ORIGINAL PAPER

Strategies for Recruiting Middle Eastern-American Young Adultsfor Physical Activity Research: A Case of Snowballs and Salaam

David Kahan Æ Alia Al-Tamimi

Published online: 23 January 2008

� Springer Science+Business Media, LLC 2008

Abstract Recruitment of minorities into health studies is

a process that has been the subject of recent research effort.

The prevalence of hypokinetic disease in the fast growing

Middle Eastern-American community is higher than whites

and some minority groups and descriptive research is

needed to further quantify morbidity status and antecedent

behavior. To date, we know of no study that reports

recruitment methods of Middle Eastern-American young

adults, a demographic group that is transitioning into an at-

risk stratum for ethnically associated morbidity. We report

and analyze a multi-method approach used in recruiting

240 young adults of this ethnic group into a 1-week study

of physical activity utilizing activity logs and pedometers.

Participants were primarily recruited through snowball

sampling (48.3%), flyers (15.8%), presentations to uni-

versity campus organizations (15.4%), and graduate

research assistants (10.8%). Access was facilitated by

assistants who were community insiders; active recruit-

ment was more successful than passive recruitment; and

different techniques appealed to different group segments

based on gender and religion.

Keywords Recruitment methods � Arab Americans �Young adults � Snowball sampling

Introduction

In the United States, over the last 20 years the influx of

immigrants and growth of all autochthonous racial

minority populations have outpaced that of the nation’s

white majority [1, 2]. These peoples’ health behaviors and

beliefs frequently differ within and between identity groups

and compared to whites [3–5]. As a result, immigrants and

minority groups are uniquely and differentially afflicted

with certain morbidities. For example, Black Americans’

death rates from stroke and heart disease are between 1.2

and 1.4 times higher, respectively than whites [6]; yet when

blacks are differentiated by birthplace, it is African-born

blacks, but not US-born blacks, who report significantly

better health and fewer activity limitations when compared

to whites [7]. Often, minority and immigrant health is

influenced by socio-cultural factors and manifest in dis-

parate conditions related to food sufficiency and safety,

access to health care and insurance, childcare, affordable

housing, and educational and occupational attainment,

which can create or reinforce a tiered status relative to

health and mortality [8–11].

The resultant burden on American society cannot be

underestimated. Morbidities directly contribute to financial

burden associated with lost wages and productivity [12,

13], strain social medicine services and their funding [14],

and induce ethical dilemmas over failed health care ini-

tiatives and services [15–17]. Disparities between

populations and ethnic groups have been noted for many

morbid conditions, including heart disease, overweight/

obesity, diabetes, and certain forms of cancer [18]. A

prophylaxis for these and other morbidities is engagement

in health-enhancing and abatement in health-damaging

behavior. Toward this end, in the Healthy People 2010

initiative [18] there are many objectives aimed toward

D. Kahan (&) � A. Al-Tamimi

School of Exercise and Nutritional Sciences,

San Diego State University, 5500 Campanile Drive,

San Diego, CA 92182-7251, USA

e-mail: dkahan@mail.sdsu.edu

123

J Immigrant Minority Health (2009) 11:380–390

DOI 10.1007/s10903-008-9117-7

narrowing the disparities between population groups for a

variety of health behaviors such as physical activity, oral

health behavior, tobacco use and immunization.

Prior to developing health behavior interventions tai-

lored toward specific populations, descriptive

epidemiological studies must be conducted with each

toward identifying the scope and severity of morbidity and

quantifying and qualifying the health behaviors that con-

tribute to or prevent the development of morbidity. One

ethnic group that has recently received attention in this

regard is the Middle Eastern population of the United

States, particularly Arab Americans, a group that has

grown by 38.3% between the 1990 and 2000 US Censuses

[19].

Results of morbidity research within this population

indicate high prevalence of hypokinetic diseases, such as

diabetes, cardiovascular disease, hypertension, and certain

cancers [20–23], which in turn may be influenced by

insalubrious changes in lifestyle and diet while living in the

US [24, 25]. Results of physical activity research con-

ducted in Canada and Sweden suggest that Arabs are: (1)

40–50% less likely of being moderately physically active

compared to whites and that these differences considerably

narrow according to time since immigration [26, 27]; and

(2) between 4.4 and 12.5 times likelier than whites to

engage in sedentary leisure time activities [28]. To our

knowledge, researchers have ignored objective assessment

of physical activity behavior within the Arab American and

American Middle Eastern communities. Additionally, there

is comparatively less research on these communities’

young adults’ (ages 18–29) health behavior. With calls to

focus on young adults’ physical activity [29] coupled with

the observation that within Arab culture children still

strongly affiliate with the family at this age [30], it is

important that we study this transition age group within this

vulnerable minority.

