The project, funded by the National Heart Lung and Blood Institute, involves two clinical centers (Miriam Hospital/Alpert Medical School of Brown University and the University of North Carolina at Chapel Hill) and a Data Coordinating Center at Wake Forest University School of Medicine. All procedures were reviewed and approved by the Institutional Review Board (IRB) at each site (Rhode Island: The Miriam Hospital (Lifespan) IRB #2018-07; University of North Carolina at Chapel Hill IRB #07-1783; Wake Forest: Wake Forest School of Medicine IRB #00010097) and study participants gave written informed consent at each clinical center.
Formative research and message development
Based on the experiences with recruiting a similar population for a pilot study[11] and previous research on weight gain prevention[7, 8], we anticipated challenges with recruitment for a weight gain prevention program targeting young adults. Thus, we designed a formative research phase to inform our recruitment plan and intervention efforts for SNAP. Qualitative research methods, such as focus groups, offer a unique opportunity to formally assess the perceptions, needs and preferences of young adults who would be eligible for a weight gain prevention trial, but who may not otherwise present for treatment. Although a detailed description of methods, analyses and findings is outside the scope of the present paper, we present a brief overview of methods below, as well as key themes that informed our recruitment efforts in the present trial.
Focus groups were conducted at both clinical sites (Providence, RI and Chapel Hill, NC) in November of 2009. Participants were recruited using a multimethod, community-based approach including email blasts and posts to listservs, ads in college newspapers and e-newsletters, on-air radio spots, local newspapers, and internal hospital and university intranets. Interested participants completed a brief phone screen with study staff to ensure eligibility (18 to 35 years of age with a BMI of 21 to 30 kg/m2). Those who remained interested and were eligible were invited to participate in the next available focus group. The primary aim of the focus groups was to help researchers understand how to make weight gain prevention programs more appealing to this age group. Groups were conducted by staff members with experience leading behavioral weight control interventions and/or trained in qualitative data collection and lasted approximately 90 minutes; a facilitator’s guide was developed to ensure consistency across groups and sites. The agenda focused on three key areas: 1) perceptions of weight gain/determining whether 18 to 35 year olds viewed the potential for weight gain as a problem; 2) recruitment messages (that is, how to frame prevention/‘sell’ it to this age group); 3) recruitment outlets (that is, where should we advertise and what mediums should we use). All participants provided informed consent and were paid $20 for participation.
Across sites we conducted a total of 14 groups (nine all-female groups, four all-male, and one mixed sex) before achieving theoretical saturation. Participants (n = 68; 32% male; 68% female) were mostly non-Hispanic whites (58.4%), with a mean age of 26.1 ± 4.85 years and a mean BMI of 24.69 ± 2.71 kg/m2. Groups were audio-taped and executive summaries were prepared that summarized major themes within each agenda section, accompanied by interpretations by researchers as to the implications for the study. The executive summaries were compiled using a combination of debriefing summaries and structured audio reviews from each group.
Completion of the focus groups influenced our subsequent approach to recruitment by highlighting several themes. First, there was recognition of weight gain as a problem as one ages. Groups noted that highlighting the statistics among young adults would be of benefit to raise awareness. They also indicated that the cumulative effect of weight gain over time was perceived as more powerful and motivating than hearing about the expected year-to-year gains. For example, using the tag line or message ‘young adults gain an average of 20 pounds over 10 years’ was perceived as more influential than ‘young adults gain 1 to 2 pounds per year’. The second theme that emerged was consensus across groups that to capture young adults’ attention, messages should be positive and brief, with an emphasis on ability to produce positive changes and take action. This is consistent with efficacy promoting messages. Groups noted that they would prefer to visit a recruitment website than to call for information and indicated that a website address might be more easily remembered than a phone number and should be highlighted. Groups preferred using a specific age range in ads as opposed to ‘young adults’, using bright colors and realistic images, and avoiding an exclusive focus on images of scales. Finally, all groups generally noted that online recruitment methods would be effective, particularly email-based recruitment. They reported that ads should be primarily placed in online versions of papers as opposed to print and that a social media presence for the study might be helpful. Notably, they reported being unlikely to click on paid advertising placed on social networking sites (for example, Facebook).
Recruitment plan
Following the formative phase, a recruitment plan was devised. The strategy began by hiring a professional marketing firm that provided recommendations for branding, marketing and advertising based on the findings of our formative work. We selected recruitment channels that had been successfully used in other studies, were suggested by the focus groups, and reached our target demographic based on data available from the media outlets (for example, TV stations chosen based on their viewership). Finally, our approach was chosen to balance cost with opportunities to recruit a more diverse group. For example, while free email listservs were convenient and appealing, direct mail was deemed likely to enable us to reach a more economically diverse potential participant pool, so both methods were used. Special attention was paid to developing community relationships within organizations that might enable recruitment of men and minorities. Recruitment was also planned in cohorts but generally did not stop between cohorts. The timing and use of specific channels of recruitment can be seen in Figure 1. Our recruitment plan included careful real-time tracking of recruitment methods, which enabled us to prioritize channels with successful yields to recruit subsequent cohorts.
