them into the sample.
There were no statistical associations between
the way participants were recruited and such
basic sociodemographic characteristics as

TABLE 2—Percentage of Women Endorsing Reasons for Participation in the Study, by
Recruitment Strategy: Mexican-Origin Women and Their Partners Recruited From Southern
California Genetic Clinics, 1995–1997

Gaining knowledge
Helping researcher
No particular reason

On the Spot
(n = 17)

Co-Recruitment
(n = 29)

Standard
(n = 58)

Brokering
(n = 43)

52.9
23.5
23.5

24.1
20.7
55.2

13.8
39.7
46.6

18.6
81.4
...

Note. See text for description of strategies. Minimum pairwise comparison, t = 1.98, P < .05 (on-the-spot group vs corecruitment group).

their age, birthplace, religion, household income, education, or degree of acculturation.
But other study variables were statistically associated with the recruitment approach.
We found strong statistical associations between recruitment approach and women’s
and men’s reported reasons for participating
in the investigation (χ2(6) = 50.44, P < .001,
and χ2(9) = 41.61, P < .001, respectively). Categories for reasons for participating in the
study were created inductively and openended responses were coded into them. We
found that both male and female respondents
who were recruited on the spot were much
more likely than others to indicate “gaining
knowledge” as their principal reason for participation. On the other hand, women recruited through the standard approach or
through brokering were more apt to say that
they agreed to participate in order to help the
researcher. In contrast, men enrolled through
co-recruitment said that their main reason for
participating was that their partners had
asked them to, while men recruited by the
standard approach typically said they agreed

either to gain knowledge or to help their
community (Tables 2 and 3).
We also found a statistically significant relationship between recruitment strategy and the
domestic stability of the couple (χ 2(3) = 33.06,
P < .001). The brokering group had the highest proportion of women in unstable domestic
situations. As previously indicated, the group
also comprised most of our male recruitment
failures. Of the 45 women who offered to act
as brokers, 10 were in somewhat friendly relationships but living separately from their
partners, while 7 had recently had serious arguments with their partners and asked us to
postpone their interviews until their relationships had settled back down. Of those 7
women, 5 were subsequently abandoned by
their partners during the course of the study,
and the other 2 were unable to motivate the
men to keep previously scheduled interview
appointments. In addition, 3 men who were
cohabiting with their partners left before
starting the interview because they had
fought with their partners, and 2 couples with
no apparent problems began to argue with

TABLE 3—Percentage of Men Endorsing Reasons for Participation in the Study, by
Recruitment Strategy: Mexican-Origin Women and Their Partners Recruited From Southern
California Genetic Clinics, 1995–1997

Gaining knowledge
Partner asked
Helping community
No particular reason

On the Spot
(n = 16)

Co-Recruitment
(n = 26)

Standard
(n = 55)

Brokering
(n = 23)

87.5
...
6.3
6.3

34.6
42.3
19.2
3.8

38.2
5.5
27.3
29.1

34.8
26.1
4.3
34.8

Note. See text for description of strategies. Minimum pairwise comparison, t = 3.26, P < .01 (on-the-spot group vs
brokering group).

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 RESEARCH 

TABLE 4—Status of Relationships of Women Participating in the Study, by Recruitment
Strategy: Mexican-Origin Women and Their Partners Recruited From Southern California
Genetic Clinics, 1995–1997

Unstable
Stable

On the Spot
(n = 17)

Co-Recruitment
(n = 29)

Standard
(n = 58)

Brokering
(n = 43)

...
100.0

10.3
89.7

1.7
98.3

39.5
60.5

Note. See text for description of strategies. Minimum pairwise comparison, t = 2.71, P < .01 (brokering group vs corecruitment group).

their children and each other and stopped the
interviews. The brokering group was the only
one in which we lost 2 women and the only
one in which we were unable to recruit or retain nearly half of our male population, a
striking statistic considering that we lost only
7% of male partners in the other 3 groups
combined (Table 4).
We have no data to tell us whether candidates were persuaded to participate in the
study by their relatives. But as a proxy measure, we can look at how much candidates
said they were influenced by relatives when
making their amniocentesis decision. We discovered a statistically significant relationship
between the way candidates were recruited
and the weight they gave to the opinions of
relatives when making their amniocentesis
decisions (χ 2(12) = 55.17, P < .001, and
χ 2(12) = 32.64, P < .001, for women and men,
respectively).
The majority of men and women in the onthe-spot group said that both partners’ opinions counted equally in the amniocentesis decision. In contrast, most of the female
“brokers” (who recruited their partners independently) said that their own opinion was
the most important. Women in the standard
group (who were first contacted at the clinic
and then recruited with their partners over
the telephone) were evenly divided between
those who thought their own opinion carried
the most weight and those who thought both
partners’ opinions held equal weight. Most of
the men in the standard group thought both
partners’ opinions counted equally, with some
20% thinking that their own opinion counted
most. Interestingly, the co-recruitment group
contained the largest proportion of individuals who said that the opinion of someone

