Recruiting: A picture's worth a thousand words

Men like gadgets; women like bright colors

Sponsors and clinical trial sites increasingly are turning to multimedia material for both recruiting subjects and for explaining particulars of a study during the informed consent process.

But how can investigators and trial sites know whether the recruitment material is helping or hindering their cause?

Investigators at Summa Health System in Akron, OH, decided to explore this question after finding some surprisingly negative responses to a mock-up of a patient education brochure.

"We sent the brochure around to some people to look at, and most people had no problem with it," recalls Jere M. Boyer, PhD, director of research and research administration at Summa Health System.

But several people thought at least one photo was coercive, Boyer says.

It was a picture of a female health care provider who stood over a subject as the person signed a health care form, and it looked as though the woman had her hand on the subject's shoulder, Boyer explains.

"One person said, 'It looks like they're lording it over them by standing while the subject is sitting,'" Boyer says. "Some people said the hand on the shoulder made it look as though the health care provider was pushing a subject to sign the document."

Boyer and the others who selected the photos were curious about the response and decided to conduct a study of what potential subjects think about various recruitment/educational photographs.1

They obtained IRB approval for the study and enrolled 68 volunteers, including 26 men and 42 women, who had a mean age of 52 years. They were shown 10 photographs, including two from a federal research brochure, and they answered questions about the photos from an interviewer. Questions included the following:

  • Which of the 10 pictures would encourage you the most to participate in a research study?
  • Do you like this photograph?
  • Do you believe the subject in the picture has a free choice to participate (or not) in the research project?

"The results were quite interesting," Boyer says. "There was a difference between male and female replies."

For example, men tended to want to see photos that displayed instruments or equipment, even if these had nothing to do with the study, Boyer notes.

"They like gadgets," he says. "And women wanted to see a perky setting where the subject looked happy and where the individual presenting the information seems to be actively involved with the subject."

Women also were more interested in seeing bright colors, and they responded well to a sharp picture rather than a blurry picture, Boyer says.

"College-level individuals seemed to be attuned to whether there was actual teaching and learning occurring in the setting and whether it looked as though the health care provider was explaining the study to the subject, as opposed to doing something else," Boyer says.

Also, all subjects were concerned about the dress appearance of health care professionals, wanting to see a neat appearance, regardless of the venue, Boyer adds.

Since Akron has a small minority population, the trial did not have enough African American subjects or others of minority backgrounds to make any cultural determinations, he notes.

Subjects also indicated a dislike for photos that looked staged, Boyer says.

"You can fake the health care scenes, but don't let it look like it was faked," he says. "Even with real pictures of health care providers, subjects didn't like it if it looked faked."

Nearly 80% of the subjects said they would be willing to participate in a clinical trial, Boyer says.

Investigators did not determine whether this high percentage reflected original bias or was the result of the study and recruitment photos, he adds.

However, it's safe to assume that audio-visual materials presented to potential trial participants could help with recruitment and informed consent, Boyer suggests.

"I think educational film strips, as well as photos, may be better than just sitting down with 20-page consent forms and trying to explain a study to the subject, who might tune out much of the information," Boyer says.

"My biggest problem with the consenting process today is that consent forms are long, and cancer patients, for instance, may not be in a state of mind to read or understand them," Boyer says.

In addition to providing visual aids to the consent process, the investigator or clinical trials professional should give potential subjects a couple of days to think about the study and to discuss it with their family, friends, and family doctor, Boyer says.

Research about how people learn suggests that visual stimulation and one-on-one education help with the learning process, he notes.

"The sponsors are getting attuned to the fact that they need to do more than explain a 20-page consent document to subjects," Boyer says.

Since conducting the study, Summa Health System has changed its recruiting materials and has developed a brochure that uses pictures that have bright colors and display a health care activity, as well as health care devices and technology, Boyer says. These are distributed in hospital/clinic lobbies and other places where potential subjects might be found, he says.


  1. Waechter D, Rice M, Schlegel E, et al. How do photos in research recruiting materials affect a patient's participation? Poster presented at the 2005 PRIM&R/ARENA Annual HRPP Conference, held Dec. 3-6, 2005, in Boston.