snowball sampling in qualitative research pdf

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Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia

Julian kirchherr.

1 Faculty of Geosciences, Utrecht University, Utrecht, the Netherlands

2 School of Geography and the Environment, University of Oxford, Oxford, United Kingdom

Katrina Charles

Associated data.

All data underlying the study are within the paper and its Supporting Information files.

Snowball sampling is a commonly employed sampling method in qualitative research; however, the diversity of samples generated via this method has repeatedly been questioned. Scholars have posited several anecdotally based recommendations for enhancing the diversity of snowball samples. In this study, we performed the first quantitative, medium- N analysis of snowball sampling to identify pathways to sample diversity, analysing 211 reach-outs conducted via snowball sampling, resulting in 81 interviews; these interviews were administered between April and August 2015 for a research project on anti-dam movements in Southeast Asia. Based upon this analysis, we were able to refine and enhance the previous recommendations (e.g., showcasing novel evidence on the value of multiple seeds or face-to-face interviews). This paper may thus be of particular interest to scholars employing or intending to employ snowball sampling.

Introduction

Snowball sampling is a commonly employed sampling method in qualitative research, used in medical science and in various social sciences, including sociology, political science, anthropology and human geography [ 1 – 3 ]. As is typical of terms adopted by a variety of fields, however, the phrase ‘snowball sampling’ is used inconsistently across disciplines [ 4 ]. The most frequently employed definition, suggested by Patton [ 5 ], Atkinson and Flint [ 6 ], Cohen and Arieli [ 7 ] and Bhattacherjee [ 8 ], is as a sampling method in which one interviewee gives the researcher the name of at least one more potential interviewee. That interviewee, in turn, provides the name of at least one more potential interviewee, and so on, with the sample growing like a rolling snowball if more than one referral per interviewee is provided.

This definition can initially seem self-explanatory, which may explain why snowball sampling is rarely discussed in most peer-reviewed papers that employ it. Various scholars use snowball sampling in their empirical work, but most provide only limited information on the method (see, e.g., [ 9 – 13 ]). Similarly, qualitative research textbooks often lack substantive discussion of snowball sampling (e.g., [ 8 , 14 – 19 ]). Bailey [ 14 ], for instance, devotes only a half-page of his 595-page book on social research methods to snowball sampling, acknowledging that ‘snowball sampling procedures have been rather loosely codified’ ([ 14 ], p. 96), an observation echoed by Penrod et al. [ 3 ].

This paper focuses on snowball sampling procedures, which we define as those actions undertaken to initiate, progress and terminate the snowball sample [ 1 , 20 ]. Despite the lack of substantive writing on snowball sampling as a method, several authors [ 2 , 3 , 21 ] have provided recommendations for enhancing a sample’s diversity in snowball sampling procedures (we discuss this further in Section 4). However, as this advice is not based on a quantitative analysis of evidence, but only on anecdotal evidence, there is a risk that these recommendations are based on coincidence. The aim of this paper is to provide advice on enhancing the sample diversity of a snowball sample. This advice is grounded in a medium- N analysis of relevant evidence, thus reducing the probability of positing advice that is based on coincidence [ 22 ]. A medium- N analysis is generally based on 10–100 cases, whereas anecdotal evidence is usually based only on a handful of cases [ 23 , 24 ]. At the core of our work, we provide descriptive analyses of various commonly prescribed strategies for enhancing the sample diversity of a snowball sample. These analyses are based on reach-outs to 211 individuals via snowball sampling for a research project on anti-dam movements in Southeast Asia, resulting in 81 interviews conducted between April and August 2015. As far as we are aware, ours is the first medium- N analysis to focus on enhancing the sample diversity of a snowball sample.

The remainder of this paper is organised as follows: in Section 2, we discuss snowball sampling as a method; in Section 3, we present the research project on anti-dam movements in Southeast Asia that served as the basis for our medium- N analysis on snowball sampling procedures; in Section 4, we present and discuss insights on snowball sampling procedures based upon this analysis as well as our resulting recommendations; finally, in Section 5, we summarise our argument.

Throughout this paper, we employ social science methodology terminology. We define key terms for this paper such as ‘snowball sampling’ or ‘sampling’, since these terms are not consistently codified in the scholarly literature. Due to limited space, however, we refrain from defining terms we have deemed common in this field of study, referring only to the relevant literature.

On snowball sampling

Traditional sampling methods are comprised of two elements [ 25 , 26 ]. First, a full set of data sources is defined, creating a list of the members of the population to be studied, known as a sampling frame. Second, a specific sample of data is collected from this sampling frame. Snowball sampling defies both elements, since it does not rely upon a sampling frame [ 27 ] (which may indicate that a different term for snowball sampling would be more accurate). Snowball sampling is often employed when no sampling frame can be constructed.

Researchers frequently cannot construct a sampling frame if a difficult-to-reach population is to be studied. Difficult-to-reach-populations are also referred to as ‘hard-to-reach-populations’ [ 28 ], ‘hidden populations’ [ 29 ] or ‘concealed populations’ [ 21 ] in the scholarly literature. Although not all scholars may agree that these terms are interchangeable, we deem them interchangeable for the purposes of this paper. For further discussion of this terminology, see [ 30 , 31 ].

A difficult-to-reach population does not wish to be found or contacted (e.g., illegal drug users, illegal migrants, prostitutes or homeless people [ 6 , 31 ]). Snowball sampling was originally used by researchers to study the structure of social networks [ 32 ]. The earliest empirical account of snowball sampling is from 1955 [ 33 ], with snowball sampling first described as a method in 1958 [ 34 ]. While it is still used to study the structure of social networks [ 35 ], over the last few decades, the method’s key purpose has largely transformed ‘into […] an expedient for locating members of a [difficult-to-reach] population’ ([ 36 ], p. 141).

Researchers grounded in quantitative thinking, such as Lijphart [ 37 ] and King et al. [ 38 ], tend to view the drawing of a random sample from a sampling frame as the gold standard of data collection. Even these researchers may nevertheless consider non-probability sampling methods, such as snowball sampling, a ‘necessary and irreplaceable sampling [method]’ ([ 39 ], p. 367) when confronted with difficult-to-reach populations, particularly if the dismissal of snowball sampling would mean that no research could be conducted at all. Ultimately, ‘an important topic is worth studying even if very little [access to] information is available’ ([ 38 ], p. 6). Still, some of those grounded in quantitative thinking call snowball sampling a method ‘at the margin of research practice’ ([ 6 ], p. 1), since the lack of a sampling frame means that, unlike individuals in a random sample, individuals in a population of interest do not have the same probability of being included in the final sample. Findings from a snowball sample would therefore not be generalisable [ 40 ] (on generalisability, see [ 41 ]).

Several qualitative scholars rebut such criticism. Creswell, for instance, notes that ‘the intent [of qualitative research] is not to generalise to a population, but to develop an in-depth [and contextualised] exploration of a central phenomenon’ ([ 42 ], p. 203). Others [ 1 , 39 ] specifically oppose quantitative scholars’ negative framing of snowball sampling, arguing that this method would ‘generate a unique type of social knowledge’ ([ 1 ], p. 327). Due to the diversity of perspectives gathered, this knowledge would be particularly valuable for an in-depth and contextualised exploration of a central phenomenon. We therefore define the diversity of a sample as a measure of the range of viewpoints that have been gathered on a central phenomenon.

Researchers critical of snowball sampling respond to this defence by arguing that the method is unable to ensure sample diversity, which is a necessary condition for valid research findings. Indeed, some scholars have stated that snowball samples underrepresent and may even exclude those least keen to cooperate, since referrals may not materialise in an interview if a potential interviewee is only somewhat keen or not at all keen to be interviewed [ 3 , 43 ]. Similarly, potential interviewees with smaller networks may be underrepresented, as they are less likely to be referred for an interview [ 31 , 44 ]. Those with smaller networks may also be in a specific network whose different perspectives may be of interest but are excluded in the final sample. Meanwhile, snowball sampling is said to over represent those interviewees (and their respective networks) that the interviewer spoke with first; the relevant literature refers to this as ‘anchoring’ [ 20 , 39 ].

We do not aim to argue the ‘validity’ of the method, but rather to inform snowball sampling methodologies in order to promote sample diversity. From a qualitative perspective, ‘validity’ can be defined as ‘the correctness or credibility of a description, conclusion, explanation, interpretation or other sort of account’ ([ 45 ], p. 87), while quantitative researchers frequently use the terms ‘generalisability’ and ‘(external) validity’ interchangeably [ 46 , 47 ]. The term ‘validity’ is contested among qualitative researchers, and some qualitative researchers entirely reject the concept for qualitative work [ 48 , 49 ]. We do not aim to resolve this debate via this paper; instead, we focus on the (seemingly less-contested) term ‘sample diversity’. While we acknowledge that this term is not codified in qualitative textbooks such as the SAGE Encyclopedia of Qualitative Research Methods , sample diversity is considered desirable by the various qualitative scholars we reviewed. Boulton and Fitzpatrick demand, for instance, that qualitative researchers ‘ensure that the full diversity of individuals […] is included [in their sample]’ ([ 50 ], p. 84), a mandate echoed by other scholars [ 16 , 51 – 53 ].

