Applied Nursing Research 33 (2017) 1–4

Contents lists available at ScienceDirect

Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Clinical Method

Challenges and strategies for conducting sensitive research with an Arab

American population
Shahrazad M. Timraz, RN, MSN, PhD student ⁎, Dalia I. Alhasanat, RN, PhD candidate,
Maha M. Albdour, RN, MSN, PhD candidate, Linda Lewin, PhD, PMHCNS-BC,
Carmen Giurgescu, PhD, RN, WHNP, Karen Kavanaugh, PhD, RN, FAAN
Wayne State University, College of Nursing, 5557 Cass Avenue, Detroit, MI 48202, USA

a r t i c l e i n f o a b s t r a c t

Article history: Recruiting minority groups such as Arab Americans (Ar-Am) for research studies has been challenging. To
Received 1 June 2016 date no studies were found that explicitly addressed challenges to recruit Ar-Am for sensitive research.
Accepted 27 September 2016 The purpose of this article is to present the challenges across three pilot studies that involved Ar-Am
samples and the strategies that were implemented to overcome these challenges. The challenges faced
Keywords:
with conducting studies with Ar-Am included difficulty for participants to express emotions, influence of
Arab American
Recruitment challenges
male/female authority to consent for the study, lack of trust to disclose sensitive information, language
Strategy barrier, and slow recruitment. Having bilingual female recruiters of Arabic descent, engaging the women's
Sensitive research family members in the consent process, and addressing the sensitive topics in culturally appropriate
Culture language were effective strategies to overcome these challenges. These strategies might be helpful for
other researchers who recruit Ar-Am for sensitive research.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction
Successful recruitment and retention of the general population for
health research is often challenging and costly, and more difficult
when the target population is from minority groups, such as African
Americans and Latinos (Ibrahim & Sidani, 2014). Some of the recruit-
ment challenges that are common among minority groups are mistrust,
language barrier, lack of access to transportation and childcare, lack of
time, fear of disclosing legal status, stigma of participating in research,
and lack of knowledge about the research process (George, Duran, &
Norris, 2014; Ibrahim & Sidani, 2014; Jaber, 2003; Knobf et al., 2007;
Richards & Thyer, 2004). Recruiting minority groups for socially sensi-
tive topics, research that is threating to any individuals involved in it
(Lee, 1993), is an additional barrier that may prolong and complicate
the recruitment process (Kavanaugh, Moro, Savage, & Mehendale,
2006).
The number of Arab Americans (Ar-Am), one of the fastest growing
minority groups in the U.S., has increased dramatically in the past
20 years (Kahan & Al-Tamimi, 2009), reaching 3.6 million Ar-Ams living
in the U.S. (Arab American Institute, 2015). In general, “Arab” and “Arab
⁎ Corresponding author at: 15705 Goddard Rd, Apt #208, Southgate, MI 48195, USA.
E-mail addresses: eh1489@wayne.edu (S.M. Timraz), Dalia.alhasanat@wayne.edu
(D.I. Alhasanat), eg1130@wayne.edu (M.M. Albdour), Linda.lewin@wayne.edu (L. Lewin),
Carmen.giurgescu@wayne.ed (C. Giurgescu), Karen.kavanaugh@wayne.edu
(K. Kavanaugh).
American” refers to anyone with family ties to any of the 22 countries
that belong to the Arab State League such as Jordan, Lebanon, Syria,
Iraq, Palestine, and Yemen (Nassar-McMillan, Ajrouch, & Hakim-
Larson, 2014).
Despite this growing population of Ar-Am, the majority of published
articles have focused on recruitment challenges among African
Americans and Latinos (Ibrahim & Sidani, 2014; George et al., 2014).