To conduct descriptive research of this type, adequate

recruitment of participants is necessary, which may prove

difficult with an under-researched population because the

size of the group is unknown, group members may be

reluctant to acknowledge their membership, and may dis-

trust nonmembers [31]. Additionally, at the community

level, participation may be compromised if a group has

been previously patronized or stigmatized, or is skeptical

regarding how research outcomes might be used and how it

stands to benefit [31]. Observational studies that utilize

non-probabilistic sampling appear to pose the fewest bar-

riers to the recruitment of minorities [32]. Nevertheless,

recruitment of some minority’s members can be further

expedited by snowball sampling; making face-to-face

contact with prospective participants; establishing rapport

and building trust with individuals and their community;

prioritizing participants’ convenience over that of the

research team’s; effectively conveying a study’s purpose,

tasks, and benefits to the individual and community;

including meaningful incentives; and utilizing cultural

adaptation strategies [32, 33]. Kreuter and colleagues [34]

qualified cultural adaptation strategies by category: (1)

peripheral (i.e., producing study materials that visually

appeal to a specific culture); (2) evidential (i.e., presenting

data concerning relevant health issues); (3) linguistic (i.e.,

responding to language preferences of minority group

members); (4) constituent involving (i.e., seeking group

members for input or staffing); and (5) sociocultural (i.e.,

imbuing a study’s methods with normative group beliefs

and values).

Several of the aforementioned strategies and cultural

adaptations have been used with varying degrees of success

in recruiting within the Arab American community [20,

35–38]; however, to our knowledge only two papers

explicitly and centrally focus on recruitment strategies for

health-related research within this population.

First, Aroian and colleagues [38] found that: (1) a panel

of advisory experts’ assumptions and recommendations

were not always accurate and fruitful; (2) cultural and

religious community gatekeepers were not helpful in

recruitment efforts; (3) personal contact was the only

means of advertising that was successful; (4) ample bud-

geting of money and time was required to provide adequate

incentives and opportunity for rapport building; and (5)

having a community insider on the research team facili-

tated access to community members.

Second, Barry [39] studied the acculturation experiences

of male Arab immigrant university students. He discovered

that traditional recruitment methods (e.g., canvassing

undergraduate psychology classes, flyers, networking with

local Arab groups, personal contacts) were inadequate. He

resorted to Internet solicitation of Arabs affiliated with

campus and community organizations. Interested persons

replied by e-mail and were sent questionnaires by mail. Of

the 700 persons solicited, 17% replied and 11% of the

original total participated. Feedback about using the

Internet included: (1) Concerns about the rationale of the

study and potential injurious findings about Arabs were

alleviated by receiving quick one-on-one e-mail replies; (2)

comfort using the medium motivated their participation;

(3) usage of the Internet was linked to participants feeling

actively involved in the fine-tuning of recruitment methods

as well as casting the Internet as a medium that was less

biased toward Arabs than standard media; and (4) interest

in participating was heightened by participants’ sense of

novelty and creativity associated with the Internet.

In our study, we aim to broaden the focus of previous

work [38, 39] to include a broader segment of the Middle

Eastern American population and an unreported health

behavior. We descriptively report recruitment methods

J Immigrant Minority Health (2009) 11:380–390 381

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used to recruit Middle Eastern-American young adults for a

physical activity behavior study as well as analytic results

of those methods. Results of this study may be used to

verify or refute recruitment methods of Arab- and Middle

Eastern Americans for health research in general while

adding an unreported demographic to the literature.

Methods

Setting

A majority (92.1%) of participants were living in San

Diego County, California at the time of the study with

remaining participants residing in adjacent or nearby

counties. According to US 2000 Census data [40], there

were a combined *24,000 (0.85% of San Diego County

population) persons reporting Arab or Assyrian/Chaldean/

Syriac (ACS) ancestry. It is possible that this estimate

underreports the true county population, as a discrepancy

of nearly 13,000 Chaldeans is noted between Census 2000

and local [41] estimates. These figures exclude the county’s

Kurdish population—estimated at greater than 8,000

[41]—whose members were eligible for the present study if

their or their family members’ birthplace was an Arab

League nation (typically the Kurdistan region of Iraq).

Characteristics of the combined Arab and ACS population

of San Diego County include: 55.5% foreign-born; 53.4%

male; 41.3% younger than 25; 21.2% living below the

poverty level; and 20.9% of those 25 years of age and older

having at least a bachelor’s degree [40].

Project SALAAM-E

Before making local inquiries, the lead author, who is a

cultural, religious, and linguistic outsider to the commu-

nity, undertook a sustained period of inquiry into the

history, beliefs, and customs of Arabs and Muslims with

particular focus paid to Arab- and Muslim Americans and

their health behaviors. Additionally, the lead author con-

tacted The Arab Community Center for Economic and

Social Services (ACCESS; Dearborn, MI), a community

health service agency, and was advised that participation in

health research among this demographic required contact-

ing prospective participants actively and directly (i.e., face-

to-face) and working in schools as opposed to houses of

worship (D. Rabiah, personal communication, November

20, 2003).

