Background: Who participates in public and patient engagement processes, and in what capacity they participate, matters. The strategies employed to recruit participants shape the outcomes and legitimacy of engagement processes. We explore these issues through a case study of workshop recruitment.

Methods: We conducted a mixed-methods study drawing on literature about existing theories of engagement, and integrated findings from the research team's own public engagement workshop in September 2022. We sought to align theoretical frameworks with practical approaches to recruiting for engagement.

Results: There are inherent trade-offs in recruitment methods. While the theory of recruitment is valuable, practical implementation is complex and highly context-dependent. Engaging existing partners and fostering relationships beyond specific events is crucial. Hybrid workshops and low-barrier honoraria promote participation; however, decisions about location and time create barriers. Finally, balancing trusting relationships with critical perspectives can create tension.

Discussion: Recruitment is foundational for the engagement process, and requires flexibility, responsiveness and a realistic understanding of barriers. Our study suggests that there is no universal formula for ideal participant makeup or event format. Meaningful engagement requires ongoing dialogue and constant adjustment based on practice. Policy makers can use these insights to align recruitment and engagement strategies with their goals in order to move beyond quick, technocratic fixes.

Introduction

Public and patient engagement is a broad term that describes the act of involving citizens and patients in health system decision making (Abelson et al. 2016).¹ Who participates, and in what capacity they participate, matters. Are participants contributing from the perspective of their lived experience with the health system or from the perspective of their public values? Are participants from a diverse range of perspectives given meaningful opportunities to participate? The process of recruiting participants for public engagement critically shapes the outcomes and legitimacy of the engagement. In this article, we review the recent literature on recruiting and design for public engagement to understand how theory and practice align and reflect on the process of recruiting participants to the Reimagining Public Engagement workshop organized by McMaster University's Public Engagement in Health Policy Project team in September 2022 (Massie et al. 2022).

Our survey of public engagement in Canadian health policy over the last 20 years found limited evidence of efforts designed to include marginalized or underrepresented groups in public engagement for health policy (Dhamanaskar et al. 2024). Our colleagues' research on Black community-led engagement also demonstrates crucial gaps in who is engaged in Canadian health policy (George and Abebe 2024). These gaps have implications for the legitimacy of public engagement projects: the systematic exclusion of certain individuals and groups means these processes fail to meet democratic goals of representation and inclusion and deprive policy makers of necessary information.

Faced with these challenges, researchers and engagement professionals often turn to “better” recruitment and the adoption of technical fixes to “reach the hard-to-reach.” However, labels such as “hard to reach” blame communities for their lack of participation when, in fact, these activities are often difficult to access for reasons including and beyond faulty recruitment. Epstein (2008) argues that “recruitmentology,” a study of “the efficacy of various social, cultural, psychological, technological, and economic means of convincing people” to participate in health research and health policy, falls short, and advocates for researchers and practitioners to instead “focus attention on issues of trust, collective memory, and power relations” (Epstein 2008: 823). Many communities justifiably mistrust the health system. Engagement, especially government- and researcher-led engagement, will not meet their needs and may indeed perpetuate further harms. Rowland and Kumagai (2018) note a lack of clarity about precisely what patients are being asked to represent, affecting both the patient experience and process outcomes. Dr. Nav Persaud warns against equating diversity with equity when it comes to recruiting public and patient participants without addressing wider, systemic barriers to equity and diversity in the health system (Johannesen and Angl 2021).

This paper integrates theories of recruitment with practical experiences of organizing a workshop. Our goal is to facilitate more nuanced conversations about recruitment for public engagement and prompt new research about the relationship between participant recruitment and engagement outcomes. We purposely interweave existing literature with data and reflections from our workshop to emulate the dynamic nature of making recruitment decisions – moving between theories and methods, engagement goals, organizational constraints and participant preferences.

