Chapter 15. Recruiting Older Immigrants for Research: Opportunities and Challenges

Including older immigrants in research is critical to generate a representative evidence base and prevent health inequalities that may arise from excluding this group. Changes to the immigration patterns over the last few decades have resulted in more linguistic, ethnic, social, and religious diversity in many countries (Sethi, Guruge, & Csiernik, 2021). This is also the case in Canada: more immigrants are now coming from Asia and Africa, unlike the historical patterns of European immigration (Immigration, Refugees and Citizenship Canada, 2020). Immigration now accounts for about 80 percent of Canada’s annual population increase (Immigration, Refugees and Citizenship Canada, 2020). Despite their large numbers in Canada and elsewhere, immigrants have historically been excluded from research for reasons related to language and access (Hughson et al. 2016; Smart & Harrison, 2017). Other challenges include mistrust of research projects, especially among older immigrants (Arean et al. 2003). As a result, little is known about their health and social conditions that shape their health and wellbeing in Canada. Researchers are now recognizing the imperative to design inclusive recruitment strategies.

Effective recruitment involves disseminating information about a study to the population of focus: the goal is to raise awareness and encourage enrollment to obtain a sufficient sample size. For quantitative studies, the sample size should be adequate to reach valid conclusions regarding the relationships among concepts or the intervention’s effects, while minimizing the chances of type I error (false conclusion that there is a relationship or the intervention is effective) and type II error (false conclusion that there is no relationship or the intervention is ineffective) (Sidani & Braden, 2021). For qualitative studies, sample sizes may differ depending on the method, but the goal is to generate a credible description of the phenomenon of interest (Thorne, 2016). Recruitment strategies must also yield a sample that is adequate in composition based on the study method and design, meaning that it must represent all of the various groups making up the target population. These groups may be defined by aspects including those related to health, socio-economic or ethnic and racialized background, or experience of the phenomenon under investigation (Sidani & Braden, 2021).

Recruitment strategies can be categorized as active or passive. Active strategies involve direct contact between the recruiters and members of the population of focus; contact may take the form of informal or formal presentations to individuals or groups at relevant locations and events. Passive strategies include advertisements on social media or in newspapers. The information shared with potential participants may include the study’s purpose and general eligibility criteria, the main research activities, and how to contact the research staff to learn more about the study. All types of recruitment involve challenges, most of which can be overcome. The following discussion summarizes the current state of research evidence related to effective recruitment strategies for older immigrants; we also augment this evidence with our own experiences in recruiting older immigrants for a range of research projects.

Challenges in Recruiting Older Immigrants

Inequitable Research Practices

All researchers should prioritize equity in their work and recruitment practices. However, historically many have used exclusionary research practices, such as requiring participants to speak and write in English or French, often due to the costs of interpretation and translation of research materials (Smart & Harrison, 2017). In extreme cases, inequitable research practices were applied because of lack of interest in equity in research endeavors. Even when researchers actively try to prioritize equity, recruitment challenges may be hampered by a lack of research evidence about practical strategies to overcome challenges (Feldman et al. 2008).

Communication Barriers

Some older immigrants have low levels of education, limiting their ability to read and write, even in their first language. Many newcomer older immigrants have little or no English or French language proficiency (Wang, Guruge, & Montana, 2019). Research practices that privilege English and French and written materials create communication barriers to participation. Another issue is that study materials may simply be too complicated or too lengthy (Forsat et al. 2020). Moreover, even when researchers or research assistants share a language with the older immigrants being recruited, they do not necessarily have shared life experiences, religions, and (dis)advantages etc., all of which can negatively affect effective communication (Resch & Enzenhofer, 2018).

