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Deja E, Weeks A, Van Netten C, Gamble C, Meher S, Gyte G, Lavender T, Woolfall K. Questioning approaches to consent in time critical obstetric trials: findings from a mixed-methods study. BMJ Open 2024; 14:e081874. [PMID: 38341214 PMCID: PMC10862288 DOI: 10.1136/bmjopen-2023-081874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/15/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE Trial legislation enables research to be conducted without prior consent (RWPC) in emergency situations, yet this approach has rarely been used in time-critical obstetric trials. This study explored views and experiences of antenatal recruitment and consent and RWPC in an emergency intrapartum randomised clinical trial. DESIGN Embedded, mixed-methods study within a trial, involving questionnaires, recorded recruitment discussions, interviews and focus groups in the first 13 months of trial recruitment (December 2020-January 2022). SETTING COPE is a double-blind randomised controlled trial, comparing the effectiveness of carboprost or oxytocin as first-line treatment of postpartum haemorrhage. PARTICIPANTS Two hundred and eighty-six people (190 women/96 birth partners), linked to 198/380 (52%) COPE recruits participated in the embedded study. Of these, 272 completed a questionnaire (178 women/94 birth partners), 22 were interviewed (19 women/3 birth partners) and 16 consent discussions with 12 women were recorded. Twenty-seven staff took part in three focus groups and nine staff were interviewed. RESULTS Participants recommended that information about the study should be more accessible antenatally for those who wish to be informed. Most women and staff did not think it would be appropriate to seek consent during pregnancy or early labour as it may cause 'unnecessary panic' and lead to research waste, as most women would not become eligible. There was support for the use of RWPC as COPE interventions are used in standard clinical practice and viewed as low risk. Women who were approached about the trial while having a postpartum haemorrhage also supported RWPC as they could not recall research discussions. CONCLUSIONS Findings support the use of RWPC for time-critical interventions, and raise questions about the appropriateness of other commonly used consent pathways, including antenatal consent and verbal assent.
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Affiliation(s)
- Elizabeth Deja
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Andrew Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | | | - Carrol Gamble
- Health Data Science, University of Liverpool, Liverpool, UK
| | | | | | - Tina Lavender
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Manisha M, Verma K, Ramesh N, Anirudha TP, Santrupt RM, Rao L. Water, sanitation, and hygiene implications of large-scale recycling of treated municipal wastewater in semi-arid regions. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 904:166631. [PMID: 37659564 DOI: 10.1016/j.scitotenv.2023.166631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023]
Abstract
Access to water, sanitation, and hygiene (WaSH) is crucial for national development, as it improves human health and fulfills a fundamental need. This study examines the impact of a large-scale groundwater (GW) recharge scheme using secondary treated wastewater (STW) on WaSH characteristics and identifies the major determinants of improved WaSH charecteristics in drought-hit regions of Kolar district, southern India. The study quantifies improved WaSH practices by comparing WaSH characteristics between impacted areas (influenced by STW) and non-impacted areas (not influenced by STW) of Kolar, using household survey data. Pearson's chi-square and student's t-test are used to verify differences between WaSH characteristics. Furthermore, a composite WaSH score is formulated, and a hierarchical stepwise multiple linear regression model is constructed to identify major determinants of improved WaSH scores. The results show that impacted areas have better WaSH characteristics, including daily water supply by gram panchayat, enhanced toilet uses among all family members, bathing patterns, cloth washing practices, toilet cleaning patterns, and water consumption per capita per day. The maximum and minimum WaSH scores of impacted areas were 17.50 and 6.50, respectively, while those of non-impacted areas were 14 and 4.5. This study finds that improved water availability, quality, and security due to daily water supply at the household level are the major determinants of improved WaSH practices. These results can inform policymakers in designing sanitation and hygiene improvement policies that integrate water recycling projects in drought-hit areas.
