Recruitment Strategies and Challenges in a Pilot HIV Prevention Study among Cisgender Black Women in Houston, Texas
Abstract
Recruitment for research studies focused on communicable diseases such as HIV (Human Immunodeficiency Virus) has historically been challenging, particularly among populations who have been underrepresented in media messaging, yet maintain a significant vulnerability to new HIV cases, like Black women. This study examines the recruitment strategies utilized in Aim 2 of pilot study at the University of Texas Health Science Center (UTHealth) in Houston, Texas that was funded by the Ujima Mentoring Program to develop, implement, and evaluate a video log (vlog)-based intervention. The overarching goal of the pilot study was to promote the uptake of pre-exposure prophylaxis (PrEP) among cisgender Black women in Harris County, Texas. Aim 2 involved the creation of a culturally relevant vlog for use in Aim 3, which sought to educate and motivate participants to consider PrEP as an HIV prevention strategy.
With the growing role of digital platforms in public health outreach, social media was employed alongside traditional recruitment methods such as flyers and word-of-mouth referrals. Despite an expanded online reach, engagement remained low, and participation rates did not increase proportionally to the number of individuals who viewed recruitment materials. The reluctance to participate was largely attributed to stigma surrounding HIV and concerns about being publicly associated with an HIV prevention study based on participants feedback to the research team. Even the availability of research incentives to encourage participation did not significantly improve recruitment accrual goals, particularly among healthcare providers who experienced limitations with eligibility due to institutional policies.
This study underscores the need to better understand the social and cultural barriers that prevent Black women and healthcare providers from engaging in HIV prevention research. While digital recruitment strategies can enhance visibility to a larger audience, they must be supported with trust-building efforts, community partnerships, and culturally competent messaging to encourage meaningful participation. These findings point to the critical need for multi-faceted recruitment strategies that go beyond social media campaigns and actively build trust within communities, ensuring that HIV prevention research and interventions are both accessible and culturally resonant.
Author Contributions
Academic Editor: Shivaji Kashinath Jadhav, Orange Health Infectious Laboratory, Bangalore, India
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2025 Lucy Couture, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have no conflict of interest to declare.
Citation:
Introduction
Recruiting for research studies that address communicable diseases, such as HIV, requires a high level of cultural competency and sensitivity, particularly with outreach and engagement approaches. Previous efforts have proven to be more challenging than recruitment approaches with more benign health topics 1. When HIV prevention studies target vulnerable, yet less visibly vulnerable populations, recruitment efforts can be impeded by the lack of communal awareness of HIV vulnerability, which sometimes manifest as lower enrollment rates 1. With novel recruitment strategies, including access to social media communities, research teams attempt to overcome these challenges through algorithms to directly engage their target population. Social media enables researchers to reach a broader audience than was possible with historical recruitment methods 3.
Recruiting Cisgender Black women in HIV prevention research
Cisgender women have traditionally been underrepresented in HIV studies, in part, due to some inefficiencies with existing recruitment strategies 1, 2. When cisgender women make conclusions from media messaging that HIV is a disease commonly associated with homosexual men, and not cisgender, heterosexual women, this misinterpretation of the information presented and the individuals represented in the media messaging may contribute to a conclusion that their participation in HIV research is not needed, thereby diminishing an urgency to participate 2.
In the United States, roughly 70% of women that diagnosed with HIV are of African American or Hispanic descent 11. Often times, these women face many forms of discrimination after diagnosis, hindering them from open communication with their family members, friends, and healthcare providers 6. Research has begun to understand the complexity that surround these issues and stigma theory, which can work together to form formidable barriers to care for these women based on their gender, sexuality, poverty and minority status. Experiences of discrimination these women, can lead to manifestations of psychological distress in the form of shame, depression, anxiety, and suicidal ideation 7.
Recruiting Cisgender Black Women into the Ujima Pilot Study
Recruitment strategies in Aim 2 of Ujima video logging study.
