F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.145823.1 Research Article Articles Using X, Facebook QR codes to optimise recruitment to a feasibility trial Enhancing Men’s Awareness of Testicular Diseases (E-MAT) in a cluster randomised Study Within A Trial (SWAT): Lessons learned.

[version 1; peer review: 1 approved with reservations]

 Shiely Frances Conceptualization Formal Analysis Funding Acquisition Investigation Methodology Project Administration Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-0969-8321 a 1 2 3 Cooke Eoghan Data Curation Investigation Project Administration Writing – Review & Editing 1 4 McCarthy Megan Data Curation Formal Analysis Investigation Project Administration Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-1415-8461 4 Dahly Darren Data Curation Formal Analysis Methodology Validation Writing – Review & Editing 1 Harrington Janas Data Curation Funding Acquisition Methodology Supervision Writing – Review & Editing 2 Shorter Gillian W. Conceptualization Formal Analysis Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0001-5752-2297 5 Davoren Martin P. Funding Acquisition Project Administration Writing – Review & Editing 2 6 Hegarty Josephine Funding Acquisition Project Administration Supervision Writing – Review & Editing 4 Murphy Aileen Conceptualization Funding Acquisition Methodology Software Validation Writing – Original Draft Preparation Writing – Review & Editing 7 Kirby Ann Formal Analysis Methodology Writing – Review & Editing 7 Murphy David Conceptualization Funding Acquisition Methodology Project Administration Resources Software Supervision Writing – Review & Editing https://orcid.org/0000-0002-9685-8292 8 Robertson Steve Conceptualization Investigation Supervision 9 Rovito Michael J. Conceptualization Methodology Writing – Review & Editing 10 Fitzgerald Serena Conceptualization Funding Acquisition Project Administration Writing – Review & Editing 4 O'Connor Alan Conceptualization Funding Acquisition Investigation Methodology Project Administration Writing – Review & Editing 11 O'Riordan Mícheál Funding Acquisition Investigation Methodology Project Administration Writing – Review & Editing 11 Saab Mohamad M Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Software Supervision Validation Visualization Writing – Review & Editing https://orcid.org/0000-0002-7277-6268 4 HRB Clinical Research Facility, University College Cork, Cork, Ireland School of Public Health, University College Cork, Cork, Ireland HRB Trials Methodology Research Network, University College Cork, Cork, Ireland Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland Drug and Alcohol Research Network, School of Psychology, Queen's University Belfast, Belfast, Northern Ireland, UK Sexual Health Centre, Cork, Ireland School of Economics, University College Cork, Cork, Ireland School of Computer Science and Information Technology, University College Cork, Cork, Ireland School of Allied Health Professions, Nursing and Midwifery, The University of Sheffield, England, UK Department of Health Sciences, University of Central Florida, Orlando, Florida, USA Gaelic Athletic Association, Dublin, Ireland F.Shiely@ucc.ie

No competing interests were disclosed.

 28 3 2024 2024 13 235 13 3 2024 Copyright: © 2024 Shiely F et al. 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

Eight out of ten adults use social media, yet its efficacy in recruitment in clinical trials remains under-explored. The purpose of this SWAT was to determine which recruitment method, X, Facebook or QR code via posters, was more efficient and cost effective for recruiting participants to the host trial.

 Methods

A cluster randomised cross-over design evaluated three recruitment strategies, X, Facebook and QR code. Seven Gaelic Athletic Association (GAA) clubs were randomised to receive either X, Facebook, or QR code. The seven clubs were re-randomised twice more, two weeks apart. There were two primary outcomes: 1. proportion of participants who consent to participate, relative to the number of players contacted; and 2. proportion of participants who consent to participate, relative to the number of players who clicked the link to register their interest.

 Results

Fifty participants were randomised to three recruitment methods, and 47 were retained in the host trial. Participants mainly heard about the study through friends, with some engagement via social media platforms Facebook and X, and little to no engagement with the QR code. Primary outcomes were hindered by the inability to disaggregate data by GAA club. Economic outcomes revealed QR code as the costliest strategy, and while X was cheaper than Facebook in terms of the number of clicks, Facebook demonstrated better recruitment and retention and thus reduced the costs per participant.

 Conclusions

While the inability to disaggregate data by club was a limitation, the study revealed that Facebook outperformed X and QR codes in terms of recruitment and participant retention and was thus considered to be more cost effective. The findings emphasise the importance of considering engagement patterns and cost-effectiveness in designing recruitment strategies for clinical trials, especially within the dynamic landscape of social media use.

