Free-living volunteer's motivations and attitudes toward pharmacologic studies in man

Barriers and facilitators to the participation of subjects in clinical trials: An overview of reviews

BACKGROUND

The demand for clinical trial participants is today one of the highest it has ever been and continues to increase. At the same time, subject recruitment continues to be problematic and the major reason for clinical trial premature terminations. The literature on clinical trial recruitment, which spans several decades and includes hundreds of studies, has an abundance of findings that can be synthesized by way of an overview to provide a well-informed and complete picture of the factors that determine subject participation.

OBJECTIVES

An overview of the systematic reviews that report barriers and facilitators to clinical trial participation was conducted. The extracted data were synthesized, and a thematic framework of the factors that affect subject participation in clinical trials was developed. The overview extended across medical subjects and demographics.

METHODS

Thirty reviews that complied with the inclusion criteria were included. These reviews covered 753 relevant primary studies and reported 881 barriers and facilitators. The barriers and facilitators were thematically synthesized and a thematic framework of 20 themes was developed. The quality of the included reviews was assessed and reported.

MAIN RESULTS

Several opportunities to increase clinical trial participation, by developing interventions and changing the trial design, derived from an analysis of the thematic framework. That analysis also showed that most of the 20 themes operate mainly as a barrier or as a facilitator, and that most have an effect across medical subjects. As to the quality elements assessed, some reviews complied almost fully but most only partially.

The motivations, barriers, and sociodemographic characteristics of healthy Chinese volunteers in phase I research

PURPOSE

To describe the motivations, barriers, and sociodemographic characteristics of healthy Chinese volunteers in phase I research and to demonstrate the factors influencing their willingness to participate in subsequent trials.

METHODS

Healthy subjects who participated in seven phase I trials at two centres were invited to participate in the cross-sectional survey at discharge by anonymously and voluntarily completing the self-administered questionnaire.

RESULTS

From 442 subjects asked to complete the questionnaire, a response rate of 94.8% (419) was obtained, and 72.8% of the respondents had participated in a mean of 2.0 ± 1.3 previous studies. Over 90% of the subjects indicated that the main motivations to participate trials were to help more people, to contribute to scientific research, and to obtain money. The top 5 barriers were time inconvenience, advertisement sources, potential risks associated with the drug, privacy, and the route of drug administration. Nearly half (49.6%) of the subjects were willing to participate in the next trial. The factors impacting the willingness of the subjects to participate in subsequent trials were gender, screening frequency, enrolment frequency, level of understanding of the research, two motivating factors (to make money and receive a free check-up), and ten barriers (e.g. risk, distance, living conditions, and trust).

CONCLUSIONS

The majority of healthy Chinese subjects were young, were less well educated, had low income levels, and had poor medical insurance coverage. Given the multiple sources of motivation and complex barriers to trial participation, investigators and recruitment staff should consider ethics aspects to guarantee volunteer safety and well-being.

The impact of the global COVID-19 pandemic on the conduct of clinical trials: Return to normalcy by considering the practical impact of a structured ethical analysis

During the outbreak of the COVID-19 pandemic many clinical trials were abruptly halted. Measures to contain the pandemic are currently taking effect and societies in general and healthcare systems in particular are considering how to return to normalcy. This opens up the discussion when and how clinical trials should be restarted while the COVID-19 pandemic has not yet resolved, and what should happen in case of a resurgence of the virus in the coming months. This article uses the four ethical principles framework as a structured approach to come to a set of practical, ethically grounded guidelines for halting and relaunching clinical trials during the COVID-19 pandemic. The framework applied provides a structured approach for all clinical trials stakeholders and thereby prevents unclear reasoning in a complex situation. While it is essential to prevent the virus from resurging and focus on developing a COVID-19 treatment as soon as possible, it is just as important to our society that we continue developing new drugs for other conditions. In this article we argue that the situation for clinical trials is not essentially different from the pre-COVID-19 era and that an overcautious approach will have negative consequences.