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Affiliation(s)
- Manjari Manisha
- Centre for Sustainable Technologies, Indian Institute of Science, Bengaluru, India.
| | - Kavita Verma
- Centre for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - N Ramesh
- Centre for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - T P Anirudha
- Centre for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - R M Santrupt
- Centre for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - Lakshminarayana Rao
- Centre for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
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Parkin S, Neale J, Strang J. Conceptualising retention in treatment with long-acting injectable buprenorphine (for opioid use disorder) as a journey: Findings from a longitudinal qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104221. [PMID: 37865052 DOI: 10.1016/j.drugpo.2023.104221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Conceptualisations of the 'patient journey' are popular within health service research. Patient journeys provide a person-centred approach to health care that typically prioritise subjective patient experience with the aim of improving relevant forms of intervention. This article explores the conceptualisation of retention in treatment for opioid use disorder (OUD) using long-acting injectable buprenorphine (LAIB) as a journey. METHODS Data derive from a longitudinal qualitative study, involving semi-structured interviews (held at six time-points), with participants who each initiated LAIB for the first time. Data analysis for this article focuses exclusively upon the experiences of those who had continued with LAIB treatment throughout one year (11 participants). Framework and thematic narrative analyses of 64 interviews with 11 participants sought to identify 'retention-narratives' that would indicate a 'retention journey' associated with LAIB treatment. FINDINGS Shared treatment experiences consisted of three distinct phases (Withdrawal and Separation, Transformation, and Engagement) that progressed in a linear and intersecting manner through time. Each phase had features that defined treatment experiences at a given time but changed as treatment progressed. All 11 participants experienced multiple features within each of the three treatment phases and all participants reported separation from their respective service provider throughout the first 12 months of treatment. Although some valued the latter separation, most were dissatisfied by reduced levels of contact. CONCLUSION Retention in treatment for OUD with LAIB, for at least 12-months, can be conceptualised as a journey. This conceptualisation emphasises the benefits (and challenges) clinicians and patients may expect to encounter during the first year of a LAIB treatment programme. An added implication of conceptualising LAIB treatment in this manner is that optimal benefits of the medication (as observed by participants) began to emerge during 'months 7-12' of the retention journey.
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Affiliation(s)
- Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK.
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; Centre for Social Research in Health, University of New South Wales, NSW 2052, Australia
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; South London & Maudsley (SLaM) NHS Foundation Trust, London SE5 8AZ, UK
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Oh KE, Vasandani N, Anwar A, Meshkat B. Informed Written Consent for Emergency and Elective General Surgery at a Model 4 Hospital: A Closed-Loop Audit. Cureus 2023; 15:e49480. [PMID: 38033440 PMCID: PMC10682740 DOI: 10.7759/cureus.49480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction The objective of this investigation was to conduct an audit of the consent form standards signed by patients before elective or emergency general surgery at our institution. The investigation involved a comparison of these standards with those outlined in the "HSE National Consent Policy 2022" established by the Health Service Executive (HSE) and the Royal College of Surgeons in Ireland (RCSI). In the event of discrepancies, we intended to complete the audit loop by educating general surgeons on the essential standards for obtaining written consent in both elective and emergency general surgical procedures. Methods To assess the quality of patient consent, a pre-interventional phase was conducted over one week. Information was gathered exclusively through electronic medical record systems. Subsequent to the data analysis, an in-person educational session was conducted to enlighten non-consultant hospital doctors (NCHDs) in surgery about the significance of informed written consent and the criteria for lawful consent according to local guidelines established by the HSE and the RCSI. Three months following the intervention, a follow-up cycle was carried out to evaluate whether there were any improvements in the standards of consent. Results In the initial phase, prior to intervention, a total of 95 consent forms were collected. The patient's name, date of birth (DOB), and hospital board number (BN) were accurately recorded in all consent forms. However, only 66% (n=63) were accurately documented without the use of abbreviations or acronyms. Following the intervention, 145 consent forms were gathered. All appropriately indicated the patient's name, DOB, and BN. However, 84% (n=122) of consent forms were correctly labeled without the use of abbreviations or acronyms (p=0.0017). Conclusion This closed-loop review illustrates that the quality of consent can be notably enhanced through a straightforward educational intervention led by NCHDs in general surgery. Such interventions can be instructive, leading to improved consent form documentation. This, in turn, enhances patient safety and helps prevent potential medico-legal repercussions for both healthcare providers and institutions.
