Background

The Hispanic population in the United States is increasing in size, is diverse in culture and countries of origin, and is experiencing unique influences from social and behavioral acculturation to the US. Consequently, Hispanic populations provide complex research challenges and opportunities, especially as evidence-based strategies and interventions become increasingly important in responding to a growing epidemic among new immigrants to high-prevalence US cities.

New York City (NYC) and its surrounding areas accounted for 91% of New York State’s total increase in foreign-born populations from Central America between 1990 and March of 2000 [1]. In 2000, approximately 136,000 Central Americans resided in NYC and the surrounding counties [1, 2]. Of these, 98,000 (72%) were born in El Salvador, Guatemala or Honduras [2]. In addition, more than 600,000 individuals classified as Hispanic in the New York Metropolitan Area report their native countries as Mexico or the Dominican Republic [2]. Demographers argue that US Census figures underestimate the size of these populations due to the undercount of undocumented residents [3].

Together with their demographic growth, the recent attention garnered by the rising number of HIV diagnoses among Hispanic groups in the United States challenge researchers, advocates and policymakers to identify HIV prevention and care priorities that address the contexts and needs of these populations [4–6].

Conceptual Framework

Conventional probability sampling is usually neither feasible nor suitable to recruit subjects from hard-to-reach populations [7], and the main challenge is the lack of an existing “sampling frame” for the study of these groups [8]. In addition, any recruitment of study subjects from hidden or stigmatized populations such as illicit drug users, undocumented immigrants, men who have sex with men (MSM) poses difficulties due to the many complex issues which exist in obtaining individual and community collaboration in research, including fears relating to stigma and the possible consequences of the exposure of illegal/clandestine behaviors and activities [7]. These issues call for sensitive, flexible and innovative recruitment methods that build on legitimization of the research and researchers and the development of a trusting relationship which assures that contact will be confidential and safe for potential respondents.

Recruitment strategies frequently used in community studies include targeted sampling [9] and respondent-driven sampling which is also a type of snowball sampling [10]. The method of “snow ball” sampling was chosen to recruit participants for this study owing to the hard-to reach characteristic of this population and the sensitive nature of the topic researched. While “snow ball” approaches have been criticized as contradictory to conventional sampling, as Atkinson and Flint [11] point out, this technique of “chain referral” may give the researcher the advantage of being considered an insider within the study population and hence, provide access to settings where special populations can be reached while enabling recruiting some study respondents as “informal research assistants” to establish rapport. This also implies appropriate and sensitive communication in carrying out recruitment, especially if researchers and subjects are from different backgrounds, have unequal power relationships and do not have the same motivations for establishing contact with one another [12]. The research population’s vulnerability due to their possible undocumented status, recent migration, lack of established social infrastructures, language barriers and, economic status emphasized the need for establishing rapport with the community first in order to identify key community members and the initial group of participants who will then aid in referring other community members they know for participation in the research. Hence it was decided that chain referral would be the most appropriate method to recruit participants for this study.

Existing literature demonstrates that researchers have examined barriers to recruitment of research subjects from special populations such as low-income Hispanic couples [13]; immigrant women caregivers [14]; Hispanic immigrants [15]; and female and male sex workers [16] but not among immigrants in general, nor immigrant populations which include undocumented community residents. This is an especially salient issue since behavioral research among Hispanics indicates that difficulties in recruiting low-income groups for health research correlate with the recruitment strategies which target them [13]. The process of recruitment of participants for this study provided valuable insights into potential barriers and facilitators to enlisting and maintaining Hispanic immigrants’ collaboration in behavioral research. This paper will address lessons learned in the recruitment of these hard-to-reach populations.