Recruiting for the Reimagining Public Engagement in a Changing World Workshop

The Public Engagement in Health Policy Project (September 2020 to December 2023) aimed to deepen understanding of, and make recommendations for, public and patient engagement in health policy and planning. The project's interdisciplinary team, primarily from McMaster University in Hamilton, Ontario, consisted of academic faculty and trainees from the departments of Health Research Methods, Evidence, and Impact and Political Science and the Faculty of Humanities. Team members brought diverse expertise in areas such as health system financing, elder care, drug assessments, Black community engagement and democratic innovations. As the project entered its final year, the team hoped to showcase project findings and seek input about the project's final stages. The team planned an event, Reimagining Public Engagement in a Changing World, held in September 2022. Our goal was to engage individuals and groups who are affected by or interested in our work, referred to as consumers or the affected public (Degeling et al. 2015).

The workshop aimed to share insights about possible directions for change in Canadian public and patient engagement, gather participant and practitioner perspectives on challenges in engagement and co-create practical resources to navigate public engagement more effectively. We hoped that participants with more engagement experience would reflect on successes, gain new insights into challenges of existing structures and explore potential directions for change. We hoped that participants with less engagement experience would gain insights into existing structures to help them navigate engagement more effectively and provide critical insights that may change and improve those structures.

As our team was interested in both the theoretical and practical dimensions of recruitment, we kept detailed notes about recruitment decision making and implementation processes throughout the workshop. We used primarily targeted recruitment, with limited self-selection opportunities as the workshop drew near. The next sections provide an overview of recent literature about these recruitment approaches, and why we chose them, and reflect on how the recruitment strategies and event design shaped the workshop outcomes. We conclude by identifying key lessons for future recruitment efforts while balancing practical constraints, namely time, resources, space and networks. We report briefly on post-workshop feedback from participants. Research was approved by the McMaster Research Ethics Board (project no. 5482).

Recruitment Methods, Costs and Benefits

Our approach to recruiting workshop participants combined targeted recruitment and self-selection. While these are only two of many approaches to recruitment (see Rowe and Frewer [2005] for an overview of approaches, and Rowland and Kumagai [2018] for types of representation), they are frequently used in health policy engagement activities, particularly when specialist firms are not employed to assist with more complex methods like stratified random sampling. We draw on recent research highlighting significant risks and trade-offs associated with these popular approaches and describe how these trade-offs shaped our workshop planning decisions.

Self-selection

Self-selection, in which individuals learn about the engagement activity and choose to participate on their own, was the most common method of recruitment in our team's survey (Dhamanaskar et al. 2024). While self-selection theoretically “promotes a kind of universal opportunity for participation that ostensibly ignores social circumstances” and is praised for its ease of implementation (Beauvais 2018: 149), social circumstances strongly influence who is able to self-select. When participants self-select, the resulting groups “are frequently quite unrepresentative of any larger public. Individuals who are wealthier and better educated tend to participate more than those who lack these advantages, as do those who have special interests or stronger views” (Fung 2006: 67) (see also Fung 2003; Ryfe and Stalsburg 2012). In the worst-case scenario, self-selection uses the guise of “openness” to absolve organizers from making concerted efforts to reach and incorporate the views of specific groups and individuals, often to the detriment of those who have less resources to engage.

Targeted recruitment and appointment

Targeted recruitment involves inviting individuals to participate based on expertise or knowledge. Appointment includes an additional step, during which applicants are assessed against preset criteria (Dhamanaskar et al. 2024). These methods may involve selectively recruiting from groups that are less likely to engage or setting criteria for the skills, experiences, and characteristics participants should have (El Enany et al. 2013; Fung 2006). For example, the Ontario Government's Roadmap to Wellness: A Plan to Build Ontario's Mental Health and Addictions System included input from health system leaders, community organizations and other governmental actors, and also specifically sought input from “people with lived experience of mental health and addiction issues, their families and caregivers” (Government of Ontario 2020).