Qualitative study investigating the underlying motivations of healthy participants in phase I clinical trials

OBJECTIVES

If patients are to reap the benefits of continued drug development, an understanding of why healthy participants take part in phase I clinical trials is imperative. The current study aimed to explore the nature of these underlying motivations which may, in turn, improve the overall participant experience and assist in the development of more effective recruitment and retention strategies.

DESIGN

This study used a qualitative design based on the theory of planned behaviour. Specifically, it explored healthy participants' underlying behavioural, control and normative beliefs which influence their participation in phase I clinical trials.

SETTING

This study took place at a company that specialises in conducting phase I and phase II clinical trials in the Australian state of Queensland.

PARTICIPANTS

Participants (n=31) were either currently undergoing a phase I clinical trial or had previously taken part in a phase I clinical trial.

RESULTS

Results showed that the motivations were varied and not solely centred on financial gains. Reported advantages of participation included altruism, while inconvenience was most often reported as a disadvantage. Friends were reported as those most likely to approve, while one's mother was reported as most likely to disapprove. Having a suitable time frame/flexible scheduling and feeling comfortable taking part in the trial were both the most commonly reported facilitators, while inflexible scheduling/time commitment was the most commonly reported barrier.

CONCLUSIONS

Practical implications included the need for organisations involved in clinical trials to be mindful of inflexible scheduling and exploring the possibility of making educational materials available to family members who may be concerned about the risks associated with participation. Overall, it is anticipated that the results of this study will improve the understanding of factors that influence phase I clinical trial participation which may, ultimately, help develop new therapeutics to improve patient health.

Reviewing the role of healthy volunteer studies in drug development

BACKGROUND

With the exception of genotoxic oncology drugs, first-in-human, Phase 1 clinical studies of investigational drugs have traditionally been conducted in healthy volunteers (HVs). The primary goal of these studies is to investigate the pharmacokinetics and pharmacodynamics of a novel drug candidate, determine appropriate dosing, and document safety and tolerability.

MAIN BODY

When tailored to specific study objectives, HV studies are beneficial to manufacturers and patients alike and can be applied to both non-oncology and oncology drug development. Enrollment of HVs not only increases study accrual rates for dose-escalation studies but also alleviates the ethical concern of enrolling patients with disease in a short-term study at subtherapeutic doses when other studies (e.g. Phase 2 or Phase 3 studies) may be more appropriate for the patient. The use of HVs in non-oncology Phase 1 clinical trials is relatively safe but nonetheless poses ethical challenges because of the potential risks to which HVs are exposed. In general, most adverse events associated with non-oncology drugs are mild in severity, and serious adverse events are rare, but examples of severe toxicity have been reported. The use of HVs in the clinical development of oncology drugs is more limited but is nonetheless useful for evaluating clinical pharmacology and establishing an appropriate starting dose for studies in cancer patients. During the development of oncology drugs, clinical pharmacology studies in HVs have been used to assess pharmacokinetics, drug metabolism, food effects, potential drug-drug interactions, effects of hepatic and renal impairment, and other pharmacologic parameters vital for clinical decision-making in oncology. Studies in HVs are also being used to evaluate biosimilars versus established anticancer biologic agents.

CONCLUSION

A thorough assessment of toxicity and pharmacology throughout the drug development process is critical to ensure the safety of HVs. With the appropriate safeguards, HVs will continue to play an important role in future drug development.

First-Year University Students Who Self-Select into Health Studies Have More Desirable Health Measures and Behaviors at Baseline but Experience Similar Changes Compared to Non-Self-Selected Students