Methods

Study Overview

“New Hispanic Communities and HIV Risk” was designed as a short-term, qualitative, exploratory study of new immigrant groups from the Dominican Republic, Guatemala, El Salvador, Honduras and Mexico. The overall objective of the study was to inform policy and program planning which address risks for HIV/AIDS experienced by these groups in the New York Metropolitan Area. In order to provide a more in-depth understanding of risk for these immigrant groups, the research aimed to explore the influence of dynamic cultural schema on HIV drug- and sex-related risk behaviors and to compare these by sex and culture group (nationality). The study also was able to investigate specifically how cultural adaptation and interactions of culture and environment shape HIV-related risk and protective behaviors in urban and suburban and semi-rural areas. Findings were then used to assess attitudes toward, perceived need of, and access to, HIV prevention services for these populations. Data obtained also have been used to describe and compare the sociodemographic characteristics of these immigrant groups as well as the cultural and environmental factors that provide the context for risk and prevention of HIV/AIDS and other health challenges [17–19]. This research was approved by an Ethics Review Committee.

Research Sites

Phase I of the research covered work undertaken from September 2002 to September 2003 in two field sites: (1) the contiguous counties of Westchester and Putnam, composed of urban, suburban and semi-rural areas; and (2) the semi-rural North Fork of Suffolk County, Long Island. Phase II of the study covered work undertaken from October 2003 until the end of the grant period in two field sites: (1) Rockland County, composed of urban, suburban and semi-rural areas; and (2) urban Northern Manhattan (including the neighborhoods of Harlem, Washington Heights, and Inwood). These sites were selected to account for differences in new immigrant target populations by urban, suburban, and semi-rural location of residence. In addition, the different sites helped address the interaction of geographical location with differences in HIV risk and access to health and social services.

Participants

New immigrants from the Dominican Republic, Guatemala, El Salvador, Honduras and Mexico were recruited as participants in this study. The communities studied were situated in urban, suburban and semi-rural locations and the research subjects were recently arrived (within the last 3 years) in the US. A total of 301 men and women participated in the study, with 100 individual interviews and 201 participating in focus groups organized by sex, nationality, and research site. Approximately half of the respondents (53%) were males and 47% were females. Trained staff of the same sex as participants led focus groups so as to facilitate rapport. Because of their relatively smaller numbers in all field sites, respondents from El Salvador, Honduras, and Guatemala were grouped together in “Central American” focus groups. [There were no focus groups with Dominicans conducted in the North Fork, as there did not seem to be any significant Dominican community there.] Overall, the mean age of respondents was 33 years, with a mean length of residence in the United States of less than 2 years. Forty individual key informant interviews and two key informant focus groups were conducted with a range of individuals including health care providers, county officials, immigrant advocates, and religious leaders.

Recruitment of Study Participants

Participants were recruited from the target populations at each site, using a snowball approach begun by community leaders and providers contacted by the research team. Self-reported criteria for recruitment were: (a) aged 18 or over; (b) born in one of the target countries (Dominican Republic, El Salvador, Guatemala, Honduras, and Mexico); and (c) having arrived from the country-of-origin 3 years or less before the date of their participation in the study. Participants received $25 for their time. The research team recruited participants for focus groups who had not participated in individual interviews. Key informants included Hispanic community religious and political leaders, immigrant advocates, legal agency staff, and health/HIV service providers.

Trained bilingual interviewers conducted the individual interviews. Since education and literacy levels were generally low, a verbal presentation in Spanish of the consent forms was made whenever interviewers had any doubts about prospective participants’ comprehension or reading ability. Interviewers were also equipped with information about local health and social service agencies through which they provided crisis referrals when needed.

Measures

The New Hispanic Communities Study utilized a qualitative, ethnographic approach to identify the range of experiences, attitudes and beliefs relating to HIV risk by men and women of the different target groups in the field sites. These qualitative methods themselves fostered the development of rapport and facilitated access to places and specific immigrant groups while obtaining information on the social context of behavior and HIV risk vulnerability. Interview instruments were designed to explore individual and collective living conditions during and after immigration; continuities and changes in attitudes, behaviors, and interactions with existing social networks and living conditions; attitudes and behaviors related to increased vulnerability to HIV and other STIs; access to health and other social services. All immigrant interviews were carried out in Spanish by bilingual researchers and textual data were analyzed in Spanish.