In order to operationalise the concept of sample diversity, we used five key methodological recommendations to inform our research. In this paper, we use quantitative analyses from our experiences with snowball sampling to further reflect on these recommendations, which are briefly described below.

Prior personal contacts of the researcher are required

Patton ([ 5 ], p. 176) notes that snowball sampling ‘begins by asking well-situated people: “Who knows a lot about ____? Who should I talk to?”‘. In the absence of a sampling frame for the population of interest, however, the researcher must retain at least some prior personal or professional contacts in the population of interest which can serve as the seeds of the snowball sample [ 2 , 54 ]. Waters contends that building a diverse snowball sample ‘depend[s] almost exclusively on the researcher’s [prior personal or professional] contacts’ ([ 39 ], p. 372).

Sample seed diversity is important

Morgan [ 21 ] has claimed that the ‘best defence’ against a lack of sample diversity is to begin the sample with seeds that are as diverse as possible. Others echo this advice [ 3 , 39 , 55 ], arguing that it is ‘compulsory for the researcher to ensure that the initial set of respondents is sufficiently varied’ ([ 55 ], p. 55). The term ‘chain referral sampling’ has been used for snowball samples that are strategically built via multiple varying seeds [ 3 ].

Technology means face-to-face interviews are no longer required

Some researchers have argued that face-to-face interviews are obsolete. For instance, over 25 years ago, it was claimed there were ‘no remarkable differences’ ([ 56 ], p. 211) between information collected via telephone and information collected via face-to-face interviews. The increasing use of telecommunications in recent years is likely to have further reduced barriers to remote interviewing, and various scholars [ 57 , 58 ] continue to claim that ‘evidence is lacking that [telephone interviews] produce lower quality data’ ([ 59 ], p. 391). In particular, they have highlighted the benefits of using Skype for semi-structured interviews [ 57 ].

However, for snowball sampling, face-to-face interviews help to generate the trust that scholars claim is required in order to gain referrals [ 1 , 31 , 39 , 60 ]. Noy argues that ‘the quality of the referring process is naturally related to the quality of the interaction: […] if the researcher did not win the informant’s trust […], the chances the latter will supply the former referrals decrease’ ([ 1 ], p. 334).

Persistence is necessary to secure interviews

Although the value of persistence may be considered self-evident by some scholars, it is seen by multiple academics [ 61 – 63 ] as a central virtue of qualitative researchers. Many young career scholars who embrace snowball sampling are likely to hear such advice as, ‘If you cannot interview your envisaged interviewees initially, don’t give up!’. A ‘helpful hint’ for qualitative researchers seeking informants is, ‘Persevere–repeat contact’ [ 64 ].

More waves of sampling are required to access more reluctant interviewees

As a remedy for snowball sampling’s previously discussed bias towards excluding those least keen to be interviewed, multiple scholars suggest pursuing a snowball sample for multiple waves (with a new sampling wave reached once an interviewee introduces the interviewer to one or more potential interviewees) [ 65 – 68 ]. Those suggesting this remedy assume that pursuing more waves increases the likelihood of being referred to an interviewee from a particularly difficult-to-reach population who is at least somewhat keen to be interviewed.

Approval for this study was granted by the Central University Research Ethics Committee (CUREC) of the University of Oxford. Our population of interest for our research project were stakeholders in Southeast Asia’s dam industry. Since ‘the most dramatic conflicts over how to pursue sustainable development’ ([ 69 ], p. 83) have occurred over the construction of large dams, we see this industry as a conflict environment with widely varying viewpoints. A conflict environment is one in which people perceive their goals and interests to be contradicted by the goals or interests of the opposing side [ 70 ]. The major conflicting parties in the dam industry tend to be local and international non-governmental organisations (NGOs) and academics (usually keen not to construct a particular dam) versus international donors, the private sector and governments (usually keen to construct a particular dam) [ 71 , 72 ]. Each sub-population operating in a conflict environment can be considered difficult to reach since fear and mistrust are often pervasive [ 7 ]. Snowball sampling is a suitable research method in conflict environments because the introductions through trusted social networks that are at the core of this method can help interviewees to overcome fear and mistrust, which, in turn, ensures access [ 7 ]. This access is needed to gather the widely varying viewpoints in the hydropower industry, in particular viewpoints with regards to what constitutes just resettlement [ 73 , 74 ]. Based on this rationale, we chose snowball sampling as the main method for our research.

In order to ensure sample diversity for our research project on anti-dam movements in Southeast Asia, we aimed to gather perspectives mostly from six main sub-populations: (1) local NGOs, (2) international NGOs, (3) international donors, (4) academia, (5) the private sector and (6) the government. We hypothesized that ‘dam developers’, a main sub-category of the interviewee category ‘private sector’, would be the most significant challenge to ensuring the diversity of our sample. Early in our process, many of the scholars with whom we discussed our research project argued that it would be impossible to interview a dam developer from a Chinese institution; meanwhile, researchers from a comparable research project that ended approximately when our project started reported being unable to interview any dam developers from European institutions. We also initially failed to collect data from dam developers: for instance, a survey we initiated that was distributed by Aqua~Media (host of a major global dam developer conference) to more than 1,500 dam developers yielded just five responses, only one of which was complete. We considered this weak response rate to be due, at least in part, to the dam industry’s negative view of academicians since the publication of Ansar et al. [ 75 ], which Nombre ([ 76 ], p. 1), the president of the International Commission on Large Dams (ICOLD), called ‘[highly] misleading’.

None of our researchers had significant direct links to the dam industry upon the start of the project; however, we did retain a variety of indirect links. Our researchers had past links to a management consultancy that serves various dam industry players, (more limited) links to an international donor working in the hydropower sector and links to activists in Myanmar advocating against dam projects.

After a favourable ethics review of our study by the CUREC of the University of Oxford, we commenced semi-structured interviews in April 2015, mostly via cold calls (we include cold e-mails in the term ‘cold calls’ throughout this paper). Initially, we conducted research via telephone only. We then undertook field research in Singapore, Myanmar and Thailand from June to August 2015 and terminated our data collection in late August 2015.

In total, 81 semi-structured interviews were carried out during this period. From a qualitative perspective, this is a relatively large sample size (for instance, the average qualitative PhD dissertation is based on 31 interviews [ 77 ]); from a quantitative perspective, however, the sample size is quite small [ 78 ]. Of our 81 interviews, 48 (59%) were conducted via telephone, 26 (32%) face-to-face and 7 (9%) online, either via e-mail or an online survey. Most of our interviews (57%) were carried out in July in Myanmar. Of our 81 interviewees, only 24 (30%) were women. Researchers who employ snowball sampling frequently employ personal/professional contact seeds and cold call seeds to build their sample (e.g., [ 2 , 79 , 80 ] with a seed defined as the starting point of a sample [ 65 ]). Of the 81 interviews analysed, 53 (65%) were rooted in a personal or professional contact ( Fig 1 ) (i.e. the seed of the interview pathway was a contact we had already retained prior to the research project). The remaining 28 (35%) interviews were rooted in cold calls.

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Given the sensitive nature of the interview topic, all interviewees were assured anonymity. Thus, all of the interviews are coded, with the first letter indicating the mode of interview ( T for telephone, F for face-to-face, O for online survey or e-mail), the second letter indicating the category of interviewee ( A for academia, G for government, I for international donor, NI for international NGO, NL for national NGO, P for private sector) and the sequence of numbers indicating the interview number within a particular mode. Researcher A is indicated by RA , Researcher B by RB ; CON represents a conference event. Bold type indicates that an interview was completed, while X that an interview was not completed.

As outlined in the previous section, snowball sampling is sometimes criticised for producing samples that lack sample diversity. To address this criticism, we reviewed the (scarce) literature on enhancing sample diversity via snowball sampling procedures prior to commencing our study. Upon reflection during our research, we chose to pursue our analysis retrospectively in order to challenge some of the recommendations provided in literature. Our analysis is structured alongside the five core pieces of advice found in this literature ( Table 1 ). Our results are based on a quantitative analysis of the 81 interviews we conducted. Although we endeavoured to include all interview attempts, some initial cold calls may have been overlooked in this retrospective approach. Therefore, some of our analysis, particularly in Section 4.4, may be too optimistic. Overall, we were able reconstruct 211 reach-out attempts.

Sample diversity is measured by representation from five identified sub-groups.

Results and discussion

On prior personal and professional contacts.

Our analysis provides evidence that sample diversity can be reached even if no prior personal or professional contacts to the population of interest have been retained. The seeds of the interviews are depicted in Fig 2 , with the left side of the figure depicting the 53 interviews based on a personal or professional contact and the right side depicting the 28 interviews that were based on cold calls. This figure shows two main points of interest: first, both types of seeds include interviews in each interview category; second, the interview sub-category ‘dam developer’, which we hypothesised would be the most difficult to include in the sample, is also covered by both types of seeds. We can therefore conclude that a diverse sample could have been built even if we had relied solely on cold calls.

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It is acknowledged, however, that building a snowball sample from cold calls is particularly labour-intensive [ 39 ]: in our research, only 25% of our cold calls led to an interview, compared to 62% of the referrals. Significant differences in the value of referrals persist from one interviewee group to another ( Fig 3 ). We measure the value of referrals via a concept we call ‘network premium’. To gauge the network premium, we subtracted the cold call response rate (i.e., the number of interviews initiated via cold calls divided by the total number of cold calls) from the referral response rate (i.e. the number of interviews initiated via referrals divided by the total number of referrals). Referrals were the most valuable when contacting international donors and private sector players, with network premiums of 74% and 52%, respectively, indicating that these groups are particularly difficult-to-reach populations.