Recruitment message development
Findings from the focus groups were provided to a professional marketing firm and were used to develop recruitment messages, create a project brand, produce a variety of recruitment materials, and design a recruitment website (see Figure 2). Branding of the study included a study logo, colors, fonts and graphic elements that were consistently used across channels and sites. Specific attention was paid to attracting a diverse group of young adults. General taglines to appeal to a broad spectrum of our target demographic were created with segmented advertising taglines to attract specific market segments or sub-groups of young adults within the eligible demographic. Recruitment of males and minority individuals was a priority as both have been underrepresented in prior studies of weight control[1, 12–14], and our funding guidelines encouraged minimum levels of diversity in the study sample of at least 25%. To encourage male and African American recruitment, images of individuals from these demographic groups were used. Figure 2 provides example messages.
All recruitment advertising referred participants to the website for more information about the study and to complete initial eligibility screening (prescreen). The recruitment website included description of the study, benefits of participating, testimonials with pictures from four participants in the pilot study[11], eligibility criteria (including a BMI calculator), study locations, and the link to complete the online prescreening questionnaire. Recruitment was conducted simultaneously in RI and in NC using the same general messaging, formats and materials but with flexibility to focus more on specific outlets or techniques that seemed to be producing the greatest yield.
Recruitment was conducted from August 2010 through February 2012 (see Figure 1) through a broad variety of mechanisms including mass mailings, email listservs, newspaper, radio, television, websites, word of mouth, etcetera. During telephone screening, participants were asked to report how they heard about the study, and method of recruitment was tracked. A small number of participants (n = 15) reported more than one recruitment method. For purposes of estimating costs for recruitment methods in this paper, a primary method was determined for each person, defaulting to those with greater cost. The procedures for each method are described in more detail below.
Recruitment strategies
Mass mailing
Mailing lists were obtained from USA Data for men and women ages 18 to 35 within a 30 to 50 mile radius of Chapel Hill, NC and Providence, RI. Over a one-year period, a total of 30,000 postcards and 318,176 brochures were mailed in batches of 30,000 to 50,000. Half of the postcards specifically added ‘Men:’ to the tagline to target males. The postcard included a very brief description of the study and directed those interested to the study website. A variety of brochure designs was created to appeal to sub-populations within the targeted demographic.
Email
Emails were sent to email listservs from affiliated organizations, contact individuals within various organizations that employed or had members in the target demographic, and purchased email lists. Html emails were sent as well as text-based versions. The majority of emails were sent at no cost. Listservs included university and hospital student and staff lists and varied across the two clinical locations based on the availability of listservs and the presence of organizations that could yield interested participants. Other email recipients (most requesting that the announcement be forwarded to constituents) included human resources directors, wellness coordinators, local business contacts, employee resource groups, and university leaders. Groups that may have a significant contingent of young men (for example, police and fire departments, builders, and barbers) and African Americans (for example, historically black colleges and African American alumni and student groups) were specifically included. Emails were also sent to former study participants and current SNAP study participants. An additional email strategy was tried during recruitment of the last cohorts at each site where email lists were purchased from USA Data. Emails from the purchased lists were sent to 24,714 email addresses. The decision to purchase email lists was made during the last cohort of recruitment since our free email list resources had been largely saturated. The list was purchased from the company from whom we had purchased the print mailing lists since that strategy had met with some success.
Print advertising
Print news ads ran in city and town papers and magazines in the Providence and Chapel Hill areas, as well as campus newspapers, newsletters, and magazines. A total of four ads were placed in NC with runs of 1 day or 1 issue to 1 week. In RI, 35 ads were placed with similar frequency. The study was also featured for free in newspaper articles related to health and obesity at each location.
Television
Television ads were placed on local cable stations in the Providence, RI and Chapel Hill/Raleigh/Durham, NC viewing areas. In NC, a total of 280 thirty-second ads were run on a variety of stations including local news, sports, and lifestyle channels. In RI, approximately 600 ads were run on similar stations. The study was also featured on a local news channel interview in RI. Television ads in both locations ran for 2- to 6-week periods over 9 months.
Radio
Thirty second radio advertisements were placed on a variety of popular location stations including music, talk and sports radio. A total of 451 spots were run over 5 months.
Website
Website ads (both paid and unpaid) were posted on websites including online newspapers, study clinic websites, university clinical trials advertising, online classifieds (Craigslist), hospital and university intranet, and health-related organization websites.
Other
Other recruitment methods included posting flyers and posters in the surrounding areas in public places and in relevant locations such as fitness clubs, libraries, auto parts stores, medical offices and university campuses. Information tables were set up at community events such as health fairs, on university campuses, at farmer’s markets, and at races. At the beginning of the study, a press release was issued in both study areas. Another study with young adults was recruiting simultaneously in the Durham metro area of North Carolina at another institution. The other study was for weight loss rather than weight gain prevention; therefore, the eligibility criteria for BMI for the two studies were not identical. Investigators from the two studies met and devised a strategy to make referrals from each study to the other for ineligible participants. As recruitment spread, word of mouth was reported as an additional recruitment method.
Statistical analysis
Descriptive statistics for continuous measures are provided with means and standard deviations. Counts and percentages are provided for the categorical variables. Logistic regression was used to identify recruitment methods that had the highest relative yield for demographic and BMI subgroups, with covariate adjustment for clinic.