This was a three-aim study at the University of Texas Health Science Center at Houston (UTHealth Houston). In the final aim, the team pilot tested two video logs as behavioral interventions to promote the uptake of pre-exposure prophylaxis (PrEP) in cisgender Black women in Harris County, Texas. Pre-exposure Prophylaxis (PrEP) is an oral or bi-monthly injection medication that is 99% effective at preventing the transmission of HIV when taken as prescribed 4. PrEP as a biomedical intervention offers equitable effectiveness at protecting against multimodal transmission methods and provides the same level of protection for exposure via sexual contact or intravenous injections with substance use 4.The vlogs were designed to motivate behavior change among two audiences: cisgender Black women, by raising awareness of HIV vulnerability and options to protect their sexual health, and prescribing healthcare providers, by encouraging them to increase PrEP prescriptions and referrals 12. This paper focuses on Aim 2, which involved the recruitment and enrollment of participants for the development and refinement of the vlog, with direct input from community partners. The completed vlogs created in Aim 2 were later shown to eligible provider and patient participants during Aim 3, when the intervention was pilot tested.
Methods
The research team utilized multiple channels and methods of recruitment strategies, utilizing both social media and other historical recruitment strategies with previous success of engaging this population 2. These recruitment strategies included distributing physical flyers, posting on multiple social media platforms, and utilizing word of mouth through established social networks.
Vlog development required community members to register for an audition in varied roles, as determined by the script for each vlog. Community members were targeted for recruitment to enhance believability of the scenarios within the vlog. While all community members were invited to register, only those who were female, African American, and at least 18 years old were eligible to be considered for roles as either vlog 1 participants or the patient in vlog 2. These women were not required to have any personal connection to HIV. The eligibility criteria, along with details about compensation, were clearly stated on both the flyers and the social media posts.
However, throughout the recruiting process, there were many obstacles encountered which hindered the registration for auditions. The limitations will be analyzed to understand how to better tailor recruitment strategies for similar community-based research studies for an increase in audience and future registration enrollment.
Description of vlog script for cisgender Black women (Vlog 1)
The vlog script for cisgender Black women included two primary characters, a hairstylist, and a client of a hairstylist. There were three extras in the vlog, including a client under a hair dryer, a second hairstylist, and a second client getting her hair done in the background. During the vlog, the primary characters engage in a conversation about the prevalence of women in the community taking injections to lose weight and share their thoughts on this approach. This conversation leads to the stylist mentioning how another client was discussing PrEP and she asks the client if she heard about PrEP. They begin to share their thoughts on PrEP and the hairstylists share the importance of having discussions with healthcare providers about our bodies, of which the client agrees. The client shares how some healthcare providers are not proactive about sexual health, and the hairstylist replies with sentiments about how a good doctor should be willing to engage in the discussion and should be as invested in ‘our sexual health as much as we are’. The vlog ends with the hairstylist stating, ‘Your health is your power. So, let's keep these conversations going. Advocate for yourself, ask questions, and make choices that are right for you.’
Description of vlog script for healthcare providers (Vlog 2)
The final vlog script for healthcare providers includes two primary characters, the physician and the patient. There were three extras, a patient waiting in the waiting room, the receptionist, and the medical assistant who took the vitals for the patient before the physician saw the patient. During the vlog, the primary characters engage in a conversation about the patient’s concern about her overall health. The physician acknowledges the patient’s concern and expresses the importance of her overall health. The physician asks for permission to discuss the patient’s sexual health and asks the patient if she is comfortable having that conversation. The patient says yes, but with some hesitation. She shows appreciation for the physician asking for permission. The physician introduces the topic of PrEP and asks the patient if she heard of it, for which, the patient replies, I heard about it on a television commercial. The physician provides baseline knowledge about PrEP and asks the patient if she would consider taking it. The patient states that she is not sure. The physician offers more information and asks the question again. This time, the patient states she is not ready. The physician shows understanding and states that the patient’s health is their priority and is there to support the patient, including her sexual health.
The scene ends here, and although the patient does not feel ready to be prescribed PrEP at this time, the intent is to model a supportive, judgment-free conversation that helps viewers feel more comfortable bringing up PrEP with their own healthcare providers.