Preparatory to the study’s inception, the lead author

contacted the Center for Islamic and Arabic Studies on

campus to solicit input as to how to conduct a study of

physical activity in San Diego. The center’s founder

assembled a panel of colleagues and graduate students

none of whom had a background in physical activity or

epidemiological research. After several meetings, between

which they solicited community feedback, they made the

following key recommendations: (1) Expand the popula-

tion focus of the study to include all persons whose native

origins were in Arab League countries regardless of reli-

gion or ethnicity; (2) conduct the study on college

campuses, where students would be more open to such a

study and would spread word back to their communities;

and (3) be willing to go out to meet students in groups and

at times and locations convenient to them.

Conducted in 2005, the Survey of Activity and Leisure

among Adult Middle Easterners (SALAAM-E) quantified

the amount and qualified the type of activity engaged in by

young adults of Middle Eastern origin living primarily in

San Diego. Eligibility for the study included age (18–29),

pregnancy status (not in 3rd trimester), and origin (oneself,

a parent, or a grandparent born in any of the Arab League

countries). The latter criterion opened up the study to non-

Arabs as well as persons who might not identify as Arab

American. (We subsequently used the more encompassing

term Middle Eastern in advertisements, questionnaires, and

conversations with participants but interchangeably use

Arab American and Middle Eastern American in this

paper).

Our initial recruitment plan was localized to our home

campus. We relied on flyer advertisements, classroom

presentations, colleague referrals, presentations at student

organization meetings, and snowball sampling through

participants who had completed the study protocol. After

the recruitment process slowed, we turned our attention

toward other campuses, community businesses and agen-

cies, and research assistant contacts.

Participants1 (N = 240; 50% male; 50% Muslim, 50%

non-Muslim) completed a 27-item questionnaire, which

included scales measuring religiosity and acculturation,2

and standard types of demographic questions (e.g., gender,

age, height, weight).

Participants wore an unsealed pedometer (Yamax Digi-

Walker SW-200) during waking hours for 7 days and

maintained a daily physical activity log, in which they

recorded step count, time wearing the pedometer, and

checked off which of 22 activities they engaged in on a

particular day and for how long. In all cases, participants

1 For analyses purposes, an adequate power of 0.80 was associated

with a minimum sample size of 180; an additional 60 participants

were recruited in case of missing or poor quality data.2 Acculturation was measured with the Acculturative Index [47],

which represents a composite score equal to [(length of residence

proportion 9 4) + (generation score - 1) + (self-identification

value - 1)]. Scores B5 were labeled low acculturation and scores

[5 were labeled high acculturation.

382 J Immigrant Minority Health (2009) 11:380–390

123

met with data collectors at times and locations convenient

for them and were compensated $25 upon completion of

the study. The study was approved by the Institutional

Review Board.

Analysis

Data for evaluating recruitment methods came from vari-

ous sources. Selected demographic data were derived from

questionnaire responses and analyzed descriptively using

SPSS 13.0 (Table 1). A participant file was maintained and

identified each participant by number, gender, age, reli-

gion, and recruitment source. When recruited through

snowballing, the participant referee was noted by number

in the recruitment source column for the new participant.

These data were analyzed descriptively through manual

calculations of frequency counts (Table 2) and percentages

(text).

An event log was also maintained and contained meet-

ing minutes, results of weekly surveillance of flyer status,

contact information of organizations and results of con-

tacts, and communication related to reasons for non-

participation as reported by the five data collectors through

Table 1 Select demographics (N = 240)

Frequency Percentage

Age

18–19 70 29.2

20–21 70 29.2

22–25 69 28.7

26–29 31 12.9

Residence

Outside parental home 128 53.3

With parents 112 46.7

Employment

Unemployed 98 40.8

Part-time 110 45.8

Full-time 32 13.3

Self-identity

More/Very ME 102 42.5

ME-American 83 34.6

More/Very American 55 23.0

Social circle

Mainly/Almost exclusively ME 84 35.0

Even mix of ME and non-ME 87 36.3

Mainly/Almost exclusively non-ME 69 28.7

Language preference with family and friends

Mostly/Only Arabic or other ME

language

66 27.5

Table 1 continued

Frequency Percentage

Equal amounts English and Arabic/Other 64 26.7

Mostly/Only English 110 45.9

Parental education

Mother

Did not graduate high school 47 19.6

High school graduate 39 16.3

Some college/college graduate 107 44.6

Graduate work or degree 47 19.6

Father

Did not graduate high school 38 15.8

High school graduate 21 8.8

Some college/college graduate 95 39.6

Graduate work or degree 86 35.8

Birthplacea

Participant

North Africa 15 6.3

Other Africa 21 8.8

Arabian Peninsula 22 9.2

The Levant 66 27.6

United States 103 43.1

Other 12 5.0

Mother

North Africa 41 17.1

Other Africa 22 9.2

Arabian Peninsula 8 3.3

The Levant 118 49.2

United States 36 15.0

Other 15 6.3

Father

North Africa 45 18.8

Other Africa 20 8.3

Arabian Peninsula 10 4.2

The Levant 129 53.8

United States 24 10.0

Other 12 5.0

Acculturation indexa

Not born in the United States

Low (B5) 104 76.5

High ([5) 32 23.5

Born in the United States

Low (B5) 9 8.7

High ([5) 94 91.3

Note: ME = Middle Eastern. North Africa includes Algeria, Egypt,

Libya, Morocco, Tunisia, and Western Sahara. Other Africa includes

Comoros, Djibouti, Mauritania, Somalia, and Sudan. Arabian Pen-insula includes Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, UAE,

and Yemen. The Levant includes Iraq, Jordan, Lebanon, Palestine,

and Syriaa Based on n = 239 (i.e., missing datum)