else—family or friends—was most important in
their amniocentesis decision. This suggests
that members of the co-recruitment group
tended to be more involved with family members than were those in the other study
groups (Tables 5 and 6).
Finally, and unexpectedly, while the overall
χ2 test was not significant (χ 2(3) = 5.69), pairwise comparisons revealed that individuals re-

1838 | Research Articles | Peer Reviewed | Preloran et al.

cruited on the spot were significantly more
likely than those in any other group (minimum t = 2.15, P < .05) to agree to amniocentesis (Table 7).

DISCUSSION
Overall, our strategies raised the recruitment rate to just under 38%, a respectable figure given all of the difficulties associated with recruiting immigrants and couples
during a sensitive time. We were even more
successful at retaining participants: only 1
man and 2 couples decided to drop out once
we had begun interviewing them. Nevertheless, because our study population was made
up of individuals who were predisposed to
seek biomedical prenatal care, we cannot generalize our results to others.
Our experiences proved that rapport is as
vital to recruitment as it is to qualitative research itself. This fact was starkly illustrated

TABLE 5—Percentage of Women Endorsing Most Important Sources of Opinion About
Amniocentesis Decision, by Recruitment Strategy: Mexican-Origin Women and Their
Partners Recruited From Southern California Genetic Clinics, 1995–1997
On the Spot
(n = 17)

Co-Recruitment
(n = 29)

Standard
(n = 57)

Brokering
(n = 42)

5.9
88.2
...
5.9
...

27.6
34.5
27.6
3.4
6.9

50.9
45.6
3.5
...
...

71.4
19.0
9.5
...
...

My own
Equal between partners
Relatives
Friends
Others

Note. See text for description of strategies. Women in the co-recruitment group reported significantly higher percentages of
“other” opinions compared with the standard group (minimum pairwise comparison, t = 4.19, P < .001) and the on-the-spot
group (minimum pairwise comparison, t = 2.22, P < .05) and showed a consistent, though not significant, trend with the
brokering group (minimum pairwise comparison, t = 1.3, P < .20).

TABLE 6—Percentage of Men Endorsing Most Important Sources of Opinion About
Amniocentesis Decision, by Recruitment Strategy: Mexican-Origin Women and Their
Partners Recruited From Southern California Genetic Clinics, 1995–1997

My own
Equal between partners
Relatives
Friends
Others

On the Spot
(n = 16)

Co-Recruitment
(n = 25)

Standard
(n = 51)

Brokering
(n = 22)

...
100.0
...
...
...

4.0
60.0
28.0
4.0
4.0

25.5
70.6
4.0
...
...

9.1
86.3
4.5
...
...

Note. See text for description of strategies.

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 RESEARCH 

TABLE 7—Percentage of Women Deciding to Accept Amniocentesis, by Recruitment
Strategy: Mexican-Origin Women and Their Partners Recruited From Southern California
Genetic Clinics, 1995–1997

Declined
Accepted

On the Spot
(n = 17)

Co-Recruitment
(n = 29)

Standard
(n = 58)

Brokering
(n = 43)

12.5
87.5

44.8
55.2

41.4
58.6

44.2
55.8

Note. See text for description of strategies. Minimum pairwise comparison, t = 2.15, P < .05 (on-the-spot group vs
standard group).

by the extremely high rates of refusal that
dogged us at the beginning of the research,
when we were required to contact candidates through medical intermediaries. Our
recruitment strategies required relatively extensive and uninhibited access to the potential candidates prior to securing their consent. Candidates who agreed to enroll in the
study said they felt we were genuinely concerned about them as individuals and sensitive to the realities of their lives, and they
wanted to reciprocate.
We asked some who were initially reluctant how they overcame their concerns. One
woman replied, “When you asked me to participate I said to myself, ‘Here it goes again,’
[but] when you kept calling me day after day
. . . chatting [with you] made me see you
were really interested in what happened to
me [at the genetic center].” Another woman
had a similar reaction: “I like it when things
are more personal. . . . When Jeff [the interviewer] told my husband he would love to go
with him to the restaurant [the participant
had invited Jeff out for dinner] we liked
that. . . . We said, ‘Fine,’ and we would do it.”
When we asked one man who had been particularly skeptical what changed his mind, he
explained, “She [his partner] convinced me
because she said that talking to the girl [the
recruiter] made her feel good.” In addition,
some participants indicated that learning that
emotional support and psychological referrals
would be available for the duration of their
pregnancies were important factors in their
decision to enroll in the study.
To raise the recruitment rate to 38%, it
was necessary to use a variety of strategies.
There was no one recruitment strategy that
could, on its own, ensure the participation of

