Nursing and Health Sciences (2010), 12, 369374

Research Article

Recruitment of hard-to-reach population subgroups via

adaptations of the snowball sampling strategy nhs_541 369..374

Georgia Robins Sadler, bscn, mba, phd,1,2 Hau-Chen Lee, bsc,4 Rod Seung-Hwan Lim, bsc4 and
Judith Fullerton, phd, cnm, facnm3
1
Department of Surgery, School of Medicine, University of California San Diego, 2Community Outreach, Moores
University of California San Diego Cancer Center, 3Project Concern International, San Diego and 4University of
California La Jolla, California, USA

Abstract Nurse researchers and educators often engage in outreach to narrowly defined populations. This article offers
examples of how variations on the snowball sampling recruitment strategy can be applied in the creation of
culturally appropriate, community-based information dissemination efforts related to recruitment to health
education programs and research studies. Examples from the primary authors program of research are
provided to demonstrate how adaptations of snowball sampling can be used effectively in the recruitment of
members of traditionally underserved or vulnerable populations. The adaptation of snowball sampling tech-
niques, as described in this article, helped the authors to gain access to each of the more-vulnerable population
groups of interest. The use of culturally sensitive recruitment strategies is both appropriate and effective in
enlisting the involvement of members of vulnerable populations. Adaptations of snowball sampling strategies
should be considered when recruiting participants for education programs or for research studies when the
recruitment of a population-based sample is not essential.

Key words diversity, hard-to-reach populations, non-probability sampling, recruitment, research strategies, snowball
sampling.

INTRODUCTION 2008). Belief systems that are linked to cultural norms about
engagement in health-care services or a history of prior
Nurses are engaged in a wide variety of research, clinical
abuses of minority groups during the research process also
care, and client education roles. Many of these roles involve
could interfere with participation (Russell et al., 2008). Isola-
the need to reach out to populations that are difficult to
tion from the mainstream sources of information due to geo-
identify and contact because they are traditionally under-
graphical, transportation, and economic barriers can be
served, vulnerable, or must fit within a set of narrowly defined
equally troublesome in securing participation from members
characteristics.
of diverse communities (e.g. residence in geographical com-
People who are traditionally underserved might be harder
munities that are a significant distance from a study center)
to reach because of a variety of personal or sociodemo-
(Fahrenwald & Stabnow, 2005). Furthermore, some age
graphic characteristics. For example, within most countries,
groups can be hard to reach, such as children, adolescents,
residents rely upon diverse languages as their preferred
and the elderly (Stoltz et al., 2007; Bjorkhaug & Hatloy,
mode of communication and that can prevent potential par-
2009).
ticipants from accessing disseminated information about
Equally difficult to contact for inclusion in service pro-
health programs and research studies from which they or
grams or to recruit for participation in research studies are
others in their circle of family and friends might derive the
those in which the target group has become stigmatized,
benefits of scientific advances. Lower literacy levels in the
either by personal circumstance or by association. Examples
language of their adopted country and sometimes in their
include: people living with HIV/AIDS and their family (Valle
native language also might make a portion of the population
& Levy, 2008); abused women (Lutz, 2005); substance abusers
more difficult to reach. Some cultural groups are reluctant to
(Vervaeke et al., 2007); commercial sex workers (Todd et al.,
volunteer personal information because of the risk of social,
2007; Shahmanesh et al., 2009); and members of the gay,
political, or other discriminatory repercussions (Tung et al.,
lesbian, or transgender communities (Browne, 2005; Gorbach
et al., 2009).
The effect of these constraints is a limit on the number and
Correspondence address: Georgia Robins Sadler, Moores UCSD Cancer Center,
diversity of the participants that can be gathered for health
3855 Health Science Drive MC 0850, La Jolla, CA 92093-0850, USA. Email:
gsadler@ucsd.edu promotion intervention activities and/or research studies. A
Received 9 November 2009; accepted 22 June 2010. particular adverse impact in the research context is that the