Cultural Barriers

Some older immigrants may come from cultural backgrounds that do not value research highly, or they might mistrust researchers, especially those working in the medical field (Barata et al. 2006; Burns et al. 2008; Choi et al. 2016). Family and community can influence older adults’ ability or desire to participate in research by encouraging or prohibiting it. Furthermore, data collection processes and assessment measures may be unsuited to the target communities (Hughson et al. 2016). Cultural barriers can also limit engagement in activities outside their household and ethnic community, which may limit their participation in research activities (such as, interviews or focus groups) outside the home. Older immigrants also face barriers to accessing healthcare services and facilities where information about research studies may be shared. Some of the barriers include underrepresentation of racialized healthcare providers, lack of translation services, lack of culturally safe care, and inappropriate assessment tools (Waheed et al. 2015).

Trust and Mistrust

Historical mistrust of research/researchers and healthcare systems are significant barriers to recruitment of older adults from some immigrant communities (Barata et al. 2006; Commodore-Menash et al. 2019; Fete et al. 2019; Forsat et al. 2020; Hughson et al. 2016; Samuel, 2014; Waheed et al. 2015). The process of signing a consent form may pose concerns for some individuals (Hughson et al. 2016). Much of this mistrust is legitimate and may be amplified among older refugees who have lived through war, civil unrest, or political or religious persecution (Njie-Carr et al. 2021; Sethi, Guruge, & Csiernik, 2021).

Views of Health and Illness

Older adults – especially older immigrants – may perceive their own health and illness in ways that differ from the perceptions of researchers. For example, some older immigrants and their families may consider some health problems, such as depression, as normal age-related changes and therefore not requiring research and intervention (Arean et al. 2003; Bistricky et al. 2010). Another issue is that older immigrants may be concerned about sharing information about their mental health or changes in cognition (Arean et al. 2003) for fear of bringing shame to their families. Older immigrants may be living with multiple chronic conditions and may be homebound, and therefore may feel especially vulnerable to potential exploitation (Hughson et al. 2016; McHenry et al. 2015), thus not engage in conversations with unknown people (such as researchers).

State of the Evidence: Strategies to Recruit Older Immigrants

Together, these multiple and interacting challenges make it critical that researchers design and implement effective recruitment strategies. We searched for strategies identified as effective using relevant databases (CINAHL, Medline, PsycINFO, Embase, Sociological Abstracts) and forward citation searches (using Web of Science). Of the 76 articles focusing on the effectiveness of strategies to recruit older adults, immigrants, or persons of diverse ethnic backgrounds, only four focused on older immigrants, and these were specifically focused on Chinese and African-American immigrants (Arean et al. 2003; Li et al. 2016; Taylor-Piliae & Froelicher, 2007; Zou 2017).

All four articles reported that active recruitment strategies were more effective than passive strategies. Specific strategies included face-to-face recruitment in neighbourhoods where older immigrants lived and participated in social and recreational activities; involving community members or bilingual research staff as recruiters; and referrals from sources trusted by older immigrants like primary healthcare teams and community centre staff (Arean et al. 2003; Li et al. 2016; Taylor-Piliae & Froelicher, 2007; Zou, 2017). Face-to-face recruitment activities were conducted in a variety of settings including peer-support group settings, the homes of older immigrants, religious organizations, community centres, English-language classes, libraries, physical activity classes, restaurants, shopping malls, healthcare facilities serving immigrants, health fairs, and social clubs (Arean et al. 2003; Li et al. 2016; Taylor-Piliae & Froelicher, 2007; Zou, 2017).

The articles specific to older Chinese immigrants (Li et al. 2016; Taylor-Piliae & Froelicher, 2007) also identified several useful passive strategies for recruiting participants for clinical trials: advertisements in Chinese newspapers, television, and radio, and circulation of bilingual flyers and posters. The reason for the usefulness of the passive recruitment strategies is unclear but may be related to the socio-educational and financial status of the Chinese immigrants in their city/neighbourhood, as well as their technological literacy. A synergistic effect may also have emerged, where potential participants saw advertisements and were also directly approached by recruiters, thus raising the profile of the research study (Taylor-Piliae & Forelicher, 2007).

