Data safety and monitoring boards for African clinical trials

Setting up a pragmatic clinical trial in a low-resource setting: A qualitative assessment of GoLBeT, a trial of podoconiosis management in Northern Ethiopia

Background

Clinical trials are often perceived as being expensive, difficult and beyond the capacity of healthcare workers in low-resource settings. However, in order to improve healthcare coverage, the World Health Organization (WHO) World Health Report 2013 stated that all countries need to become generators as well as recipients of data. This study is a methodological examination of the steps and processes involved in setting up the Gojjam Lymphoedema Best Practice Trial (GoLBeT; ISRCTN67805210), a highly pragmatic clinical trial conducted in northern Ethiopia. Challenges to the trial and strategies used to deal with them were explored, together with the reasons for delays.

Methodology and principal findings

Qualitative research methods were used to analyse emails and reports from the period between trial inception and recruitment. This analysis was complemented by interviews with key informants from the trial operational team. The Global Health Research Process Map was used as a framework against which to compare the steps involved in setting up the trial. A mini-group discussion was conducted with the trial operational team after study completion for reflection and further recommendations.

This study showed that the key areas of difficulty in setting up and planning this trial were: the study design, that is, deciding on the study endpoint, where and how best to measure it, and assuring statistical power; recruitment and appropriate training of staff; planning for data quality; and gaining regulatory approvals. Collaboration, for example with statisticians, the trial steering committee, the study monitors, and members of the local community was essential to successfully setting up the trial.

Conclusions and significance

Lessons learnt from this trial might guide others planning pragmatic trials in settings where research is not common, allowing them to anticipate possible challenges and address them through trial design, planning and operational delivery. We also hope that this example might encourage similar pragmatic studies to be undertaken. Such studies are rarely undertaken or locally led, but are an accessible and efficient way to drive improved outcomes in public health.

Podoconiosis is a disease of the lymphatic vessels of the lower extremities, caused by chronic exposure to irritant soils. It results in leg swelling, commonly complicated by acute dermatolymphangioadenitis (ADLA, or ‘acute attacks’), characterised by severe pain, fever and disability. The Gojjam Lymphoedema Best Practice Trial (GoLBeT) trial is a successfully completed randomised controlled trial of podoconiosis treatment that was conducted in the highlands of northern Ethiopia. In this study we report the steps involved in the setup of this trial, from inception to recruitment. The challenges faced are discussed, along with recommendations on how these could be overcome.

Lessons from the field: the conduct of randomized controlled trials in Botswana

Background

The conduct of randomized controlled trials (RCTs) in low-resource settings may present unique financial, logistic, and process-related challenges. Middle-income countries that have comparable disease burdens to low-income countries, but greater availability of resources, may be conducive settings for RCTs. Indeed, the country of Botswana is experiencing a rapid increase in the conduct of RCTs. Our objective was to explore the experiences of individuals conducting RCTs in Botswana to gain an understanding of the challenges and adaptive strategies to their work.

Methods

We conducted in-depth interviews with 14 national and international individuals working on RCTs in Botswana. Participants included principal investigators, research coordinators, lab technicians, research assistants, and other healthcare professionals. Interviews were audiotaped, transcribed verbatim, and coded for thematic analysis.

Results

Five primary themes were identified: ethics board relationships (including delays in the process); research staff management (including staff attrition and career development); study recruitment and retention (including the use of reimbursements); resource availability (including challenges accessing laboratory equipment); and capacity-building (including issues of exporting locally sourced samples). These themes were explored to discuss key challenges and adaptive strategies.

Conclusions

This study offers a first-hand account of individuals engaged in conducting RCTs in Botswana, a nation that is experiencing a rapid increase in research activities. Findings provide a foundational understanding for researchers in Botswana and trial managers in similar settings when planning RCTs so that the conduct of research does not outpace the ability to manage, support, and regulate it.

Podoconiosis treatment in northern Ethiopia (GoLBet): study protocol for a randomised controlled trial

Background

Podoconiosis is one of the forgotten types of leg swelling (elephantiasis) in the tropics. Unlike the other, better-known types of leg swelling, podoconiosis is not caused by any parasite, virus or bacterium, but by an abnormal reaction to minerals found in the clay soils of some tropical highland areas. Non-governmental Organizations (NGOs) have been responsible for the development of simple treatment methods without systematic evaluation of its effectiveness. It is essential that a large scale, fully controlled, pragmatic trial of the intervention is conducted. We aim to test the hypothesis that community-based treatment of podoconiosis lymphoedema reduces the frequency of acute dermatolymphangioadenitis episodes (‘acute attacks’) and improves other clinical, social and economic outcomes.

Methods/Design

This is a pragmatic, individually randomised controlled trial. We plan to randomly allocate 680 podoconiosis patients from the East Gojjam Zone in northern Ethiopia to one of two groups: ‘Standard Treatment’ or ‘Delayed Treatment’. Those randomised to standard treatment will receive the hygiene and foot-care intervention from May 2015 for one year, whereas those in the control arm will be followed through 2015 and be offered the intervention in 2016. The trial will be preceded by an economic context survey and a Rapid Ethical Assessment to identify optimal methods of conveying information about the trial and the approaches to obtaining informed consent preferred by the community. The primary outcome will be measured by recording patient recall and using a simple, patient-held diary that will be developed to record episodes of acute attacks. Adherence to treatment, clinical stage of disease, quality of life, disability and stigma will be considered secondary outcome measures. Other outcomes will include adverse events and economic productivity. Assessments will be made at baseline and at 3, 6, 9 and 12 months thereafter.

