Recruiting and retaining hard-to-reach populations: Lessons learned and targeted strategies from arthritis physical activity intervention studies


A growing menu of physical activity programs offer adults with arthritis many choices that support self-management and facilitate improved functional mobility and health outcomes. Yet many of these programs have not been adequately evaluated among hard-to-reach populations, which may be due in part to recruitment challenges (1). Our research team conducted evaluations of 4 community-based interventions among adults with self-reported arthritis: the Arthritis Foundation Exercise Program, Active Living Every Day, Walk With Ease, and the Tai Chi Program (2–5). While our studies were not exclusively designed to recruit and retain hard-to-reach populations, our methods did target these groups. Our combined sample of 1,517 participants included rural residents (33%), African Americans (19%), men (13%), and those with a high school diploma or less (32%), and one study purposefully recruited employed participants. We share overarching approaches and describe strategies we found salient for specific subgroups.

Overall, we emphasize that researchers should leverage relationships with existing demographic-specific organizations that are representative of their constituents, informed about constituent receptiveness to specific recruitment and retention methods, and lend credibility and acceptability to the research project and team. We also underscore the importance of flexibility in the scheduling of intervention classes and pre/post assessments, providing transportation if necessary, and a strategic plan for persistent, ongoing communication with participants, including hotlines, reminders, and holiday cards.

Lessons learned about recruiting and retaining specific hard-to-reach populations are delineated in Table 1. We found that establishing a diverse set of partnerships to extend outreach into small communities was key for rural populations. We worked with Area Agencies on Aging, cooperative extensions, health departments, senior centers, and family practices. We found that some rural churches offer health outreach services (e.g., parish nurses, health talks, blood-pressure screenings) and are agreeable to hosting health promotion programs. Word of mouth was the most productive recruitment strategy. Interested participants were encouraged to invite family and friends to enroll in the studies. African American participation in our studies was higher in sites where the intervention leader or coordinator was also African American. We worked with community-based African American organizations, including a historically black university, churches, and a sorority. We found that men were more likely to enroll when their female partners enrolled.

Table 1. Targeted strategies for recruiting and retaining specific hard-to-reach populations
Hard-to-reach populationStrategies
Rural residentsPartner with Area Agencies on Aging, senior centers, parish nurses, family practices, cooperative extensions, community colleges, and health departments serving rural areas
Recruit through word-of-mouth
Offer transportation to assessment and/or class sites
African AmericansRecruit African American community leaders
Focus on social and cultural community organizations (e.g., churches and sororities, and historically black colleges and universities)
MenRecruit female partner
Include self-directed/nonclass exercise options
Recruit through social and civic organizations (e.g., Veterans of Foreign Wars, Rotary Club International, and Lion's Club)
Less than high-school diplomaRecruit through word-of-mouth
Work with community leaders who can seek out individuals with lower levels of educational attainment
Create buddy/partner system for reading and written assignments; train instructors to provide one-on-one support
Partner with subsidized housing organizations
EmployedEmphasize that employer support in intervention studies can increase employee health, productivity, and morale
Publicize at worksites, universities, and community colleges using group e-mailing lists
Schedule intervention classes and assessment activities before 8 AM, during lunch, or after 5 PM

Literacy can be an issue for people without a high school diploma, as well as for those with one who are not reading at grade level. Therefore, our recruitment strategies for individuals with less educational attainment were primarily by word of mouth and by local community leaders who could seek out those individuals and discuss enrollment. Because less educational attainment often is associated with lower income, we targeted this population primarily through subsidized housing organizations. To recruit employees, we sent mass e-mails to the management of universities and businesses who agreed to forward our recruitment messages. We offered flexibility in scheduling classes around the workday and allowed participants to leave with health-assessment surveys that could be returned later by mail.

We believe our experience can serve as a starting point to help other researchers devise their own tailored recruitment and retention efforts for increased participation of hard-to-reach populations. Our lessons learned may also be applicable to recruitment of participants into locally delivered arthritis programs and possibly apply to other disease-related community-based trials or programming.


All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication.