Challenges and Facilitators of Recruitment: Lessons Learned from Conducting a Focused Ethnography in a Vulnerable Rural Population

The purpose of this article is to describe the challenges and facilitators of recruitment encountered in an ethnographic dissertation study of rural women with substance use disorders during the perinatal period. While the study is being conducted in the hospital setting post-delivery, potential participants who meet inclusion criteria are identified by practitioners through a number of perinatal practices within a wide geographic area as well as by inpatient social workers. Recruitment in this vulnerable and often socially disadvantaged population has been found to be challenging with regard to ethical approval, participant eligibility and availability, practice changes, and discrepancies in the recruitment process. The authors discuss these challenges and describe the process of practitioner engagement to facilitate participant recruitment and lessons learned in the process. Keywords: Ethnography, Vulnerable Population, Socially Disadvantaged, Recruitment Challenges Background The first author (herein referred to in the first person) lives in a rural area in the northeastern United States identified as having one of the highest rates of prescription opiate drug misuse and neonatal abstinence syndrome (NAS) in the country (Hayes & Brown, 2012; Ko et al., 2016). As a registered nurse caring for newborns with NAS, I was concerned with this trend and sought to better understand the determinants of the issue. This interest led to a search of the evidence and subsequent focus of the current dissertation study. The second and third authors serve as my advisor/dissertation committee chair and methods expert, respectively, providing continuous consultation throughout the process. Women with substance use disorders continue to face numerous impediments to accessing available resources for recovery and parenting support (Fraser, Barnes, Biggs, & Kain, 2007). Substance use disorder in women is associated with increased prevalence of mental illness, histories of physical and sexual abuse, and medical and social problems (Milligan et al., 2010). Pregnant and parenting women with substance use disorders have been reported to experience stigma, fear, shame, and guilt, as well as high rates of co-occurring mental health problems, trauma, and post-traumatic stress disorder (Brandon, 2014; Haug, Duffy, & McCaul, 2014). Studies have shown that rural healthcare disparities, specifically those related to poverty, further complicate access to treatment, and societal stigma and lack of resources further contribute to the negative outcomes for both mother and child (Lander et al., 2013). This is particularly concerning in light of findings that protective factors, such as caretaker involvement and family resources, may moderate the negative effects of substance use on the developing child (Bada et al., 2012). Of newborns prenatally exposed to addictive substances, 50% to 90% will experience some degree of neonatal abstinence syndrome (NAS), a term applied to a constellation of symptoms characterized by dysregulation and hyperirritability of the central and autonomic nervous, respiratory, and gastrointestinal systems (Sublett, 2013). Symptoms are treated with a combination of pharmacologic and non-pharmacologic therapies typically requiring specialized neonatal care with an overall mean length of hospital stay of 16 days, increasing to 23 days for newborns requiring pharmacologic treatment (Patrick, Davis, Lehman, & Cooper, 2015). Despite increasing attention on this problem and evidence-based recommendations (Dow et al., 2012; Goettler & Tschudin, 2014; Hudak & Tan, 2012; Jansson, Velez, & Harrow, 2009; Lucas & Knobel, 2012; Queensland & Neonatal Clinical Guidelines, 2010; Winklbaur et al., 2008), management remains inconsistent, hospital length of stay has not declined, and expenditures continue to rise (Patrick et al., 2015). Perinatal substance use directly impacts two constituencies, the woman and her offspring, and therefore the problem has been examined from a variety of perspectives. …