Barriers and recruitment strategies for precarious status migrants in Montreal, Canada

More than ever, migration has become a global phenomenon, and the number of vulnerable migrants is growing. Precarious status migrants are a heterogeneous category of persons who have no legal permanent status (asylum-seekers, temporary workers, foreign students, live-in caregivers, victims of human trafficking, persons from moratorium countries or undocumented) [1]. The precariousness of migratory status is a potentially deleterious factor, to the extent that it may entail difficult living and working conditions [1]. Some authors have also noted that the rapidity of deterioration in migrants’ health status over time may depend on their country of birth [2].

However, there is a lack of information regarding healthcare access and health status, as well as other determinants of health, for precarious status migrants [3]. In fact, since the majority of published studies have been conducted in healthcare centres, there are few population-based studies to provide evidence that is representative of the migrant population in its diversity [3]; yet such studies are needed to reduce the inequalities in health and access to care that these migrants face [1]. Moreover, precarious status migrants are a population that is vulnerable, heterogeneous, and difficult to reach for purposes of research and intervention [3]. As a result, researchers face many barriers related to identifying, accessing, recruiting, and collecting data from these minority groups [4, 5]; consequently, they are underrepresented in studies [5‐8].

In addition, researchers encounter language and cultural barriers [9‐12], as well as difficulties in contacting and following up with persons who are often mobile [13, 14]. Authors have also identified lack of interest and fears regarding the consequences and benefits of research as a challenge [15, 16]. Suspicion towards research teams is all the more present among migrants without status, who fear that participating in studies could lead to disclosure of their migratory status, being reported to the authorities, or experiencing discrimination [17, 18].

Given that it is not practicable to use traditional sampling methods based on a list of persons, specific methods need to be put in place to reach them [19‐21]. Some researchers use venue-based sampling [22], which involves conducting a preliminary study of the geographic areas in which there is a high proportion of the target population [23]. Other researchers use the respondent-driven sampling method [24, 25], in which respondents are recruited directly by their peers [26, 27], or the snowball method, in which participants are identified by others who have already participated in the study [28]. Partnerships between community members and research teams may also be helpful in accessing the target population [11, 14, 29, 30]. In this setting, the most frequently used recruitment strategies involve setting up a multicultural team and translating information and recruitment materials into the languages of the target communities [14, 31‐34].

To our knowledge, in the literature there are only three reviews [8, 19, 35] and two interventional studies [13, 36] that have identified recruitment strategies for use in a diverse setting of migrants. Developing research recruitment strategies, however, requires a good understanding of this population’s diversity, at both the cultural and individual levels, in terms of people’s migration pathways, social status, and level of acculturation [37, 38].

Montreal is a city of 1.9 million inhabitants in the province of Quebec (Canada), in which are represented 180 nationalities and a variety of religions, migratory pathways, and levels of social integration [39]. There are numerous community centres, some of which attempt to represent these countries or regions of the world. These large groups, called ‘communities’, refer to populations or organizations offering services, and are both part of, and the product of, social construction processes. The notions of ‘race’, ‘ethnicity’, ‘culture’, ‘nationality’, or even ‘community’ are often confounded, both in the urban and political spheres and in the scientific field. Yet the discourse on difference (for example, cultural) is often much too static and tends to ignore the fluidity of identities and practices, as well as its social grounding. Moreover, this type of discourse is entrenched in power relationships that can have harmful consequences on individuals and groups [40‐42]. It is therefore precisely by seeking to understand power relationships and their social consequences (discrimination and differential access to resources and opportunities, including healthcare) that we have attempted to draw a diversified portrait of Montreal’s migrant population on the basis of national, geographic, and cultural origins. We therefore decided to ensure a certain level of national and geographic representation of the precarious status migrant population by identifying and contacting the community centres in the Montreal region. We put in place recruitment strategies for a dozen communities (African sub-Saharan, Anglo-Caribbean, Chinese, European, American (United States), Haitian, Latin-American, Maghrebin, Middle-Eastern, Russian, South Asian, and West Balkan), covering the majority of ethnicities most represented in Montreal. In 2016, before the study was launched, several barriers and recruitment strategies were highlighted during the research planning phase based on interviews and discussion groups with key informants from the different communities [43]. A multicultural and multidisciplinary team of interviewers was created and trained. With a view to producing data on precarious status migrants’ health status, healthcare access, and determinants of health, two types of recruitment were conducted between June 2016 and September 2017: in a population-based recruitment (436 persons recruited) and in a healthcare setting-based recruitment, the Médecins du Monde (Doctors of the World) clinic (370 persons recruited) [44]. For the population-based recruitment, the research team chose mainly to use a venue-based sampling methodology, coupled with snowball sampling in certain communities, as well as with an active campaign in social media, in the different communities, in the local press (print and radio), etc. The interviewers, as community experts, were invited to make suggestions, but the project coordinator was responsible for the final decision regarding recruitment venues. While the respondent-driven sampling method has also been used to reach migrants in some contexts [24], it requires that the targeted persons be networked among themselves, which was not the case for our target population in Montreal. Therefore that method was not selected. Thus, the team put in place collaborations with community organizations and places of worship and recruited primarily in public places. The required sample size for the population-based part of the recruitment was set at 400 participants to be able to estimate the prevalence of unmet health needs. The fact that the initial objective for the study, to recruit 400 persons in the urban area, was achieved suggests that the strategies were effective. It is important to analyze reflexively [45] the strategies implemented for the population-based (or community-based) recruitment.