Data Collection

Data for this study was collected through: (1) semi-structured, in-depth individual interviews with participants from the target populations; (2) focus groups with members of the target populations; (3) key informant interviews; (4) focus groups with advocates and providers in health and social services; and (5) ethnographic observation in the different geographic locations of the study including specific national/ethnic communities and activities.

Analysis

Qualitative coding was done for data from the individual and focus group interviews (N = 301) and the key informant interviews. Coding of data collected was done at multiple levels and emergent themes were identified. Data from ethnographic observations were analyzed and utilized to triangulate the findings from the individual and focus group interviews. Review of the data collection process and field notes revealed critical information pertaining to recruiting participants for research from hidden/hard-to-reach populations such as new immigrants. The following are some lessons learned in relation gaining access to a largely undocumented immigrant community and, successfully recruiting participants for the purposes of conducting research.

Results

Development of Rapport and Legitimization of the Study Prior to Data Collection

Field visits prior to the initiation of research activities are crucial to establishing rapport and trust with the communities while understanding the cultural cues relating to appropriate and sensitive communication and establishing visibility in the community. Because recent Hispanic immigrants who are predominantly undocumented pose unique challenges to recruitment into a research study, extensive interaction with community members to gain their trust is essential and requires time, a consideration which must be made in the design stage of the research. In our study, for example, researchers conducted several field visits to Northern Manhattan to observe and interact with Mexican and Central American immigrants living there. Even though a large section of Northern Manhattan has traditionally been seen as Dominican, it is well known in the community that Mexican immigrants have been silently settling there. “Yes, there are a lot of Mexicans living here, I see them all the time and now more have come” (Dominican woman).

Field visits were carried out from 8 a.m. to 4:00 p.m. and during these visits previously contacted Mexican stores, restaurants, and Dominican-owned clothing stores helped to recruit study participants. This collaboration and recruitment was gained by repeated prior visits to these venues by researchers who observed the routine activities in each site including a restaurant frequented by potential study participants. For example, the ethnographic fieldwork at a restaurant revealed that from 8 a.m. to 12 p.m., restaurant customers were predominately women, and that at lunch time the majority of the customers were men. The male workers who arrived by themselves usually were those living in the US longer than the new immigrants.

Research staff also noted groups of new (having been in New York for only a few days or months), monolingual indigenous Mexican immigrants who spoke only their native language and were fearful of encounters with anyone who did not speak their language. These restaurant visits eventually led to the consent of the restaurant owner for interviews to be conducted at the restaurant, a legitimized and proven “safe” space for potential participants. Field work was especially crucial in accessing individuals who could not be reached through health care organizations, schools or local NGOs. Environments such as restaurants serving traditional foods instilled familiarity and nostalgia about flavors, smells, dialect, and symbols relating to country of origin and played an essential role in creating an environment conducive to the sharing of experiences and ideas, and participant observation in a natural setting.

Similar strategies yielded positive results in recruiting participants from Central American populations, the hardest populations to reach due to their extremely high levels of caution and protectiveness being minority groups new to the area, being undocumented, and/or having inadequate protective and supportive social networks. As a young Salvadoran woman stated in response to information about the study, “What is that for? No! We don’t want anything, we are eating. Why are you interrupting us?”

New Central American immigrants also exhibited concerns about being identified as “new” due to legitimate fears of deportation, especially when deportation means not being able to pay back debts acquired in their efforts to enter the US. As one respondent explained, “Like people from Guatemala, yes they are in this area, they come here to the store, but they hide a lot. I have invited the lady from Guatemala that comes by often, but it’s not been possible to interview her, they hide a lot.” [“Como le digo gente de Guatemala si hay en esta área y vienen aquí a la tienda pero ellos se esconde mucho, yo ya he invitado a la Sra. de Guatemala que viene siempre aquí y ya ve, no se ha podido hacer la entrevista, ellos se esconden mucho”.]

