Lessons learned recruiting a diverse sample of rural study participants during the COVID-19 pandemic

Residents of rural areas have been a hard-to-reach population for researchers. Geographical isolation and lower population density in rural areas can make it particularly challenging to identify eligible individuals and recruit them for research studies. If the study is about a stigmatizing topic, such as opioid overdose, recruitment can be even more difficult due to confidentiality concerns and distrust of outside researchers. This paper shares lessons learned, both successes and failures, for recruiting a diverse sample of rural participants for a multi-state research study about naloxone, an opioid overdose reversal agent. In addition, because our recruitment spanned the period before and after the COVID-19 pandemic in the U.S., we share lessons learned regarding the transition to all remote recruitment and data collection. We utilized various recruitment strategies including rural community pharmacy referrals, community outreach, participant referrals, mass emails, and social media with varying degrees of success. Among these modalities, pharmacist referrals and community outreach produced the highest number of participants. The trust and rapport that pharmacists have with rural community members eased their concerns about working with unknown researchers from outside their communities and facilitated study team members' ability to contact those individuals. Even with the limited in-person options during the pandemic, we reached our recruitment targets by employing multiple recruitment strategies with digital flyers and emails. We also report on the importance of establishing trust and maintaining honest communication with potential participants as well as how to account for regional characteristics to identify the most effective recruitment methods for a particular rural area. Our suggested strategies and recommendations may benefit researchers who plan to recruit underrepresented minority groups in rural communities and other historically hard-to-reach populations for future studies.