 Cluster randomised controlled trial; feasibility study; recruitment; SWAT; social media; testicular neoplasms; men’s health. Health Research Board DIFA-2020-028 Health Research Board, Definitive Intervention and Feasibility Awards (HRB DIFA) (Grant number: DIFA-2020-028 The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction

Successful trial recruitment is challenging, with fewer than 50% of trials meeting their targets. 1 The evidence available to trialists to support decisions on design, conduct and reporting of randomised trials is sparse, suggesting further trial methodological work is needed. 2 PRioRiTy I 3 & II 4 studies identified the most important unanswered research questions in recruitment and retention, respectively, and one of the top ten recruitment priorities was the use of technology in the recruitment process. Eight out of ten adults use social media, yet its efficacy in recruitment in clinical trials remains under-explored. 5 The purpose of this study within a trial (SWAT) was to determine which recruitment method (X, formerly Twitter), Facebook, or quick response [QR] codes via posters) was more efficient and cost effective for recruiting participants to the primary host trial. We also aimed to determine if the recruitment method influenced retention in the host trial. The SWAT protocol is registered in the Northern Ireland SWAT repository as SWAT 162.

 Methods Study design and randomisation

We used a cluster randomised cross-over design to evaluate the three recruitment strategies (X, Facebook and QR code). Seven Gaelic Athletic Association [ 1] (GAA – Irish football and hurling) clubs agreed to participate in the SWAT and were randomised using Research Randomizer ( https://www.randomizer.org/) to either Facebook (n = 2), X (n = 3) or QR code (n = 2) for a period of two weeks. After two weeks, the seven clubs were re-randomised to either one of the other recruitment methods, i.e., the two Facebook clubs were then randomised to get either X or QR. After a further two weeks, the GAA clubs changed to the final remaining recruitment method for one further two-week period. Clubs were asked to post the Facebook and X posts twice per week between 12pm and 1pm. We were dependent on the clubs to do the posting when we directed them to but had no control over this occurrence. In relation to the QR code, 10 posters were displayed in each club for the two-week period of their randomisation.

 Population

Participants were eligible to participate in the SWAT if they were assigned male at birth, members (i.e., players and coaches) of the target GAA clubs, residing in the Republic of Ireland, and aged 18 to 50 years (age group at risk for testicular diseases).

 Patient and Public Involvement (PPI)

Two PPI collaborators on the host trial are members of the participating GAA clubs and were involved in the development of the grant application which included the SWAT. They provided background information on player demographics, determining the potential recruitment strategies for the SWAT, and identified the appropriate time in the GAA season to start the recruitment. Both collaborators were compensated for their time and are included as co-authors (AOC and MOR).

 Primary outcomes: Primary recruitment

Proportion of participants who consent to participate in the host trial, relative to the number of players contacted via each recruitment method.

Proportion of participants who registered their interest to participate, relative to those consented to the host trial via each social recruitment method.

Secondary outcomes: Primary retention and cost-per-strategy

Proportion of participants randomised who remain to the conclusion of the study.

Unit cost per person who registered their interest by clicking the link/scanning QR code.

Unit cost per person consented to the host trial.

Unit cost per person retained at end point of the host trial.

Host trial description

Title

Enhancing Men’s Awareness of Testicular Diseases (E-MAT): A Feasibility Study ( ClinicalTrials.gov Identifier: NCT05146466).

Aim of host trial

To examine the feasibility of conducting a definitive trial to test the effect of E-MAT VR (Virtual Reality) (intervention) compared to E-MAT E (Electronic information only) (control) on testicular knowledge and testicular self-examination behaviours among male GAA players over three months. We developed a three-level Virtual Reality (VR) educational game called “Enhancing Men’s Awareness of Testicular diseases” or E-MAT VR, delivered using a VR headset, handheld controllers, and voiceover. 6 , 7 E-MAT VR uses light humour to educate men about testicular diseases and encourages them to examine their testicles and seek medical help for symptoms of concern. The feasibility study compares E-MAT VR to a traditional electronic intervention that uses plain text and images via a Tablet or E-MAT E. The primary outcomes measured in the feasibility trial were testicular knowledge and testicular self-examination behaviours. The feasibility trial took place in nine geographically distributed GAA sports clubs in County Cork, a southern region in Ireland, over a three-month period. For each of the nine participating GAA clubs, individual participants were randomised to either the intervention or control arm. Risk of contamination was low due to the geographical dispersion of the GAA clubs.