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(1) Unable to retrace for 13 identified reach-outs if initiated via referral or cold call; four reach-outs coded as ‘Other’. (2) Unable to retrace for one interview carried out via referral coded as ‘Other’. (3) Including personal contacts and contacts via conferences. (4) Referral response rate–Cold call response rate.

The overall results from these analyses are encouraging for scholars interested in researching a population to which no personal or professional contacts are retained prior to the research project. While personal or professional contacts maintained to the research population of interest can accelerate the research endeavour, our results also showcase that (at least for our topic of interest) a diverse sample can be built from cold calls if a researcher is willing to invest some time in reach-outs.

On seed variation

Our research confirms the scholars’ advice that seed diversity is important. Fig 4 (a variation of Fig 2 ) depicts the completed interviews from a seed perspective, with RA, RB and cold calls as the three main seeds of the sample. The sample built via RA, who has a background in the private sector, is largely biased towards this sector, with 47% of all interviews seeded via RA private sector interviews. RB conducted 57% of interviews, whose background is closest to local NGOs, were with local NGOs. Meanwhile, the sample built via cold calls indicates no significant biases towards any interviewee category. Interviews based on the network of RB included one (TNL17) with a leading activist from a remote area of Myanmar who provided unique insights into the early days of an anti-dam campaign. This insight helped us to develop a narrative of the campaign that was not skewed to the later days of the campaign and the activists prominent in these later days. The sample diversity ensured via RB was thus central to the quality of our research.

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It is noteworthy that the three different seeds in Fig 4 include interviews in all interviewee categories, including the sub-category ‘dam developer’ (the sole exception is the interviewee category ‘international NGO, which contains zero interviews for RB). This indicates that, at least for our topic of interest, a fairly diverse sample can be generated even if the researcher is unable to vary her or his seed, although the overall data suggest that seed variation can significantly enhance sample diversity. Fig 3 may therefore be viewed as a case for collaboration among researchers; if researchers with different backgrounds and different personal and professional contacts to the population of interest begin to collaborate, such collaborations are bound to contribute to sample diversity.

On face-to-face interviews

Our descriptive analysis provides evidence to further support the argument that face-to-face interviews are redundant, with our data indicating that face-to-face interviews can lead to more sought referrals than telephone interviews (perhaps since trust may be more readily established via face-to-face conversations than over the telephone). Fig 5 aims to quantify the value of face-to-face interviews. Overall, 30 (37%) of our interviews were initiated via prior face-to-face conversations, while prior telephone conversations and online contact each led to only eight interviews (10%). An examination shows that of the nine interviews conducted with dam developers, the interviewee sub-category deemed most difficult to access, seven (78%) were initiated via prior face-to-face interviews, while not a single telephone interview led to a referral to a dam developer. These interviews proved to be essential for our research. For instance, one Chinese dam developer challenged a claim from numerous NGOs that his company would not engage with NGOs, which, in turn, allowed us to present a more balanced portrayal of the interplay between Chinese dam developers and NGOs.

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(1) Comprises interviews with those already retaining a personal or professional contact prior to the research project.

While our research did not investigate whether face-to-face interviews lead to lower-quality data than telephone interviews, our data provide tentative evidence that face-to-face interviews are not obsolete; they can still be helpful for those employing or intending to employ snowball sampling, since these interviews can lead to more sought referrals and thus enhanced sample diversity. We acknowledge, however, that this finding may not be true for all populations. For instance, studies on individuals with sexually transmitted diseases have found that these interviewees (particularly men) tend to report more truthfully in an audio-computer-assisted self-interview (ACASI) than in a face-to-face interview, since interviewees tend to be more comfortable reporting on sexually transmitted diseases to a computer than to a live person [ 81 , 82 ].

On persistence

Our data suggest that persistence can indeed enhance sample diversity, but we can also conclude that excessive persistence does not necessarily yield dividends. Instead of distributing a great many interview reminders during our study, we reached out to the majority of our proposed interview subjects only once. Nevertheless, the scarce data we collected regarding persistence indicates its value. We map this data in Fig 6 , with the left side depicting our success rate in relation to the number of reach-outs (either one, two or three) and the right side depicting a deep dive on success rates achieved with two reach-outs (distinguishing between reach-out attempts to unknown potential interviewees and those to whom we were referred by other interviewees). We sent one interview reminder to 28 of our proposed interviewees. This led to 10 additional interviews, a success rate of 36%, equalling 12% of the total interviews analysed for this paper. Reminders appear to be only somewhat more helpful when contacting referrals in comparison to their usefulness with cold calls–a single reminder led to an interview in 39% of our cases for the former group and 38% for the latter. One of the most valuable interviews for our research gained via a reminder was with the CEO of a Burmese dam developer. This interviewee compared Chinese and European dam developers in Myanmar, which helped us to further refine our narrative on social-safeguard policy adherence by Chinese dam developers in Myanmar.

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(1) Number of reach-outs unknown for 32 reach-outs. Eight potential interviewees responded, but refused interview.

Excessive persistence, however, does not appear to be worthwhile. We sent three reminders to seven of our envisaged interviewees, but as Fig 6 shows, this did not lead to a single additional interview. While our data does not suggest that excessive persistence is helpful to researchers, it may also not be recommended for ethical reasons. A potential interviewee who does not respond to an interview request after two reach-outs may be indicating via this non-response that she or he is not interested in participating in the research. If a single request remains unanswered, the researcher may hypothesise that, for instance, the e-mail was overlooked, a hypothesis particularly likely when conducting interviews with time-pressed leaders of organisations. Indeed, all 10 interviews only carried out upon the second reach-out were interviews with interviewees in management positions.

Our data on persistence provide some evidence that those employing or intending to employ snowball sampling can enhance sample diversity if every reach-out is carefully tracked and followed by a reminder. We typically sent a reminder after one week if no response was obtained upon the first reach-out. This persistence may help to include those least keen to be interviewed for a research endeavour.

Our data show some evidence that, for our topic of study, pursuing interviews for even a few waves provided the perspectives of particularly difficult-to-reach populations and thus achieved sample diversity. More than 60% of our interviews were conducted in the zeroth or first wave ( Fig 7 ). These include seven of the nine interviews conducted with dam developers, the sub-category we deemed most challenging to interview. The remaining two interviews with dam developers were conducted in the second wave. However, not a single interview with a dam developer was carried out in the third wave and beyond, although a fifth of our total interviews were carried out in the third or later waves. Pursuing interviews for multiple waves nevertheless yielded novel insights. For instance, interview FNL12, which was conducted in the sixth wave, yielded insights on small dam construction in Myanmar–a topic of (some) interest to our research endeavour, but not covered in detail by previous interviews. Furthermore, we note that our finding regarding the limited value of multiple waves may also be specific to our population, with this finding perhaps indicating a low degree of network segmentation in the population in question [ 83 ]. Meanwhile, a high degree of network segmentation may impede the pursuance of multiple waves, since interviewees may lack the suitable contacts for a referral [ 84 ].

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While additional waves can lead to novel insights, our overall data on waves provide some evidence that the number of waves pursued is not a definitive indicator for sample diversity. Even very few waves can yield access to particularly difficult-to-access populations.

Our quantitative analysis of pathways to delivering sample diversity in snowball samples yielded the following revisions to the literature’s recommendations:

Prior personal contacts are not essential for achieving sample diversity but tend to be helpful, as generating new contacts during research can be labour-intensive.
Sample seed diversity is important to achieving sample diversity.
Face-to-face interviews build trust and can help to generate further referrals.
Persistence (within reason) is helpful in securing interviews.
Sample diversity is not necessarily enhanced if a seed is advanced over numerous waves.

We do not claim that these insights are comprehensive, but we believe that these interpretations of our data may serve as a starting point for future scholars using snowball sampling procedures. All of the analyses presented in this section are based only on descriptive statistics. This means, for instance, that we cannot control for confounds such as effort [ 85 ]. An experimental research design would yield the most robust insights on sampling procedures to enhance the sampling diversity of a snowball sample (with, for instance, one research project staffed with scholars with relevant personal or professional contacts and another staffed with scholars without relevant contacts).

Overall, this work aims to advance the literature on snowball sampling as a qualitative sampling approach. While snowball sampling procedures may qualify ‘as the least “sexy” facet of qualitative research’ ([ 1 ], p. 328), these procedures are ‘not self-evident or obvious’ ([ 20 ], p. 141), since the snowball sample does not ‘somehow magically’ ([ 20 ], p. 143) start, proceed and terminate when a scholar attempts to develop a diverse sample. Rather, continuous, deliberate effort by the researcher(s) is required. Our paper has attempted to provide some insights on this effort.