J Immigrant Minority Health (2009) 11:380–390 383

123

regular debriefings and e-mails. Lastly, e-mail sent to the

lead author by participants and prospective participants

related to the study were retained; those pertaining to

recruitment were filtered and content analyzed for verbiage

that explained successful or failed referrals. The authors

independently reviewed these materials and discussed to

consensus the critical events that facilitated and deterred

participation, which are found in this report.

Results

A demographic profile of study participants is found in

Table 1. Pluralities of participants were either 18–19 or

20–21 years of age (29.2% each), were employed part time

(45.8%), identified as more or very Middle Eastern

(42.5%), reported an even mix of Middle Eastern and non-

Middle Eastern friends (36.3%), spoke mostly or only

English with family and friends (45.9%), had parents who

attended some college or had a college degree (44.6%,

mother; 39.6%, father), were born in the United States

(43.1%), and had mothers who were born in Levantine

countries (49.2%). A slight majority of participants lived

outside the parental home (53.3%), had fathers who were

born in Levantine countries (53.8%), and were highly

acculturated (52.7%).

The types and results of recruitment methods that yiel-

ded participants appear in Table 2. Snowball sampling

yielded 48.3% of all participants, and for this study was

defined as a participant who successfully recruited one or

more additional participants into the study or provided

information that led to successful recruitment. In snowball

sampling, the researcher ‘‘asks each participant to suggest

others with similar ability to address the issues…[and] can

be a valuable one when the researcher does not know the

field…[or] when individuals with the knowledge or expe-

rience to provide rich data are difficult to reach’’ ([42],

p. 58). Flyer advertisement (15.8% overall, three cam-

puses) was the second most successful strategy followed by

contact with campus religious/cultural organizations and

attendance at their events (15.4% overall, three campuses).

Graduate research assistants’ (GRA) outreach efforts

directly contributed an additional 26 participants (10.8%).

The remaining 23 participants (9.6%) were recruited

through class presentations, departmental colleague refer-

rals, and other techniques.

We did not systematically ask participants why they

elected to participate. However, frequently and on an

informal level, participants voluntarily expressed reasons

for their participation: (1) The monetary incentive was

sufficiently appealing; (2) friends participated in the study;

(3) they were interested in learning about their physical

activity levels vis-a-vis pedometers; (4) they perceived the

study was for the community’s greater good; (5) they were

intrigued by the novelty of a research study focused on

Middle Easterners; or (6) some combination of factors.

Analysis of Recruitment Strategies

For succinctness, only recruitment strategies that yielded

10% or more of the total number of participants are pre-

sented: snowball sampling, flyer advertisement,

presentations at organizations’ meetings, and GRA outreach.

Snowball Sampling

To stimulate the snowball effect, participants were

informed at the intake appointment of the target number of

participants and of the researchers’ reliance on them

Table 2 Types and results of participant-yielding recruitment

methods

Type n # $ >/A ;AI :AI

Snowball 116 69 47 41 75 47 69

Flyer

Campus 1 19 7 12 6 13 6 13

Campus 2 16 10 6 4 12 5 11

Campus 3 3 1 2 0 3 1 2

Class presentations 5 2 3 2 3 2 3

Departmental colleagues 5 2 3 0 5 1 4

Organizations

Campus 1

ASU 12 2 10 8 4 8 4

MSA 3 3 0 3 0 3 0

Campus 2

MSA 16 9 7 16 0 7 9

Hillel 1 0 1 0 1 0 1

Campus 4

MSA 5 1 4 5 0 5 0

Graduate research assistants

Male Muslim 6 4 2 6 0 6 0

Female Muslim 20 7 13 17 3 11 9

Other

Librarian 9 0 9 9 0 8 1

Health fair 1 1 0 1 0 1 0

ISA social function 1 1 0 1 0 1 0

Personal acquaintance 1 0 1 0 1 1 0

Chance encounter 1 1 0 1 0 1 0

Total 240 120 120 120 120 114 126

Note: AI = acculturative index (;, low; :, high); ASU = Arab

Student Union; MSA = Muslim Student Association; ISA = Inter-

national Student Association

384 J Immigrant Minority Health (2009) 11:380–390

123

spreading word of the study to friends and relatives. They

were encouraged to share their participation experience

with anyone who fit eligibility criteria and encourage their

subsequent participation. An e-mail prompt concerning

sharing any potential contacts at the outtake meeting was

sent on Day 6 of the 7-day protocol. At the conclusion of

the outtake meeting, data collectors asked for any referrals

who agreed to be contacted about the study and e-mail or

phone information was provided with potential partici-

pants’ consent.