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Affiliation(s)
- Ke En Oh
- Department of Surgery, University Hospital Galway, Galway, IRL
| | - Nikhil Vasandani
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Afiq Anwar
- Department of Surgery, University Hospital Galway, Galway, IRL
| | - Babak Meshkat
- Department of Surgery, University Hospital Galway, Galway, IRL
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Shan H, Saharso S, Henrichs J. Experiences of peripartum depressive symptoms among Chinese middle-class migrant women in the Netherlands: a qualitative study of migrant motherhood. BMC Pregnancy Childbirth 2023; 23:638. [PMID: 37670269 PMCID: PMC10481590 DOI: 10.1186/s12884-023-05957-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 08/26/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND A low educational level and poor economic status have repeatedly been identified as the main risk factors of peripartum depression among migrant women in existing studies. However, there is limited knowledge about a group of highly educated and middle-class migrant women, and how this group of migrant women deals with those risks and which protective factors facilitate a successful transition into motherhood in the host country. This study aims to shed light on the multifaceted psychosocial challenges during the peripartum period for Chinese migrant women in their relationships with intimate partners, mothers, and mothers-in-law. METHODS In this qualitative study, semi-structured in-depth interviews were conducted digitally with 46 pregnant and postpartum middle-class Chinese migrant women with peripartum depressive symptoms in the Netherlands. The interview data were analyzed using content analysis. RESULTS The multifaceted psychosocial challenges for women with peripartum depressive symptoms were classified into three key categories: the ambivalence towards different mothering values, perceived inadequate and mismatching social support and adverse childhood experiences. CONCLUSION Well-educated middle-class Chinese migrant women with peripartum depressive symptoms faced challenges in the transition into motherhood due to the unmet self-expectations regarding the pursuit of a good quality of life and a happy motherhood. The nurturing intimate relationships and adequate social support in the host country have mitigated recollections of their adverse childhood experiences. Future prevention programs and postpartum care should consider the contextual specificity based on the childhood history. International mental health research should pay more attention to the growing and potentially vulnerable group of well-educated middle-class migrant women.
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Affiliation(s)
- Haiyue Shan
- Department of Sociology, Vrije University Amsterdam, De Boelelaan 1105, 1081HV, Amsterdam, Netherlands.
| | - Sawitri Saharso
- Department of Sociology, Vrije University Amsterdam, De Boelelaan 1105, 1081HV, Amsterdam, Netherlands
| | - Jens Henrichs
- Amsterdam University Medical Center, Vrije University Amsterdam, Amsterdam, Netherlands
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Jawa NA, Boyd JG, Maslove DM, Scott SH, Silver SA. Informed consent practices in clinical research: present and future. Postgrad Med J 2023; 99:1033-1042. [PMID: 37265442 DOI: 10.1093/postmj/qgad039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/06/2023] [Indexed: 06/03/2023]
Abstract
Clinical research must balance the need for ambitious recruitment with protecting participants' autonomy; a requirement of which is informed consent. Despite efforts to improve the informed consent process, participants are seldom provided sufficient information regarding research, hindering their ability to make informed decisions. These issues are particularly pervasive among patients experiencing acute illness or neurological impairment, both of which may impede their capacity to provide consent. There is a critical need to understand the components, requirements, and methods of obtaining true informed consent to achieve the vast numbers required for meaningful research. This paper provides a comprehensive review of the tenets underlying informed consent in research, including the assessment of capacity to consent, considerations for patients unable to consent, when to seek consent from substitute decision-makers, and consent under special circumstances. Various methods for obtaining informed consent are addressed, along with strategies for balancing recruitment and consent.
