Recruiting National Guard Members for Online Suicide Prevention Research: Engagement, Eligibility, and Ethical...

National Guard suicide rates have been comparable to active-duty rates, yet Guard members may face geographic, stigma-related, and occupational barriers to mental health care. Recruiting National Guard members at elevated suicide risk into remotely delivered mental health and suicide prevention trials is difficult, particularly when direct suicide-related language may deter participation. This study examined whether a construct-targeted label intended to align with warrior-culture values ("fearlessness about death") was associated with greater engagement and study eligibility than a broad "mental health" label.

Twenty recruitment posts were placed in military-related Reddit communities between January 19, 2021, and April 18, 2022. Each post offered 2 otherwise identical study links labeled as either "fearlessness about death" or "mental health"; link position was counterbalanced, and respondents self-selected a link. A brief screener assessed current National Guard status, contact information and preferences, and the 7-item Acquired Capability for Suicide Scale-Fearlessness About Death (ACSS-FAD). Eligibility for the parent online suicide prevention trial required current National Guard membership and an ACSS-FAD score greater than 17. Bot-generated, duplicate, incomplete, and non-National Guard responses were excluded. Group differences were examined using chi-square, independent-samples t, Fisher's exact, and risk-ratio analyses. All study procedures were approved by the institutions IRB before data were collected.

The fearlessness-about-death link generated 797 raw responses, including 500 consecutive bot-generated responses, whereas the mental-health link generated 139. After exclusions, 124 valid and complete submissions remained. Valid submissions were more frequent through the mental-health label (99 vs. 25), contrary to the engagement hypothesis, χ² = 44.16, P < .001, ϕ = 0.60. Respondents entering through the fearlessness-about-death label had higher ACSS-FAD scores (M = 18.64, SD = 4.65) than those entering through the mental-health label (M = 16.47, SD = 5.15), t = 2.03, P = .049, d = 0.43. Eligibility rates were 60.0% (15/25) and 38.4% (38/99), respectively (risk ratio = 1.56); however, despite the large effect, this difference did not reach conventional statistical significance, Fisher's exact P = .073. Most respondents preferred email to phone contact.

A broad mental-health label was associated with substantially more valid responses and more eligible participants overall. The fearlessness-about-death label yielded fewer responses but may have concentrated respondents with greater suicide capability and thus study eligibility. Strengths include naturalistic recruitment of an understudied military population. Limitations include unequal group sizes. Suggestions for recruitment strategies that balance broad messaging that maximizes overall response volume against targeted messaging are provided. Methods include using staged anonymous screening, transparent eligibility criteria, and respectful explanations and resources to minimize disappointment among ineligible respondents in this important population.

Yes. Clinical Trials.gov: https://clinicaltrials.gov/study/NCT04098588.