Studies demonstrate that first-year university students are at high risk for weight gain. These reports typically rely on self-selected participants. The purpose of this study was to explore if students who chose to participate in a health-based research study had more desirable health measures and behaviors than students who completed health assessments as part of a first-year seminar course. Health measures included blood pressure (BP), body mass index (BMI), and percent body fat. Health behaviors included dietary patterns (Starting the Conversation questionnaire) and alcohol use (Alcohol Use Disorders Identification Test-Consumption). A total of 191 (77% female) participants completed testing in the self-selected “Health Study” group, whereas 73 of the 91 students (80%, 55% female) enrolled in the “Seminar” allowed their data to be used for research purposes. Baseline measures favored Health Study participants, including but not limited to fewer participants with undesirable BMI (≥25.0 kg/m²; males and females) and a smaller percentage of participants with undesirable BP (systolic ≥120 mmHg and/or diastolic ≥80 mmHg; females only). Differences in dietary behaviors at baseline were inconsistent, but Seminar students engaged in more problematic alcohol-use behaviors. While both groups experienced undesirable changes in health measures over time, the degree of change did not differ between groups. Changes in health behaviors over time typically resulted in undesirable changes in the Seminar group, but the magnitude of change over time did not differ between groups. Thus, results from first-year university students who self-select into health studies likely underestimate the seriousness of undesirable health measures and behaviors but may accurately reflect the degree of change over time.

Phase 1 healthy volunteer willingness to participate and enrollment preferences

BACKGROUND/AIMS

Healthy volunteers in phase 1 clinical trials contribute to the development of safe drugs and other biologics and accept risks and burdens without anticipated health benefits from participation. Although emerging data have shown that healthy volunteers are influenced by risk, some still worry that financial incentives lead them to take on unreasonable risk. Yet little is known about healthy volunteers' preferences and how they make choices about enrolling in research studies.

METHODS

We surveyed 654 healthy volunteers at the end of their participation in a phase 1 Pfizer trial in the United States, Belgium, and Singapore to examine their reported willingness to enroll in studies of different types, with various procedures, and with possible side-effects.

RESULTS

The majority of respondents were willing to join many kinds of studies, but fewer were willing to participate in first-in-human vaccine studies or studies of psychiatric drugs than in other study types. With regard to procedures, a substantial proportion were unwilling to participate in studies that involved invasive procedures, such as a lumbar puncture (45.4%) and bone marrow biopsy (42.3%), but willing to participate in studies with less invasive procedures such as a computed tomography scan of the heart (86.8%), magnetic resonance imaging (87.4%), and skin allergy testing (86.8%). Although there was some variation by gender and region, the majority were willing to participate in studies with side-effects like pain (80%) or nausea and vomiting (64%), but only a minority were willing to join if the research drug would result in their having a one in a million chance of death (34.4%), a small chance of kidney damage (16.7%), or influence how their mind works (23.2%; Figure 4).

CONCLUSION

Our results suggest that healthy volunteers are willing to participate in a wide range of types of phase 1 clinical trials, and express preferences for low risk and familiar studies and study procedures, preferences which are partially affected by offers of payment.

A privacy preserving protocol for tracking participants in phase I clinical trials

OBJECTIVE

Some phase 1 clinical trials offer strong financial incentives for healthy individuals to participate in their studies. There is evidence that some individuals enroll in multiple trials concurrently. This creates safety risks and introduces data quality problems into the trials. Our objective was to construct a privacy preserving protocol to track phase 1 participants to detect concurrent enrollment.

DESIGN

A protocol using secure probabilistic querying against a database of trial participants that allows for screening during telephone interviews and on-site enrollment was developed. The match variables consisted of demographic information.

MEASUREMENT

The accuracy (sensitivity, precision, and negative predictive value) of the matching and its computational performance in seconds were measured under simulated environments. Accuracy was also compared to non-secure matching methods.

RESULTS

The protocol performance scales linearly with the database size. At the largest database size of 20,000 participants, a query takes under 20s on a 64 cores machine. Sensitivity, precision, and negative predictive value of the queries were consistently at or above 0.9, and were very similar to non-secure versions of the protocol.

CONCLUSION

The protocol provides a reasonable solution to the concurrent enrollment problems in phase 1 clinical trials, and is able to ensure that personal information about participants is kept secure.

Strategy for recruitment and factors associated with motivation and satisfaction in a randomized trial with 210 healthy volunteers without financial compensation

Background

The aim was to describe a strategy for recruitment of healthy volunteers (HV) to a randomized trial that assessed the efficacy of different telephone techniques to assist HV in performing cardiac massage for vital emergency. Participation in the randomized trial was not financially compensated, however HV were offered emergency first-aid training. We also studied factors associated with HV motivation and satisfaction regarding participation in the trial.