Unfortunately, we developed the idea to write this paper only during the course of our research project, and thus some of our data may be skewed. For instance, we may not have been able to trace all original reach-out attempts and our data on persistence may therefore be biased. Some of those scholars grounded in quantitative thinking may also claim that the insights outlined in Section 4 lack external validity since our sample size is relatively small from a quantitative methodological perspective. In addition, our population was very specific and thus may not be comparable to other difficult-to-reach populations, and we also did not adopt an experimental research design as described above. Hence, we encourage scholars to replicate our findings via their respective research projects that employ snowball sampling. With many scholars claiming to feel more pressed than ever to deliver research results with maximum efficiency, we hope that these initial descriptive analyses of snowball sampling procedures provide some valuable insights to those employing or intending to employ this method and aiming to improve their management of it.

Supporting information

Acknowledgments.

We wish to thank our reviewers at PLOS ONE who provided constructive thoughts on this piece of work. We also thank Ralf van Santen for his outstanding contributions to this work as a research assistant.

Funding Statement

The authors received no specific funding for this work.

Data Availability

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Peer-reviewed

Research Article

Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia

Contributed equally to this work with: Julian Kirchherr, Katrina Charles

Roles Conceptualization, Investigation, Visualization, Writing – original draft

* E-mail: [email protected]

Affiliations Faculty of Geosciences, Utrecht University, Utrecht, the Netherlands, School of Geography and the Environment, University of Oxford, Oxford, United Kingdom

Roles Supervision, Writing – review & editing

Affiliation School of Geography and the Environment, University of Oxford, Oxford, United Kingdom

Julian Kirchherr,
Katrina Charles

Published: August 22, 2018
https://doi.org/10.1371/journal.pone.0201710
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Citation: Kirchherr J, Charles K (2018) Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia. PLoS ONE 13(8): e0201710. https://doi.org/10.1371/journal.pone.0201710

Editor: Timothy C. Guetterman, University of Michigan, UNITED STATES

Received: September 13, 2017; Accepted: July 20, 2018; Published: August 22, 2018

Copyright: © 2018 Kirchherr, Charles. 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.

Data Availability: All data underlying the study are within the paper and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

On snowball sampling

Prior personal contacts of the researcher are required

Sample seed diversity is important

Technology means face-to-face interviews are no longer required

Persistence is necessary to secure interviews

More waves of sampling are required to access more reluctant interviewees

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https://doi.org/10.1371/journal.pone.0201710.g001

Sample diversity is measured by representation from five identified sub-groups.

https://doi.org/10.1371/journal.pone.0201710.t001

Results and discussion

On prior personal and professional contacts.

https://doi.org/10.1371/journal.pone.0201710.g002

https://doi.org/10.1371/journal.pone.0201710.g003

On seed variation

https://doi.org/10.1371/journal.pone.0201710.g004

On face-to-face interviews

(1) Comprises interviews with those already retaining a personal or professional contact prior to the research project.

https://doi.org/10.1371/journal.pone.0201710.g005

On persistence

(1) Number of reach-outs unknown for 32 reach-outs. Eight potential interviewees responded, but refused interview.

https://doi.org/10.1371/journal.pone.0201710.g006

https://doi.org/10.1371/journal.pone.0201710.g007

Our quantitative analysis of pathways to delivering sample diversity in snowball samples yielded the following revisions to the literature’s recommendations:

Prior personal contacts are not essential for achieving sample diversity but tend to be helpful, as generating new contacts during research can be labour-intensive.
Sample seed diversity is important to achieving sample diversity.
Face-to-face interviews build trust and can help to generate further referrals.
Persistence (within reason) is helpful in securing interviews.
Sample diversity is not necessarily enhanced if a seed is advanced over numerous waves.

Supporting information

https://doi.org/10.1371/journal.pone.0201710.s001

Acknowledgments

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Snowball Sampling

Snowball sampling is one of the most popular methods of sampling in qualitative research, central to which are the characteristics of networking and referral. The researchers usually start with a small number of initial contacts (seeds), who fit the research criteria and are invited to become participants within the research. The agreeable participants are then asked to recommend other contacts who fit the research criteria and who potentially might also be willing participants, who then in turn recommend other potential participants, and so on. Researchers, therefore, use their social networks to establish initial links, with sampling momentum developing from these, capturing an increasing chain of participants. Sampling usually finishes once either a target sample size or saturation point has been reached. This entry begins with a description of the conveniences of snowball sampling, followed by some criticisms and limitations of the technique. The next section provides examples of how snowball sampling is used in qualitative research projects. Subsequent sections examine instances in which snowball sampling stalls or fails to produce participants, and offers two examples of cases in which researchers successfully overcame those obstacles. The entry concludes with a look at some variants of snowball sampling that have emerged given technological advances.

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Snowball Sampling: A Purposeful Method of Sampling in Qualitative Research

2017, Strides in Development of Medical Education

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Robert A. Bednarczyk 3 &
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Introduction

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices.

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers’ approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges.

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Peer Review reports

Human papillomavirus (HPV) is a common sexually transmitted infection (STI) in the United States (US) with an estimated prevalence of 42.5 million people and an incidence of 13 million people per year [ 1 ]. HPV-associated cancers, including vulvar, vaginal, cervical, penile, anal, and oropharyngeal cancers, can develop years or decades following persistent HPV infection [ 2 , 3 ]. Between 2015 and 2019, it was estimated HPV caused 47,199 new cancer cases each year [ 2 ]. Georgia has an incidence rate of 12.9 per 100,000 persons of all HPV associated cancers compared to the United States at 11.8 per 100,000 persons [ 4 ]. Additionally, Georgia is ranked in the top 15 nationally for having high cervical cancer incidence rates (7.4 per 100,000 persons) and the national incident rate is 6.5 per 100,000 persons [ 4 ]. Due to the high incidence rates of HPV associated cancers, the Georgia Cancer Plan: 2019–2024 made targeting HPV associated cancers a priority in an effort to support cancer prevention efforts [ 5 ]. The objective related to this priority is (Objective 1): “To increase the number of females and males who complete the HPV vaccine series in accordance with the Advisory Committee on Immunization Practices (ACIP) and recommendations” [ 5 ].

HPV vaccine was developed to prevent HPV associated cancers and genital warts; [ 6 ] currently HPV vaccine is one of two cancer prevention vaccines available globally [ 7 ]. Previous research determined each HPV vaccine is safe and has at least 96% efficacy for preventing HPV-associated cancers [ 8 ]. HPV vaccination was recommended in the US for adolescent females in 2006, and for adolescent males in 2011 [ 9 ]. The Advisory Committee on Immunization Practices (ACIP) recommends vaccination from as young as 9 years old to age 26, with the possibility of receiving the vaccine up to the age of 45 through a shared decision making process between the provider and the patient [ 10 ]. The earlier a person receives the HPV vaccine before engaging in sexual activity, the better protected they will be from HPV-associated cancers and genital warts [ 11 ]. If the vaccine is initiated prior to the 15th birthday, vaccine recipients need to complete a two-dose vaccine series; if the first dose is given after the 15th birthday, vaccine recipients need to complete a three-dose series [ 12 ]. Healthy People 2030 offers standardized 10-year measurable health objectives for the United States. Among their target goals is to have 80% of adolescents aged 13 to 15 receive all recommended doses of the HPV vaccine. As of 2021, the current national rate is suboptimal at 58.5% [ 13 ].

According to the National Immunization Survey-Teen (NIS-Teen) data from 2022, 76.0% of adolescents aged 13–17 have received at least one HPV vaccine dose with 62.6% having completed the series [ 14 ]. Comparatively, other adolescent vaccines such as Tdap and meningococcal are closer to 90% for receiving one dose. [ 14 ] Compared to the national percentage from the NIS-Teen 2022, Georgia’s HPV vaccine initiation and up-to-date rates among adolescents aged 13–17 are 70.8% and 61.5%, respectively [ 15 ]. Adolescents residing in rural areas compared to urban areas have lower initiation (68% versus 77.8%) and up-to-date (49.2% versus 60.4%) HPV vaccination rates from NIS-Teen 2020 [ 16 ]. Similarly, in the District of Albany (rural GA), only 47.9% adolescents aged 13–17 were up-to-date on their HPV vaccinations, which is 13% lower than the rest of the state, provided by Georgia Registry of Immunization Transactions and Services (GRITS) [ 17 ]. Therefore, this shows a gap in HPV vaccine uptake in rural communities and understanding the reasons behind low vaccine rates is crucial to increasing vaccination efforts.

Research has examined facilitators and barriers at the patient- (adolescent & parent), provider-, and practice-levels. The facilitators at both the patient- and provider-levels are patient’s trust in the provider, knowledge of the vaccine, and self-efficacy in one’s own ability to discuss the vaccine [ 18 , 19 ]. For practice-level, the facilitators are the availability of the vaccine, scheduling future vaccine appointments, and prioritizing the vaccine [ 18 ]. The barriers at the patient- and provider-levels are the lack of knowledge and self-efficacy discussing the vaccine, concerns about safety and adverse effects, and not receiving provider recommendation for HPV vaccine [ 18 , 20 ]. The barriers for practice-level are lack of access to vaccine provider, clinic logistics, and reminder system. [ 19 ] Few studies have explored facilitators and barriers of receiving the HPV vaccine intersecting at multiple levels of the socio-ecological model (SEM), and even fewer have been conducted in rural southwest Georgia [ 18 , 21 , 22 , 23 , 24 ].

