Putting the 'informed' into 'consent': a matter of plain language

Prisoners' understanding and experiences of parole

BACKGROUND

In Scotland, as elsewhere, there has been growing political and public interest in the function and process of parole accompanied by a lack of empirical research on the operation and effectiveness of parole.

AIMS

Against the backdrop of a Scottish Government review of parole aimed, among other things, at improving the transparency of the process, the aim of the study was to explore the experiences of prisoners seeking early release on licence.

METHODS

In conjunction with the Scottish Prison Service a national survey was conducted of 197 long-term prisoners who had experience of seeking early release on parole.

FINDINGS

The survey revealed that prisoners did not have a clear understanding of parole and often did not feel fully engaged in the process.

CONCLUSIONS

It is argued that better support for prisoners prior to, during and following parole hearings might foster their increased engagement and alleviate some of the anxiety associated with the parole process.

Consent Rates Reported in Published Pediatric Randomized Controlled Trials

OBJECTIVE

To determine the average reported consent rate for published pediatric randomized controlled trials (RCTs) and whether this rate varies by trial characteristics.

STUDY DESIGN

A review of pediatric RCTs published in Medline in 2009, 2010, or 2015 was performed. Secondary analyses of prior trials, trials including adults, trials not requiring consent, or trials with missing or unclear consent data were excluded. Consent rate was defined as the number of patients enrolled divided by number of eligible patients where families were approached. Random effects meta-regression was conducted to determine the weighted average consent rate.

RESULTS

Of 2347 trials identified, 1651 were excluded. An additional 418 of 696 (60%) were excluded because the consent rate was missing or unclear. The average consent rate for 278 included RCTs was 82.6% (95% CI, 80.3%-84.8%) and was higher for vaccination compared with behavioral trials and for industry-funded compared with National Institutes of Health-funded or other government-funded trials. The average consent rate was <70% for 26% of included trials. Of these trials, US trials (28/77 [36.4%]) had a higher probability of a consent rate of <70% than non-US studies (35/64 [21.3%]) and multinational (9/37 [24.3%]) studies. There was slight variation by funding category.

CONCLUSIONS

Although the average consent rate for published trials was reasonably high, approximately one-quarter of trials had consent rates of <70%. Consent rates reporting has improved over time, but remains suboptimal. Our findings should assist with the planning of future pediatric RCTs, although consent data from unpublished trials are also needed.

Improving Comprehension in Written Medical Informed Consent Procedures

Abstract. Older adults are frequently required to undergo medical informed consent procedures. This study investigates the influence of four types of written language and visual support (Elaborated Plain Language, Easy-to-Read Language, Standard Version with additional picture, Easy-to-Read-Language with additional picture) on comprehension and affect, compared with the Standard Version alone. In an online survey, n = 87 younger participants aged 26–59 and n = 72 older participants aged 60–81 read a simulation of an informed consent form. Directly after reading it, we used the Understanding dimension of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to ask them about the information presented in the form. The results showed that, by reducing complexity and elaborating the provided information, comprehension of medical information could be improved in the older participant group. In the so-called Elaborated Plain Language groups, the results were the same for younger and older participants. This was not true for the groups that received the Standard Version, on which younger participants performed better. Variations in the language used had no influence on affect. Our conclusion is that Elaborated Plain Language can be recommended for use in medical informed consent procedures with older patients and should be taught to medical professionals.

Simple genetics language as source of miscommunication between genetics researchers and potential research participants in informed consent documents

Informed consent is based on communication, requiring language to convey meanings and ensure understandings. The purpose of this study was to investigate the use of language in informed consent documents used in the genetics research funded by Canadian Institutes of Health Research and Genome Canada. Consent documents were requested from the principal investigators in a recent round of funding. A qualitative content analysis was performed, supported by NVivo7™. Potential barriers to informed consent were identified, including language that was vague and variable, words with both technical and common meanings, novel phrases without clear meaning, a lack of definitions, and common concepts that assume new definitions in genetics research. However, we noted that difficulties in comprehension were often obscured because the words used were generally simple and familiar. We conclude that language gaps between researcher and potential research participants may unintentionally impair comprehension and ultimately impair informed consent in genomics research.

Research information for minors: Suitable formats and readability. A systematic review

As children age, their capacity to consent or dissent to research participation increases. Numerous regulations and guidelines require that children should receive information 'according to their capacity of understanding'. In order to gain more insight in the quality of patient information forms for minors, a systematic literature search was performed. Two aspects of quality will be analysed in this paper: the effect of format on understanding and the readability of text in the documents. A systematic search was executed in PubMed, Embase and PsycINFO. Seventeen papers on format were included. Interventions testing information formats indicate that improvement is possible, but outcome measurement varied per study and no apparently successful intervention was repeated. Only three readability papers were found, all indicating a readability gap between patient information forms and children's actual reading level. The results indicate an urgent need for further research on how to adequately inform minors about clinical trials.

Comic strips help children understand medical research: targeting the informed consent procedure to children's needs

OBJECTIVE

Children involved in medical research often fail to comprehend essential research aspects. In order to improve information provision, a participatory approach was used to develop new information material explaining essential concepts of medical research.