Later in the interview process, some people from El Salvador and Guatemala told fieldworkers that it is hard for them to trust people they do not know, because it was very hard and expensive for them to cross two borders and they do not want to have problems or be deported because they have a family and debts that need to be paid.

Understanding the Potential Meanings, Costs and Benefits of the Study as Perceived by the Target Population

As the research was initially described only as a study about “immigration and health,” by community members assisting with the recruitment, most potential participants did not have detailed information about the interview prior to initial contact with the researchers. The researchers had to gain the acceptance of the community members who were assisting in the recruitment process and the trust from potential research participants before the actual data collection began. On average, fieldworkers spent at least three visits lasting about 4–8 h at recruitment sites beginning with interactions with proprietors at the venue, for example, restaurant owners. After such familiarity with the venue was established, the fieldworkers began interactions with potential participants visiting the venue. In most cases, the owners of the establishments such as stores and restaurants interacted personally with potential participants to acquire their permission for the fieldworkers to interact with them before any direct contact occurred between the participants and fieldworkers. At least two direct encounters were necessary with potential participants before they agreed to collaborate in the research.

It was also found that potential participants needed additional details and explanation about the study despite carefully worded informed consent information due to their relatively low education levels, particularly in understanding the potential benefits of the research to their new immigrant communities. Once it became evident to participants that they were doing something that would help others in their community and that they would earn some money for participating, many consented to participate. Although they knew they would not benefit directly from the study, many respondents reported positive reactions to their own participation, as it gave them an opportunity to speak candidly about their lives and concerns to people willing to listen and learn from them and their experiences. Understanding such benefits and possible interventions to assist immigrant communities enabled candid conversations and effective communication between researchers and the participants.

The researchers also observed that the use of particular words and ways of framing the description of the study provoked fearful reactions and thus affected recruitment. Words such as “investigation,” “research,” and “interview” had to be conveyed through synonyms such as “study”, “conversation” and “dialogue” which were not seen as threatening. Participants responded positively to terms which avoided associations with any type of government or legal activities. For example, the word “travel” (“viaje”) when substituted for “immigration” which could refer to immigration authorities, facilitated open responses disassociated from legal and emotional issues attached to immigration concerns.

Another important lesson was the impact of the careful explanation by the researchers of why they were “students” and the interviewees the “teachers”. In doing this, the study team validated the knowledge, experiences and insights shared by individuals, many of whom had never been asked for their thoughts, opinions or concerns before.

Identification of Communication Channels and Legitimate/Utilized Information Sources

Ethnographic fieldwork, and later the interviews as well, illustrated how new immigrants rely on their social networks in the receiving communities to address most of their initial needs. These social networks are comprised of co-workers, relatives and non-kin from their countries of origin and once identified, also served as valuable resources for participant recruitment.

Other than social and family networks from their countries/towns of origin, immigrants seek help from local religious institutions not only due to their religiosity, but for a sense of “community,” and the refuge, emotional and even economic support these institutions provide especially in rural areas. The religious leaders who facilitated recruitment and data collection were also critical informants regarding anti-immigrant hostilities that confront new immigrants and that they themselves face on a regular basis because of their role as advocates of immigrant health and rights. In general, religious institutions served as major resources for this study. But these institutions also posed challenges as researchers sought to separate the study from the religious biases and influences which could affect the content of the interviews. The research team specified to the participants that the information collected would not be shared even with trusted clergy. As one Salvadoran woman told a researcher; “The lady invited me to participate in an interview for the study, but I doubted because I didn’t know what it was about and I was scared I would be used, you know?, for something bad, so I asked my pastor what he thought, if he would authorize me to participate. Then my pastor gave me permission to participate and so I came to the interview with you”.