2010 Blackwell Publishing Asia Pty Ltd. doi: 10.1111/j.1442-2018.2010.00541.x

370
accrued sample might be neither large enough nor suffi-
ciently representative of the at-large population to achieve
results that can be generalized to the larger group.An equiva-
lent concern arises when vital services do not reach all
members of the group who could benefit from them. Recruit-
ing these diverse individuals requires culturally sensitive, cus-
tomized recruitment strategies.
Snowball sampling was conceptually designed as a sample
recruitment method that offered a way to overcome many of
the recruitment challenges associated with inviting difficult-
to-reach communities to join health-care intervention pro-
jects or research studies. The experience that was gained over
many years of use generated a body of knowledge about both
the benefits and limitations of the basic approach. Adapta-
tions of the basic approach then were developed in order to
extend the effectiveness of the strategy in identifying hard-
to-reach and hidden populations and to expand the character
of the achieved sample in order to make it more representa-
tive of the general population among whom these hidden
populations reside (Magnani et al., 2005). This article offers
examples from the primary authors personal research in
order to demonstrate how adaptations of the snowball sam-
pling technique can be used to improve outreach efforts for
health education programs and research studies assessing
health education interventions.
DESCRIPTION OF THE TRADITIONAL
SNOWBALL SAMPLING TECHNIQUE
The snowball sampling technique is modeled after contact
tracing in public health, in which one individual names all
the other individuals who were associated with a specific
event. The snowball sampling outreach strategy finds an
individual (the source, also referred to as the seed) who researcher or program coordinator.
has the desired characteristics and uses the persons social
networks to recruit similar participants in a multistage
process. After the initial source helps to recruit respondents,
the respondents then recruit others themselves, starting a
process analogous to a snowball rolling down a hill (Wasser-
man et al., 2005). Thus, the semi-self-directed, chain-referral,
recruiting mechanism is able to reach the hard-to-reach
target group in a more pragmatic and culturally competent
way.
Advantages of using snowball sampling strategies
The benefits of the classic snowball sampling technique are
considerable. The personal aspects that are inherent in these
techniques often shorten the time and diminish the cost
required to assemble a participant group of sufficient size
and diversity to be representative of the specific target
group. The technique is often more efficient and sometimes
less expensive than using traditional recruitment strategies
to gather participants in proportion to the focus community.
Consider the situation in which the community from
which a studys participants are sought is small and so well
integrated with the mainstream community that it is
2010 Blackwell Publishing Asia Pty Ltd.
G. R. Sadler et al.
difficult to identify individual group members. For example,
researchers who seek representative numbers of Pacific
Islanders and Filipinos will discover that the surnames in
those communities are often of Hispanic or French descent
due to the prior imposed occupation of those countries.
Community informants can help to identify which individu-
als with potentially eligible surnames are actually from
the community of focus, as well as those who, through
marriage, have lost surnames that link them to a specific
community.
Another situation that can benefit from snowball sampling
occurs when representation from diverse communities is
needed and it is impossible for the research team to include a
representative of all the communities sought. The team might
discover that it will have a difficult time distinguishing
members of the subgroups that are nested within the larger
community; for example, the diverse Asian community. In
this example, a member of one community subgroup usually
will know the subgroups distinctions and be able to guide the
research team to members of each subgroup and they will, in
turn, know others.
A third example of the benefit of snowball sampling is that
it can help researchers to identify study participants where
there are multiple eligibility requirements; this is particularly
so when the studys eligibility criteria involve characteristics
that some people consider to be very private (e.g. participants
whose partner gave them a sexually transmitted infection or
teenagers whose pregnancy is out of wedlock). However, if
one eligible person is identified, that person often can iden-
tify and recruit others to the study.
A particular advantage of snowball sampling is its cultural
competence and the inherent trust it engenders among
potential participants.This can help to increase the likelihood
that the identified person will agree to talk with the
Disadvantages of using snowball sampling strategies
The use of probability sampling methods is considered to be
the gold standard for recruiting participants who are most
likely to be representative of the larger population from
which they are drawn. Thus, the downside to classic snowball
sampling in the research context is that it is a non-probability
method; that is, it does not recruit a random sample. Partici-
pants do not enroll in the health intervention program or
research study by chance alone. Any conclusion that is
reached in a study that used a snowball recruitment strategy
might be biased; for example, the sample might include an
over-representation of individuals with numerous social con-
nections who share similar characteristics (Magnani et al.,
2005). However, even probability sampling strategies have
inherent bias. Probability sampling is intentionally conducted
by study recruiters who randomly contact potential partici-
pants who are drawn from a community-wide database.
These recruiters, by definition, have no prior relationship
with the potential participants who they are contacting. In
marketing jargon, this would be the difference between a
warm call (a call to ask a favor of someone with whom the
Hard-to-reach populations
marketer already has a prior positive relationship) and a
cold call (a call to ask a favor of random contacts with