Methods

Strategy for recruitment of 210 HV aged 18 to 60 years was based on: (1) the updated records of all telephone number since January 2000 of HV registered in the Rouen Clinical Investigation Centre HV database, (2) a communication campaign for the general public focussing on posters and media advertisements. Data on the recruitment, socio-demographics, motivation and satisfaction of the 210 HV were collected by anonymous self-administered questionnaire.

Results

Of the 210 HV included, 63.3% (n = 133) were recruited from the HV database and 36.7% (n = 77) by the communication campaign. On the one hand, the HV database enabled screening of 1315 HV, 54.8% (n = 721) of whom were reached by phone, 55.2% (n = 398) of these latter accepted to participate in the study and 10.1% of the initial screening (n = 133) were finally included. One the other hand, for the 77 HV not recruited from the HV database, word-of-mouth (56.1%) was the main means of recruitment. The male/female ratio of the 210 HV was 0.5 and mean age 43.5 years (Standard Deviation = 12.4). The main motivations given for participating in the trial were to support research (87.6%) and receive emergency first-aid training (85.7%). Overall satisfaction with the welcome process was significantly higher for older HV (46–60 years) (adjusted odds ratio (AOR): 3.44; 95% confidence interval (95% CI): 1.48-7.99), and for HV in management jobs (AOR: 4.26; 95% CI: 1.22-14.87). Satisfaction with protocol management was higher for women (AOR: 2.33; 95% CI: 1.18-4.60) and for older HV (46–60 years) (AOR: 4.76; 95% CI: 1.97-11.52).

Conclusions

Recruitment of non-compensated HV required broad screening with a primary HV database alongside word-of-mouth communication which seemed more efficient than media advertising. To enhance HV recruitment to randomized trials without financial compensation it seems crucial to provide them not only with a direct interest but also to ensure their satisfaction.

A Review of Paying Research Participants: It's Time to Move Beyond the ethical Debate

CURRENT REGULATORY GUIDELINES REQUIRE the ethical review committee to consider one question when evaluating payment: Is the payment to the participant undue or coercive? Although this is a seemingly simple question, determining appropriate payment involves a series of complex issues. There is limited empirical knowledge to assist with this determination and little consensus on which elements of a study should be considered in making these decisions. For example, should the culture of the study population or the potential risks and benefits of the research be considered in the selection of appropriate payment? Following a review of national and international guidelines, the concerns and benefits of paying research participants are presented, and prior ethical debate is outlined. The current research literature on the practice of paying participants and the impact of payment on participants and study integrity are reviewed. Finally, given continued debate with limited data to help determine best practices, a research agenda is proposed to assist in the development of an empirical basis to aid investigators and ethical review committees in making appropriate decisions about payment to research participants.

More than the money: a review of the literature examining healthy volunteer motivations

BACKGROUND AND OBJECTIVE

Few existing data report the motivations of healthy volunteers in clinical research trials. Some worry that volunteers consider only financial motivations. This study summarized and analyzed existing empirical research on self-reported motivations of healthy volunteers participating in studies not intended to offer benefit from participation.

STUDY SELECTION

A systematic PubMed search was conducted. Inclusion criteria captured English-language empirical studies on the self-reported motivations, reasons, or factors influencing the decision of healthy volunteers to enroll in clinical research. Thirteen studies involving more than 2000 healthy volunteers met the criteria and were included in this review.

DATA EXTRACTION

Independent review by the authors and extraction of information about the sample, methodology and objectives of the motivations study, description of the clinical trial and whether participation was actual or hypothetical, reported primary and secondary motivations of the healthy volunteers, risk evaluation, and reported differences in motivations related to sociodemographic variables.

RESULTS

This review showed that although financial reward is the primary motivation for healthy volunteers to participate in clinical trials, financial motivations are one among many other reported motivations, including contributing to science or the health of others, accessing ancillary healthcare benefits, scientific interest or interest in the goals of the study, as well as meeting people and curiosity. Volunteers consider risk when making a decision about participation.