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Affiliation(s)
- Natasha A Jawa
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3L4, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
- Department of Critical Care Medicine, Kingston Health Sciences Centre, Kingston, Ontario K7L 2V7, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
- Department of Critical Care Medicine, Kingston Health Sciences Centre, Kingston, Ontario K7L 2V7, Canada
| | - Stephen H Scott
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - Samuel A Silver
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
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Kituuka O, Munabi IG, Mwaka ES, Galukande M, Harris M, Sewankambo N. Informed consent process for emergency surgery: A scoping review of stakeholders' perspectives, challenges, ethical concepts, and policies. SAGE Open Med 2023; 11:20503121231176666. [PMID: 37362612 PMCID: PMC10285587 DOI: 10.1177/20503121231176666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023] Open
Abstract
Background A scoping review of literature about the informed consent process for emergency surgery from the perspectives of the patients, next of kin, emergency staff, and available guiding policies. Objectives To provide an overview of the informed consent process for emergency surgery; the challenges that arise from the perspectives of the patients, emergency staff, and next of kin; policies that guide informed consent for emergency surgery; and to identify any knowledge gaps that could guide further inquiry in this area. Methods We searched Google Scholar, PubMed/MEDLINE databases as well as Sheridan Libraries and Welch Medical Library from 1990 to 2021. We included journal articles published in English and excluded non-peer-reviewed journal articles, unpublished manuscripts, and conference abstracts. The themes explored were emergency surgery consent, ethical and theoretical concepts, stakeholders' perceptions, challenges, and policies on emergency surgery. Articles were reviewed by three independent reviewers for relevance. Results Of the 65 articles retrieved, 18 articles were included. Of the 18 articles reviewed, 5 addressed emergency informed consent, 9 stakeholders' perspectives, 7 the challenges of emergency informed consent, 3 ethical and theoretical concepts of emergency informed consent, and 3 articles addressed policies of emergency surgery informed consent. Conclusion There is poor satisfaction in the informed consent process in emergency surgery. Impaired capacity to consent and limited time are a challenge. Policies recommend that informed consent should not delay life-saving emergency care and patient's best interests must be upheld.
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Affiliation(s)
- Olivia Kituuka
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Moses Galukande
- Makerere University College of Health Sciences, Kampala, Uganda
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Romano G, Ayers S, Constantinou G, Mitchell EJ, Plachcinski R, Wakefield N, Walker KF. The acceptability and feasibility of a randomised trial exploring approaches to managing impacted fetal head during emergency caesarean section: a qualitative study. BMC Pregnancy Childbirth 2023; 23:216. [PMID: 36991399 DOI: 10.1186/s12884-023-05444-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/13/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Caesarean sections (CS) account for 26% of all births in the UK, of which at least 5% are done at full dilatation, in the second stage of labour. Second stage CS may be complicated by the fetal head being deeply impacted in the maternal pelvis, requiring specialist skills to achieve a safe birth. Numerous techniques are used to manage impacted fetal head, however, there are no national clinical guidelines in the UK. AIM To explore health professionals' and women's views on the acceptability and feasibility of a randomised controlled trial (RCT) designed to explore approaches to managing an impacted fetal head during emergency CS. METHODS Semi-structured interviews with 10 obstetricians and 16 women (6 pregnant and 10 who experienced an emergency second stage CS). Interviews were transcribed and analysed using systematic thematic analysis. RESULTS The findings considered the time at which you obtain consent, how and when information about the RCT is presented, and barriers and facilitators to recruiting health professionals and women into the RCT. Obstetricians emphasised the importance of training in the techniques, as well as the potential conflict between the RCT protocol and current site or individual practices. Women said they would trust health professionals' to use the most appropriate technique and abandon the RCT protocol if necessary. Similarly, obstetricians raised the tension between the RCT protocol versus safety in reverting to what they knew under emergency situations. Both groups reflected on how this might affect the authenticity of the results. A range of important maternal, infant and clinical outcomes were raised by women and obstetricians. However, there were varying views on which of the two RCT designs presented to participants would be preferred. Most participants thought the RCT would be feasible and acceptable. CONCLUSIONS This study suggests an RCT designed to evaluate different techniques for managing an impacted fetal head would be feasible and acceptable. However, it also identified a number of challenges that need to be considered when designing such an RCT. Results can be used to inform the design of RCTs in this area.