(“La señorita me invito a participar en una entrevista para el estudio, pero yo dudaba porque no sabía de que se trataba y tenía miedo de que me utilizarán, ¿usted sabe?, para algo malo, entonces yo le pregunte a mí pastor que él que pensaba, que si él me autorizaba a participar. Entonces mi pastor me dio permiso de participar y por eso es que yo vine a la entrevista con usted.”)

However, recruiting people through faith groups or churches also could influence the participants’ responses between “lo que debe ser” (what should be) and not about what they really thought, felt and did. In this particular interview the woman was quite defensive during the first part of the interview (especially regarding sexual issues) and her answers always started with “no eso es malo mi pastor dice” (no that is bad, my pastor says so) “no, no yo no pienso en es,o mi pastor dice…” (“no, no, I don’t think about that, my pastor says”) but in the second part of the interview when she felt safer and more comfortable, she was able to share perceptions, beliefs, and experiences concerning her sexual behavior which addressed the sexual risk research domains of the study.

Some faith groups or faith-influenced NGOs supported this study by offering their local offices/venues to conduct the interviews for this study, however, the researchers realized on several occasions that the religious symbols or the presences of clergy influenced the participants’ responses. For example, a Salvadoran woman in Rockland was talking about oral sex, but when she turned her face to a huge crucifix aside her, she changed the conversation and told the researcher “ay!!, no!!, pero esas cosas no son naturals, son feas, no son buenas” (ay, no, but these things are not natural; they are ugly and not good”). For this reason the team sought more neutral and confidential environments where people could feel free to speak as well as feel safe.

Identification of Agencies, Social Venues, Facilities Used (Safe Spaces)

Identification of “safe places”, the agencies and other locations where interviews and focus groups were to be conducted, was also important in establishing contact, and gaining and maintaining the cooperation of participants. Settings for individual interviews varied greatly from office space arranged by contacts to using benches in parks and secluded spots in coffee shops or malls. Focus groups in the North Fork, for example, were carried out in the offices of the Spanish Apostolate in Riverhead, while local health and social service providers facilitated spaces for focus groups in Northern Manhattan and in the Tri-County area.

Due to the lack of available space, one fieldworker was required to interview one of his participants in his car. In extreme situations, some interviewers had to conduct interviews in less-than-ideal environments such as the homes of participants. Although the context and number of interruptions were challenges, managing privacy became almost impossible in some interviews. One fieldworker who conducted interviews in the home of a participant noted that the participant’s children and other housemates walked in on them while the interview was ongoing:

“I had to explain once again the need for privacy. I offered to come back or to move to another room, but it appeared that the interviewee just wanted to get the interview over with. My own observation was that the interviewee was highly distrustful of the process, and therefore was far from forthcoming with her responses, most specifically about the immigration experience.”

Researchers also learned that unstated biases against new immigrants can exist in some organizations and that this subtle discrimination could deter research participant recruitment even if the organization was recommended by community members. For example, an organization from Brooklyn which addresses legal and immigration issues was cited by a Salvadoran male community member as a valuable source for participant recruitment. However, when the researcher spoke with the director of the organization (an American woman) about the study and shared with her some preliminary study findings, as well as the difficulties researchers had in reaching such populations, she replied with hostility, “I know all about Hispanic immigrants and the only thing they need is their papers and work. I do not know why all this research, everyone knows and I know because I work with them what they need. We need funding to continue working and supporting them…I cannot help you; we are very busy”.

The study team also gained valuable knowledge and sensitivity concerning gender differences during recruitment and interviewing. Women, for example, appeared to need more privacy while talking with researchers than men, and shared more detail about sensitive issues such as domestic violence, depression and anxiety resulting from being separated from their children.