TABLE 8—Percentage of Endorsed
Reasons for Participation in the Study,
by Sex: Mexican-Origin Women and
Their Partners Recruited From
Southern California Genetic Clinics,
1995–1997

Gaining knowledge
Partner asked
Helping researcher
Helping community
No particular reason

Men
(n = 120)

Women
(n = 147)

43.3
16.7
3.3
15
21.7

21.8
NA
46.3
0
32

Note. NA = not applicable. Because the code
categories for this variable differed for the men and
women, these data are presented for descriptive
purposes only.

a high proportion of male and female Latino
candidates. The strategies we have outlined
here are complements, not substitutes: they
were not better or worse strategies per se,
they were better or worse for specific subgroups of the population, according to their
circumstances and inclinations. To achieve
an overall recruitment rate of 38%, the entire set of strategies—on-the-spot, standard,
co-recruitment, and brokering—was needed.
While aspects of our approach, such as financial incentives and expressions of genuine caring, have been used successfully in
other investigations, the cultural scripts of
comadrismo and poderismo we developed
made a real contribution. Why were these
cultural scripts effective? We can shed some
light on this issue by looking at the different
reasons men and women gave for participating in the study (Table 8).

American Journal of Public Health | November 2001, Vol 91, No. 11

Forty-six percent of the women recruited
through comadrismo indicated that they had
enrolled in the study as a way of reciprocating the support and assistance we had provided. On the other hand, 43% of the men
enrolled in order to gain more knowledge.
Many men, even those who attended the genetic consultation, felt unsure about the genetic information they had been given and
seemed to regard the interview as an opportunity for clarification. For example, one man
said, “I didn’t understand the chart with the
black spots that come in pairs [chromosomes],
so if you come with it and explain it to me, I’ll
do the interview.”
In both cases, the cultural scripts served to
recast an unfamiliar relationship into one that
was culturally familiar. Most of our candidates
were uncertain, concerned, and confused
about prenatal diagnosis. They tended not to
feel sure of themselves or in command of
their situation. If we had not recognized this
fact, our recruitment efforts might have
added to the confusion: we were approaching
candidates at a clinic, but we were not doctors; we were asking questions related to
medicine, but we were not offering any medical services. However, by framing our requests in terms of comadrismo and poderismo,
we encouraged our male and female candidates into roles that were familiar and perhaps even comforting to them. Many female
participants felt close enough to us to talk
very openly about what it meant to them to
have their pregnancies declared high-risk and
what was involved in their decision to accept
or decline amniocentesis. Likewise, by putting
men “in charge” of the research proceedings,
poderismo gave men a reassuringly familiar
role in an otherwise unfamiliar domain.
These approaches were successful in raising the recruitment rate, but we must also
consider the pattern of recruitment: what type
of person is being attracted by a particular recruitment tactic and what type of person is
rejecting it? Is the pattern of recruitment affecting the composition of our sample in a
way that might bias our findings? As we have
shown, our recruitment strategies were systematically related to a number of study
questions, including the domestic stability of
the couple and whether they agreed to amniocentesis.