To our knowledge, a few studies conducted with Ar-Am reported that
challenges of recruiting Ar-Am included the gatekeepers' (family mem-
ber, Imam, and Priest) concern of using the research that negatively por-
trays Arabs; the preference of women to obtain their husbands'
permission prior to consenting for the study; unsuccessful recruitment
through flyer advertisement; lack of knowledge about the research pro-
cess; willingness to discuss the study with their healthcare provider
prior to consent; and the concern of confidentiality and revealing med-
ical problems (Aroian, Katz, & Kulwicki, 2006; Jaber, 2003; Kahan &
Al-Tamimi, 2009). No published articles addressed recruitment chal-
lenges for sensitive research with Ar-Am.
Although the Arabic population living in the U.S. is diverse, they are
unified by speaking the same language and sharing the same culture
(Haboush & Alyan, 2013). Collectivism, family honor, and respect of
male authority are some cultural norms that are shared by all Arabs re-
gardless of their religious affiliation (Nydell, 2012). Collectivism reflects
the solidarity of the family ties. Family honor is the name and reputation
of the family (Beitin & Aprahamian, 2014) and is represented by a
female's virginity, modesty, behavior, and reputation (Haboush &

http://dx.doi.org/10.1016/j.apnr.2016.09.009
0897-1897/© 2016 Elsevier Inc. All rights reserved.
2 S.M. Timraz et al. / Applied Nursing Research 33 (2017) 1–4
Alyan, 2013). Filial piety is the respect, obedience, and care of an
individual's parent and elderly (Haboush & Alyan, 2013). Patriarchy re-
flects males' domination, power, and influence over females and can
vary among regions (Beitin & Aprahamian, 2014; Haboush & Alyan,
2013; Nydell, 2012).
These cultural norms and values may impact recruitment of Ar-Am
especially for sensitive topics that might not be acceptable socially.
Therefore, the purpose of this paper is to present the recruitment chal-
lenges and successful strategies for three pilot studies conducted with
Ar-Am which involved sensitive research (Child sexual abuse, Postpar-
tum depression, Bullying) (see Table.1).
2. Challenges and strategies
Conducting research among minorities is challenging and requires
proper planning, preparation, and understanding of the targeted popu-
lation. A summary of the challenges that we encountered and the strat-
egies we implemented are presented in Table 2.
2.1. Challenge 1: difficulty expressing emotion
One of the issues that has emerged among the child sexual abuse
(CSA) and post-partum depression (PPD) studies was the difficulty for
the participants to talk about deeply personal experiences that may re-
quire reliving the trauma of abuse or revealing mental health issues. Ac-
knowledging mental health issues or discussing anything sexual is
uncommon among Arabs. Thus, strategies were implemented to en-
courage participation by women in the studies to minimize having the
burden of expressing their experiences with PPD or CSA. One strategy
was providing absolute privacy and building rapport by approaching
each woman separately to explain the purpose of the study in a non-
judgmental manner. The principal investigator (PI) approached and
treated all women equally with respect regardless of their age and liter-
acy level. It was very important to describe PPD and CSA in a lay lan-
guage that was not biased or stigmatizing to the culture. For example,
we found it helpful to address PPD as a mood swing rather than a mental
health problem, and to identify CSA as a prevalent social problem that
did not pertain only to Arabs. One of the factors that facilitated building
trust was that the PIs were of the same cultural background and gender
as the targeted population. During the recruitment, the PIs also allowed
ample time during the recruitment process for women to ask questions.
For example, in the CSA study some women contacted the PI several
times to ask questions before they were willing to provide their consent.
Table 1
Description of studies.
Study Purpose
Coping with Childhood Sexual Abuse Explore the coping processes and
of Arab American Females long-term outcomes of CSA
(CSA Study) among Ar-Am women.
Risk for Postpartum Depression Determine the proportion of
among Immigrant Arabic Women women at high risk for PPD and
in the U.S: Pilot Study the risk factors that are related to
(AA-PPD Study) PPD among immigrant women of
Arabic descent.
Arab-American Adolescents' Per- Describe Arab American adoles-
ceived Stress and Bullying Experi- cents bullying experience and re-
ence: A Qualitative Study lated stress.