 Data collection

Outcomes were measured at baseline (T0, pre-engagement with E-MAT VR or E-MAT E), immediately post-test (T1, post engagement with E-MAT VR or E-MAT E), and three months post-test (T2) using electronic surveys. We expected that players would pass the study link to other players. To capture this, at T0 we asked the participants if they learned about either of the three recruitment methods directly, link through WhatsApp, or if they were referred by a friend.

Facebook

The GAA club has a record of self-identified males on the club Facebook page, which gives us the total number targeted (denominator). We were dependent on the clubs to make the Facebook posts.

X

On X there is an Engagement Application Programming Interface (API) which measures engagements - a count of the number of time a user has interacted with the X post, how often it has been favourited, liked, reposted, replied, and shared. We were dependent on the clubs to make the X posts.

QR code

The QR code was displayed by means of a professionally designed poster at each club. Ten posters were displayed in each club for the 2-week period of their randomisation. We were able to monitor the number of people who used the QR code.

 Costing methodology

Micro-costing techniques were used to estimate cost-per-strategy. Costs include direct design and distribution for each strategy; print (received from the company who created the posters and Facebook and X posts), collection costs (travel as per the University’s travel allowance) and personnel costs (valued using national salary scales for staff grade level as per national guidelines 8 ). Trial data were used to identify and measure the quantity of each resource and market values were employed to value them in Euros, for the year 2022.

 Data analysis

Exploratory data analysis was conducted, and outliers reconciled. Analysis was conducted on an intention-to-treat basis using the cluster randomisation scheme. Analysis was conducted using R (version 4.0.3; R Project for Statistical Computing, Vienna, Austria) and, in all cases, a 2-sided type I error rate of 0.05 was taken as statistically significant.

 Results

Nine GAA clubs were recruited to the host trial. Seven agreed to participate in the SWAT. Fifty participants, from seven GAA clubs, were randomised to the three recruitment methods. Table 1 shows the number of male members in each club, i.e., target population. In total, 47 out of 50 SWAT participants were retained in the host trial.

Characteristics of the SWAT GAA clubs.
GAA Club No. male members >18 years GAA Club Facebook (Likes) GAA Facebook Clicks GAA Club X (Followers) X Clicks QR Code posters QR code poster clicks No. recruited from each club No. retained from each club
1 53 987 NA * 2,804 NA * 10 NA * 11 11
2 451 2,600 NA * 3,241 NA * 10 NA * 15 15
3 166 2,092 NA * 5,295 NA * 10 NA * 1 0
4 350 4,000 NA * 15,800 NA * NA * 7 7
5 110 3,085 NA * 4,920 NA * 10 NA * 6 5
6 Unknown 2,179 NA * 3,640 NA * 10 NA * 7 7
7 50 3,859 NA * 2,709 NA * 10 NA * 3 2
Total 177 ^ 234 ^ 13 ^ 50 47

NA = Not available.

Unable to ascertain which of the clubs the clicks came from.

At T0 we asked participants where they heard about the feasibility trial ( Table 2). The majority heard about it exclusively from a friend (n = 20). Facebook and X were the next most common. Only one participant heard about the trial through the QR code.

Where participants heard about the feasibility trial.
Where participants heard about the trial Number of participants
Friend 20
Facebook 9
X 6
Other 4
Facebook link by text message (e.g., WhatsApp) 3
X link by text message (e.g., WhatsApp) 3
QR code 1
Facebook and X 1
Facebook, X and Friend 1
Facebook and Facebook link by WhatsApp 1
Facebook, Facebook link by WhatsApp and X 1
Total 50

We had two primary outcomes: 1) the proportion of participants who consent to participate, relative to the number of players contacted via each recruitment method; and 2) the proportion of participants who consent to participate, relative to the number of players who clicked the link to register their interest via each recruitment method. We were unable to disaggregate our data by GAA club thus we were unable to present data for the primary outcomes. We worked with a design company and used one Facebook link, one X link and one QR code link for ALL of the GAA clubs.

However, we are able to present some useful data, to assist others who use these recruitment methods in the future. The data presented in Table 3 are for the 16 people who entered the host trial, but not coming exclusively from the SWAT. Though X had the most clicks, it had fewer people who consented to the trial when compared to Facebook. Engagement via the QR code was poor.