This qualitative study aimed to identify socio-ecological determinants influencing HPV vaccination uptake among parents, young adults, and public health professionals and providers in rural Georgia. We applied the P3 (patient-, provider-, practice-levels) Model to examine all three levels at the same time and how they impact each other, specifically around HPV vaccination [ 25 ]. At the patient level we assessed parents and young adults perceived susceptibility and severity. To assess all three levels we asked parents, young adults, providers and public health professionals about the facilitators and barriers of receiving the HPV vaccine series.

We conducted a cross-sectional qualitative study to assess attitudes, knowledge, perceived severity and susceptibility, and reasons for HPV vaccination uptake (or lack of) among parents and young adults. In addition, interviews with healthcare providers and public health professionals were conducted to assess their knowledge, attitudes, practices, and the facilitators and barriers to HPV vaccination in rural communities. Between September 2020 to March 2022, a series of 40 interviews were virtually conducted with participants from southwest Georgia. At the beginning of the interview, the participant was told about the study, their role, risks and benefits of the study, and consented to participate. After consent was given, the interview was recorded on Zoom or an audio recorder. Emory staff (coordinators and students) were trained on the study, interview guide and conducted the interviews. The interviews were between 30–45 min and participants were compensated with a $25 electronic gift card. The study was deemed exempt by the Institutional Review Board at Emory University.

Conceptual framework

This study was informed by the P3 Model and the SEM [ 25 , 26 ]. The P3 Model is a unique approach since it encompasses not one but all three levels (patient, provider, and practice) of the clinic approach and integrates key components of health promotion and behavioral theoretical models (e.g., Health Belief Model, Theory of Planned Behavior, and ecological models (SEM) to impact health outcomes (Fig. 1 ) [ 25 ]. Since the P3 Model integrates multiple theories into the model, we utilized the model to guide our study and focused on targeting each of the levels in the model. The SEM describes the interplay of different levels of health factors that may influence the uptake of health behaviors at the individual, interpersonal, organizational (i.e., health systems), community, and policy levels [ 26 ]. From the SEM, we included questions beyond the P3 Model including community and policy-level factors that facilitate or hinder vaccine uptake. The frameworks applied to this study address limitations in existing rural health literature on HPV vaccination by considering healthcare system components beyond patient-level factors influencing parents’ and young adults’ vaccination decisions [ 25 , 27 ].

The HPV vaccine applied to the P3 (practice, provider, and patient level) model

Eligibility

This study included diverse participant categories from parents, young adults, providers and public health professionals. The parent of a child category was split into two groups: 1) vaccinated and 2) unvaccinated. The eligibility criteria for parents with a vaccinated child is a parent whose child received at least one dose of the HPV vaccine series and the child were between the ages 9–17. The eligibility for parents with an unvaccinated child is a parent whose child did not receive any doses of the HPV vaccine series and were between the ages 9–17. To be eligible for the young adult category, the person had to be between the ages of 18–34. Providers and public health professionals had to be a person who worked in a clinical setting or public health department or public health organization. The eligibility criteria of the interview sample are in Table 1 .

Recruitment

We used snowball and convenience sampling methods for participant recruitment and recruited only from southwest Georgia, which consists of 33 counties. Participants (e.g., parents and young adults) were recruited from the Emory Prevention Research Center (EPRC) Community Advisory Board (CAB), Facebook advertisements, and emails. The CAB is comprised of community members and leaders, health providers or staff from health systems, the public health district, businesses, and non-profits in southwest Georgia. This CAB has been in existence for over 20 years and members typically commit for two–three years. The Facebook advertisements were posted on the EPRC Facebook page targeting parents and young adults who live in southwest Georgia. Some parents, young adults, and providers were recruited from elementary schools and universities by receiving cold emails from the study team. In the email, eligibility and demographic questions were asked such as the age of the child/young adult, has the child/young adult received the HPV vaccine series, and if not, whether there are any plans for them to receive the HPV vaccine series in the future. The last two questions were about county of residence and race. These two questions were asked to make sure the study team captured a diverse sample. Public health professionals were recruited from non-profits and health agencies through word of mouth, fliers, and emails. To ensure saturation was met we had at least 10 participants for each category.

Interview guide development

The qualitative study had three interview guides for different audiences (parents, young adults, and providers/public health professionals). The interview guides were informed by the P3 Model and the socio-ecological model [ 25 , 26 ]. The questions revolved around six topical categories, including: 1) knowledge, 2) facilitators to receipt of HPV vaccine, 3) barriers to receipt of HPV vaccine, 4) healthcare delivery factors, 5) community and resources, and 6) demographics. In addition, in the parent and young adult interview guides we asked about preventive care and interaction with providers around HPV vaccination. For providers, we also asked about promotional methods for the vaccine, the use of the Vaccine for Children’s program, staffing and supply issues, and if they have strategies or received training on how to talk to patients and parents about the vaccine (Table 2 ). Across all categories, we assessed participant demographics by asking demographic questions at the end of the interview before concluding the recording. The demographic questions included age, gender, race, and ethnicity (whether they are of Hispanic/Spanish descent). In addition, for providers and public health professionals, we inquired about their title and discipline, the organization they work for, and how long they have worked there. The interview guides and methods were reviewed by the study team and a working subgroup consisting of researchers from the EPRC and the EPRC CAB. The CAB members who participated are a healthcare provider, an infectious disease epidemiologist, and a health district deputy director. These CAB members, EPRC researchers, and our Emory team met three times before the data collection to guide the instrument development, recruitment methods, and data analysis plans. The results also were shared with them through several CAB meetings.

All the interviews except for two were recorded on Zoom. The two interviews not recorded on Zoom were recorded on an audio recorder since the interviews were conducted over the phone. The interviews were then transcribed by a professional transcription service. We applied a systematic method for thematic data analysis including iterative codebook development with deductive codes from the interview guide, first-round coding, secondary coding, refinement of the codebook, consensus, final analysis, and matrices of themes [ 28 ]. A codebook with definitions was developed using a deductive coding approach from the three interview guides (parent, young adult, and providers/public health professionals) and the P3 Model and inductive codes. All transcripts were uploaded to MAXQDA for analysis [ 29 ]. Two trained researchers coded each transcript with the secondary coder reviewing coding from the primary coder. If there were discrepancies, then the coders would meet to discuss and come to an agreement and add new codes to the codebook when needed [ 28 ]. Emerging themes were identified for barriers and facilitators across each of the levels and finalized until saturation was reached [ 30 ]. Themes were sorted by facilitators and barriers and then broken down further by each of the levels in the P3 Model and socio-ecological levels (community and policy) in matrices with stronger themes ranked first.

We had 10 young adults, 20 parents, and 10 providers and public health professionals (health system participants) participating in the qualitative study. The young adults were 80% female and 20% male, 60% Black, and 40% White, 90% non-Hispanic and 10% Hispanic. The parents were 95% female and 5% male, 60% Black, 35% White, and 5% did not specify their race. Adolescents of the parents were 53% female and 47% male, 42% were ages 9–12, 48% were ages 13–17 and 10% were 18 and over. Health system participants were 90% female, 10% male, 60% Black and 30% White and 10% not specified. More than half of all participants and providers identified as African American (60%), about a third identified as White (35%), and 5% of participants did not specify their race. Additional demographics of the sample are displayed in Tables 3. and 4 . The 40 participants reside in 11 out of the 33 counties in southwest Georgia and the top three counties are: Dougherty (52.5%), Lee (15%), and Colquitt (10%) seen in Supplemental Table 1.

Facilitators

There were facilitators for receiving the HPV vaccine identified at each of the three levels in the P3 Model. Facilitators at the patient level were having existing knowledge of HPV and the HPV vaccine, knowing the vaccine is safe, having knowledge on who can receive the vaccine and when, and having trusted individuals provide information about the HPV vaccine to their community. At the provider level, they were having efficacy of the vaccine, framing of the HPV vaccine to patients, and revisiting the HPV vaccination with hesitant parents. Facilitators at the practice level were immunization reminders, patient registries, the use of social media (e.g., educational videos), and other health clinics who support the vaccine. Immunization reminders was the most mentioned strategy mentioned across participants, both for the patients and providers to remind patients about the vaccine. See Table 5 for more facilitator quotes for each level.

Patient level

At the patient level, participants (primarily parents of vaccinated children and young adults both vaccinated and unvaccinated) consistently referenced having existing knowledge of HPV as a facilitator to increase uptake in administering the HPV vaccine. In describing the vaccine, participants referenced a basic understanding of which cancers it can prevent, and ages at which adolescents can receive the vaccine. Parents and young adults understood the safety of the vaccine, which assisted in having positive attitudes towards the vaccine. One parent described: "I’m going to say it’s [HPV vaccine] some insurance for your child’s behaviors and actions later on in life, you know? Lots of insurance." (Participant 7, parent of vaccinated child). For young adults, they learned about the vaccine on social media, and through school. Enlisting trustworthy individuals to connect community members with information within the community serves as another facilitator for increasing HPV vaccine uptake. A director of a non-profit alluded to this: "I think once they are educated, you know, by a trusted voice, you know, whether that’s their physician or, you know, pastor or somebody, whoever that trusted voice is for them, I think they’re more likely to be acceptable to that ." (Participant 39, health systems).