CONCLUSIONS

Although financial incentives are important in recruiting healthy volunteers, their motivations are not limited to financial motivations. Further research is needed to examine motivations in different contexts and countries, the decision making of healthy volunteers, and the dynamics of repeat participation.

Who's doing the math? Are we really compensating research participants?

Although compensation for expenses to participants in research projects is considered important and the primary reason for paying, there is no evidence to support that investigators and IRB members actually calculate participant cost. Payment recommendations for six hypothetical studies were obtained from a national survey of IRB chairpersons (N = 353) and investigators (N = 495). Survey respondents also recommended payment for specific study procedures. We calculated participant cost for the six hypothetical cases both by procedures and by time involvement. A large percentage recommended only token payments for survey, registry, and medical record review studies. Most chose payment for pharmaceutical studies but the recommended payment did not compensate for calculated costs. Results suggest that compensation and reimbursement as the primary reasons for paying research participants may not match actual practice.

Financial remuneration for clinical and behavioral research participation: ethical and practical considerations

PURPOSE

Although the practice of providing payment to clinical research participants has been ongoing for more than a century, it remains an ethically controversial topic among members of the research community. The aims of this commentary are to summarize ethical and practical considerations regarding financial remuneration of research participants and to make recommendations for researchers contemplating this practice.

METHODS

A PubMed search was conducted to explore the ethical implications surrounding financial remuneration and review the body of empiric data on this topic.

RESULTS

Financial remuneration is perceived to be ethically acceptable by many researchers and research participants and can be helpful in the recruitment process. It is recommended that when investigators are contemplating whether to offer payment to research participants, they should consider the nature of the study and the potential benefits and risks to the participants, institutional or organizational guidelines, and cultural and societal norms specific to the population being studied.

CONCLUSIONS

Financial remuneration has the ability to serve as a sign of appreciation for the contributions of research participants and a way to facilitate clinical and behavioral research.

Payments to normal healthy volunteers in phase 1 trials: avoiding undue influence while distributing fairly the burdens of research participation

Clinical investigators must engage in just subject recruitment and selection and avoid unduly influencing research participation. There may be tension between the practice of keeping payments to participants low to avoid undue influence and the requirements of justice when recruiting normal healthy volunteers for phase 1 drug studies. By intentionally keeping payments low to avoid unduly influenced participation, investigators, on the recommendation or insistence of institutional review boards, may be targeting or systematically recruiting healthy adult members of lower socio-economic groups for participation in phase 1 studies. Investigators are at risk of routinely failing to fulfill the obligation of justice, which prohibits the systematic targeting and recruiting of subjects for reasons unrelated to the nature of the study. Insofar as we take seriously the obligation to engage in just subject recruitment and selection, I argue that we must acknowledge the implications low payments might have for subject recruitment and selection and examine the effect of low payments. If low payments de facto target the less well-off for phase 1 studies, we must defend the priority ranking of the obligation to avoid undue influence over the obligation of justice or adopt an alternative recruitment approach. This paper identifies a number of alternatives to the current system of low-value payments to research participants.

Incidence and predictors of screen failures due to positive urine tests for alcohol, drugs of abuse, and cotinine among normal healthy research volunteers (NHRVs): analysis of data from 687 NHRVs screened at a large clinical pharmacology unit in the United States

Accurate medical histories for all NHRVs screening to participate in clinical pharmacology trials are vital to ensure volunteers' safety, and integrity of study results. Evidence from previous studies illustrate the potential for NHRVs to misrepresent their histories, especially when monetary incentives are offered, and the need to objectively verify these self-reported histories whenever practical. This study demonstrates that among the sample participants, all of whom self-reported a negative history of drug and alcohol abuse and tobacco smoking, 16% failed urine testing for either alcohol and drugs of abuse (6%), or cotinine (11%). Male sex and increased number of screenings in the preceding 12 months were significantly associated with increased odds for urine screen failure whereas increased enrollments in the same time period and increased study stipend decreased the same odds. These results emphasize the importance of diligently screening NHRVs participating in phase I clinical trails.