Numbers of clicks, consented and retained per recruitment method.
X Facebook QR Code
No. Clicks 234 177 13
No. Consented 6 9 1
No. Retained 5 7 1

We were able to identify the peak hours of use for X and Facebook, using the Engagement API which provides access to post impression and engagement metrics. X peaks in use at 12pm, 6pm and 9pm. Facebook peaks in use at 8am and 8pm. In terms of the days of the week that showed most usage, X peaked on Tuesday and Thursday while Facebook peaked on Friday. This may have been the days the X and Facebook posts were made but we do not have that information from each club to clarify this.

Secondary outcomes

We had four secondary outcomes. Of the 50 participants randomised to the SWAT, 47 were retained. As so few were lost to follow-up (n = 3), we could not assess primary retention across the three recruitment methods. The remaining three secondary outcomes were economic outcomes related to cost-per-strategy. 1) unit cost per person who registered their interest by clicking the link/scanning QR code; 2) unit cost per person consented to the host trial; 3) unit cost per person retained at end point of the host trial. We were unable to disaggregate the SWAT information (n = 50) from the host feasibility trial (n = 74). Thus, the information presented below, and in Tables 4 and 5, is for the host trial. We first determined the total costs per recruitment strategy. As can be seen in Table 4, the QR code was the most expensive, while X and Facebook had equivalent total costs. As per Tables 4 and 5, in all cases, the QR code was the most expensive. While X was cheaper than Facebook in terms of the number of clicks, the engagement was better with Facebook resulting in more being consented and retained through Facebook, thereby reducing costs per participant.

Total cost per strategy (€, 2022).
X Facebook QR code
Digital design and distribution 1 €50.33 €50.33 € 50.33
Poster design, printing and distribution 2 - - €380.56
Communication and follow-up: personnel time 3 €3,689.97 €3,689.97 €3,689.97
Total €3,740.30 €3,740.30 €4,120.86

Design company cost €151 equally split between 3 strategies (Source: Trial documentation).

Poster design (€160), printing (€113.65) and delivery (€106.91) (Source: Trial documentation).

Research Assistant salary €31,617 pa (Source: Trial documentation).

 Economic outcomes.
X Facebook QR Code
Outcome 1 € /Clicks 15.98 21.13 316.99
X Facebook QR Code
Outcome 2 € /Consent 623.38 415.59 4,120.86
X Facebook QR Code
Outcome 3 € /Retained 748.06 534.33 4,120.86
Discussion

The results of our study provide insights into the effectiveness and cost-effectiveness of different recruitment methods in the context of a community sports club setting. Our study involved nine GAA clubs (n = 74), with seven participating in the SWAT (n = 50) who were randomised to three recruitment methods. Most participants heard about the study exclusively from a friend, highlighting the importance of interpersonal networks in disseminating information within the GAA community; replicated in other studies showing the centrality of social networks on and offline in transmitting health care information. 9 This is likely a feature of communication in all sports clubs in the community. Facebook and X were also prominent sources of information, with only one participant discovering the study through the poster with QR code. This indicates the limited effectiveness of QR codes as a standalone recruitment method in this context. When compared to other social media recruitment methods Facebook and X, the QR code was also relatively expensive. We do not recommend using it in a trial in the community. X and Facebook set-up costs were equal, but initial engagement, i.e., numbers of clicks, was greater in X, thereby reducing the cost per participant. However, the proportion who consented from the engagement was greater with Facebook, thus Facebook can be considered cost effective compared to X when considering those consented and retained.

Lessons learned

The inability to disaggregate data by GAA club due to the use of a single Facebook link, one X link and one QR code link for ALL of the GAA clubs is a limitation. Understanding the aggregate is useful, but there may be diversity in recruitment that is under-explored, such as impact on recruitment by individual or group characteristic (e.g., ethnicity 10 ). Creating separate links (Facebook, X, QR code) for each of the GAA clubs would have allowed for a more granular analysis of the recruitment process. This would have provided valuable insights into the effectiveness of each method within individual clubs and could have informed targeted recruitment strategies.

Monitoring X and Facebook interactions in a sport club setting is challenging, as it was not possible to disentangle the SWAT participant data from general GAA club data. The reason for this was because we did not have direct administrative access to the club accounts. To conduct recruitment in the way we did, and to be able to evaluate it, researchers would need to be given user/administrator rights to each club’s Facebook and X accounts.

In addition to members of the GAA club, there were other individuals that follow the GAA Club’s X and Facebook pages, so relying on club membership to determine the denominator was not meaningful.