(AA-Bullying Study)
2.2. Challenge 2: influence of male/female authority to consent for the study
Approaching women for the PPD and CSA studies was sometimes
challenging when women were accompanied by a family member. Dur-
ing the CSA study recruitment, the PI faced some situations where the
woman's companion, who was a male or senior female family member,
refused to take the study flyer or even listen to the PI. For the PPD study,
the husbands expressed concern about the well-being of their wives to
take part in the study. Of utmost importance was the inclusion of family
member in the decision to participate in the study and assurance that
the woman's well-being was the priority of the PI. The PIs established
a relationship to build trust with the women and their family members
by explaining privately and in lay language: the purpose of the study,
how the data would be handled confidentially and results disseminated,
and the benefit to the community. We showed our genuine apprecia-
tion to the women and their family members for taking the flyer even
when their participation was uncertain.
2.3. Challenge 3: lack of trust to disclose sensitive information
A lack of trust was a common challenge among the CSA and bullying
studies. CSA is a highly sensitive issue and a large number of Ar-Am fe-
male survivors have never disclosed their abuse previously, which made
them reluctant to participate in the study. Moreover, a few women
contacted the PI prior to their consent with specific concerns about
their privacy and questions about who would have access to the infor-
mation. In such cases, the PI assured the women of their privacy and de-
scribed in much detail how the data would be protected. Women were
assured that the interviews would be conducted in a very private set-
ting. In addition, the PI offered a variety of data collection methods in-
cluding email and phone interview for those who preferred to
maintain their anonymity. In the bullying study, the adolescents
expressed their concern about revealing sensitive information that
might be shared with their parents. The parents also had concerns
about confidentiality and were afraid that the information might threat-
en their child's safety at school or their immigrant status in the U.S. The
PI assured the parents and adolescents of their privacy and confidential-
ity and was explicit in describing how the study results would be dis-
seminated and its benefit to the community. Gaining the adolescents'
and their parents' trust was also facilitated by explaining the role of
the adolescents and their parents in the study and ensuring that the par-
ents understood their rights to withdraw their child from the study
without any obligations or cost. To further build trust, the interviews
were conducted at the participants' place of residence.
Measures/data collection Sample/setting and recruitment
One individual semi-structured, open-ended N = 9 Ar-Am female
interview conducted over the telephone or in person; who were18 to 40 year-olds, fluent in
sociodemographic questionnaire. English, and experienced the abuse before
the age of 18-year-old.
Recruitment: Advertisement were posted
on the university website and clinical sites.
Setting: Private office at the university.
Postpartum Depression Predictors Inventory-Revised N = 50 Arabic women
(PDPI-Revised) who were 1–6 months postpartum and
Edinburgh Postpartum. Depression Scale (EPDS) had been in the US for 10 years or less.
Demographic form. Recruitment/setting
Community health center.
One semi-structured individual interview conducted N = 10 Arab American adolescents
at the participants' residence who classified themselves as victims of
bullying, were 14–16-year-old, and spoke
and understood English
Recruitment: Community health center.
Setting: The participant's place of
residence.
 S.M. Timraz et al. / Applied Nursing Research 33 (2017) 1–4
Table 2
Challenges and Strategies to conduct sensitive research with Arab Americans.
Challenges Strategy
Difficulty expressing Provide privacy and build rapport with the women
emotion during the recruitment.
Having female recruiters, who were bilingual and of
Arabic descent.
Adequately introducing PPD and CSA in a culturally
sensitive manner.
Influence of male/female Establish a relationship with the potential
authority to consent participant and her family member to build trust.
Explain the purpose of the study in a lay language
privately.
Engage family members in the decision making and
assure them about your priority of the well-being of
the participant.
Appreciate the women and their companion for
their time and effort to either participate or tell
others about the study.
Assure the women and their companion about the
confidentiality of the giving information.
Address the women and their companion questions
in non-judgmental manner.