Provider level

At the provider level, parents of vaccinated children highlighted the approach their children’s providers took when discussing the HPV vaccine with them. The providers framed the vaccine as a preventative measure against other diseases. Providers often spoke of the efficacy the vaccine has against contracting and spreading sexually transmitted infections (STIs), and how those STIs may have more serious ramifications later in life. A parent described this perspective: "Just putting it out and putting the information out and let them stress that it is an STD just like any other STD. Of course, with repercussions in the future, and if you can prevent it, why not." (Participant 6, parent of vaccinated child) .

In addition to framing the discussion, several education and messaging strategies were viewed as successful facilitators; these included patient visits at clinics, health departments, and utilizing community events to educate local community members. Some health system participants offered effective strategies such as revisiting the topic with hesitant parents and using information sheets to allow the parents to learn about the vaccine and its importance. One provider described their approach: "And I try to re-educate if they didn’t, just because a lot of it is that they kind of don’t know what HPV is. They’ve heard of the vaccine. They understand that it’s a vaccine, but I don’t think they really know what HPV is and why they should be concerned about it." (Participant 40, health systems). Parents of vaccinated children emphasized the use of brochures and pamphlets offered by providers as effective learning strategies. Some reflected on how this allowed for parents to take their time learning about the vaccine, and its benefits. Others viewed the brochure as a first step towards having a deeper conversation with the provider. Ultimately, parents thought brochures may bridge the gap for parents who do not know enough about the vaccine but want to learn more about it.

Practice level

At the practice level, immunization reminders sent to parents and young adults were seen as effective strategies by parents whose children were vaccinated and vaccinated young adults for patients to receive their HPV vaccine doses. Reminders included different formats depending on the health system, including phone calls and reminder cards. Health system participants also recognized different strategies to ensure patients returned for subsequent doses. These included the use of patient registries and highlighting those due for immunizations, as well as through the standardized Georgia Registry of Immunization Transactions and Services (GRITS), the statewide immunization information system. As one provider described their practice’s strategy:

"We have what’s called precall-recall, and so once a month we print out a list of our patients here that either they’re coming due for a set of immunizations they’ll be turning 11 in the next month. We’ll send out a letter that says your child will be due for immunizations on this day. We won't specifically say what immunization, but we’ll say they’re due for immunizations…" (Participant 9, health systems) .

Community and policy levels

At the community and policy levels, parents with vaccinated children and health system participants discussed techniques of using central and familiar locations like schools to engage in community outreach. Another one was to have champions within the community. One provider described: “I’d say insight into the community, definitely, to get the word out. Because if you don’t have somebody from the community that also buys in, then they’re not going to participate, not going to show up” (Participant 25, health system nurse). For policy, health system participants mentioned vaccine programs, explaining : “I think we have a free program with HPV…We get them (adult patients) to sign something and then we can get it for free for people who are uninsured” (Participant 23, health system provider).

The barriers for receiving the HPV vaccine at each of the three levels in the P3 Model were the lack of information and dialogue around the HPV vaccine. At the patient level, the main barriers were a dearth of education on HPV and the HPV vaccine, misinformation, and stigma as is relates to STIs and sexual intercourse. At the provider level, a deficiency exists in direct provider-patient communication, including instances where providers fail to inform and recommend the HPV vaccine to their patients. At the practice level, there are a lack of systematic reminders for patient immunizations reminders, limited information, time, staff, and resources committed to the HPV vaccine (Table 6 ).

At the patient level, a persistent theme among parents of both vaccinated and unvaccinated children in our study focused on a dearth of knowledge among parents and their communities about the importance of vaccinating their children against HPV. They highlighted how it is not a common topic to be discussed among parents with their children. One young adult described their experience as a child, “They’re (doctor) like, oh yeah, we now offer the HPV vaccine. Is it something you want to get? And my mom was like, eh, no, she doesn’t need that right now. And I was like, okay. I don’t really want a shot either, so it’s fine with me.” (Participant 17, unvaccinated young adult). Not only is it not being discussed, but parents described not knowing where to go to find more information about the vaccine. Health system participants also discussed how parents often did not have the necessary knowledge about the vaccine to effectively make decisions on behalf of their children. Stemming from this lack of education is the impact that misinformation has surrounding the efficacy, safety, and utility of the HPV vaccine. Two non-vaccinated young adults address misinformation, one stated, “… they’re [young adults] very hesitant about getting like even the COVID vaccine, just because, you know, they heard rumors, oh, it has this in it, it has that in it… ” another stated, “They [young adults] look at social media and certain people may say this is what they do, this is what they don’t do, this is that. So, I think actually with social media and peer pressure that conveys a lot of the youth.”

A director of a non-profit described, “I think all of the conspiracy theories that are out there now, and it’s even worse since COVID, nobody trusts, or a lot of people don’t trust public health messages anymore.” (Participant 12, health systems). In this context, the participant emphasizes the challenge of discussing the vaccine with parents and how a lack of trust in public health complicates messaging strategies.

Coupled with this misinformation was the resulting stigma of discussing HPV due to it being a STI. Vaccinated and unvaccinated young adults, both parents of vaccinated and unvaccinated children, and health system participants described how some parents may be reluctant to vaccinate their child, because they perceive it to indicate their child could be engaging in sex, or receiving the vaccine encourages the child to be sexually active. As one parent described, “Well, I think part of it is that since it is sexually transmitted, I think that a lot of parents don’t want to really delve into that thought that their kids are being sexually active or may be sexually active soon” (Participant 1, parent of vaccinated child). Particularly in southwest Georgia, sexual intercourse is stigmatized. As one provider described,

“ I think the – I think stigma, because it is associated with sexual – a sexual nature. So, they kind of clam up like here in southwest Georgia, Bible belt, like it’s just kind of a – you know, you don’t speak of those things. Those are kind of taboo. Like everybody knows it’s occurring, but you don’t really want to I guess see your child doing – you know, doing things like that. So, I think it’s just the culture here” (Participant 15, health system nurse).

By attempting to discuss a vaccine to prevent STIs, health system participants believed this may contradict many who view teenage sexual health education as only relevant through abstinence.

At the provider level, parents of unvaccinated children and young adults (both vaccinated and unvaccinated) alluded to the dearth of direct communication with providers about the vaccine and revisiting the topic with their patients. Specifically, some parents described how their child’s doctor did not educate them on the reasons for getting the vaccine. As one parent described their experience with a doctor as:

"…they presented it, and asked did I want him to receive the vaccine, but at that time, I just had not had enough information on it personally, and with that, they did not give me any more information. And so, with that being said, you know, if my – if the doctor is not willing to provide more and give me more insight into it, any side effects, you know, statistics, and things of the sort, then you know, (laughs) yeah." (Participant 2, parent of unvaccinated child).

This parent highlighted how they may have been convinced had the doctor provided more details about the reason for vaccinating their child. Another parent with an unvaccinated child described providers not revisiting the HPV vaccine with them at later visits if the parent initially said “no.” Aligned with the lack of direct communication, providers were not informing and recommending the HPV vaccine to patients. As a director of a non-profit stated, “ I think maybe lack of consistent recommendations. You know, they may get tied up in, you know, other bunch of check list of things that they’ve got to do and then may – it just may not be consistent throughout the flow…” (Participant 39, health systems). A parent also felt the providers need to be speaking more about the HPV vaccine in the exam room. One parent described, “I feel they should be more open and mention it in an exam. I do. I feel like they should. Not just have the poster up, like in the hallway. They still should mention it. The same way that they’re stressing the COVID vaccine, they should stress that vaccine in the same manner, I think.” (Participant 35, parent of unvaccinated child) . Here, the parent wished the approach to HPV and the HPV vaccine was similar to the COVID-19 vaccine in order for them to understand its importance during their child’s visits.

At the practice level, participants described lack of systematic reminders for patient immunizations, limited time, resources, and staff allocated per patient, and lack of education in the clinic or medical offices. A parent of each a vaccinated and unvaccinated child referenced not receiving vaccine reminders. One of the parents stated: "Yeah. I think that like, for example, in my case, if there were an actual mailing that came to our house-…I would have seen it. I would have at least begun a conversation with my husband about it, and he was the one responsible for taking him to the pediatrician and getting it handled." (Participant 1, parent of vaccinated child) . Although their child was vaccinated, the need for a mailed reminder would have facilitated discussions between the parents about vaccinating their child. Similarly, a young adult who received their first shot did not return for their second shot since they did not know when to return to the doctor’s office. Other barriers at the practice level include limited information, time, staff, and resources dedicated to the HPV vaccine. Both parents and health system participants mentioned time being a factor. One provider stated,

“ Time would be one I would see, because with a lot of the things that we’re having to do now, you don’t’ have as much time to do the education as you would like to, and sometimes when you’re talking about sex and HPV, if it’s on a one to one basis, it’s hard to establish a rapport in five, ten minutes and get all the information that you need to get to them and then allow them to ask questions” (Participant 25, health system nurse).

As for the lack of resources, parents with a vaccinated child mentioned they have seen posters about measles, mumps, and rubella but not on the HPV vaccine and clinics not having enough of vaccines to distribute. A barrier widely mentioned across participants (parents, young adults unvaccinated, and health systems) were the differences between private practices and public health departments in rural communities. The differences between the two discussed were the patient-provider relationship and patient privacy differences. A parent explained:

“If you’re more familiar with the doctor you have more trust, and you’re more likely to take their advice. When you go to one of the local clinics, the convenient care clinics, it’s not a guarantee you’re going to get the same doctor. So, you may not be as comfortable having a certain conversation with one doctor as you would with a doctor that you’re used to seeing on a regular basis” (Participant 13, parent with a vaccinated child).