Many of the participants heard about the study from friends, therefore, we were unable to determine which recruitment method they were recruited through.

While we were focused on three recruitment methods, as we can see in Table 1, some people accessed the Facebook and X links via Text Message or WhatsApp, making it difficult to track the reach of the recruitment method.

We were overambitious when defining our outcomes and for a small SWAT, there were too many. The ‘keep it simple’ approach – fewer outcomes – would have been better.

It is evident that the hours of use for X and Facebook which would help identify suitable times to post information on the study in future trials. For this community of users, X spikes in use at 12pm, 6pm, and 9pm. Facebook peaks in use at 8am and 8pm. In terms of the days of the week that showed most usage, X peaked on Tuesday and Thursday while Facebook peaked on Friday. This may have been the days the X and Facebook posts were made but we do not have the required information from each GAA club to determine that.

Conclusion

In conclusion, we have tentative evidence on the ability to recruit males to healthcare trials which demonstrated better value for money through Facebook, followed by X, with little to no-engagement with QR codes. Engaging with social networks is essential to support recruitment. The limitations of data tracking and customisation to evaluate recruitment methods in research studies are highlighted, especially when dealing with multiple groups or recruitment methods in a pragmatic community setting. We encourage others to evaluate their recruitment methods in SWATs to support or refute our conclusions and support trial engagement. These insights can inform future research, particularly future definitive trials, allowing for more robust recruitment of participants, data collection and analysis, ultimately enhancing the validity and reliability of research findings.

Ethical considerations

Ethical approval for this SWAT was obtained from the Clinical Research Ethics Committee (CREC), University College Cork in December 2021 (CREC Review Reference Number: ECM 06/2023 PUB). We confirm that we obtained written, informed consent from all participants enrolled in this study.

 Data availability statement Underlying data

The data underlying the results are available as part of the article and no additional source data are required, except for social media data and the data from the QR code posters. The social media data came from the Facebook page and X pages of the GAA clubs. This data is in the form of posts, likes, followers and clicks. The QR code posters contained data on clicks only. The social media data cannot be shared due to the ethical and copyright restrictions surrounding social media data. The Methods section contains detailed information to allow replication of the study. Also, the study is small due to its nature and it could potentially identify the GAA clubs if we release it publicly. Any queries about the methodology should be directed to the corresponding author. If someone requests the data or have questions about the methodology, we are happy to discuss this with them.

 Reporting guidelines

We await reporting guidelines for SWATs which are being led by the University of York and are expected to be published in 2024.

 Acknowledgements

We wish to express our appreciation to the GAA clubs who facilitated the data collection for this SWAT, and to their members for partaking.

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https://www.gaa.ie/

10.5256/f1000research.159827.r289144 Reviewer response for version 1 Boumparis Nikolaos 1 Referee https://orcid.org/0000-0002-3693-0168 Swiss Research Institute for Public Health and Addiction, Zurich, Switzerland

Competing interests: No competing interests were disclosed.

 19 6 2024 Copyright: © 2024 Boumparis N 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

This study investigates the effectiveness and cost-effectiveness of three recruitment methods (X, Facebook and QR codes) for a feasibility trial aimed at increasing male awareness of testicular disease. 

- The manuscript is well written and generally easy to follow. The inclusion of a patient and public involvement component is appreciated as it ensures that the design and conduct of the study is informed by the target population.

- However, the inability to disaggregate data by GAA club due to the use of a single link for each recruitment method severely limits the findings.

- The inability to present primary outcomes due to data aggregation issues is a major drawback. 

-The aim of the study was to evaluate different social media-based recruitment methods. However, the high incidence of participants being referred by friends dilutes the ability to accurately assess which recruitment method was most effective.

- The study appropriately highlights the limitations and provides some good lessons for future studies. 

- Although the manuscript states that "exploratory data analysis was performed" and "outliers were reconciled", these statements lack sufficient detail to ensure reproducibility. The manuscript should explicitly state the criteria used to identify outliers, and any impact of outlier handling on the results and conclusions should be discussed to provide transparency on how these decisions may have influenced the results.

Overall, a lot of things went wrong in this study, but it is still a useful paper because it describes several lessons learned that could prevent future studies from making the same mistakes. It also provides some valuable insights of different recruitment methods for clinical trials in similar contexts.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

No

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Digital health, addiction, randomised controlled trials, systematic reviews and meta-analyses.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.