Physical Flyers
Physical flyers were distributed and advertised in multiple locations throughout the UTHealth Houston campus and our affiliated hospital systems, Memorial Hermann Hospital and Lyndon B. Johnson Hospital. Two versions of flyers were utilized to recruit for this study, each recruiting for varied roles for the vlog. One version of the flyer aimed to recruit cis-gender Black women from the community. There were no exclusions on recruitment for this role, such as age, sexual orientation, or health status. Those that registered with this inclusion criteria filled the roles of the hairdresser, client, and patient within the vlog . The other flyer was targeted to recruit healthcare providers. The inclusion criterion for this role was experience and ability to write prescriptions. The concept behind this criterion was that the authenticity of employing a prescribing healthcare provider to portray an actual licensed healthcare provider in the vlog would bolster believability during the pilot test period.
The two hospitals that received flyers consisted of varying patient demographics. Lyndon B. Johnson is a community resource hospital and serves mainly individuals who are experiencing an uninsured and uninsured condition 8. The patient payor mix includes uninsured patients with 44.3% of the hospitalized patients, Medicaid and Children’s Health Insurance Program (CHIP) at 22.6%, Medicare patients at 11.4% and commercial or other funding at 21.7% of the patient population 8. The majority of patients seen at Lyndon B. Johnson hospital are Hispanic (ethnicity), accounting for around 53% of the patient population, with African Americans (race) compromising approximately 23% 8. While Memorial Hermann Hospital at the Texas Medical Center sees over 40,000 patients annually and is one of the only Level One trauma centers in the Greater Houston area, there is no publicly available information regarding the race/ethnicity or socioeconomic breakdown of their patient population 9.
Social Media Accounts
The UTHealth Houston Population Health in Emergency Medicine department had three social media accounts: X (formerly Twitter), Instagram, and Facebook. During the study, research personnel found X and Instagram to be the most common among people within the Houston community, spanning large age ranges. Both accounts were set to public profiles, allowing anyone to see and interact with the posts, viewing was not limited to current followers. The posts on all social media accounts were reposted multiple times throughout the recruitment period, which encompassed approximately 3 months.
Metrics
The X account had 14 followers. The flyers for all roles were posted 11 times total; the hair stylist role was posted 7 times. The Instagram account had 148 followers. The flyers for community members and healthcare providers were posted 8 times. This did not include stories, which the post was shared 5 times. The Facebook page had 24 friends. Each flyer was posted one time with one reshare for each flyer afterwards.
Word of Mouth
We emailed 13 people from the team’s previously created community network. This included people such as community members, healthcare providers, graduate and doctoral students, and other researchers and public health practitioners in the Houston area.
The team reached out to friends, family members, and colleagues that fit the inclusion criteria for the study. Verbal messages were also relayed to anyone who had a contact interested in auditioning. Other community members connected the research team to local actors in the area through previously established network connections.
Results
Due to X’s post analytics insights, the research team was able to ascertain quantitative data from social media posts, which helped the team tailor the recruitment strategies. The total number of impressions of all posts containing the flyer and recruitment information was 1,009. This number includes anyone who viewed the flyer on their ‘timeline’ or while looking at the study’s social media profile. The study page received 63 total engagements, which is the total number of times a user interacted with a post. This includes all clicks anywhere on the post including links, hashtags, profile, and post expansion. This engagement also includes likes, reposts, replies, and follows. The link directed community members to a survey that provided study information and audition registration instructions. This link was clicked 10 times. There were 17 instances where users expanded the post information to read more about the study. The study page was viewed five times total out of all the posts. There were three instances of someone sharing the posts, with the flyer, which accumulated another 1,417 views of the post. Due to these shares being posted by another source, only the view count is available for analytic purposes.
For the study’s Instagram account, there were 19 likes total and four shares to other users’ stories. Unfortunately, unlike X, the method of post analytics to gain insights to views, clicks, and engagement is still under development. However, some data is available for quantative purposes. Within the final 90 days of the study’s recruitment period, from the beginning of flyers being posted, recruitment efforts reached 54 different Instagram accounts. This is the number of unique accounts that viewed the study’s content on at least one occasion. Of the five posts with the most engagement, there were 118 views from other users.