Lack of trust to disclose Assure potential participants that their
sensitive information confidentiality and privacy are maintained within
the legal limits.
Provide a description of how the study data will be
protected.
Describe how the study data will be disseminated
and distributed to the public.
Provide a private place to conduct the interviews.
Inform potential participants that the data collection
is going to be conducted by the same recruitment
personnel.
Assure potential participants that their participation
has nothing to do with neither their legal status nor
public relations.
Language barrier/Literacy Ask for language preferences.
Explain the study's purpose and benefit in both
Arabic and English.
Examine potential participants English proficiency
and for their eligibility for the study.
Read the questionnaire to the participant.
Slow recruitment Plan for multiple methods to recruit during IRB
submission and budgeting.
Provide a meaningful incentive.
Prepare the study brochure in Arabic and English.
Make sure that the language of the study
advertisement is culturally sensitive.
Allow for anonymous and convenience participation
via email or phone especially if the targeted
population is young adult.
Be flexible about the time and location for data
collection.
2.4. Challenge 4: language barrier/literacy
The language barrier presented a challenge during recruitment and
data collection. The preferred language for many individuals for the
CSA study was Arabic. Hence, during the active recruitment the PI ex-
plained the study flyer in Arabic when needed. For the PPD study,
some women were illiterate in both Arabic and English. In such circum-
stances, the PI opted to talk to the women in their native language.
When describing the study, the PI considered the participant's educa-
tional level, encouraged questions to improve understanding, and
helped the participants when needed by reading the study questions
in neutral tones.
2.5. Challenge 5: slow recruitment
Slow recruitment was one of the main challenges of the CSA study.
Active and passive recruitment were implemented using different
methods such as social media (e.g. Facebook); distribution of flyers at
3
various locations in community centers and a university with a large
population of Ar-Am; and a university campus and Ar-Am studies
websites. For all of the various recruitment strategies employed, online
posting of the study advertisement on the university webpage was the
most successful method. However, this recruitment method was not to-
tally supported (e.g., the university online postings received many dis-
likes), which may have negatively impacted the study and influenced
the survivor's decision to participate. To overcome this challenge, the
PI posted the study advertisement on a weekly basis and initiated online
discussions to draw more attention. For those who were eligible and
consented to participate, the PI accommodated data collection at their
convenience.
3. Discussion
Multiple challenges to recruit Ar-Am for research were reported in
the literature, and some of these challenges were observed in the pres-
ent studies. However, there were some additional challenges that were
encountered for recruiting Ar-Am for sensitive research such as difficul-
ty expressing emotion and disclosing sensitive information. Recruit-
ment of Ar-Ams for sensitive research might be influenced by some
cultural values that are closely held by its community such as patriarchy,
family, collectivism, and stigma of mental health issue.
Patriarchy exists among cultures, and it varies from family to family
depending on the female's age and male's degree of expressing mascu-
linity (Nassar-McMillan et al., 2014). Male domination and decision
making varies among the studies and may or may not impact the deci-
sion by women to participate in research. The study by Aroian et al.
(2006), stated that some Arab immigrant women preferred to obtain
their husbands' approval prior to participation, while others preferred
to make the decision without the approval of their husbands. In the
PPD study, the husbands who accompanied their wives were the prima-
ry decision makers for participation. Some husbands told their wives to
refuse participation in the study, while others were very cooperative in
providing approval. For the CSA study, the aforementioned strategies
were usually successful in obtaining the family member approval to ac-
cept the flyer, but in some instances these strategies failed. It is note-
worthy that the recruitment and data collection of the PPD study
occurred simultaneously. In other words, those who were eligible and
consented to participate completed the study's questionnaires in a pri-
vate office at the recruitment site. Thus, no future planning was required
to collect the data. Studies differ in their design and data collection,
which may impact the women and their family members' decision for
participation.