Identification of Social Networks Within the Study Population

Most of the social networks were identified with assistance from local health and social service providers in the study areas. Where communities appeared resistant to being approached for the study, such as in Putnam and Rockland Counties, some members of local service coalitions aided in abating the fears of immigrants which resulted directly from local anti-immigrant hostilities. The lack of Hispanic community leaders and supportive infrastructures in these communities posed significant challenges to recruiting study participants there. Identifying such networks was also useful to create a referral network to send study participants who required legal, emotional and/or health support. The interviews also revealed a broad range of situations and problems which new immigrants face daily. These problems ranged from rape, exploitation, domestic violence, discrimination, sexual abuse stories, and depression due to reproductive health problems (breast cancer, vaginal infections, vaginal tract pain) and dental infection.

Researchers observed that members of a particular social network were also more willing to participate in the research if one or few members of the network regarded participation in the study as a positive experience. For example, many study participants expressed feelings of being respected, freedom to express feelings, lack of judgment, safety, and most important, ownership, as a result of participating in the interviews. In some cases, women indicated that they experienced a sense of empowerment when they shared their knowledge, experience, suggestions and insights about their lives and communities.

Interestingly, participants also expressed some insights about their own contradictions, prejudices, stereotypes, myths or misconceptions about other immigrant groups, sexuality issues, sexual practices, issues about HIV/AIDS and self care in general. They felt that their contribution was crucial to improve and/or design new programs which really cover the real new immigrants’ needs.

Some participants refused to accept money for participation in the research interviews. “No señorita, como me va a dar dinero, si estoy haciendo esto para ayudar a la comunidad, ojála se pueda hacer algo bueno para nosotros los Hispanos” (No, Miss, how are you going to give me money if I am doing this for the community; if only this can do some good for us Hispanics!” (Salvadoran woman).

“Como me va dar dinero, yo soy la que le tengo que dar las gracias a usted por preocuparse y hacer este estudio y escucharnos, yo espero haber contribuido con algo” (“How are you going to give me Money; I am the one that should thank you for caring and for doing this study and listening to us. I hope to have contributed with something” (Guatemalan woman).

A Salvadoran woman conveyed the following to a researcher at the end of her interview:

“Usted me pidió que fuera honesta en la entrevista ¿verdad?, pues no le dije todo y le quiero contar sobre una situación que esta pasando en mi trabajo” (“You asked me if I was honest in the interview, right? Well, I didn’t tell you everything and I want to tell you about a situation that is happening at my job”).

The woman then related that the manager in the factory where she was working forced all the new female employees, including her, to have sexual intercourse with him by threatening deportation if they refused. The woman mentioned that she was concerned about a very young woman from México who was being forced to have sex every day by this manager. “Yo no le había contado a nadie acerca de esto por miedo, pero usted me dio confianza y yo quisiera ayudar a mis compañeras del trabajo” (“I had not confided this to anyone because of fear, but you gave me confidence and I want to help my co-workers”). After the interview, the woman offered her support to the study and she recruited other women for interviews, including the Mexican woman who had been abused by the manager. The study team assisted her in seeking help for this situation.

Addressing the Participants’ Fear of Contact with “the System”

The fear of all institutional contact, especially any institution representing immigration authority, was present in all of the communities visited. This fear is a serious barrier to recruitment among immigrant populations and only can be minimized or overcome by consistent presence, visibility and legitimization of the researchers by trusted sources of information such as community leaders, clergy and service providers. Clear and repeated messages must assure community members that the information to be obtained will not put them at risk of violence, loss of jobs or deportation. Mexican and Dominican communities, with more developed infrastructures and longer experience in the US, were relatively more accessible than newer communities of Guatemalan, Salvadoran and Honduran immigrants.