METHODS

A draft of a comic strip was developed by a science communicator in collaboration with pediatricians. The draft was presented to children participating in a clinical trial and to two school classes. Children were consulted for further development in surveys and interviews. Subsequently, the material was revised and re-evaluated in four school classes with children of varying ages and educational levels.

RESULTS

In the first evaluation, children provided feedback on the storyline, wording and layout. Children thought the comic strip was 'fun' and 'informative'. Understanding of 8 basic research aspects was on average 83% and all above 65%, illustrating that children understood and remembered key messages.

CONCLUSION

A comic strip was developed to support the informed consent process. Children were consulted and provided feedback. The resulting material was well understood and accepted.

PRACTICE IMPLICATIONS

Involving children in the development of information material can substantially contribute to the quality of the material. Children were excited to participate and to 'be a part of science'.

Evaluating the quality of informed consent and contemporary clinical practices by medical doctors in South Africa: an empirical study

BACKGROUND

Informed consent is a legal and ethical doctrine derived from the principle of respect for autonomy. Generally two rights derived from autonomy are accorded legal protection. The constitutional right to bodily integrity followed by the right to bodily well-being, protected by professional negligence rules. Therefore healthcare professionals treating patients' without valid consent may be guilty of infringing patients' rights. Many challenges are experienced by doctors obtaining informed consent in complex multicultural societies like South Africa. These include different cultural ethos, multilingualism, poverty, education, unfamiliarity with libertarian rights based autonomy, and power asymmetry between doctors and patients. All of which could impact on the ability of doctors to obtain legally valid informed consent.

METHODS

The objective of this study was to evaluate whether the quality of informed consent obtained by doctors practicing in South Africa is consistent with international ethical standards and local regulations. Responses from 946 participants including doctors, nurses and patients was analyzed, using a semi-structured self-administered questionnaire and person triangulation in selected public hospitals in Durban, KwaZulu-Natal, South Africa.

RESULTS

The median age of 168 doctors participating was 30 years with 51% females, 28% interns, 16% medical officers, 26% registrars, 30% consultant/specialists. A broad range of clinical specialties were represented. Challenges to informed consent practice include language difficulties, lack of interpreters, workload, and time constraints. Doctors spent 5-10 minutes on consent, disclosed most information required to patients, however knowledge of essential local laws was inadequate. Informed consent aggregate scores (ICAS) showed that interns/registrars scored lower than consultants/specialists. ICAS scores were statistically significant by specialty (p = 0.005), with radiologists and anaesthetists scoring lowest, while internists, GPs and obstetricians/gynaecologists scored highest. Comparative ICAS scores showed that professional nurses scored significantly lower than doctors (p ≤ 0.001).

CONCLUSIONS

This study shows that though doctors had general knowledge of informed consent requirements, execution in practice was inadequate, with deficiency in knowledge of basic local laws and regulations. Remedying identified deficiencies may require a 'corps' of interpreters in local hospitals to assist doctors in dealing with language difficulties, and continuing education in medical law and ethics to improve informed consent practices and overall quality of healthcare service delivery.

A primer for clinical researchers in the emergency department: Part II: research science and conduct

Research is an important part of emergency medicine and provides the scientific underpinning for optimal patient care. Although increasing numbers of emergency physicians participate in research activities, formal research training is currently neither part of emergency physician training in Australia nor easily available for clinicians interested in clinical research. In a two-part series, which is targeted at part-time clinical researchers in the ED, we set out and explain the key elements for conducting high-quality and ethical research. Part I addressed ethical and regulatory aspects. In Part II, we describe important elements of research science, and practical elements of research conduct and administration, which form the basis for high-quality research.

The ethics of reflective research in single case study inquiry

TOPIC

Recent developments in policy change in the governance of research ethics in the UK are reviewed and discussed regarding how the changes in informed consent impacts on single case study research.

CONCLUSIONS

Changes in the ethics of health research (particularly in the UK) and informed patient consent have potentially negative implications for case study research where overregulated research guidance may impinge on patient treatment.

PRACTICE IMPLICATIONS

The psychotherapy milieu is a highly protective environment where case study research design has, historically, been effectively applied without compromising clients' interests and treatment. A distinction between "prospective" and "reflective" psychotherapy research is proposed that offers an ethical foothold, protecting patients and allowing scope for practitioners to continue to advance knowledge from their reflective practice.

Development of children's assent documents using a child-centred approach

The call for researchers to obtain children's informed assent, prior to their participation in medical procedures and research, has increased over recent years and parallels moves to implement child-centred approaches to health care. This article describes the processes used to include children in developing a research information sheet and assent form for use in future research into children's understandings of their surgery and hospital experiences. The process involved primary school children aged between six and 12 years. Children worked in small groups to consider information to include in these documents. Their words were collated to construct the research information sheet and assent form. Working with children resulted in documents that were more understandable for their intended audience. The article includes discussion of 'language', 'understandability' and 'readability'; concepts that researchers seeking to work with children need to come to terms with if they are to obtain 'informed assent'.