whom no prior relationship has been established). A high
refusal rate is commonplace under the latter circumstances,
thus contributing to a type of self-selection bias that can
confound study outcomes.
Another inherent bias in probability sampling is that it
tends to generate a sample that is unbalanced in selected
demographic characteristics. For example, people from
higher socioeconomic groups and those with higher educa-
tion levels are more likely to understand the value and risks
of research participation and are more able to discern which
research studies are legitimate. Therefore, they are more
likely to be responsive to invitations to participate when
random sampling strategies are used.
An additional limitation of snowball sampling in the
research context is the fact that there is no statistically reli-
able way to estimate whether saturation of the sample has
been reached. This is particularly important in qualitative
research because, in that body of work, saturation is
defined as when no new information is forthcoming from the
participants in the sample that has been recruited already.
Therefore, it is not possible to know whether new or other
information could be gleaned had a random sample been
recruited.
Finally, though snowball sampling has the advantage of
helping researchers to identify potential study participants
and helping educators to identify individuals who might
benefit from participation in a health intervention, the tech-
nique does carry the inherent risk of disclosure of personal
information to others. The sources might be reluctant to
contact other individuals whom they believe to have a certain
characteristic, as that might represent a disclosure of infor-
mation about themselves or information that has been
obtained in a personal and private context. The named indi-
viduals, when contacted by the source, are faced with the
challenge of deciding whether to disclose information about
their personal status to the outsider in order to declare their
eligibility for participation in the health intervention pro-
gram or research project.
Achieving sampling balance
Thus, in relation to both probability and non-probability sam-
pling methods, there can be concern regarding the generaliz-
ability of the study findings. However, in these circumstances,
sampling adjustments can be made. For example, randomly
selecting participants from the larger pool of potential par-
ticipants that were recruited through the chain-referral
method can compensate to some degree. Recent advances
in the methodology of snowball sampling have attempted
to incorporate anticipatory compensation for these poten-
tial imbalances in the recruited sample. The methodology
of respondent-driven sampling is one such adaptation
(Salganik, 2006). In addition, some compensation can be
accomplished for sampling imbalances through the applica-
tion of statistical manipulations during the data analysis
phase (Knoke & Yang, 2007).
371
ADAPTATIONS AND VARIATIONS:
DESCRIPTIVE APPLICATIONS
Table 1 provides examples of variations and adaptations of
the snowball sampling strategy, as used in research and edu-
cation programs with which the primary author has been
associated. In addition to recruiting to her own research
studies, she has been funded by the National Institutes of
Health in the USA to help other researchers to develop
effective recruitment strategies for people who are com-
monly under-represented in such programs. These examples
are offered to demonstrate the ways in which this recruitment
technique has been applied effectively to reach members of
under-represented groups. The provided examples demon-
strate the use of a broad variety of sources, including indi-
viduals (e.g. business people) (Sadler et al., 2007), formal and
informal group leaders (e.g. business leaders) (Sadler et al.,
1998), elected officers of business guilds and social leagues
(Matteson et al., 2008), affinity and social groups (Choe et al.,
2009), and third-party entities (e.g. membership lists or tele-
phone directories) (Wu et al., 2005). These examples demon-
strate the adaptability and flexibility that are inherent in
non-probability sampling strategies that are based on the
concepts that are inherent in the snowball sampling strategy.
Personal communication is fundamental to the snowball
sampling process. For example, participants at health fairs
can be viewed as potential sources who can be invited to
participate themselves and to facilitate the recruitment of
others. The individual contacts are first given information
about a study or program for which they might be personally
eligible. Then, they are asked to pass the information along to
other individuals whom they know and for whom the infor-
mation might be relevant. For example, women who learned
about a study were asked to host health parties in their
homes, where multiple other attendees could be recruited
simultaneously (Sadler et al., 2006).
Another example of this strategy is accomplished when
outreach workers identify community sources that have an
appreciation of the value of spreading program and research
information to their community members. The outreach
workers share information about one or more studies with
the community sources and ask them to address flyers to
potential participants with a note saying, Sending this to you
in the hope that you will know someone who might be eli-
gible. Please call me if you would like more information.
(This non-personalized message avoids disclosing personal
information about the recipients presumed eligibility should
another person read the recipients mail.) Alternatively, a
community source might prefer to phone potential partici-
pants directly. For research study recruitment, this must be
accomplished in a way that precludes the disclosure of per-
sonal information to the outreach worker until the potential
participant gives the source permission to do so. In this
example, community sources are like the connectors and
mavens whom Malcolm Gladwell (2002) described in his
book, The Tipping Point: How Little Things Can Make a Big
Difference.
There are additional variations and adaptations of the
classic snowball sampling strategy that are less precise in
2010 Blackwell Publishing Asia Pty Ltd.
 Table 1. Examples of adaptations and variations of the snowball recruitment strategy 372