Another parent stated, “Private, is not private, and a lot of people may avoid going to the health department and would rather go to an outside pediatrician but don’t have the transportation to get there (Participant 6, parent with a vaccinated child). This parent explained health department layouts are openly structured and patients get called to a window to discuss their health information and people in the waiting room can hear those discussions, causing a lack of privacy for the patient, Similarly, a young adult unvaccinated also mentioned how privacy and courtesy of health professionals at certain clinics can be a barrier for patients. A lack of privacy is a concern at a patient level, while limited resources for transportation infrastructure affect the community at large.

Several barriers at the community and policy level were mentioned by participants. At the community level the barriers include inadequate transportation, and lack of information within the community about HPV and the HPV vaccine and resources. A parent alluded to how important having a car is: “If I didn’t have a car, I probably wouldn’t even – I would barely go to the doctor if I had to use public transportation” (Participant 27, parent with an unvaccinated child). There is public transportation, but it takes more time and some unvaccinated young adults also stated how rural communities are spread out, which makes it challenging to travel to clinics that are out of their town and far away. A young adult described the lack of discussion around the vaccine in rural Georgia communities: “No, just that there is really not a lot of talks about it. I definitely think there needs to be more communication about it for sure” (Participant 17, unvaccinated young adult). At the policy level, the two main barriers participants mentioned were the financial barriers and lack of policies facilitating the uptake of the HPV vaccine. A provider described not being able to provide the vaccine to a minor without parental consent, “…hey, we can’t give them to you, because you’re not 18. We can give you, you know, reproductive care, but we cannot give you any vaccine without your parents’ permission” (Participant 15, health system nurse).

Our study used the P3 Model framework and found common facilitators and barriers to receipt of the HPV vaccine in rural communities. Some of the facilitators we found were trusted individuals in the community, existing knowledge, and providers stating the vaccine is a cancer prevention tool. Parent participants from a study in Alabama reported that guidance from pediatricians or family physicians influenced their decision to vaccinate their children against HPV [ 31 ]. Another study in Montana noted parents may be more receptive to the HPV vaccine when it is discussed as a cancer prevention tool rather than an STI prevention tool [ 32 ]. A pivotal facilitator at the provider level in our study involved how providers phrase and frame the HPV vaccine to patients. Medical providers and public health stakeholders from a prior study in Montana identified a presumptive style of recommending the HPV vaccine. An announcement and conversation training HPV intervention for providers led to an increase in HPV vaccinations for adolescents ages 11–18 over those in a control group in North Carolina [ 33 , 34 ]. This style included offering the HPV vaccine with other immunizations such as meningococcal, HPV, and Tdap together, which was successful [ 32 , 34 ].

Additionally, our research revealed that immunization reminders were a key facilitator in improving HPV vaccination rates. A study in rural Alabama similarly reported that receiving appointment reminders via card, call, or text helped ensure all doses were received [ 35 ]. Similarly, healthcare provider participants from a study in Georgia highlighted the importance of scheduling subsequent HPV vaccine appointments before patients leave their first vaccination appointment and the use of reminder systems [ 18 ]. In addition to immunization reminders, health education material such as educational videos, and incorporating the use of social media were mentioned as strategies to engage people on the HPV vaccine by our participants. Our participants suggested that employing simplified strategies will better attract and engage the general population, especially those with lower health literacy. Previous research found that rural communities need increased access to education on HPV, the HPV vaccine, and sexual health [ 36 ].

In addition to examining facilitators within the P3 Model, we also examined community and policy-level factors. From our study, the community facilitators were trusted community key stakeholders and how they were instrumental in the development of interventions, [ 37 ] community and school education programs, [ 38 ] and county-wide social marketing campaigns [ 39 ]. Our participants mentioned having webinars and the use of school events and outreach is beneficial for increasing the uptake of the HPV vaccine. Future research could investigate interventions like technological reminders and capacity-building for rural healthcare systems to boost HPV vaccination rates. Additionally, future HPV vaccine promotion efforts could focus on community education and participation in campaigns such as the American Cancer Society’s Mission HPV Cancer Free [ 40 ]. At the policy level, some existing facilitators were the Vaccines for Children (VFC) program and private clinics instituting standing orders within their practice for the HPV vaccine [ 41 ]. The VFC was designed so children can receive vaccines regardless if the parent or guardian can afford the vaccines. Similarly, our study participants mentioned how beneficial vaccine programs are not only for children but for adults too.

Data from the 2010–2020 National Immunization Survey-Teen identified the following barriers to receiving the HPV vaccine: lack of knowledge, abstinence, safety concerns, and viewing the vaccine as unnecessary [ 42 ]. A lack of knowledge on HPV was reported as a prominent barrier among our rural participants, which has been observed across multiple rural-based studies [ 18 , 19 , 31 , 35 , 43 ]. Studies in rural Alabama found a lack of parental understanding about the HPV vaccine was a key barrier as reported by parents, pediatricians, and nurse participants [ 19 , 35 ]. Provider participants from a quantitative study reported vaccinating adolescent females (13–17 years old) at higher rates compared to pre-adolescent females (9–12 years old) [ 44 ]. Barriers such as parental discomfort and potential adverse side effects in vaccinating their pre-adolescent child against HPV, especially if the child has underlying health conditions can influence the age group disparity in vaccine uptake [ 44 , 45 ].

Another frequently discussed barrier in our study was stigma surrounding HPV as an STI and challenges in discussing sexual health, particularly given the conservative nature of southwest Georgia, located in the “Bible Belt” region. Previous research in the south (Georgia, Alabama, Kentucky, and North and South Carolina) found that parental perception of the HPV vaccination encouraging or permitting sexual activity discourages parents from having their child vaccinated against HPV [ 18 , 31 , 36 , 43 ]. Prior research with healthcare providers from Georgia noted providers avoid discussing sex at all when recommending the HPV vaccine due to STI stigma [ 18 ].

Similarly, a lack of provider recommendations or discussion about HPV was a prominent barrier among our participants, consistent with previous literature [ 18 , 35 , 42 ]. According to providers in Georgia, low provider confidence in the HPV vaccine can pose a barrier to giving patients strong recommendations for the vaccine [ 18 ]. A national survey examining the quality of physician recommendation for HPV vaccination revealed that physicians in the sample often lacked consistency, urgency, and timeliness in their recommendation of the HPV vaccine [ 46 ]. Strategies such as education from other lay health professionals such as community health workers or navigators, training or mentoring of providers through technology, or partnering with other health organizations may be possible intervention strategies to explore [ 47 ]. Provider training on strong recommendations and presumptive communication has been effective in approaching this discussion about the HPV vaccine with parents and/or adolescents and effective in promoting vaccination [ 33 , 48 ]. This type of training should be delivered to rural public health and healthcare providers to address these barriers [ 49 ].

Additionally, we found that a lack of patient reminders can hinder increases in HPV vaccination rates, which has been observed in prior studies. Reminder cards can easily be lost, so technology-based options, particularly email or text should be utilized based on individual patient preferences [ 43 ]. However, not all rural areas have the capacity to utilize text messaging based on limited cellar service [ 50 ]. Future efforts to increase HPV vaccination need to include relevant reminders for patients and/or caregivers. In addition to a lack of patient reminders, there is a lack of privacy within healthcare for patients. As shown in our study, patients commented on the lack of privacy in health departments and previous research highlights healthcare does not have appropriate privacy protections for patients [ 51 ]. Moreover, our participants noted that in rural areas, inadequate staffing and resources were also barriers to HPV vaccine uptake. A study in rural North and South Carolina also found that provider shortages in rural areas result in fewer opportunities for parents and adolescents to learn about the HPV vaccine [ 36 ].

From previous research, barriers at the community level consist of a lack of transportation and how it negatively affects people getting to their appointments to receive medical care [ 52 , 53 ]. Participants in our study mentioned how a lack of transportation is a challenge, especially when one does not own a car or is unable to drive. Future research can explore methods to increase vaccinations outside of clinical settings including community settings or in pharmacies, as recommended by the President’s Cancer Panel report [ 54 ].

Similarly, a lack of policies can impact the uptake of the HPV vaccine. For example, the HPV vaccine is not routinely mandated for school entry at the state level, unlike other vaccines such as Tdap. While all states and the District of Columbia have middle school entry requirements for Tdap vaccination, only four U.S. jurisdictions (Rhode Island, Virginia, Puerto Rico, and the District of Columbia) currently have HPV vaccination requirements [ 41 , 55 ]. Georgia did propose a bill in 2019 to allow adolescents younger than 16 to consent to vaccinations without parental consent, however, the bill did not pass [ 56 , 57 ]. Due to this, minors will need parental approval to receive the vaccine and our participants explained the difficulty of this. Other policy barriers are financial vaccine burdens on health systems that administer the vaccines and lack of reimbursement from insurance companies [ 58 ]. Future implementation and evaluation of HPV policies (e.g., school or policy requirements) could assess policy solutions and impacts on HPV vaccine uptake.