There is a risk that targeted recruitment and appointment replicate the problems of self-selection if they privilege familiar groups – people with whom organizers have an existing relationship and/or those who have previous experience with patient engagement. In such cases, targeted recruitment can lead to professionalization of participants and their loss of legitimacy with the group they purport to represent (El Enany et al. 2013). While an existing relationship with organizers can promote trust in the engagement process, it risks excluding dissenting voices and privileging those who have proven to be agreeable, especially if the relationship is predicated on organizers having power over outcomes that are important to participants. Where recruitment is shaped by narrow eligibility criteria and norms of engagement, targeted recruitment risks having the participants fit the process rather than the other way around. Glimmerveen et al.'s (2021) study of community engagement in a long-term care organization in the Netherlands finds that critical voices were excluded from the engagement process by organizers and more supportive participants because they violated the norm of “constructive engagement.” Participants who were critical of the process were characterized by organizers and other participants as “too loud,” “not saying anything substantial” or not really looking for solutions, and thus their participation was deemed illegitimate (Glimmerveen et al. 2021: Table 2).

The problem of replicating issues of self-selection may be relatively obvious and therefore easy to avoid by dedicating additional resources; however, problems of participant professionalization leading to a loss of credibility and an informal exclusion of critical voices are more subtle, and may require fundamental changes to the design and implementation of an engagement process. Meaningful participation is not just “recruiting better” – it is also ensuring that the engagement process is able to accommodate and metabolize the contributions of a wider range of participants.

Whom to Engage and How to Reach Them?

Early in planning, we knew we wanted a participant composition that balanced researchers, government, healthcare organizations and community members – patients, caregivers and members of the public who have lived experience of illness/with the health system or who are affected by health policy planning, either directly or indirectly. Realizing that we wanted participant diversity and a balance among target groups, we decided to use targeted recruitment. Leveraging our existing networks, we sent invitations in rounds to specific individuals, assessing attendee composition at regular intervals. We used snowball sampling to expand the list of invitees, which generated further invitees. Finally, as the event date approached, we used a self-selection approach and sent open invitations to organizations, groups and listservs we thought might be interested.

We intended for the majority of community members who participated would be people who are not well-served by existing structures for public engagement. To reach these communities, we relied on our existing networks and reached out directly to organizations working in health services, policy and Black advocacy. While we took steps to lower participation barriers for these audiences, all patient advisor participants were part of well-established engagement programs (see Appendix 1, available online here). The participation of these attendees was very valuable, although we reflect below on possible barriers to broader participation.

Our team, with rich interdisciplinary networks within the target groups we wanted to engage with, assumed that these strong, pre-existing networks would be a benefit, as existing trust provides a valuable foundation for communication. While these networks produced a diverse invitee list, comparing the list of initial invitees to that of attendees suggests that uptake across team members' networks was variable in ways we should have better anticipated and accounted for. (Please note that we did not collect detailed demographic data from participants, so cannot quantify the diversity of participants in terms of race, gender or age.)

We knew that using our existing networks also risked biasing participant composition, relying too heavily on partners who have been “professionalized” (El Enany et al. 2013), excluding negative contributors (Glimmerveen et al. 2021) or working with people who were too familiar to be able to provide novel perspectives (Greenhalgh et al. 2011). Yet we were reasonably confident that contributors with critical feedback would have space to share their reflections, for three key reasons. First, the diversity of our networks meant that some invitees were newer to the space. Second, the established collaborative relationships many invitees had with one or more project team members was expected to mitigate power imbalances, as being empowered to critique processes requires a certain amount of trust that there will be no personal or professional repercussions. Finally, the workshop goals were relatively low stakes: the project team was not making policy decisions, but rather seeking to share and improve its research practices and results. Participant feedback during and after the workshop suggested that there was space for critical reflection, although biases may have persisted.