Snowball sampling Who/what is the Who is the direct Who is the indirect focus of Manner of application of the
framework source? focus of the source? the source? Study focus Outcome measures adapted strategy

Affinity resources Chamorro Directory 100 adult men and 100 Other qualifying Health practices and Behaviors related to The social directory was provided to the
International adult women of the Chamorro adults not prevention assessment participation in health research team by the collaborating
Chamorro community listed in the Directory of the Chamorro screening and risk communitys leaders
(indigenous to Mariana community factor management; The directory entries were numbered; the calls
Islands) of all ages comprehensiveness of were placed in computer-generated random
the directory order
The participants were asked to name three
other Chamorro community members to test
the inclusiveness of the directory
Affinity organizations Deaf Community Deaf or Other deaf or Cancer education Changes in The organization sent postal and electronic
Services of San Diego hard-of-hearing adults hard-of-hearing adults interventions cancer-related mail to its membership; the members were
(multiple studies) knowledge, attitudes, asked to pass along the information to their
and screening associates

2010 Blackwell Publishing Asia Pty Ltd.

behaviors Organization-sponsored community events
were opened to the researcher
Affinity social groups Deaf bowling league Deaf adults Family and friends Computer-based Effectiveness of an The research team was introduced to the
leader with the same dietary and exercise interactive computer league members who self-declared their
characteristics intervention education program interest by initiating dialogue with the
when used by research team
members of the Deaf The league members then passed the
community information to others or introduced the team
to other community members
Affinity social groups An elected official African American men Family and friends Glaucoma research Defining the reference An elected official encouraged the leadership
notified the leadership and women aged with the same levels for normal to invite the study coordinators to make a
of an inner-city AARP 50 years characteristics intraocular pressure presentation about the study
group about the study and the characteristics The members were asked to consider their
among age-appropriate personal participation and to invite friends
African Americans and families to do so
Affinity businesses African American Adult African Other similar clients Cancer and diabetes Changes in cancer- and The stylists initiated the recruitment among
cosmetologists American women literacy and screening diabetes-related their clients and asked the clients to
promotion knowledge, attitudes, disseminate what they learned to others
and screening
behaviors
Affinity businesses Asian grocery store Adult women of Their loved ones Efficacy of a cancer Changes in The opportunity to participate was conveyed
owners Pan-Asian descent education intervention cancer-related via volunteer community health educators
offered at a convenient knowledge, attitudes, through personal contacts made at the grocery
community site and screening store
behaviors The contacts were asked to pass along the
information to others
Affinity businesses Community Asian, Hispanic, and The readership Multiple studies open Changes in knowledge A news article presented information about a
newspapers African American to recruitment and behavior related health problem and the opportunity to
editors to glaucoma, breast participate in a study addressing the problem
cancer, and exercise and asked readers to pass along the
information to others
Community leaders: African American Adult African Family and friends Efficacy of a spousal Changes in mood The sources initiated recruitment among their
formal and informal church leaders, barbers, American couples with the same problem solving states and clients and social networks and asked their
community leaders Brotherhood of Black coping with prostate characteristics therapy intervention problem-solving skills clients and friends to recruit other participants
Firefighters, and Black cancer
Men United
G. R. Sadler et al.
Hard-to-reach populations
definition, but that can be considered when designing a par-
ticular population-based outreach strategy. For example,
there are times when the initial source might not need to
make direct contact, but instead will use his or her mantle of
authority to convey approval that the information be shared.
For example, recruitment brochures that are placed in church
bulletins carry the implied and actual support of the church
leadership. Similarly, study notices that are placed in commu-
niqus that are sent by elected officials to their constituents
carry a similar tone of endorsement. Other examples of such
recruitment strategies include program recruitment litera-
ture that is appended to the newsletters that are disseminated
by home owners associations, inserted into water and elec-