First-in-Man (FIM) clinical trials post-TeGenero: a review of the impact of the TeGenero trial on the design, conduct, and ethics of FIM trials

A recent first time in man (FIM) trial of an "immuno modulator" compound (TGN1412) resulted in unprecedented toxicity. Since this occurred in 2006 a widely publicized scientific debate, as well as a controversy in the lay community has examined the principle of design and content of the study as well as the concept of FIM studies. This paper reviews the controversy, analyzes the problems of the TGN1412 trial and FIM trials in general and the reaction of the lay and scientific communities. Difficulties in these high risk trials is highlighted and possible design and execution procedural improvements are recommended. Consideration is given to the ethical debate regarding participation of normal, healthy research volunteers in FIM studies. The role of monetary incentive(s) is discussed as well as the opposition of many participants in this debate on financial compensation of volunteers for the assumption of risk and the need to adopt a no-fault scheme that fairly compensates injured trial participants.FIM studies are critical for the development of new therapeutic agents. Improving trial design and execution and fairly compensating volunteers will facilitate these studies, enhance equity and thus provide an ethical basis for continuing FIM studies that may pose a serious risk to participants, a risk that society needs taken for the development of needed therapeutic agents.

Why healthy subjects volunteer for phase I studies and how they perceive their participation?

OBJECTIVE

To characterize the motivations and attitudes of healthy subjects who volunteer for phase I studies as well as their perception of the informed consent procedure and participation in the study.

METHODS

Subjects (n = 136, 48.5/51.5% males/females, 26.9 +/- 5.5 years; 51.9% students, 42.2% employed, 5.9% unemployed) anonymously answered questionnaires regarding study participation and personality (Revised NEO Personality Inventory).

RESULTS

Financial reward was the most important motivation and was most valued by subjects with a lower monthly income (p < 0.01) and lower education (p < 0.05). Personality traits correlated differently with the various motivators for participation. "Word-of-mouth" (mainly by ex-participants) was the source of information on the phase I study for 94.9% of the participants. Most (88.2%) subjects consulted other people (family member/partner, 53.3% of participants; friends, 40.0%; physician, 25.0%) before deciding to participate. In 80% of the cases, the people consulted recommended that the subject not participate, with the risk of serious complications being the main objection in 75.7% cases. The information provided was generally assessed favorably; 34.6% of subjects considered the discomfort caused by participation to be less than that originally reported during the consent procedure, 58.8% considered it to be identical and 6.6% considered it to be higher. Most of the subjects (81.6%) declared that they never felt at risk of a serious complication during their participation in the study, 16.2% occasionally felt that they were at risk and 2.2% felt that they were at risk for a significant period of time. Personality traits correlated with the decision to ask someone else's opinion, the manner in which information provided was rated and the perception of the risk taken during participation.

CONCLUSION

Financial reward as the main motivator for participation in phase I studies was less valued by healthy volunteers with a higher income and education. A subject's motivations and perceptions toward participation were found to be influenced by individual characteristics, including some personality traits.

Balancing justice and autonomy in clinical research with healthy volunteers

In clinical research, ethics review generally first examines whether study risks are reasonable in light of benefits provided. Through informed consent, then, prospective subjects consider whether the risk/benefit balance and procedures are reasonable for them. Unique ethics issues emerge in clinical research with healthy volunteers. Certain types of studies only recruit healthy volunteers as participants. Phase 1 studies, for example, including first time in human studies of investigational drugs and vaccines, generally are conducted in healthy volunteers. Although such research carries inherent and often unknown risks, healthy subjects provide the most efficient target population in which to conduct such research, as these volunteers generally are free of concurrent diseases or medications that could confound interpretation of toxicity. Other studies enrolling healthy volunteers often are simply looking for the most scientifically sound population for the study of normal human physiology.

Healthy participants in phase I clinical trials: the quality of their decision to take part

AIMS AND OBJECTIVE

This study was set out to test the quality of the decision-making process of healthy volunteers in clinical trials.

BACKGROUND

Researchers fear that the decision to volunteer for clinical trials is taken inadequately and that the signature on the consent forms, meant to affirm that consent was 'informed', is actually insubstantial.

DESIGN

The study design was quasi-experimental, using a convenience quota sample.