Beyond Recruitment: Accessibility and Compensation

Once we had decided on targeted and self-selection recruitment methods, we knew we had to design our workshop in a way that allowed those we recruited to participate according to their preferences while also meeting the goals of engagement. We sought to balance in-person, discussion-based small group sessions with the knowledge that participants may be better able to participate if they could join remotely, particularly those not in academia or with caregiving responsibilities (e.g., Abelson et al. 2022 Tripp et al. 2022). We ultimately decided to break the day into two components. In the morning, we showcased new and emerging research, and participants were able to engage both online and in person. The afternoon session was designed to further our collective understanding of engagement in health policy and help develop resources to aid engagement, and as such, was in person and interactive.

We held the event on campus at McMaster University in Hamilton, ON, which enabled us to use campus resources to host online participation; it reduced logistical barriers (e.g., we were easily able to provide parking passes) and it was accessible. However, this decision runs counter to the engagement principle of meeting people where they are at. This critique was picked up in a post-event survey, where one respondent commented that “meaningful inclusion is hard when activities always take place on researchers' ‘turf'”. A subsequent event organized by the team was held at an off-site satellite campus of McMaster, and in future we would consider the possibility of other accessible public spaces, like the Art Gallery of Hamilton.

We had decided early on to offer compensation to acknowledge the contributions of articipants (Fox et al. 2024; Greenhalgh et al. 2011), but we did not anticipate the complexity of university policies. For example, we could reimburse travel expenses, but could not offer a per diem since the workshop included lunch. We also recognized that a burdensome reimbursement process may in itself be a disincentive. We therefore offered an opt-in honorarium with a low barrier to apply – all participants received an expense claim form (see Appendix 2, available online here) that allowed them to opt into the honorarium, which did not have minimum participation requirements. We ensured information about compensation was easily accessible in all workshop communications.

We were also navigating the ongoing effects of COVID-19 during event planning. We held the event in person on the McMaster campus, although we were prepared to pivot to a virtual event if necessary. Workshop communications outlined specific health measures being taken, including offering high-quality masks, which we strongly encouraged (but did not require) participants to wear. We also ensured that there was accessible outdoor space during refreshment breaks. Still, we recognize that barriers may have persisted, especially as the afternoon sessions were held in smaller rooms and mask-wearing was not mandated.

Evaluating Recruitment: Tracking Participation and Promoting Reflection

As we did not track demographic details of participants (race, gender), we cannot know whether groups were underrepresented or overrepresented. We faced a tension common to researchers seeking to conduct meaningful engagement. On the one hand, collecting demographic data is critical for understanding who is under- or overrepresented. However, collecting these data may act as a disincentive to participation; it risks exacerbating the perception of participants as research “test subjects.” Such feelings may be amplified for groups who have been harmed through historical and ongoing research practices, justifying our decision not to track demographic details.

While we were not planning a workshop that was statistically representative of the wider population, we recognize that choosing not to track demographic details hindered our ability to gauge the success of our outreach efforts. Rather than avoiding demographic data entirely, we would recommend collecting basic data and openly communicating the goals of the engagement activity and intended use of the data.

While we did not collect demographic information, we do have some information about attendees, such as organization type and role (Appendix 2 available online here). The morning session was hybrid, and 57 participants joined the discussion via Zoom. The majority of participants identified were either researchers or engagement professionals. Online participation allowed multiple people to attend from the same organization, and also meant broad geographic participation, including attendees from other provinces (British Columbia) and cities (Ottawa).

Afternoon workshop participants were asked to complete a consent log indicating how they would like to be identified. This allowed participants to identify their role in relation to engagement. Participants were primarily patient advisors, students, researchers or engagement practitioners. However, we note that although participants may have indicated their primary attribution, participants may bring experience from multiple perspectives. All in-person community participants were patient advisors associated with two organizations, both of which have existing relationships with research team members and/or the university. These existing relationships were likely important in individuals' decision to participate, reiterating the importance of networks. Our experience suggests that more organization-specific outreach is important early in the recruitment process to ensure that prospective participants find both the “ask” and the “offer” of the engagement activity acceptable, and to ensure sufficient flexibility to respond to participants' needs and interests.