During the course of data collection, 22 distinct snow-

balls formed as a result of the outlined methodology—17

were initiated by females and 5 by males. Of 15 secondary

referees (i.e., referees within a snowball cascade), 12 were

male and 3 were female. A majority (81.8%) of snowball

events were two-generation in nature (i.e., a participant was

responsible for bringing in one additional participant and

then the chain stopped). Additionally, there were 1 three-, 2

four-, and 1 eight-generation snowballs, respectively. With

116 participants recruited through snowball methodology,

the mean snowball size, excluding the initial referee, was

5.6 (SD = 12.4) participants. The majorities recruited

through this technique were highly acculturated (67.2%),

non-Muslim (64.6%), and male (59.5%), respectively

(Table 2).

Figure 1 depicts an eight-generation cascade that rep-

resents the single largest snowball event. The scrolls on the

left numerically represent successive generations with the

cumulative number of participants recruited denoted by

subscript. The ovals on the right identify referees by

participant number when more than one participant from a

previous generation referred someone else. The numbers

within the rectangular boxes identify all participants

enveloped by the snowball by participant number. Lastly,

letter subscripts indicate the gender of the referee.

Within this particular snowball, nine males and two

females were responsible for initiating or perpetuating the

chain, which resulted in 60 participants (25.0% of the total

sample). A breakdown of the snowball provides insight

into the nature and complexity of the snowball recruitment

method. (For succinctness a participant will be referred to

by the letter ‘P’ followed by his or her participant number).

A collegial referral led the author to P83 who partici-

pated and also identified her brother (P94) as a potential

participant who was well connected within the Campus 2

Middle Eastern community. Besides participating, P94

indicated interest in assisting with recruitment along with

his friend (P110). Both were Christian males of Jordanian

and Syrian heritage, respectively. After their pool of on-

campus referrals dwindled, they were hired and trained as

recruiters and protocol administrators in order to reach

persons beyond the campus. Toward this end, both

attempted to establish contact with his respective church

and were unsuccessful: The priests indicated initial interest

in assisting but upon learning of the lead author’s last name

refused their church’s involvement because of political-

ideological differences. P94 shifted focus to soliciting

faculty teaching Arabic classes at two campuses to allow

him to make class presentations. Very few responded to his

repeated phone and e-mail queries and the few classes he

38 F

49 M

,111-106 ,69 671-571 ,131-031

,731 ,821 ,621 ,421 ,221042-532 ,132-622 ,422-212

021 M

251 ,831 ,721

471251 F

741 M831 M

871 M

981-881 ,581-381

781-681 591-391

69 M

011 M

581 M

12

2 31

3 44

4 74

5 94

6 05

7 55

8 06

981 M

Fig. 1 Schematic diagram of

largest snowball event across

generations

J Immigrant Minority Health (2009) 11:380–390 385

123

did address yielded no additional participants. P110 spent

vacation time in his hometown near Los Angeles and met

friends and family at their homes and on- and off-campus

residences, which resulted in an additional 25 participants.

Later in the cascade, a student (Fig. 1, Generation 6,

dashed line) who had seen a flyer advertisement contacted

us. Although ineligible because the target number of

female Muslim participants had already been reached, she

referred us to P178 who referred his sister and cousins to

the study (Fig. 1, Generation 7), who in turn referred their

friends to the study (Fig. 1, Generation 8).

The preceding vignette demonstrates the snowball

method’s potential for generating a critical mass of par-

ticipants. The success of the method in this study was the

product of tenacious querying of participants for procuring

referrals; dedication to following up these referrals and

establishing an initial rapport partly based on the referral’s

trust in the referee; and a large measure of serendipity.

Identifying key members of the participant pool who could

formally assist in recruitment on a for-compensation basis

was an additional mitigating factor.

Flyers

Bold colored flyers that briefly described the study, eligi-

bility criteria, and compensation; and had detachable tabs

containing contact information were posted on three cam-

puses. The majority recruited through flyers was non-

Muslim (73.7%), highly acculturated (68.4%), and female

(52.6%) (Table 2).

On Campus 1 (authors’ home campus), flyers were

posted at 42 different locations in 20 buildings and their

status regularly monitored during the spring semester. Only

40 (1.7%) tabs were taken of the possible 2,412 total during

the monitoring period with six tabs total being the most

removed from any venue over the course of inspection.

On Campus 2, posting flyers was a less laborious pro-

cess. University policy allowed unrestricted posting at the

main campus commons area where hundreds of adver-

tisements for research studies were regularly posted.

Although official monitoring was not conducted, nearly as

many participants as Campus 1 were recruited through

flyer advertisement under less difficult conditions.