This study had two objectives: 1) to analyze the strategies implemented by the research team to respond to the challenges of that recruitment, and assess the effectiveness of those strategies; and 2) to share the lessons learned by the interviewers (interviewers, coordinators, trainees) who recruited migrants, with a view to increasing the representation of precarious status migrants in quantitative healthcare studies.

We used two frameworks to collect and analyze the data. Based on a systematic literature review, Bonevski et al. [4] summarized the main barriers to sampling, recruitment, and participation of hard-to-reach populations: suspicion about the study and the research team; fear of authorities; perception of negative impacts; fear of mistreatment and exploitation; fear of stigmatization; absence of benefits; lack of awareness about the research; issues of gender and age; and poor response rates. Even if strategies are implemented to overcome these barriers, those strategies, too, take place in different contexts [46]. For this reason, we decided also to use Pawson’s conceptual framework on the dimensions of context [47]. In fact, the strategies relate to the interviewers (individual context), but also to interpersonal relationships among the team members and with the precarious status migrants (interpersonal context). Lastly, they relate to the research setting (institutional context) and to the social and cultural environment of the organization (infrastructural context).

We used a mixed sequential research design with three phases, in which the results of each phase contributed to the development of the next phase [48] (Fig. 1). The results of phases 1 and 2 were used to analyze recruitment strategies, whereas the results of phase 3 highlighted lessons learned by the interviewers.

The reflexive workshop (RW) was held on August 3, 2017, for 3 h. The purpose of a reflexive workshop is to enable participants to produce a retrospective and reflexive analysis of an action implemented. In the present case, this involved allowing participants to reflect on the recruitment process, analyse the processes, and draw lessons from them. The reflexive approach is an important process in public health [49]. During this workshop, open discussion reflections were focused on community-based recruitment strategies and lessons learned, as well as on the classification of recruitment venues based on their relevance. The interviewers still in service (n = 22) were invited, and 16 participated (72%). Notes were taken and the discussions were fully transcribed and analyzed. Individual interviews (II) were conducted between September 18 and October 29, 2017, lasting 1.5 to 2 h. The semi-structured interview grid was adjusted following pilot interviews conducted with two interviewers. The content of the interview corresponded to the dimensions of the two analysis frameworks of Bonevski [4] and Pawson [47]. Notes were taken and statements were fully transcribed and analyzed. The interviewers who participated in this research were selected based on a contrasted heterogeneous sample representative of the full set of interviewers for maximum diversification of viewpoints. Table 1 presents the characteristics of the population of interviewers (n = 41) and of the sample (n = 15) who were interviewed. The interviewers who participated in the present study came from diverse backgrounds (social work, intercultural mediation, psychology, public health, law, and politics). Most already had experience working with vulnerable populations, and some interviewers were in contact with persons without status, either in their work or through volunteer involvement with local associations. One interviewer had significant experience as a research assistant working with minors in precarious situations, but for most, this was their first research work experience in Canada. The majority of the interviewers were themselves migrants with very diverse pathways.