Preloran et al. | Peer Reviewed | Research Articles | 1839

 RESEARCH 

The statistical relationship between domestic stability and recruitment approach is not
difficult to explain. An unstable couple that
does not function well as a unit is unlikely to
be recruited as a unit. Getting the 2 partners
together requires negotiation. In our study,
the female partner normally wanted to handle this negotiation herself, rather than letting
an unknown researcher intrude on difficult
emotional territory. Unfortunately, this kind
of independent brokering had the worst rate
of retention of all the recruitment strategies.
These difficulties in recruitment and retention mean that unstable couples are liable to
be underrepresented in study samples in general. The problem is compounded by the fact
that domestic stability is difficult to assess a
priori—at the time that the sample is being
taken—with the consequence that the researcher cannot know the extent of the sample bias. This raises the likely possibility that
social scientific research on couples is based
disproportionately on stable couples.
Of more direct concern to our research
project was the relationship between recruitment strategy and our central study variable:
the amniocentesis decision. We can offer a
number of plausible explanations for the fact
that candidates recruited on the spot, at a genetic clinic, were significantly more likely to
agree to amniocentesis. We know that women
who were accompanied to the genetic consultation by their male partners (roughly 50% of
the total) were significantly more likely to
agree to amniocentesis,55 and by definition,
women who were recruited on the spot were
so accompanied. It may be that couples who
jointly attend a genetic consultation are more
compliant and more likely to follow clinical
recommendations.48 Alternatively, it may be
that women who are already inclined toward
amniocentesis encourage their partners to
come with them, so that they themselves will
not bear the full weight of the decision.56 It
may also be that men who are more involved
in their partners’ pregnancies are more likely
to want them to have amniocentesis and
make a point of attending the genetic consultation in order to have some influence over
the decision.
Whatever the explanation, this relationship
illustrates the profound way in which recruitment strategies can affect study findings. Had

our study of amniocentesis decisions relied
exclusively on on-the-spot recruitment, our
sample would have been seriously biased
against couples who refuse amniocentesis.
Hence, our decision to employ multiple recruitment strategies was necessary not only to
boost the recruitment rate, but also to balance
the recruitment rate, ensuring that our study
did not over- or undersample people on one
side of an important research question. As it
was, there was no significant difference between the rate of amniocentesis acceptance in
our interview sample and the rate among all
of the AFP-positive, Mexican-origin women
offered amniocentesis at the 6 participating
genetic clinics during 1996.55

CONCLUSION
Our exploratory investigation has drawn
needed attention to the relationship between
recruitment strategies, sample construction,
and research results. Our findings certainly
highlight the challenge of eliciting information
on nonparticipants while respecting their desire to be left alone. Although in our case recruiters’ ethnic backgrounds matched those of
participants, this does not mean that our recruitment strategies were successful for this
reason alone. Researchers from cultural backgrounds that are different from those of study
participants can also develop recruitment
strategies that are sensitive to participants’
ethnic backgrounds.
Although our investigation was qualitative, our findings should also apply to the
design of recruitment strategies for quantitative research that involves couples and for
public health initiatives in a variety of areas,
ranging from sexuality and family planning
to health education and immunization campaigns; the difficulties in gaining candidates’
trust and eliciting participation are the
same. Regardless of candidates’ ethnic background, recruitment designs should be flexible and diverse, because candidates typically bring diverse and multiple agendas to
a research endeavor. By offering more effective ways to enroll Latino couples in health
research, we hope this article will promote a
better understanding of how to meet the
public health needs of this and other understudied populations.

1840 | Research Articles | Peer Reviewed | Preloran et al.

About the Authors
The authors are with the Center for Culture and Health,
Department of Psychiatry and Biobehavioral Sciences,
University of California, Los Angeles.
Requests for reprints should be sent to H. Mabel
Preloran, PhD, Center for Culture and Health, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA
90024-1759 (e-mail: [email protected]).
This article was accepted July 6, 2001.

Contributors
H. Mabel Preloran planned the study, gathered and analyzed the data, and wrote the paper. Carole H.
Browner designed the instruments, analyzed the data,
and contributed to the writing of the paper. Eli Lieber
assisted in planning and conducting analyses and contributed to the writing of the paper.

Acknowledgments
Funding for this research was provided in part by the
National Center for Human Genome Research (1R01
HG00138401), the Russell Sage Foundation,
UCMEXUS, the UCLA Center for the Study of Women,
and the UCLA Center for Culture and Health.
Maria Christina Casado, Nancy Monterrosa, and Ricardo Rivera provided invaluable assistance at all stages
of the research. Simon J. Cox helped sharpen the argument. We also wish to thank Silvia Balzano, Susan
Markens, Melissa Pashigian, Betty Wolder Levin, Arthur
J. Rubel, and members of the UCLA Latino Mental
Health Research Group (Kimlin Ashling-Giwa, Victor
Diaz, Victoria Hendrick, and Marvin Karno) for their
helpful comments on an earlier draft of the paper. We
are grateful to the directors and staffs of the participating genetic clinics both for facilitating the research and
for giving us access to their patients. Permission was obtained from the institutional review board of each participating genetic clinic, and interviewees signed consent forms.

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Preloran et al. | Peer Reviewed | Research Articles | 1841