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Affiliation(s)
- Gabriella Romano
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK.
| | - Georgina Constantinou
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Natalie Wakefield
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kate F Walker
- Population and Lifespan Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Lawrence DS, Ssali A, Jarvis JN, Seeley J. Clinical research for life-threatening illnesses requiring emergency hospitalisation: a critical interpretive synthesis of qualitative data related to the experience of participants and their caregivers. Trials 2023; 24:149. [PMID: 36849961 PMCID: PMC9972707 DOI: 10.1186/s13063-023-07183-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/17/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Research into life-threatening illnesses which require emergency hospitalisation is essential. This group of patients is unique in that they are experiencing an unfolding emergency when they are approached, enrolled, and followed up in a research study. We aimed to synthesise qualitative data from trial participants and surrogate decision-makers to deepen our understanding and inform the design and conduct of future clinical trials for life-threatening illnesses. METHODS We conducted a critical interpretive synthesis of qualitative data from trial participants and surrogate decision-makers related to the experience of participating in a clinical research study when suffering from a life-threatening illness. A scoping review informed a systematic review of published data. We searched research databases and reviewed papers for inclusion. Primary data and interpretations of data were extracted from each paper. Data were analysed using reciprocal translational analysis, refutational synthesis, and lines of argument synthesis to develop a synthetic construct. RESULTS Twenty-two papers were included. Most individuals had no previous knowledge or experience with clinical research. Individuals making decisions were directly experiencing or witness to an unfolding emergency which came with a myriad of physical and psychological symptoms. It was difficult to differentiate clinical research and routine care, and understanding of core concepts around research, particularly randomisation and equipoise, was limited. We found that this led to an underestimation of risk, an overestimation of benefit, and an expectation of being allocated to the intervention arm. The decision-making process was heavily influenced by trust in the research team. Individuals suggested that abbreviated information, presented in different ways and continuously throughout the research process, would have increased knowledge and satisfaction with the research process. CONCLUSION Individuals suffering from a life-threatening illness who are being invited to participate in clinical research need to be managed in a way that adapts to the severity of their illness and there is a need to tailor research processes, including informed consent, accordingly. We provide suggestions for further research and implementation work around research participation for individuals suffering from a life-threatening illness. TRIAL REGISTRATION PROSPERO CRD42020207296.
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Affiliation(s)
- David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
| | - Agnes Ssali
- Social Aspects of Health Across the Life-Course Programme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Seeley
- Social Aspects of Health Across the Life-Course Programme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Manisha M, Verma K, Ramesh N, Anirudha TP, Santrupt RM, Das R, Mohan Kumar MS, Chanakya HN, Rao L. Socio-economic impact assessment of large-scale recycling of treated municipal wastewater for indirect groundwater recharge. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 859:160207. [PMID: 36402318 DOI: 10.1016/j.scitotenv.2022.160207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/21/2022] [Accepted: 11/11/2022] [Indexed: 06/16/2023]
Abstract
Reusing treated wastewater is an emerging solution to address freshwater scarcity, and surface water contamination faced worldwide. A unique large-scale wastewater recycling project was implemented to replenish groundwater by filling secondary treated wastewater (STW) into existing irrigation tanks in severely drought-hit areas of the Kolar districts of Southern India. This study quantifies the socio-economic impacts of this large-scale indirect groundwater recharge scheme. The changes in areas receiving STW i.e., impacted areas and those areas which did not receive STW i.e., non-impacted areas was studied. Also, pre and post recycling changes were quantified in the Kolar district. The results show that surface water quality meets India's most stringent treated wastewater discharge standards prescribed by the Hon'ble National Green Tribunal. Due to these recycling efforts, significant improvements in groundwater level and quality were found. It was observed that there was a noticeable difference in agricultural cropping areas, seasons, patterns, and production between impacted and non-impacted areas. Post-recycling, farmers tended to cultivate cash and water-intensive crops over less water-intensive crops. During the post-recycling period, livestock and milk production also increased, and in impacted areas, it was significantly higher. Post-recycling, fish production increased and land prices per hectare increased by 118 % in impacted areas. The farmer's net income under flowers and vegetable farming increased by 202 % and 150 % respectively in impacted areas compared to non-impacted areas. Furthermore, this project contributes to a circular economy transition in the water sector, which has economic, environmental, social, and cultural benefits. A key recommendation from the outcomes of the study is to draft and implement a policy that encourages the reuse of recycled water for groundwater recharge which in turn will improve the agro-economic system and food security.