The third and final step consisted of a conceptual mapping workshop based on a methodology presented elsewhere [50]. This four-hour workshop involved a quantitative and qualitative group consensus method. It was held on November 23, 2017. The interviewers present in Montreal at the time of the workshop (n = 20) were invited to participate. There were 10 participants (50%), and all had previously taken part in individual interviews and the reflexive workshop. The reason why not all of the 16 reflexive workshop participants attended the concept mapping workshop was that, by the time of the concept mapping workshop, the interviewers were either no longer employed in the study, or had work or family obligations that prevented them from attending.

The analysis process followed a convergent synthesis design with integration of results. To integrate the qualitative and quantitative results, we combined two methods. On one hand, we used the data comparison method [51] by highlighting similarities or differences. On the other, we used the data assimilation method by merging the qualitative and quantitative data into themes [52]. For the qualitative data analysis performed using QDA Miner, we used the framework analysis method [53] combined with the inductive and deductive approach, which consists of developing the analytical framework for coding based on both the conceptual framework and emerging themes [54]. QDA Miner is a software program for managing and coding qualitative data to support analysis. The data from the concept mapping were entered into the Provalis Research software program. Quantitative analyses (multidimensional scaling, hierarchical cluster analysis [50]) were used to produce a collective map with all the participants’ statements. Two statements were reclassified and eight clusters were identified; names were assigned to these by the researchers and then validated via email by 50% (5/10) of the interviewers having participated in the present study. The clusters presented a very homogeneous relevance score, with a standard deviation very close to zero (= 0.1359). As such, we examined the links between the relevance scores and the feasibility scores of the different clusters.

For the interviews, we adapted to the interviewers’ needs by being flexible with regard to interview location and by respecting certain participants’ wish not to have their interviews recorded. They were given a compensation of 20 CAD at the end of each interview. They were free to respond or not, and to withdraw from the study at any time. The interviews were anonymous. This study of interviewers was part of a study of migrants that was approved by the ethics committee of the University of Montreal Hospital Research Centre (CRCHUM) (14.204).

Table 2 presents the various strategies to be implemented in response to the barriers identified. In the following text, we develop the main strategies implemented that might have had the greatest impact, according to the interviewers.

First, there are ethical issues with regard to appropriate compensation for precarious status migrants’ participation in research. In our study, monetary compensation was not without controversy, whereas providing a guide to community resources led to effective and non-instrumental participation in research. While the amount paid out was intended to compensate participants for the time and effort invested in the survey [56], some communities in the present study perceived that compensation negatively. One study stated, in fact, that monetary compensation raised more suspicions among certain minority ethnic groups [57]. However, the majority of studies on ethnic minorities and migrants provide monetary compensation or non-financial alternatives (e.g. restaurant vouchers, subway tickets) [20], without putting participants in contact with resources suited to their needs. The development of a community resource guide tailored to the needs of participants [58] and the cultural appropriateness of incentives [20] should be major components of any research project targeting migrants. In addition, the study becomes an intervention in itself if interviewers redirect and accompany participants to resources, which was done in particularly vulnerable cases. The research team needs to consider the ethical dilemmas in which interviewers can be placed. This is particularly the case if they receive certain requests from participants, when there are not always resources available, because this population is often excluded from the services offered by aid organizations.

Second, in our study one challenge was to build stable links of trust with community organizations. Partnering with community organizations to sample target populations has been identified in the literature as useful for accessing the target population [13, 30, 59], and for overcoming the suspicions of hard-to-reach persons towards research [55]. However, in the present study, it was not always easy to build relationships of trust with all the community organizations and to fit exchange relationships into the time available. Indeed, some authors stress that participatory action research requires not only an investment of time and resources to establish relationships of trust with migrants and community organizations [30, 60], but also diplomacy and power-sharing [61]. In fact, it is difficult to have reciprocal exchange relationships when many organizations related to the different groups targeted by the study must be approached. While, in the present study, the community partnership approach could not therefore be sufficiently exhaustive to allow recruitment in all the targeted communities, it has proven effective in certain studies recruiting persons from three specific immigrant and refugee groups [62]. As such, this strategy may be better suited to projects targeting a particular geographic area or ethnocultural group. To be effective in a context of diversity, it is recommended that this approach be linked with recruitment in public spaces, as well as with a communication strategy. Some articles, in fact, confirm that using a diversity of approaches to contact vulnerable populations [63] and migrants [19] is essential for successful recruitment.