The sociodemographic characteristics of the women are an addition-
al factor that influenced the gatekeepers' roles in recruiting female par-
ticipants. For the CSA study, most of the participants were recruited
online and were mainly well educated; thus the PI did not encounter
the issue of obtaining the spousal approval for participation. The vast
majority of the interviews were conducted during the week days at a
private office at the university, where the participants usually had clas-
ses and were not accompanied by any family member.
Protecting and defending family honor is of paramount importance
in the Arab culture and no effort can be spared to preserve it (Abu-
Odeh, 2011). Even though some CSA does not involve penetration, the
reputation and the rumor of being touched prior to marriage may dis-
grace the entire family and ruin the survivor's reputation to get married
in the future (Fontes & Plummer, 2010). Thus, disclosing the abuse by
taking part in research is a disquieting decision for survivors to make.
Arabic society is collective in nature and the family well-being may
take precedence over the individual's well-being (Haboush & Alyan,
2013; Nydell, 2012). Survivors who experienced CSA by family mem-
bers, family friends, or an unknown person may prefer not to disclose
their abuse for the sake of protecting the family ties and reputation. Fur-
thermore, many survivors may never disclose their abuse or share such
information with an outsider like the PI.
4 S.M. Timraz et al. / Applied Nursing Research 33 (2017) 1–4
The stigma of having a family member with a mental health issue is
common and not only restricted to Arabic culture (Nassar-McMillan
et al., 2014). In addition to stigma, some individuals do not acknowledge
the existence of mental health issues either due to lack of education or
other beliefs such as being possessed by an evil spirt. Some families pre-
fer to handle the mental health issue within instead of using healthcare
for the sake of avoiding stigma and maintaining the secret. The stigma
can reach to the extended family and may affect the women's chances
of getting married (Nassar-McMillan et al., 2014). Thus, recruiting par-
ticipants for research that involves mental health issues is challenging.
However, the PI was successful in recruiting 50 Ar-Am women with
PPD by employing some strategies that targeted the issues addressed
above. Advertising PPD as a mood swing experienced by new mothers
rather than a mental health problem might minimize the stigma of hav-
ing mental health issues and draw women's attention to the study. Hav-
ing the PI from the same cultural background and gender can also
facilitate building trust and openness to talk about PPD.
The stigma of taking part in sensitive research and the attention that
it could bring among friends and family is another barrier to recruiting
this population. For the CSA study, multiple participants contacted the
PI and were concerned how their identity would by secured during
and after participation. They also questioned if another researcher
would have access to the information shared during the interviews.
Those who had such concerns about sharing of information and confi-
dentiality issues were provided a brief explanation of the privacy pro-
cess, who would have access, and how information would be shared.
Multiple strategies were employed by the PIs to overcome the re-
cruitment challenges which included assuring privacy and building rap-
port with the prospective participants, engaging the family member
(usually the husbands, or senior female) in the participation decision,
and explaining the research process and how the results would benefit
Ar-Am. Some of the lessons learned include developing protocols that
use multiple recruitment methods, building a study budget that pro-
vides meaningful incentives, preparing bilingual study flyers, and the
inclusion of sufficient information about the topic of concern.
One important strategy to overcome these challenges was to consid-
er female PIs who are fluent in Arabic and English and have the same
cultural background of the participants. Talking about sensitive issues
such as PPD, CSA, and bullying is not easy, but having the female PIs
may have facilitated openness and building rapport to talk about sensi-
tive issues. These observations from small samples may not be general-
izable as most recruitment challenges are associated with specific
research topics, study designs, or targeted populations. Research is
needed to explore the challenges of recruiting Ar-Am for sensitive re-
search and other areas of research in general.
4. Conclusion
Recruiting individuals of diverse ethnic and cultural background
such as Ar-Am for sensitive research is challenging. However, it is im-
perative to enroll this group in research and advance the existing
knowledge. This article addressed some of the challenges that emerged
from three independent pilot studies that targeted Ar-Am and focused
on sensitive topics. This article provided some insight into the chal-
lenges that might be encountered to recruit Ar-Am and the successful
strategies to overcome these challenges.
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