METHODS

Over a period of a year, candidates were approached during their screening process for a proposed clinical trial, after concluding the required 'Informed Consent' procedure. In all, 100 participants in phase I trials filled out questionnaires based ultimately on the Janis and Mann model of vigilant information processing, during their stay in the research centre.

RESULTS

Only 35% of the participants reached a 'quality decision'. There is a definite correlation between information processing and quality decision-making. However, many of the healthy research volunteers (58%) do not seek out information nor check alternatives before making a decision.

CONCLUSIONS

Full disclosure is essential to a valid informed consent procedure but not sufficient; emphasis must be put on having the information understood and assimilated. Research nurses play a central role in achieving this objective.

Payment of clinical research subjects

Offering payment to clinical research subjects, in an effort to enhance recruitment by providing an incentive to take part or enabling subjects to participate without financial sacrifice, is a common yet uneven and contentious practice in the US. Concern exists regarding the potential for payment to unduly influence participation and thus obscure risks, impair judgment, or encourage misrepresentation. Heightening these concerns is the participation not only of adults but also of children in pediatric research trials. Thorough assessment of risks, careful eligibility screening, and attention to a participant's freedom to refuse all serve to reduce the possibility of compensation adversely affecting the individual and/or the study. Institutional review boards currently evaluate payment proposals with minimal guidance from federal regulations. Here, reasons for providing payment, payment models, ethical concerns, and areas for further research are examined.

Factors influencing parental consent in pediatric clinical research

BACKGROUND

Although previous studies have looked at the motivation behind enrollment in clinical trials of adults and healthy subjects, little is known about the factors influencing parental consent in pediatric clinical studies where the subjects themselves do not provide consent.

OBJECTIVE

This study was conducted to define a group of factors that impact parental consent in the pediatric clinical trial. This may allow investigators to identify a subset of specific appealing aspects of clinical trials that will promote participation while also bringing ethical issues to light that may require further consideration.

METHODS

Forty-four parents or guardians of children currently participating in clinical asthma research completed questionnaires from July 1999 to September 1999 pertaining to motives for allowing their child to participate in clinical trials. The responses were then rated on a Likert numerical scale.

RESULTS

The most important motive for parents is learning more about their child's illness. Next important was the motive of helping medical knowledge. Availability of free medication was negatively correlated with family income.

CONCLUSIONS

Although altruistic motives are present in pediatric asthma research, most parents/guardians gave consent for their child to learn more about their child's asthma. Access to free medication was more important in families with lower incomes than in families with higher incomes.

Motivation for participation in clinical trials of drugs for the treatment of asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis

BACKGROUND

While previous studies of enrollment motivation have been conducted with either healthy subjects or subjects with certain other diseases, little is known about the motives of subjects with asthma or rhinitis symptoms who seek to enter clinical trials.

OBJECTIVE

This study was conducted to assess the self-reported role that altruism, healthcare receipt, and financial gain play in the motivation of subjects with symptoms of bronchial asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis who attempted to enroll in clinical trials.

METHODS

Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis who sought to enroll in phase III clinical trials completed surveys from December 1991 to August 1992 (n = 295). The importance of altruistic and nonaltruistic motives was rated on numerical scales.

RESULTS

Improved control of symptoms and learning more about the illness and medications for treatment were the most important nonaltruistic motives (P less than .05). Financial motives and second opinion were moderately important but less important than healthcare motives (P less than .05). This population as a whole agreed that the altruistic motives listed in the survey were reasons to enroll.

CONCLUSION

Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis entered clinical trials for altruistic reasons and to receive healthcare treatment for their chronic illness including related health education. For the entire group, self-reported financial motives were less important than illness-related healthcare.