We cannot describe the effectiveness of the recruitment strategies without taking into account the infrastructural context described by Pawson [47] representing the social and cultural contexts. The various recruitment methods were effective when they were culturally adapted. This confirms the results of other studies, which have stressed the importance of translating the study materials into the languages of the targeted communities and of having the strategies implemented by a team that has the linguistic competency to connect with ethnic minorities [34, 64]. Moreover, some authors [65, 66] suggest that, to be accepted and thus effective, recruitment strategies need to reflect the behaviours, habits, and expectations of a group’s members. Even though a shared ethnocultural identity between interviewers and interviewees can sometimes reinforce trust [23, 67, 68], this strategy should not be systematic. In our study, matching the so-called ethnocultural identities of respondents and interviewers was not always appropriate. One study has shown that the perceptions, beliefs, and values of migrants who migrated at different times or who come from different social classes or educational backgrounds can vary considerably from one person to another. Thus, some participants preferred to share information with strangers who had no connection with the ethnocultural community [61]. Cultural homogeneity is an illusion that public health actors sometimes harbour [69]. In the present study, shared common experiences between the interviewers and participants were more relevant than cultural issues in fostering relationships of trust. This may have been particularly because sharing a similar life experience made it possible to overcome differences in social class, income, or education [30]. However, while some articles highlight the importance of having staff who are sensitive to the cultural and social dimensions of the people encountered [20], or are in contact with community organizations [62], few articles mention the importance of recruiting interviewers with migratory pathways similar to those of the target population. It should be noted that this raises ethical challenges and power issues.

The results of our study showed that the presence of an interviewer during the recruitment is crucial, not only to establish relationships of trust, in order to obtain a proper response rate to the questionnaire, but also to ensure good data quality. Training interviewers on the questionnaire is crucial to ensure their restating does not alter the meaning of the questions and thus to ensure the quality of data collection. This has been confirmed in certain studies conducted with ethnic minorities. In fact, the interviewer’s presence helped respondents to better understand the questions [34] and resulted in a higher response rate than is usually obtained in self-administered questionnaires in the case of one study conducted in areas of extreme precariousness [70]. Prior to data collection, collaboration between researchers and bilingual interviewers helps ensure accurate translation of the questionnaire, which is essential for its linguistic and cultural validity [71].

Implementing these recruitment strategies requires a significant budget. In our study, the time and resources needed for recruitment were underestimated, and it was calculated that an additional amount of 102,060 CAD, or 76% of the budget allocated for recruitment activities, would have been more expedient [44]. In the literature, the need for significant budgetary resources has been identified as a challenge specific to the recruitment of ethnic minorities. Indeed, recruiting a multicultural team, translating documents into the languages of the target communities, and having interviewers present during questionnaire administration requires a greater budget than is needed to recruit other hard-to-reach populations [34, 72, 73].

Based on our study, we are able to propose some recommendations regarding strategies to be used in this type of research (Table 3). We believe these recommendations could also apply to other populations that are under-represented in research projects, particularly ethnic minorities.

Only 39% of the total number of interviewers (n = 41) participated in this study. We were unfortunately unable to interview the interviewers who worked in community organizations or those who, due to conflicts, left the team. It should be emphasized that the data from the reflexive workshop are dependent on the social context in which the interactions took place. Certain dynamics may have contributed to the production of a dominant discourse that, as such, may not have been representative of the individual views of all participants [74]. Also, for reasons of social desirability, the interviewers may not have raised all the problems associated with the project’s management. Nevertheless, the preliminary results of the present study were presented to and validated by the interviewers during the conceptual mapping workshop. Lastly, it is important to keep in mind that only the interviewers’ perspectives were taken into account in analyzing the strategies, and that we did not consult the participants in the study, in contrast to recent studies in Europe [13] and in the United States of America [14].