Strengthens and limitations

The strengths of this study include interviewing three categories of community stakeholders and receiving their insights on the facilitators and barriers of the HPV vaccine in rural Georgia. In addition, for parents and young adults, we received perspectives from those who received and did not receive the HPV vaccine. Using the P3 Model in our study and the subsequent findings, allowed for consideration of multi-level interventions for increasing HPV vaccination. Research has shown numerous programs that promote HPV vaccination operate at a single level [ 59 ]. Mostly focusing on either the patient or provider levels and a lack of focus on including facilitators and barriers at the practice level [ 60 , 61 , 62 ]. Public health professionals and providers can learn from these facilitators and barriers to test strategies at different levels to increase rural HPV vaccination rates. However, our study has some limitations. The study findings may not be generalizable outside of rural southwest Georgia to other states or regions. There were also delays in recruitment because of participants’ limited time due to the impact of the COVID-19 pandemic. We had to pause recruiting providers because the community asked us to due to the demands of the pandemic and we focused our efforts on recruiting parents and young adults for the study. Participants may have offered socially desirable responses during the interview regarding the HPV vaccine. Finally, although we used several methods to increase the reliability of the qualitative data analyses such as using verbatim transcripts, a structured, iterative codebook and training of coders, and two research team members coding each interview, there may be research biases in the analyses and interpretation of our data.

Identifying multi-level facilitators and barriers influencing HPV vaccination is necessary for increasing vaccine uptake, particularly in rural areas where vaccine coverage is disproportionately low. We found some key barriers at all three levels of the P3 model including misinformation, lack of knowledge, provider-patient communication, provider recommendation, lack of systematic reminders, and limited time and resources. These barriers highlight the need for future research to explore the effectiveness of the following strategies in rural communities: HPV vaccine education in rural communities through public health providers, provider training on strong recommendations, and technological health systems activities such as patient reminders.

Availability of data and materials

The data supports the findings of this study are available in tables and supplementary materials of this article. We can share general data matrices or summaries of the qualitative data if there are requested. Since this is a qualitative data and there is sensitive information about the vaccine and perhaps health systems, we will not share the actual transcripts. Contact Cam Escoffery at [email protected] about data availability.

Abbreviations

Community advisory board

Human papillomavirus

Patient-provider-practice-level Model

Socio-ecological Model

Sexually transmitted infections

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Acknowledgements

The authors would like to acknowledge the Emory Prevention Research Center Community Advisory Board members who assisted with recruiting participants and all the participants who provided their time and insight for this study.

This study was supported by Centers for Disease Control and Prevention, SIP 19–005 Cancer Prevention and Control Research Network, U48 DP006377 and Winship Cancer Institute, P30CA138292. The funders had no role in the study design, data collection, analysis, and interpretation of data and in writing the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the CDC. The authors thank the members of the Emory Prevention Research Center’s Community Advisory Board for their many contributions to this project. They thank the organizations and participants that participated in this qualitative study.

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Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA

Courtney N. Petagna, Stephen Perez, Erica Hsu, Ionie Banner & Cam Escoffery

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Robert A. Bednarczyk

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Contributions

C.E. and C.N.P. are responsible for the study design and oversight of the study. B.M.G. contributed to recruiting participants and to the conception of the study. C.N.P. and S.P. interviewed participants, and C.N.P., S.P., and I.B. coded transcripts. S.P., C.N.P., and C.E. contributed to the data analysis and the results. C.N.P., E.H., and C.E. contributed to the discussion. E.H. and C.N.P. prepared Fig. 1 and Table 2 . C.N.P. and I.B. prepared Tables 3. and 4 . S.P. prepared Tables 5 and 6 . C.N.P. prepared Table 1 and the Supplemental Table 1. R.A.B. contributed his model, expertise, and design of the study. All authors read, edited, and approved the final manuscript.

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Correspondence to Courtney N. Petagna .

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We submitted the protocol and instruments to the Emory University IRB for project approval and consent to participate. The IRB deemed this study exempt because the study meets the criteria for exemption under 45 CFR 46.104(d)(2) from Emory University.

Informed consent was obtained by all participants who enrolled in the study.

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The authors declare no competing interests.

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Petagna, C.N., Perez, S., Hsu, E. et al. Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia. BMC Cancer 24 , 592 (2024). https://doi.org/10.1186/s12885-024-12351-1

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The selection of these 24 students employed the snowball sampling technique, commonly used in qualitative research, to identify and recruit participants through referrals from initial subjects.
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Upon studying sampling methods in qualitative research, students commonly learn what not to do (see literature review in Curtis et al., 2000, p. 1002). The qualitative researcher is left to her or his own devices in the task of weighing the consequences that one or other methods of sampling will have on the research, knowing that sampling
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Introduction. Snowball sampling is a commonly employed sampling method in qualitative research, used in medical science and in various social sciences, including sociology, political science, anthropology and human geography [1-3].As is typical of terms adopted by a variety of fields, however, the phrase 'snowball sampling' is used inconsistently across disciplines [].
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Background and Objectives: Snowball sampling is applied when samples with the target characteristics are not easily accessible. This research describes snowball sampling as a purposeful method of data collection in qualitative research. Methods: This paper is a descriptive review of previous research papers. Data were gathered using English keywords, including "review," "declaration ...
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Keywords: Purposeful Sampling, Snowball, Qualitative Research, Descriptive Review 1. Background Qualitative research is an organized method of describing people's experiences and internal feelings (1). It can be said that qualitative research provides a thorough and deep overview of a phenomenon through data collection and presents a rich ...
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Snowball sampling is a commonly employed sampling method in qualitative research; how-ever, the diversity of samples generated via this method has repeatedly been questioned. ... page of his 595-page book on social research methods to snowball sampling, acknowledging that 'snowball sampling procedures have been rather loosely codified' ([14 ...
(PDF) Snowball Sampling: A Purposeful Method of Sampling in Qualitative
Background and Objectives Snowball sampling is applied when samples with the target characteristics are not easily accessible. This research describes snowball sampling as a purposeful method of data collection in qualitative research. Methods This
[PDF] Sampling Knowledge: The Hermeneutics of Snowball Sampling in
The latter have been overlooked, qualifying only as a 'technical' research stage. This article attends to snowball sampling via constructivist and feminist hermeneutics, suggesting that when viewed critically, this popular sampling method can generate a unique type of social knowledge—knowledge which is emergent, political and interactional.
What Is Snowball Sampling?
Snowball sampling is a widely employed method in qualitative research, specifically when studying hard-to-reach populations. These may include: Populations that are small relative to the general population. Geographically dispersed populations. Populations possessing a social stigma or particular shared characteristic of interest.
Objectifying Contextual Effects. The Use of Snowball Sampling in
In a previous article, I emphasized the qualitative benefits of snowball sampling, namely its ability to reveal the peculiar interaction logic when the personal relationships created during the research (between informants and respondents) highlighted the participants' relation to politics (Audemard, 2016). In the present article, I will ...
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Snowball sampling is a commonly employed sampling method in qualitative research; however, the diversity of samples generated via this method has repeatedly been questioned. Scholars have posited several anecdotally based recommendations for enhancing the diversity of snowball samples. In this study, we performed the first quantitative, medium-N analysis of snowball sampling to identify ...
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Hence the evolving 'snowball' effect, captured in a metaphor that touches on the central quality of this sampling procedure: its accumulative (diachronic and dynamic) dimension. Snowball sampling is arguably the most widely employed method of sampling in qualitative research in various disciplines across the social sciences.
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ful sampling," "snowball," "qualitative research," and "de-scriptive review." First, all articles related to qualitative research in Iran were gathered. The articles, which contained the afore-mentioned keywords in the abstract, were included in our preliminary list, while the rest of the articles were dis-carded.
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271 Jalali R. Qualitative research sampling. J Qualitative Research in Health Sciences. 2013;1(4):310-20. [In Persian] Walsh A, Edwards H, Fraser J. Attitudes and subjective norms: determinants of parents' intentions to reduce childhood fever with medications.Health Educ Res. 2009;24(3): 531-45.
Facilitators and barriers of HPV vaccination: a qualitative study in
We used snowball and convenience sampling methods for participant recruitment and recruited only from southwest Georgia, which consists of 33 counties. Participants (e.g., parents and young adults) were recruited from the Emory Prevention Research Center (EPRC) Community Advisory Board (CAB), Facebook advertisements, and emails.

Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia

Katrina Charles

Introduction

On snowball sampling

Prior personal contacts of the researcher are required

Sample seed diversity is important

Technology means face-to-face interviews are no longer required

Persistence is necessary to secure interviews

More waves of sampling are required to access more reluctant interviewees

Results and discussion

On seed variation

On face-to-face interviews

On persistence

Supporting information

Funding Statement

Data Availability

Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia

Introduction

On snowball sampling

Prior personal contacts of the researcher are required

Sample seed diversity is important

Technology means face-to-face interviews are no longer required

Persistence is necessary to secure interviews

More waves of sampling are required to access more reluctant interviewees

Results and discussion

On seed variation

On face-to-face interviews

On persistence

Supporting information

Acknowledgments

Snowball Sampling

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Snowball Sampling: A Purposeful Method of Sampling in Qualitative Research

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Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

Introduction

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Strengthens and limitations

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