This study contextualized survey response rates from a community health center-based study focused on multiple types of discrimination and health, conducted during the first years of the COVID-19 pandemic, with results underscoring the need to interpret lower-than-expected response rates in relation to the impact of the pandemic and the broader sociopolitical context.

Public health protocols, such as restrictions and shutdowns, spanned the globe in 2020. In the US, community health centers (CHCs), serving primarily patients who are low income and/or people of color, confronted the challenges of responding to the COVID-19 public health emergency (which disproportionately affected their patients) in addition to providing standard patient care. Research has demonstrated that during this time, major US surveys (social and health) had notably reduced response rates (Krieger, 2023).

In our article, Contextualizing Response Rates During the COVID-19 Pandemic: Experiences From a Boston-Based Community Health Centers Study, we highlight contextual factors associated with the COVID-19 pandemic that likely affected who we were able to recruit and contributed to our study’s lower-than-expected response rate (48.4%). We document how we reached the level of recruitment we did by referring to best research practices, documenting continuous changes in public health protocols, and observing the needs of patient participants. We offer practical considerations for researchers in both interpreting survey response rates of studies conducted during the pandemic and for conducting future research in population health.

Our investigation, the Life + Health Study, was designed to analyze experiences of multiple forms of discrimination within the patient population at three CHCs in Boston. In May 2020, we began recruitment (delayed) for diverse US-born working age participants (25-64 years old), including sexual and gender minorities, members of racialized groups (predominantly Black, Latinx, and White), and low-income patients. Our team met virtually each week to discuss the challenges that research assistants (RAs) faced while conducting recruitment calls. These barriers were often related to the challenging sociopolitical and public health context during the study implementation period which aligned with the height of the pandemic (2020-2022). This team collaboration proved beneficial for problem-solving and improving recruitment methods, leading to more focused monitoring of CHC-specific completion reports and response rates.

RAs recorded detailed notes on obstacles faced by participants, including the newly encountered issue of needed childcare coverage due to school closures, feeling overburdened by stress associated with pandemic-related restrictions, and health threats experienced personally and by loved ones. Participants also reported experiencing constant reminders of contentious political relations in anticipation of the results of the 2020 presidential election, the storming of the capitol on January 6th, 2021, and regular reports of violence, including police violence, perpetrated upon marginalized communities (our study was concurrent with the horrific police killing of George Floyd on May 25, 2020, and subsequent public protests throughout the US and worldwide). Identifying and noting these various factors during the recruitment period made it clear that it contextualized participants’ reluctance, fatigue, and/or inability to complete our computer-based online survey.

Challenges faced during recruitment and enrollment:

The study faced challenges due to enforced remote recruitment and participation, including delays in study recruitment start-up, limited in-person participation and recruitment opportunities, and an unsuccessful pivot to utilizing social media and internet advertisements.

Our diverse CHC patient participants may have faced respondent burden, namely perceiving burdensome effort and difficulty in survey participation, based on the impacts of COVID-19 and experiences related to the sociopolitical context. For example, using Boston Public Health Commission reports of case counts and wastewater data, we found that the study’s weekly lower completion rates aligned with higher rates of COVID-19 transmission and infection among the community throughout the recruitment period, spanning Omicron and Delta variants (see Figure).

Lessons learned during recruitment and enrollment:

Given the undeniable challenges posed by the COVID-19 pandemic, many researchers needed to pivot and adjust traditional recruitment methods. Throughout this experience, we found that it was essential to be flexible, responsive, and adaptable as a result of collecting and incorporating participant feedback, building trust and rapport with participants and study-site staff, and using strategic methods to engage underrepresented groups.

We found that equitable and tailored outreach strategies were beneficial to our study, such as

(a) offering nontraditional recruitment call hours for those whose employment hours may have shifted;

(b) working with CHC staff to identify and provide relevant and financially adequate incentive options, including a gift card to a local independent supermarket and online options for those following the stay-at-home orders; and

(c) working with the CHCs to provide safe in-person modes of participation by creating an outdoor computer station for those who needed access to the internet or a computer or needed extra assistance navigating the study protocol.

Given that few guidelines or frameworks discuss how to conduct recruitment during a global pandemic or during periods of sociopolitical conflict, sharing experiences and practices from the field is necessary. Our study of research recruitment conducted during the COVID-19 pandemic demonstrates the importance of interpreting response rates within their broader contexts while underscoring the importance of best practices to address existing challenges of recruitment and enrollment of underrepresented populations in population health.

Figure. Life+Health Study completions, wastewater, and daily case trends, Boston, MA, June 2020 – August 2022

The number of Life+Health Study completions reported by week juxtaposed with the counts of RNA copies detected per mL and COVID-19 cases by day from June 2020 to August 2022. 

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Study Authors

Nancy Krieger, PhD (PI); Pamela D. Waterman, MPH; Jarvis T. Chen, ScD; Christian Testa, BS; Emry R. Breedlove, BA; Farimata Mbaye, BA; Alicetonia Nwamah are/were based at Harvard T.H. Chan School of Public Health/Harvard University, Boston MA at the time of the study.

Merrily E. LeBlanc, BA, Sari L. Reisner, ScD; and Kenneth H. Mayer, MD, are based at The Fenway Institute, Fenway Community Health Center, Boston MA.

Apriani Oendari, MD, is based at Center for Community Health Education, Research and Service (CCHERS) Boston MA.

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