Organizations

The general approach toward identifying campus organi-

zations was to initially access university web sites and

phone campus student services offices in order to deter-

mine whether a student club or organization by its name,

description, or purpose might have a Middle Eastern con-

stituency. Follow-up phone calls, e-mail, or both to an

organization’s listed contacts were made. When the contact

person or affiliated individual was reached, the lead author

introduced himself and briefly identified the study and its

purpose. Occasionally, a follow-up e-mail was required,

which included a summary of what the study was about and

why we wanted access to their members and study mate-

rials such as consent forms and questionnaire were

attached. When agreeable, organization leaders granted

permission to us to attend meetings to announce the study,

distribute flyers, recruit participants, and in some cases

administer the intake protocol. We realized the potential

efficiency and efficacy of recruiting participants in this

manner and were aware of the collective social affiliations

that are characteristic of many Middle Easterners; there-

fore, in order to improve the likelihood of cooperation, an

incentive of $10 per affiliated participant or any non-

member that participated as a result of an affiliated par-

ticipant’s referral (snowball technique) was offered to an

organization to be used in any manner deemed appropriate.

(This offer was also made to P189 and P204, who identified

themselves as members of non-campus-based Lebanese

and Somali church and social groups, respectively).

Table 2 shows the number of organization members

(excluding non-members who were ‘‘snowballed’’ into the

study) recruited in this manner.

Being in the right place at the right time: Arab Student

Union. On Campus 1, the Arab Student Union (ASU) was

only active during spring semester 2005. After consider-

able explanation and reassurance by the coauthor, the ASU

president allowed us to present at upcoming meetings.

Typically, most attendees were female and saturation was

quickly reached. However, the ASU set out weekly infor-

mation tables in the university commons, and we were

welcomed to table with them. Additionally, one member

recruited friends and family into the study, whom the lead

author met at the family’s residence.

A case of contrasts: two Muslim Student Associations.

Unlike the ASU, the Muslim Student Associations’ (MSA)

memberships were partially composed of students who

were ineligible for the study based on nationality, which

posed an impediment on Campus 1, where the president

and vice-president of the MSA were Iranian and Afghan,

respectively. We made repeated attempts to contact them

and once formal contact was established ensuing commu-

nication demonstrated lengthy response latency. These

gatekeepers were cordial and respectful but not overly

enthusiastic toward the study and questioned why the focus

was on Arabs, thereby excluding their own participation.

Nevertheless, they permitted us to make several presenta-

tions at meetings throughout the semester, but in our

presence did not overtly encourage members. (There was

some overlap of the ASU and MSA membership that may

have contributed to a relatively weaker response by the

386 J Immigrant Minority Health (2009) 11:380–390

123

MSA considering the organization was contacted later than

the ASU. Additionally, the ASU was headed by an eligible

participant).

In contrast, the response of the MSA on Campus 2 was

much different. The vice president’s (P64) mother was a

close friend and colleague of the coauthor’s and encour-

aged her son to participate and help publicize the study. We

were invited to present at MSA’s regular Thursday night

Islamic Studies meeting. The MSA president and P64 (vice

president) were grateful for the group monetary contin-

gency that was offered and this aspect was reframed and

presented as sadaqah, the Islamic concept of extra charity

(beyond obligatory zakat). In addition to this meeting, the

lead author was welcomed to Friday afternoon Jummah

prayers, when the largest gathering of the organization’s

members and non-affiliates came to pray and listen to a

sermon. The lead author was given time during

announcements to announce the study, after which mem-

bers voluntarily approached him while P64 brought over

shier members.

Graduate Research Assistants (GRA)

Two GRAs (one is the coauthor)—both religious Muslims,

fluent speakers of Arabic, and ineligible for the study due

to their age—assisted in recruitment and protocol admin-

istration. Both were passionate about the study’s premise

and through assisting earned independent study credit

toward their respective Masters degrees in Exercise and

Nutritional Sciences.

Of the 26 participants they recruited, 88.5% were

Muslim, 65.4% were less acculturated, and 57.7% were

female (Table 2). Work associations, and random and

planned social encounters were channels by which they

independently recruited participants. Both were reticent of

approaching unknown members of the opposite sex, in

accordance with Islamic values. However, the male GRA’s

wife, a more acculturated and noticeably outgoing librarian

at Campus 4 (Table 2, Other), approached female Middle

Eastern-looking students in the library, and this approach

yielded nine female Muslim participants. The coauthor was

particularly effective in recruiting less acculturated par-

ticipants, particularly religious females who trusted her as a

co-religionist. She was adept at transparently explaining

the study and its purpose to participants and tying in Arab

and Muslim community ethos during personal encounters.

Problems Encountered

Despite it taking only 255 days to recruit all 240 partici-

pants, there were a number of events and factors that

prevented earlier completion of the study. First, the most

neutral term we could think of using to describe the par-

ticipants we were looking for was ‘‘Middle Eastern.’’

However, to avoid excessive inquiries from persons who

would have been ineligible, a list of countries of origin was

included on flyers and in presentations with a disclaimer

that persons of any religious faith with origins from one of

those countries were eligible. Nevertheless, we occasion-

ally experienced resentment from persons not of those

countries who may have known eligible persons but would

not refer them to us or vice versa; and by including Pal-

estine, there was one documented instance where a female

student voiced anger during a presentation as to the

exclusion of Israel and inclusion of Palestine and how she

would never participate even though she was eligible

through her grandparents’ birthplace.