Discussion

The evidence is highly likely to inform implementation of the new master plan for integrated control of Neglected Tropical Diseases (NTDs), in which podoconiosis is identified as one of eight NTDs prioritised for control. Potentially, an estimated 3 million patients in Ethiopia will therefore benefit from the results of this trial.

Trial registration

International Standard Randomised Controlled Trial Number. Registration number: ISRCTN67805210. Date of registration: 24 January 2013.

The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action

Background

There is increasing recognition among trialists of the challenges in understanding how particular ‘real-life’ contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted.

Methods

A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection.

Results and discussion

From our experiences of the realities of conducting these evaluations, we identified six key ‘lessons learned’ about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention.

Conclusion

The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making.

Adaptive trial design: could we use this approach to improve clinical trials in the field of global health?

We need more clinical trials in the world's poorest regions to evaluate new drugs and vaccines, and also to find better ways to manage health issues. Clinical trials are expensive, time consuming, and cumbersome. However, in wealthier regions these limiting factors are being addressed to make trials less administrative and improve the designs. A good example is adaptive trial design. This innovation is becoming accepted by the regulators and has been taken up by the pharmaceutical industry to reduce product development times and costs. If this approach makes trials easier and less expensive surely we should be implementing this approach in the field of tropical medicine and international health? As yet this has rarely been proposed and there are few examples. There is a need for raising the awareness of these design approaches because they could be used to make dramatic improvements to clinical research in developing countries.

Health research oversight in Africa

Increased research involving human participants in developing countries has resulted in commensurate rise in needs for functional research oversight activities. The importance of developing countries regulatory and ethical review authorities to demonstrate capability in reviewing clinical trials, quality of the products as well as clinical data obtained through well-coordinated oversight systems cannot be over-emphasized. According to the recent international changes in regulatory frameworks and evolving manufacture's strategies, African countries are now responsible to review applications and license new products without necessarily having them licensed in the north so long as they are not intended to be used there. This paper reviews the status of health research oversight in Africa and gives an overview of some mechanisms that are being put in place in an effort to strengthen oversight of health research. Practical challenges that are prevailing in the field will be highlighted.

From research to control: Translating research findings into health policies, operational guidelines and health products

Although Africa's health research capacity is still weak, African R&D institutions are contributing immensely to the development of health policies, guidelines and products essential for diagnosis, treatment, prevention and control of Africa's leading health problems. In order to increase Africa's contributions, all health research stakeholders should participate in setting health research priorities and agenda, followed by establishing health research networks and consortia, holistic capacity strengthening, and gathering of baseline data. The evaluation of candidate tools, and the research preceding it, must abide by international scientific and ethical standards, and must involve institutional and national regulatory authorities. The funding of product development and product availability in Africa benefits from national governments, bilateral, multilateral, and philanthropic agencies. When a trial is over poses many social and ethical issues, and not infrequently existing guidelines may not be adequate. Mechanisms for making products available in resource constrained countries are presented, as are problems relating to manufacturing, markets and procurement. So are obligations to trial and research communities. The paper concludes by outlining the obligations of each stakeholder, in order to make research products readily available in resource constrained settings.

Health research ethics in public health: trials and implementation of malaria mosquito control strategies

Health research ethics has its roots in protecting individuals participating in clinical trials. There is, however, nascent interest in ethics in public health, although it does not yet cover ethics in the development of public health products. The paper reviews the history of the development of malaria vector interventions, which initially aimed at promoting colonial interests. Attempts at eradicating malaria in Africa ended in 1969, and DDT, the leading malaria vector control tool was banned soon after. Insecticide Treated Nets, which later gave rise to Long Lasting Insecticidal Nets have resurrected malaria mosquito vector control, and their development has set new benchmarks, which it is suggested should be followed by all vector control tools under development. Furthermore, DDT has been exonerated and is back in the vector control arsenal. New tools under development include the sterile male technique, genetically modified mosquitoes, entomopathogenic fungi, and odorants.The paper proposes that these new tools be tested in community settings, abiding by all the leading bioethical principles, and calls for the development and implementation of international ethical guidelines for trials in public health.

An ethics perspective on responsibilities of investigators, sponsors and research participants

The major international guidelines for health research have come a long way in setting standards and providing direction on acceptable practices for the conduct of research. However, the responsibilities of the key players have generally been addressed in a rather uncoordinated manner, and there still remain gaps in addressing the responsibilities of some of the key players in the research setting. This paper is a review of crosscutting guidelines and mix of the key responsibilities of investigators, sponsors, study participants together with their communities. Some new responsibilities for the participants and research institutions have be suggested based on understanding and practical experience as they are not described in any traditional literature.