Sensation seeking amongst healthy volunteers participating in phase I clinical trials

1. Phase I clinical trials are usually carried out in healthy volunteers. In addition to economic gain, factors that may influence willingness to participate include scientific interest, curiosity and choice for risky activities. 2. We assessed the relationship between personality variables and volunteering for clinical pharmacology research. Two personality questionnaires, the Sensation Seeking Scale (SSS, form V) and the Eysenck Personality Questionnaire (EPQ), were administered to 48 male healthy university students who volunteered to participate in a phase I clinical trial and to 43 male university students who were not willing to participate in phase I clinical trials. General norm data were also used for the comparison of results. 3. When healthy volunteers were compared with unwilling subjects, significant differences were found in thrill-and-adventure seeking (7.9 vs 6.7, P = 0.0034), experience seeking (6.4 vs 5.2, P = 0.0012), disinhibition (6.2 vs 4.3, P < 0.0001), boredom susceptibility (3.9 vs 2.8, P = 0.0073), total sensation seeking trait (24.3 vs 19.0, P < 0.0001), extraversion (15.1 vs 13.3, P = 0.0490), and psychoticism (4.4 vs 3.5, P = 0.0086). When healthy volunteers were compared with general norm data similar statistically significant differences were found in all these scales, except for boredom susceptibility and psychoticism. 4. The personality profile of healthy volunteers was characterized by a higher sensation seeking trait and extraversion as compared with individuals who were not willing to participate in phase I clinical trials and general norm data.

Motives and perception of healthy volunteers who participate in experiments

Healthy volunteers who participated in an experiment were asked to complete a questionnaire about their experiences. Special attention was paid to their motives and the informed consent procedure. The motives of healthy volunteers for participating in a study differed according to age. Young volunteers mostly participated because of the financial compensation, while older volunteers mainly participated to get a medical check-up, which was part of the selection procedure, or because of the benefit that other people might obtain from the results of the experiment. In most experiments the volunteers were content with the information given about the experiment, which was provided orally and in a hand-out. The information procedure was crucial for the experiment, because optimum information was of the utmost importance in keeping the volunteers motivated during the experiment. Another conclusion was that the researcher should not be afraid that too much information was given. Adequate information was also important in recruiting new volunteers, because they mostly become interested because of information obtained from their predecessors. A personal approach towards the volunteers during the experiment was appreciated by them and was an important help in keeping the volunteers motivated during the experiment.

Weight of financial reward in the decision by medical students and experienced healthy volunteers to participate in clinical trials

The aim of this survey was twofold: to assess the willingness of medical students to volunteer for clinical trials and to evaluate the weight of the financial reward and other general details as seen by healthy volunteers who had already participated in clinical trials. A specific questionnaire was given to each group to be answered anonymously. Among the medical students only 2.9% had already volunteered, 39.7% said that they would never participate, 24.7% would do it for scientific interest, 32.2% for scientific interest and financial reward, and 4.2% for the financial reward alone. In experienced volunteers, financial reward was the main reason to participate (90%) followed by curiosity (6.3%). The financial reward actually received was considered adequate compensation for the time and discomfort by most of the volunteers (83.7%). The information supplied by the research team and the arrangements made to treat any hazardous event were considered adequate (47.5%) or optimal (42.5%). Almost all the experienced volunteers (93.8%) answered positively when asked about participation in future studies. The results show that financial reward is a very important reason for healthy volunteers to participate in clinical trials.

Ethical concerns and guidelines in research in geriatric pharmacology and therapeutics: individualization, not codification

Compared with people of other ages, the elderly are much more heterogeneous in terms of physical and mental status, and they are subject to more day-to-day variability. However, some see the institutionalized elderly as stereotypes, having little autonomy and being easily subjugated such that they will consent to take part in any sort of experiment. Thus, a counter-productive paternalism may lead them to protect elderly patients by making such choices for them. The interests of the incompetent elderly must be scrupulously protected, but competent elderly potential subjects can appropriately be assumed to be responsible and should be accorded the dignity of making their own choices. The consent process should be individualized rather than codified for the elderly, as for potential subjects of other ages.

Is it ethical to conduct volunteer studies within the pharmaceutical industry?

There is a case for appropriately selected drug studies within the pharmaceutical industry in which employee volunteers are used. Provided the organisation and conduct of such studies are approached in an ethical manner, with attention to safe-guarding the volunteer and recognising the limitations, this work can be done expeditiously, cheaply, and safely. Some details are given of the arrangements made for volunteer studies within a company.