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Affiliation(s)
- Manjari Manisha
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India.
| | - Kavita Verma
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - N Ramesh
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - T P Anirudha
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - R M Santrupt
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - Reshmi Das
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - M S Mohan Kumar
- Department of Civil Engineering, Indian Institute of Science, Bengaluru, India; Gitam University, India
| | - H N Chanakya
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
| | - Lakshminarayana Rao
- Center for Sustainable Technologies, Indian Institute of Science, Bengaluru, India
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Fitzpatrick A, Wood F, Shepherd V. Trials using deferred consent in the emergency setting: a systematic review and narrative synthesis of stakeholders' attitudes. Trials 2022; 23:411. [PMID: 35578362 PMCID: PMC9109432 DOI: 10.1186/s13063-022-06304-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute conditions often lack the capacity to provide informed consent, and narrow therapeutic windows mean there is no time to seek consent from surrogates prior to treatment being commenced. One method to enable the inclusion of this study population in emergency research is through recruitment without prior consent, often known as 'deferred consent'. However, empirical studies have shown a large disparity in stakeholders' opinions regarding this enrolment method. This systematic review aimed to understand different stakeholder groups' attitudes to deferred consent, particularly in relation to the context in which deferred consent might occur. METHODS Databases including MEDLINE, EMCare, PsychINFO, Scopus, and HMIC were searched from 1996 to January 2021. Eligible studies focussed on deferred consent processes for adults only, in the English language, and reported empirical primary research. Studies of all designs were included. Relevant data were extracted and thematically coded using a narrative approach to 'tell a story' of the findings. RESULTS Twenty-seven studies were included in the narrative synthesis. The majority examined patient views (n = 19). Data from the members of the public (n = 5) and health care professionals (n =5) were also reported. Four overarching themes were identified: level of acceptability of deferred consent, research-related factors influencing acceptability, personal characteristics influencing views on deferred consent, and data use after refusal of consent or participant death. CONCLUSIONS This review indicates that the use of deferred consent would be most acceptable to stakeholders during low-risk emergency research with a narrow therapeutic window and where there is potential for patients to benefit from their inclusion. While the use of narrative synthesis allowed assessment of the included studies, heterogeneous outcome measures meant that variations in study results could not be reliably attributed to the different trial characteristics. Future research should aim to develop guidance for research ethics committees when reviewing trials using deferred consent in emergency research and investigate more fully the views of healthcare professionals which to date have been explored less than patients and members of the public. Trial registration PROSPERO CRD42020223623.
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Affiliation(s)
| | - Fiona Wood
- Division of Population Medicine and PRIME Centre Wales, University Hospital of Wales, Cardiff University, 8th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS Wales
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Sweeney L, Lanz D, Daru J, Rasijeff AMP, Khanom F, Thomas A, Harden A, Green L. Deferred consent in emergency obstetric research: findings from qualitative interviews with women and recruiters in the ACROBAT pilot trial for severe postpartum haemorrhage. BMJ Open 2022; 12:e054787. [PMID: 35508349 PMCID: PMC9073399 DOI: 10.1136/bmjopen-2021-054787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The ACROBAT pilot trial of early cryoprecipitate for severe postpartum haemorrhage used deferred consent procedures. Pretrial discussions with a patient and public involvement group found mixed views towards deferred consent. This study aimed to build an understanding of how the deferred consent procedures worked in practice, to inform plans for a full-scale trial. SETTING Qualitative interview study within a cluster-randomised pilot trial, involving four London maternity services. PARTICIPANTS Individual interviews were conducted postnatally with 10 women who had received blood transfusion for severe postpartum haemorrhage and had consented to the trial. We also interviewed four 'recruiters'-two research midwives and two clinical trials practitioners who conducted trial recruitment. RESULTS Consent procedures in the ACROBAT pilot trial were generally acceptable and the intervention was viewed as low risk, but most women did not remember much about the consent conversation. As per trial protocol, recruiters sought to consent women before hospital discharge, but this time pressure had to be balanced against the need to ensure women were not approached when distressed or very unwell. Extra efforts had to be made to communicate trial information to women due to the exhaustion of their recovery and competing demands for their attention. Participant information was further complicated by explanations about the cluster design and change in transfusion process, even though the consent sought was for access to medical data. CONCLUSION Our findings indicate that deferred consent procedures raise similar concerns as taking consent when emergency obstetric research is occurring-that is, the risk that participants may conflate research with clinical care, and that their ability to process trial information may be impacted by the stressful nature of recovery and newborn care. A future trial may support more meaningful informed consent by extending the window of consent discussion and ensuring trial information is minimal and easy to understand. TRIAL REGISTRATION NUMBER ISRCTN12146519.