Together, the four articles focusing on the recruitment of older immigrants identified four general principles or approaches that may be helpful:

• Building trust and considering gender and cultural concordance of recruiter and target group, cultural competence of recruiter, and common experiences of recruiter with the target group (Arean et al. 2003). Heterogeneity within groups may render this strategy ineffective, so recruiter competence and experience may become more important (Arean et al. 2003).
• Forming a community advisory board to advise on recruitment plans, including feedback to ensure recruitment materials and consent forms are relevant to the cultural beliefs of older immigrants (Arean et al. 2003).
• Ensuring interaction with and visibility in the community (Bistricky et al. 2010).
• Communicating information about the study in the preferred language of potential participants (Taylor-Piliae & Forlicher, 2007).

Overall, a combination of active and passive strategies is recommended. Active strategies appear to be more effective than passive strategies, but more research is needed to confirm these findings.

Insights from Fieldwork: Recruiting Older Immigrants

In this section, we share insights from our own program of research (led by Guruge). One study involving older immigrants was focused on developing preventive strategies to address elder abuse; another investigated the formal and informal social support received by older immigrants (Guruge et al. 2019a; Guruge et al. 2019b). These studies included participants from Chinese, Korean, Punjabi, Tamil, and Arabic immigrant communities. Recruitment was conducted in collaboration with community partners, using several active and passive recruitment strategies that were relevant to each community. The following discussion details our experiences, and which strategies were effective in recruiting older immigrant participants for our studies.

Snowball Sampling and Group Participation

Snowball sampling (word of mouth) is one of the most useful strategies for recruiting older people from diverse immigrant communities. It was very effective in our study on the risk factors contributing to elder abuse in immigrant communities. Many older immigrants (including those who were not eligible) forwarded information about the study to their contacts, and as a result, we were able to recruit sufficient participants for our studies. Many of these older immigrants were willing to participate because the study provided a social space for them to connect with people of the same language and culture. Our participants told us that they wanted to remain socially active as they aged, but that their participation was limited due to lack of English-language skills. Therefore, snowball sampling may be particularly helpful for newer immigrants who do not speak English/French and are therefore not aware of, or lack access to, other recreational activities and programs available in their community.

Tailored Incentives

As with research participants in other age categories, offering meaningful incentives can be useful when recruiting older immigrant participants. Some of our participants commented that the costs associated with transportation were a barrier to participation. They wanted to contribute to Canadian society and regarded research participation as part of this contribution. However, most had not lived in Canada long enough to be eligible for a pension, and as a result, they relied on their own savings, a pension from their home country, or their children for financial support. We have found that providing cash to cover the costs of parking, transportation, and the time required to take part in the study is an effective incentive to recruitment. In contrast, honoraria such as gift cards were not as appreciated.

Flexible Interview Locations

Providing a variety of interview location options is another key strategy for optimizing study participation. We have worked with community partners to identify potentially appropriate locations for older immigrants. One effective method was scheduling interviews after regular activities of older immigrants, for example, after they had attended churches or temples. We also worked with community partners to help book a meeting room in convenient locations (such as nearby libraries or places of worship) so that older immigrants were familiar with the location/building, or they did not need to make an additional trip to participate in the study. We were aware that some elements of this method might make older immigrants worry that their relationships with the community partners would be affected if they declined to participate. To mitigate this risk, we stressed the voluntary nature of the study participation and that the community partners would not know about their decision to participate (or not), nor would they have access to any of the participants’ responses.

Online Recruitment Advertisements

One passive strategy we have used is posting printed recruitment flyers in different locations frequently visited by older immigrants, such as ethnic grocery stores, community centres, churches, and temples. For example, we posted flyers at a Korean ethnic grocery store and a community agency serving older Arabic-speaking immigrants. However, this strategy was ineffective (no one responded). In contrast, we found that posting recruitment ads online is an effective way to recruit older immigrants. We posted flyers in the form of an electronic image file on our social media platforms and on various social media networks, such as Kakao Talk to reach out to the Korean community, and WeChat, a messaging application used by the Chinese community. We have also used WhatsApp and Facebook to share recruitment information, because we have found that many older immigrants use multiple instant-messaging applications to stay connected. An added benefit of online flyers is that older immigrants can enlarge the image file with their devices, if needed, to compensate for poor vision. While the online advertisements generally targeted older immigrants with higher digital literacy, they helped amplify our reach by sharing the electronic flyers with others in their networks who were more likely to open an attachment from a friend.