In total, the online flyer was viewed at least 2,544 times; however, we are unable to track how many people saw the flyers in person or shared them without our knowledge. Tthe online registration form for the audition scheduling was completed 39 times. Out of these, 28 individuals selected roles related to Black women in vlog 1, including hairstylist, client, or extra. Nine participants opted for the healthcare provider role in vlog 2. Additionally, there were two instances where no information, including preferred role or contact details, was provided.
Of the 37 individuals that completed their audition registration with information, 26 women scheduled an audition. The 11 remaining participants were contacted at least three times and failed to reply after submitting their initial response, .and therefore did not complete an audition. Of 26 women scheduled, 21 completed their online audition. Of those that completed their audition, 14 people auditioned for the client role in vlog 1, while five people auditioned for the healthcare provider role in vlog 2. Two individuals auditioned for the hairstylist role in vlog 1.
There were three no-shows in total. Each auditioner was given a courtesy window of 15 minutes along with a call to their mobile phone number (if one was provided in the initial registration form). One of the no-shows was rescheduled and completed their audition. Three auditioners cancelled in advance of the scheduled audition. After multiple attempts to connect and reschedule, rescheduling did not occur.
Discussion
Recruiting cisgender Black women for health communication-based research studies that require vlog technology, acting, and social media-based recruitment in tandem with social networking recruitment strategies on the topic of HIV prevention required a multi-faceted and rigorous approach with unanticipated challenges along the continuum towards study aims. While social media platforms allowed for broader outreach, increased visibility did not translate into higher engagement or participation in the way the study team originally projected. Although the strategy was successful at accruing over 1,000 impressions across platforms, only a small fraction of individuals clicked on the audition registration link, and fewer completed the audition process. This discrepancy suggests that visibility alone is not sufficient enough to secure study participation, especially in regard to stigmatized diseases such as HIV. Deeper social and cultural factors contribute a significant role in recruitment success.
One factor that we encountered during recruitment was the societal stigma surrounding HIV, especially from B lack women in the community. The preconceived idea that those performing in the vlogs may be seen by other members in their community, during Aim 3 , and potentially be incorrectly associated with having HIV was a powerful deterrent. During thise recruitment phase, many women cited this reasoning for their lack of interest and commitment in the filming process. A lack of confidentiality that can occur when creating a video talking about a topic that is considered taboo by their community, was also brought up as another possible factor of disinterest. Both vlog script excluded any mention of testing positive for HIV, however, it was found that even talking about HIV and PrEP discouraged some people from learning more.
A significant outcome that was evident, was the lack of male participants, even though gender was not a restriction for community member and healthcare provider roles. This could be attributed to the nature of the study and its targeted outreach to Black women. However, the absence of male participants may have limited the diversity and realism of the vlogs. Future recruitment efforts could explore strategies to engage a broader demographic, including Black men who may serve as allies or advocates for PrEP awareness within their communities. This bias may have been due to our network being mainly Black women and healthcare providers. Unfortunately, even though the target audience and final product is intended for cisgender Black females, men could have improved the vlog’s authenticity and relevance, as the majority of healthcare providers are male 10.
Another element that was illuminated by our network was the rate of compensation. Compensation played a dual role in recruitment outcomes. While it was a motivating factor for some participants, particularly younger individuals and community members, it did not appear to be a strong incentive for healthcare providers. Many providers cited time constraints and scheduling conflicts as primary barriers to participation, which suggests that alternative incentives—such as professional development credits, research collaborations, or flexible filming schedules—may be more effective in engaging clinicians in similar studies. Additionally, recruitment efforts were hindered by institutional policies prohibiting UTHealth employees from participating due to potential conflicts of interest. This policy significantly reduced the available pool of eligible healthcare providers, highlighting the need for expanded recruitment beyond institutional networks.