tricity bills, or printed on grocery store and other retail
receipts.
The ever-expanding social networking capacity of the
Internet community has generated additional options for the
dissemination of recruitment materials. Examples of these
social networking options include targeted email communi-
cations, individual or institutional Internet home pages, or
social networking sites, such as blogs and such Wiki sites as
Facebook, MySpace, LinkedIn, and Plaxo (Bowen et al.,
2004). Recruiters can place descriptions of research and edu-
cational opportunities on these sites for widespread dissemi-
nation. Then, the respondents can contact the recruiter
directly, contact the person (the seed) who sent the recruit-
ers message to them, or forward the message to others in
their social circle, which is the essence of the snowball sam-
pling strategy.
SPECIAL CONSIDERATIONS WHEN
RECRUITING PARTICIPANTS FOR
RESEARCH STUDIES
The international community recognizes that the protection
of human participants privacy is a primary consideration
when engaging participants using any recruitment strategy.
International agreements have generated universal prin-
ciples for research ethics. When the purpose of the recruit-
ment is to attract participants for research studies, special
attention must be given to assuring adherence to these
national and international ethical guidelines (Brody, 1998;
Claudot et al., 2009). In the context of the snowball sampling
variations described above, researchers must take care to
protect the privacy of both the source (the seed) and those
who are being invited to participate. It is critical that com-
munications do not disclose or imply the disclosure of per-
sonal information about either party. Although this privacy
protection is mandated by ethical review boards for research
study recruitment, it should be of equal concern for recruit-
ment to educational and support programs.
These same considerations hold true when communica-
tions are conducted through the Internet. The Internets
rapidly evolving capacities are creating extraordinary social
networking opportunities for educators and scientists. It is
imperative that both groups stay alert to these new opportu-
nities as they emerge, while also staying abreast of evolving
international human subject regulations that address the
373
rights of personal privacy when using these public discussion
forums.
DISCUSSION
Snowball sampling strategies have evolved from many of the
concepts that have been developed for the field of social
marketing (Kotler et al., 2002). Social marketing describes
the phenomenon of reaching people with an action-
prompting message. Narrowcasting is a term that has
emerged to describe the impactful dissemination of a
message to a narrowly defined and often hard-to-reach audi-
ence. In order to achieve their goals, social marketers also
borrow from the sales force such promotion techniques as
guerrilla marketing, buzzmarketing (Hughes, 2005), and
permission marketing (Godin, 1999) in order to create
effective contact and promotion strategies.
However, unlike the sales marketing force, those con-
cerned with recruitment to research studies and health edu-
cation opportunities must be ever-vigilant about protecting
the privacy of patients and the public. International human
subject guidelines place researchers and the providers of
health-related services and information in a position of
higher accountability for maintaining privacy than any other
sales force. The consequences of non-compliance with
these guidelines range from a reprimand to the closure of a
research study to the disqualification of a researcher from
engaging in future research.
CONCLUSIONS AND IMPLICATIONS FOR
CLINICAL PRACTICE
The need to find more effective and efficient recruitment
strategies is paramount. Snowball sampling is a recruitment
strategy that is particularly effective in reaching hard-to-
reach groups. Variations on this technique have proven to be
adaptable and appropriate in a wide variety of education and
research applications. The benefits and limitations of these
adaptations of snowball sampling, when used in the research
context, must be carefully evaluated against the benefits and
limitations of probability sampling in order to select the
optimal strategy. The benefits of using these approaches to
recruit participants for health intervention programs must be
weighed against the privacy concerns that are inherent in any
individual social situation or health condition.
ACKNOWLEDGMENTS
This study was funded by grants from the National Cancer
Institute (R25CA65745, P30CA023100, U54CA132379/
U54CA132384, and U56CA92079/U56CA92081) and the
National Institutes of Health, Division of National Center
on Minority and Health Disparities-sponsored UCSD Com-
prehensive Research Center in Health Disparities (P60
MD000220). The protocol for all of the research projects that
are described in this article have been approved by the
UCSD Human Research Protections Program.
2010 Blackwell Publishing Asia Pty Ltd.
374
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