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Affiliation(s)
| | - Doris Lanz
- Barts Research Centre for Women's Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jahnavi Daru
- Barts Research Centre for Women's Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Annika M P Rasijeff
- Blizard Institute, Queen Mary University of London, London, UK
- Katie's Team Patient and Public Advisory Group, Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | - Farzana Khanom
- Katie's Team Patient and Public Advisory Group, Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | | | - Angela Harden
- School of Health Sciences, City University of London, London, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
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Elfeky A, Treweek S, Hannes K, Bruhn H, Fraser C, Gillies K. Using qualitative methods in pilot and feasibility trials to inform recruitment and retention processes in full-scale randomised trials: a qualitative evidence synthesis. BMJ Open 2022; 12:e055521. [PMID: 35437247 PMCID: PMC9016401 DOI: 10.1136/bmjopen-2021-055521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 03/28/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To systematically review published pretrial qualitative research studies and explore how their findings were used to inform recruitment and retention processes in full-scale trials. DESIGN Qualitative evidence synthesis using thematic analysis. DATA SOURCES AND ELIGIBILITY CRITERIA We conducted a comprehensive search of databases; Dissertation Abstracts International, CINAHL, Embase, MEDLINE, Sociological Abstracts and PsycINFO. We included all reports of pretrial qualitative data on recruitment and retention in clinical trials up to March 2018. DATA EXTRACTION AND SYNTHESIS Two authors independently extracted data using a predefined data extraction form that captured study aims, design, methodological approach and main findings, including barriers and facilitators to recruitment and or retention. The synthesis was undertaken using Thomas and Harden's thematic synthesis method and reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. Confidence was assessed using Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. RESULTS Thirty-five papers (connected to 31 feasibility studies) from three different countries, published between 2010 and 2017 were included. All studies were embedded in pilot or feasibility studies to inform design aspects in preparation for a subsequent full-scale trial. Twelve themes were identified as recruitment barriers and three as recruitment facilitators. Two themes were identified as barriers for retention and none as retention facilitators. The findings from qualitative research in feasibility or pilot trials are often not explicitly linked to proposed changes to the recruitment and retention strategies to be used in the future or planned full-scale trial. CONCLUSIONS Many trial teams do pretrial qualitative work with the aim of improving recruitment and retention in future full-scale trials. Just over half of all reports of such work do not clearly show how their findings will change the recruitment and retention strategy of the future trial. The scope of pretrial work needs to expand beyond looking for problems and also look for what might help and spend more time on retention.
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Affiliation(s)
- Adel Elfeky
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Karin Hannes
- Research Group SoMeTHin'K, Faculty of Social Sciences, KU Leuven, Leuven, Belgium
| | - Hanne Bruhn
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Do Community-based Livelihood Interventions Affect Sexual and Reproductive Health and Rights of Young People in Slum Areas of Uganda: a Difference-in-difference with Kernel Propensity Score Matching Analysis. J Urban Health 2022; 99:164-189. [PMID: 35034278 PMCID: PMC8866584 DOI: 10.1007/s11524-021-00596-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 02/03/2023]
Abstract
Slum dwellers across Africa have been targeted in interventions whose impacts remain unclear. We evaluated the impact of a livelihood intervention on the sexual and reproductive health and rights (SRHR) of young people in the slum areas of Kampala, Uganda. We carried out a repeated cross-sectional survey in 2014 and 2017 to examine the impact of community-based livelihood interventions on the SRHR of young people in the slum areas of Kampala, Uganda. Impacts were observed such as reduced sexual activity, reduction in aspects of gender-based violence attitudes and beliefs, increased access to and decision-making about contraceptive and family-planning services, increased availability and affordability of SRHR services, reduced need to seek further knowledge on SRHR, reduced barriers to HIV testing, and increased knowledge of health responsibilities. Unexpected results included: increased proportion of young people who had ever had sex, decreased mean age of sexual debut, unaffordability of contraceptives, and increased culturally shaped attitudes and social norms related to gender-based violence. We observed no impact on condom use, consensual sex and sexual assault, the number of sexual partners, knowledge about HIV/AIDS, stigma and discrimination against people living with HIV/AIDS, affordability of male and female condoms, and uptake of HIV testing services. Rights-based interventions are crucial to how we understand the SRHR of young people in complex sociocultural environments. While the livelihood interventions made significant impacts on the SRHR of young people, there are questions about how such interventions address deeply rooted sociocultural practices to maximise outcomes.