Hiring bilingual and bicultural research assistants

It is critical to establish trust between potential participants and researchers/research assistants. One key strategy we have used to build trust with older immigrants is to hire bilingual and bicultural research assistants. Older immigrants are more willing to participate in research if the research assistants share the same language and/or cultural backgrounds. They can learn more about the study in their preferred language and directly interact with the research assistants (i.e., without a translator), which fosters comfort and trust. If older immigrants understand and trust the person recruiting and interviewing them, they are also more likely to help share information about the study with others (such as, their peers) as well. Awareness and attention to cultural nuances also help the research assistants build trusting relationships with older immigrants.

Direct contact with potential participants

Another effective strategy involves the active recruitment strategy of direct contact with potential participants during community activities. For example, we found that it was very effective to have Tamil research assistants directly contact older Tamil immigrants, most of whom had come to Canada after the civil war and were wary of figures of authority. This personal contact, especially before or after a community event, helped older immigrants get to know the research assistants who would later conduct the research interviews, reducing feelings of uncertainty who might be interviewing them. This approach also helped us obtain consent from all study participants to be re-contacted for subsequent phases of our longitudinal research study.

Implications for Research

Older immigrants in Canada are a heterogeneous group. When recruiting older immigrants for research, it is important to consider the intersections of various social identities (such as, ethnicity, culture, gender, age, disability, migration status, and religion), as well as systems of oppression (e.g., racism, sexism, ageism, colonialism) that can create health and social inequities (Dhamoon & Hankivsky, 2011; Sethi, Guruge, & Csiernik, 2021). Experiences of aging and dealing with aging-related health and social concerns require thoughtful consideration and tailored support: recruitment strategies that are effective for one older immigrant group may not be effective for all groups – or even all members within one group. Researchers should consider features such as community dynamics, length of time in Canada, and previous experiences with research when attempting to recruit study participants, as well as within-group diversity related to acculturation, ethnicity, socioeconomic status, and gender.

Researchers should also work in consultation with the community of focus, and be flexible and responsive to changes as recruitment progresses, to ensure the inclusion of older participants (Chamberlain & Hodgetts, 2018). The onus is on the research community, not on older immigrants, to create the necessary conditions for inclusion. For example, researchers can employ study designs that foster citizen engagement, such as participatory action research or the use of citizen advisory boards (Markle-Reid et al. 2021). An effective recruitment plan will include multiple and synergistic active and passive recruitment strategies based on knowledge of the population of focus: this plan should be monitored and evaluated, and will likely be adapted over the course of recruitment based on feedback and observations.

Given the lack of research evidence on effective recruitment of older immigrants, we recommend that researchers document both effective and ineffective recruitment strategies for groups at various intersections of social identity. By documenting these in publications and knowledge translation activities, it will be possible to improve practical knowledge among researchers seeking to recruit older immigrants. This will also help raise awareness of the importance of employing inclusive research practices. Ideally, researchers will include an assessment of the effectiveness of recruitment strategies as part of the study design, and report this information as part of their methods or results. More research is needed to explore and understand effective recruitment strategies at the intersections of age and immigration, as well as other social locations such as those involving older refugee women or older immigrants with disabilities.

Conclusion

A thoughtfully constructed recruitment plan is necessary to ensure the inclusion of older immigrants in research, to generate a representative evidence base, and to promote health equity in research as well as in healthcare and social settings. We recommend a multifaceted approach to recruitment that is informed by the immigrant community of focus, including both active and passive recruitment strategies at the community level, with the overall goal of building and establishing trusting relationships between older immigrant communities and researchers.

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