Lessons and Recommendations

We finish by reflecting on lessons from the literature, and the challenges and trade-offs that come from applying them in practice. This is not to critique the theories of recruitment and engagement listed above, but rather to highlight the barriers to real-world application of such theories.

We chose two methods of recruitment, self-selection and targeted recruitment, both of which carry inherent biases. However, we were confident that these methods matched our engagement goals and took steps to mitigate common pitfalls.

Recognizing that self-selection may lead to an over-representation of certain groups, we limited the first tranche of invites, being intentional about the composition of researchers, practitioners and community members. We offered low-barrier compensation, which was clearly communicated to partners. We sought to mitigate concerns about COVID-19 by outlining the safety measures we were taking and going beyond the minimum required by the university.

Our conservative and iterative recruitment process allowed us to balance representation of various groups and respond to participant needs to ensure the agenda reflected their priorities. However, this iterative approach also limited broad recruitment and promotion. In hindsight, promoting the event widely from the outset may have attracted more diverse voices. While ensuring a balance of participants was important, it came at the expense of attracting a broad audience and potentially reaching individuals who were not familiar with our research project. Likewise, our decision to not collect demographic data limited our ability to reflect on the diversity of our participant composition. Requesting this information, and communicating its purpose clearly, would be beneficial for people seeking to improve their own recruitment processes as long as this aligns with participant preferences.

Our recruitment strategy leveraged existing networks and relationships branching from the research team. A key lesson here is that building rich, trust-based networks is essential for designing responsive and meaningful engagement. However, building these networks requires significant time and investment. Policy makers and researchers should allocate time to foster relationships well in advance of, and outside the purpose of, engagement. For managers, we suggest that this time investing in relationships should be recognized and valued, even if there are no immediate tangible benefits. This long-term relationship building is especially essential when making “asks” of time-constrained, overworked and under-resourced community organizations, who must see engagement as a worthwhile investment before they decide to participate. Finally, we recommend recognizing the boundaries of one's networks and consider how to include voices that lie outside networks or those voices that may be excluded from formalized networks. There are tools available to help with this work; we recommend in particular the Public Engagement in Health Policy Project's step-by-step guide to equity-centred engagement (Ul Haq et al. 2023).

Hybrid events, or at least some hybrid components, are largely expected now. We recommend that event organizers consider their goals and understand the trade-offs when deciding to host events online versus in person. Although it requires more logistical planning, hybrid components can help promote accessibility, especially as we adjust to post-pandemic life. Event organizers may find it helpful to consider the geography of their potential audiences, the format of the event and what technological supports would be required. Finally, we suggest that online participants are not treated as secondary participants; small steps, like having an online question-and-answer moderator, may help to build online inclusion. The field of engagement would also benefit from more research that investigates the implications of online versus in-person participation.

We also recognize that a single event is unlikely to facilitate the full range of input and voices needed to make informed decisions and will systematically exclude those who have other responsibilities during the day. We suggest considering how to garner different perspectives from different places (e.g., offering shorter evening meetups or changing the location to a community centre) and, where possible, engaging in more personalized outreach to meet the preferences of the communities and organizations being engaged. This diversity of approaches would also help to create conditions in which participants with “fresh eyes” can be critical, while also working with partners with whom there are trusting relationships. This mosaic approach is present in work by Rowland et al. (2021) who advocate for incorporating different activities and participants based on the objectives of the engagement. We recommend being up front and honest about the limitations of the event format; a single event is unlikely to achieve all goals of engagement. Relatedly, we suggest that managers set reasonable expectations of engagement activities and dedicate resources for multiple points of engagement where possible.