Second, on our home campus, we could not get past

bureaucratic hurdles designed to limit synchronous access

to the entire student body in accordance with university

regulations. We were rebuffed or made to follow lengthy

due process to electronically advertise through various

large-scale channels and decided to abandon the effort.

Third, on Campuses 1 and 2, a number of operating

student organizations were splinter advocacy groups for

larger organizations that we had already contacted and thus

turned out to be dead ends. Other organizations that were

cultural in nature (e.g., Somali Student Union, Horn of

Africa, ASU, Coptic Club) either dragged their feet for such

time as to make us abandon our outreach attempts, flatly

denied our request, or deferred by stating that their orga-

nization was loosely organized and not meeting regularly.

Fourth, in the community, even when some extant

connection was tapped, the resultant product was nil. A

recent immigrant from Egypt, working at a local super-

market and referred by a coworker, would not participate

for fear of his immigrant status being used against him. An

Arab restaurant and supermarket were contacted and

seemingly positive meetings were held with the proprietors

who knew the coauthor, yet we were unsure if flyers given

to them were ever hung as we did not feel comfortable

following up with or pressing these persons further. The

health and welfare representative at one community out-

reach organization—which served Iraqi Kurds, Shiites, and

Chaldeans—met with the lead author, was supportive of

the study, and took flyers for distribution, but again our

instinct was not to follow up and no referrals came from

this source. The House of Palestine cultural group met with

us at its monthly business meeting and was supportive in

principle but only informally offered to disseminate the

existence of the study to its members. Unreturned phone

messages categorized our one attempt at contacting a

Sephardic Jewish rabbi with knowledge of eligible students

through his campus ministry.

J Immigrant Minority Health (2009) 11:380–390 387

123

Fifth, access to the ACS community was closely guar-

ded by one clergy member who on the community web site

indicated a distrust of Muslims; and a Chaldean graduate

student declined to assist in recruiting because it was his

belief that Chaldeans would be weary of wearing a

pedometer. Of the participants who were ACS, some made

attempts to speak with the head priest on our behalf, but

subsequently expressed discomfort doing so. (The authors

were advised not to cold call the church). During one

outtake meeting, over the course of several extra hours of

conversation, a Chaldean participant (P201) asked the lead

author to teach her about his religion. At various junctures

during the conversation, P201 volunteered that she was

taught differently about his faith and people by her parents,

family, and church and felt that many of her friends’ atti-

tudes were similar to hers, which bore tinges of

stereotypical thinking. These events in concert suggest that

targeting the ACS community directly without a respected

inside contact in support of the study was misinformed and

ACS participation was chiefly the result of snowball and

flyer methods used on campuses.

Sixth, medical doctors expressed interest in assisting

with recruitment in their communities. In one case, a

Somali doctor, who had practiced in the UAE initiated

contact with the lead author having heard about the study

from a Somali student. However, he was looking for

employment and expected to be compensated beyond the

lead author’s means. In a second case, P113’s father ran a

pediatric and young adult medicine clinic that catered to

Middle Eastern persons and was also on the Board of

Directors of the city’s Islamic Center. P113’s intent was to

recruit participants at his father’s practice over the summer;

however, he received late notice of acceptance into medical

school and relocated.

We did not systematically query non-participants as to

their reasons for declination. However, recruiters identified

the following reasons for non-participation based on

informal conversations with non-participants: (1) They did

not know of anyone who was eligible; (2) did not have the

time or resolve to participate or contact others; (3) claimed

their own or acquaintances’ lack of interest in the study; (4)

found it to be too involved or require too much effort; (5)

were reluctant to wear the pedometer due to inconvenience,

discomfort, fear of being under surveillance, or the device

being construed by others as threatening or a weapon; (6)

were concerned about repercussions from responding to

portions of the questionnaire regarding citizenship status,

language use, and religiosity; (7) felt that their answers

would result in them being branded as radical or too liberal;

(8) claimed that the compensation for participation was

insufficient; (9) felt the study’s purpose was a pretense for

some underlying negative motive directed at Middle

Eastern persons; or (10) some combination.

Discussion and Lessons Learned

A purposeful mixed-method recruitment strategy was used

to obtain an adequately sized sample of Middle Eastern

American young adults, similar to procedures used in other

studies recruiting ethnic minority groups with heteroge-

neous membership [43, 44]. Relying on one or two

methods would have proved insufficient for ample

recruitment or would have extended the time required to

recruit 240 persons, similar to what Barry encountered

[39]. While recruitment methods need to be planned in

advance, methods need to be adjusted in response to events

at hand, particularized for specific venues and subgroups,

and be implemented at multiple sites.

Peripheral, evidential, linguistic, constituent involving

and sociocultural adaptations recommended by Kreuter and

colleagues [34] were all incorporated in the study with the

latter two being most prominent.