Researchers found that it was crucial to understand potential participants’ previous experiences of abuse and/or mistreatment by local organizations, employers, relatives and/or neighbors in order to validate and legitimatize such experiences they have lived. This insight helped researchers to establish a better rapport with the study participants and to understand their most salient issues. As one participant confided: “…yo quisiera decir muchas veces a todas las personas que quieren enfocarnos ¿cómo se puede vivir?, ¿cómo se puede encontrar trabajo” (“…Many times I want to say to people that focus on us, ‘how does one live?’, ‘how does someone find work’). Another participant told of not being paid and his fear of being deported if he complained: “…dos personas no, no me han pagado… pero el hispano a veces tiene miedo de ser deportado, deportado y por eso es que no se queja con las autoridades…” (“…two people have not paid me…but the Hispanic sometimes is scared of being deported, deported and so he doesn’t complain to the authorities…”).

Designing Strategies to Address Stigma Surrounding HIV/AIDS

Stigma related to HIV/AIDS is also a major barrier in subject recruitment for HIV/AIDS behavioral research. Stigma affecting HIV positive individuals of Mexican origin, for example, has been manifested as homophobia, racism, sexual silence and machismo, and results in their marginalization [20]. Such data illustrating the fear and marginalization of people and issues relating to HIV/AIDS supported our finding that introducing this study as “immigration and health” related and providing continual additional detail as recruitment activities progressed proved less intimidating to the participants. Local health education agencies also proved to be valuable resources in introducing the topic of HIV/AIDS to the target communities during their trainings.

Enlisting Community Leaders in the Research Process

Community leaders identified through events such as Latino heritage festivals and special film screenings were incorporated into the research process, not only as intermediaries between the investigators and the communities, but also as partners in the development, analysis and dissemination of results. While collaborating with community members who had immigrated in the past from the same country as the potential study participants, researchers learned that there can be levels of mistrust even toward individuals from the same countries and communities of origin if they had resided in the US for long periods of time. As one key informant explained: “They become Americanized. They no longer greet you. They only think of themselves. No one else matters. It’s not like in our countries where one greets saying ‘Neighbor, good morning’. Here they don’t even want to do that”. These perceived changes and experiences created a lack of trust between new and more established immigrants. In fact, some community members who tried to support the research team in recruitment garnered mistrust themselves from some new immigrants.

Nevertheless, recruitment of participants through community members from the same country including NGO workers and those involved in HIV/AIDS prevention activities within the community appeared to be the most productive strategy as it built upon their credibility in the community. Networking for recruitment also had the potential to create a system of referrals for legal, emotional, and health problems of the community.

Discussion

Multiple and creative community-specific strategies are required to identify and recruit research subjects from hidden/hard-to-reach populations such as new immigrants while ensuring a diverse sample. Initial exploratory ethnographic fieldwork can provide a foundation for efficient recruitment, establishing visibility, credibility and legitimization of the study and the researchers as well as obtaining data on the context, environment and populations. Recruitment strategies need to include the identification of community leaders, communication channels, “safe spaces” and appropriate language and knowledge of social norms before initiating recruitment activities. Additionally, researchers need to: (1) assure clear communication about the study objectives, confidentiality, data collection methods and use of the data with community resources and potential participants; (2) involve community leaders and role models in identifying potential participants and in gaining trust and collaboration; (3) understand the effects of stigma and discrimination relating to immigrant status and the study topics (i.e. HIV) in different cultures; (4) be sensitive to language and the meanings associated with terms relating to government authorities (immigration authorities in particular); and (5) design sufficient time for the researchers to establish visibility and trust before initiating recruitment activities.

Contribution to Literature

The lessons learned during the participant recruitment process for this study can inform behavioral research strategies aimed at new immigrant communities. We have documented that in addition to obvious issues such as fear of deportation, such factors as the initial stage of acculturation, fragile or non-existent social networks, issues inherent in new community formation, the role of faith-based and community organizations and cultural norms regarding communication and behavior are crucial in effectively reaching and engaging these at risk populations. The experience and recruitment strategies utilized in this study have much potential in aiding a better understanding of the cultural and contextual factors which must be considered in researching such hidden and hiding populations and thus the development of more appropriate and effective community-based and participatory research.