One of the most promising aspects of the study was the use of culturally relevant settings to enhance the believability and relatability of the vlogs. The inclusion of a hair salon setting, for example, was based on prior research indicating that salons serve as trusted spaces for open discussion and health interventions within Black communities 5. Studies have shown that PrEP education in a salon-based setting, as an intervention method, is not only feasible, but plausible 5. By embedding HIV prevention messages in familiar and culturally significant environments, the study aimed to foster a sense of connection and trust among participants. However, the recruitment challenges encountered suggest that even culturally tailored interventions must be accompanied by strategic engagement efforts to overcome stigma and hesitation.
Overall, this study highlights the complexities of recruiting participants for HIV prevention research and underscores the importance of culturally competent, community-driven approaches. While social media alone was insufficient in driving engagement, the insights gained from this recruitment effort can inform future strategies to better reach and involve marginalized populations in public health research. The findings with cisgender Black women may also be relevant to other communities, particularly in contexts where social media and online outreach are less accessible or effective, and personal engagement through trusted professionals, such as social workers and nurses, remains a more reliable method of recruitment.
Limitations
A contributing factor that the study team believes impeded the recruitment process was that the academic institution did not allow any current employees to participate due to the compensation given for auditions and selections due to a potential conflict of interest. This made recruitment for the healthcare provider especially difficult, as the network created included many from within the institution. In affiliated hospital systems, all prescribing clinicians were employed by UTHealth Houston, which made them ineligible to participate as well. However, even while our healthcare provider connections were ineligible, we reached out to them for feedback throughout the recruitment process. Their feedback offered new insights into why recruitment numbers for this role may be less than desirable. Our network stated that prior commitments and time were a large issue with availability and therefore enrollment for this role. Out of the healthcare providers who have a connection to community health research that were eligible, all of them were unavailable, could not guarantee availability for an audition, or film the vlog. The filming process of the final vlog was slated to require up to four hours, of which the clinicians did not have available.
Conclusion
Aim 2 of the Ujima pilot study focused on recruiting participants to support the creation and development of vlogs designed to promote PrEP awareness, prescriptions, and referrals among cisgender Black women and their healthcare providers. The completed vlogs were pilot tested in Aim 3 to evaluate their effectiveness. Recruitment challenges highlighted the limitations of social media alone, particularly when addressing sensitive topics like HIV prevention. Findings underscore the importance of cultural competency, trust-building, and community engagement within recruitment strategies. Concerns around confidentiality, limited PrEP knowledge, and stigma were major barriers. Word-of-mouth and community-based networks proved more effective than social media. Future efforts should emphasize partnerships with community leaders, faith-based groups, and local influencers to build credibility. Practical recommendations include: 1) strengthening partnerships with community leaders, salons, and local organizations, 2) using incentives tailored to providers (e.g., professional credits) rather than only monetary compensation, and 3) addressing stigma through education and confidentiality safeguards. Implementing these strategies can improve engagement and PrEP uptake among Black women in HIV prevention research.
Funding
Mandy J. Hill: Resources: Funding was awarded through a supplement to the Center for AIDS Prevention Studies (CAPS) grant NIH/NIMH 5P30MH062246 (PI: Mallory Johnson, PhD), for the Ujima Mentoring Program grant NIH/NIMH 3P30MH062246-21S6 (Program Director, Cherrie Boyer, PhD and Program Co-Director, Emily Arnold, PhD); The pilot project presented here was funded as a subcontract of the NIH/NIMH Ujima Mentoring Program between The Regents of the University of California, San Francisco and the University of Texas Health Science Center at Houston (UTHealth Houston).
Statements and Declarations
Conflicts of Interest: Mandy Hill is the recipient of an Investigator Research Award from Merck Pharmaceuticals Project Grant #100099, which funded a qualitative study in Houston and Austin, Texas, with an objective to explore perspectives and beliefs related to PrEP among healthcare providers whose primary population is CBW. A small percentage of Mandy Hill’s effort towards the conduct of the research was supported as a part of the funding provided. The primary outcome of this study is different but related to the project presented here in this manuscript and overlaps in the geographic location and population of focus.
All other authors have no information to disclose.
Acknowledgements
We acknowledge the leadership of the UCSF CAPS Ujima Mentoring Program for their support during the conduct of the work and preparation of the manuscript.
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