To address constituent involvement, we recommend the

inclusion of input from those who perform research and are

also members of the community of interest (i.e., academic

colleagues from the Center for Islamic and Arab Studies)

during the planning stages of a study. Without their unique

knowledge, it is quite possible that a major error in judg-

ment may have been made that would negatively impact

recruitment. Staffing with members of the community,

particularly in roles that interface directly with participants,

is another important piece of constituent involvement. We

employed male/female and Muslim/non-Muslim Arabs,

which helped in gaining access to individuals and groups.

We were not as effective recruiting from the large East

African community in San Diego, which may have

reflected the absence of a Somali research assistant or

someone who spoke the language or knew the customs

(i.e., Somalis are typically not Arab).

To address sociocultural adaptations, we recommend

that researchers be versed in the social dynamics, cus-

toms, language, and beliefs of the target population. For

example, incentives were reframed in Islamic terms as

charity when interacting with Muslim organizations.

Findings and recommendations specific to Arab American

recruitment [38, 39] were corroborated in this study:

Experts’ recommendations were not always accurate;

some non-participants were concerned about the study

casting Arabs in a bad light; community gatekeepers were

not particularly nor uniformly helpful; personal contact

was a successful means of recruitment; ample budgeting

of time but not money (only $10,000 was available) was

required; and access was facilitated by assistants who

were also community insiders.

Strategies aimed at the community (e.g., houses of

worship, businesses, community outreach organizations)

were only tepidly pursued per expert recommendation and

388 J Immigrant Minority Health (2009) 11:380–390

123

in most cases failed. In hindsight, we see the need for

establishing connections early with off-campus community

leaders who have connections with the young adult

demographic we were seeking. Clearly presenting our

objectives and connecting the study to the entire commu-

nity’s welfare while identifying suitable reinforcement for

cooperation may have resulted in additional recruits.

At the organizational level (e.g., social- and religious-

oriented clubs), a more focused approach was aggressively

pursued, which included organizational incentives and

results were more positive, yet still inconsistent. While

extremely convenient for the researchers, presentations

took away from regularly scheduled agenda items and were

sometimes not made known to members beforehand. We

recommend getting in touch with campus organizations

very early in a semester so they can commit to a presen-

tation without it interfering with other business. Providing

refreshments and prizes in addition to the monetary

incentives may increase positive response.

At the individualistic level, a combination of active (i.e.,

personal contacts with the authors, assistants, and previous

participants) and passive (i.e., flyers) recruitment strategies

yielded the most successful response. Personal face-to-face

contact also characterizes the most successful recruitment

method of other studies of Arab Americans’ health behavior

[36, 38], whereas the less successful passive methods of this

study were utilized with more success in studies conducted

by research teams composed of at least one community

insider who was not a graduate student, in denser Arab

American communities, and with older community

members [22, 35, 37]. We recommend active recruitment

strategies that engage participants convivially and not

clinically (i.e., establishing a respectful and personal rela-

tionship with participants that extends beyond labeling them

as P1, P2, etc.).

Combined, the success of individualistic and organi-

zational methods employed in the present study may be

attributable to several explanations singularly or in

combination: (1) a desire to educate an outsider (lead

author) so he could realize the value or truth of Islam

[45] and clear up misperceptions associated with Arab

Americans; (2) a good fit of snowball methods for this

sample, whose self-identity and social circle were pre-

dominantly skewed toward Middle Easterners (Table 1);

(3) a sample that was more educated and more receptive

to research (i.e., 54.2 and 75.4% of participants’ mothers

and fathers, respectively had at least some college edu-

cation); (4) a sample that was linguistically comfortable

with English (Table 1); (5) data collectors who were

willing to meet with participants at times and places

convenient to the latter; and (6) energetic assistants who

were community insiders and who were diverse reli-

giously and culturally.

Limitations and Key Suggestions

We acknowledge the limitations of this study as being

context specific to demographic (young adults who pri-

marily were attending college), region (southern

California), time (4 years after the events of September

11, 2001) and purpose (observational study of physical

activity behavior). We were also somewhat unsystematic

from a methodological standpoint, as we used multiple

strategies and shifted between them based on their effi-

cacy with a certain subgroup; however, such an approach

is noted in the literature [39, 43, 46]. Similar to other

studies [38, 46], it is impossible to disentangle the effect

of any one strategy from others because in some cases

multiple methods acted synergistically but in unquantifi-

able ways. For example, when a faculty member

announced the study on Campus 2, he was told by his

students that they had already participated or knew of the

study through flyers or friends.

Key suggestions for recruiting from this demographic

include outsiders learning about the target group as a

gesture of respect and goodwill, foregrounding active

recruitment strategies, stimulating the snowballing effect

through systematic follow up of participants, allocating an

additional monetary incentive for every successful referral,

including insiders in the planning and recruitment stages,

budgeting large chunks of time for travel, as well as being

flexible to accommodate the contingencies for participation

posed by the prospective participant. Additional accounts

and analyses of methodology employed in studying

minority health are welcomed, whether they are particu-

laristic or reinforce findings obtained under different

conditions.

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