It is clear that there is no formula or process that organizers can use to fulfill all goals of engagement. Organizers have to be flexible, responsive and willing to invest time to engage diverse communities. This means carefully considering the location and timing of the event, planning opportunities for satisfying online participation and considering the possibility of multiple points of engagement in different formats. It also means devoting time and resources to “engagement about engagement”: how researchers and practitioners can get feedback on the engagement activity itself and incorporate those lessons into future work.

Conclusion: A Call for Reflexive Recruitment

Through our workshop, we were able to apply theories of recruitment in practice. We now offer some directions for the future. For researchers, we suggest more comparative research that explores the ways in which recruitment affects both the process of the engagement itself and the outcomes that follow. Few comparative studies explore this question, which has led to a lack of understanding of the impact that different recruitment methods have on engagement. For practitioners, we suggest thoughtful reflection about the goals of engagement and how recruitment may shape their ability to realize these goals. We urge practitioners to be reflexive, and regularly consider how design decisions may produce exclusionary effects. Exclusion can be complex and requires frank conversations, not only with participants but also invitees who chose not to participate. It requires asking about experiences with engagement, and what voices or perspectives are missing. It also requires recognition that barriers to participation go beyond logistical issues such as costs, location and time and extend to experiential elements such as how safe, welcoming and inclusive the space feels and whether the institution has the capacity to hear different perspectives and respond to calls for change.

Key lessons from our own experience include setting aside time to build relationships outside of specific engagement activities; ensuring that the event design allows for critical reflection; providing online participation options if relevant; having strategies in place to evaluate the success of recruitment strategies; and, where possible, hosting multiple engagement opportunities. Where it may not be feasible or desirable for some prospective participants to come to a full- or part-day workshop, pursue other opportunities to work with communities who might find value in the work. Finally, in some instances, the best solution may not be a marginal adjustment to standard recruitment methods, but instead a process of public engagement that turns recruitment on its head by seeking out community-led engagement so that affected groups determine the terms on which they contribute to the policy process (George and Abebe 2022).

The first step to improved engagement, whether for a researcher or for a practitioner, is understanding what the potential pitfalls are; to address them requires reflexivity, honesty and a commitment to balance trade-offs and adapt to participants' needs.

Correspondence may be directed to Joanna Massie by e-mail at massij1@mcmaster.ca.

Recrutement pour la participation aux politiques de la santé

Résumé

Contexte et objectifs de l'étude: Il importe de savoir qui participe aux processus de mobilisation du public et des patients, et à quel titre. Les stratégies utilisées pour recruter des participants déterminent les résultats et la légitimité des processus de mobilisation. Nous explorons ces questions à travers une étude de cas sur le recrutement en atelier.

Méthodes: Nous avons mené une étude mixte en nous appuyant sur la littérature concernant les théories existantes sur la mobilisation et les résultats intégrés de l'atelier de mobilisation publique de l'équipe de recherche en septembre 2022. Nous avons cherché à aligner les cadres théoriques avec les approches pratiques du recrutement.

Résultats: Les méthodes de recrutement comportent des compromis inhérents. Bien que la théorie du recrutement soit précieuse, sa mise en œuvre pratique est complexe et dépend fortement du contexte. Il est crucial de mobiliser les partenaires existants et d'entretenir des relations au-delà des événements spécifiques. Les ateliers hybrides et la facilité d'accès favorisent la participation; cependant, les décisions concernant le lieu et le temps créent des obstacles. Enfin, l'équilibre entre les relations de confiance et les perspectives critiques peut donner lieu à des tensions.

Discussion: Le recrutement est fondamental pour les processus de mobilisation et exige de la souplesse, une réactivité et une compréhension réaliste des obstacles. Notre étude suggère qu'il n'existe pas de formule universelle pour le format idéal des participants ou des événements. Pour bien fonctionner, la mobilisation demande un dialogue continu et des ajustements constants fondés sur la pratique. Les décideurs peuvent utiliser ces renseignements pour aligner leurs stratégies de recrutement et de mobilisation sur les objectifs visés, afin de dépasser les solutions rapides et technocratiques.

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