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Aberese-Ako M, Magnussen P, Ampofo GD, Gyapong M, Ansah E, Tagbor H. An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context. PLoS One 2021; 16:e0257666. [PMID: 34618812 PMCID: PMC8496863 DOI: 10.1371/journal.pone.0257666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background Intermittent preventive treatment of malaria among pregnant women with sulfadoxine-pyrimethamine (IPTp-SP), is one of the three recommended interventions for the prevention of malaria in pregnancy (MiP) in sub-Sahara Africa. The World Health Organisation recommended in 2012 that SP be given at each scheduled ANC visit except during the first trimester and can be given a dose every month until the time of delivery, to ensure that a high proportion of women receive at least three doses of SP during pregnancy. Despite implementation of this policy, Ghana did not attain the target of 100% access to IPTp-SP by 2015. Additionally, negative outcomes of malaria infection in pregnancy are still recurring. This ethnographic study explored how health system, individual and socio-cultural factors influence IPTp-SP uptake in two Ghanaian regions. Methods The study design was ethnographic, employing non-participant observation, case studies and in depth interviews in 8 health facilities and 8 communities, from April 2018 to March 2019, in two Ghanaian regions. Recommended ethical procedures were observed. Results Health system factors such as organization of antenatal care (ANC) services and strategies employed by health workers to administer SP contributed to initial uptake. Women’s trust in the health care system contributed to continued uptake. Inadequate information provided to women accessing ANC, stock-outs and fees charged for ANC services reduced access to IPTp-SP. Socio-cultural factor such as encouragement from social networks influenced utilization of ANC services and IPTp-SP uptake. Individual factors such as refusing to take SP, skipping ANC appointments and initiating ANC attendance late affected uptake. Conclusion Health system, socio-cultural and individual factors influence uptake of optimum doses of IPTp-SP. Consequently, interventions that aim at addressing IPTp-SP uptake should focus on regular and sufficient supply of SP to health facilities, effective implementation of free ANC, provision of appropriate and adequate information to women and community outreach programmes to encourage early and regular ANC visits.
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Affiliation(s)
- Matilda Aberese-Ako
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
- * E-mail: ,
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Gifty D. Ampofo
- School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Margaret Gyapong
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Evelyn Ansah
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Harry Tagbor
- School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
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Jepson M, Lazaroo M, Pathak S, Blencowe N, Collingwood J, Clout M, Toogood G, Blazeby J. Making large-scale surgical trials possible: collaboration and the role of surgical trainees. Trials 2021; 22:567. [PMID: 34446065 PMCID: PMC8390009 DOI: 10.1186/s13063-021-05536-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recruitment to surgical randomised controlled trials (RCTs) can be challenging. The Sunflower study is a large-scale multi-centre RCT that seeks to establish the clinical and cost effectiveness of pre-operative imaging versus expectant management in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. Trials such as Sunflower, with a large recruitment target, rely on teamworking. Recruitment can be optimised by embedding a QuinteT Recruitment Intervention (QRI). Additionally, engaging surgical trainees can contribute to successful recruitment, and the NIHR Associate Principal Investigator (API) scheme provides a framework to acknowledge their contributions. METHODS This was a mixed-methods study that formed a component part of an embedded QRI for the Sunflower RCT. The aim of this study was to understand factors that supported and hindered the participation of surgical trainees in a large-scale RCT and their participation in the API scheme. It comprised semi-structured telephone interviews with consultant surgeons and surgical trainees involved in screening and recruitment of patients, and descriptive analysis of screening and recruitment data. Interviews were analysed thematically to explore the perspectives of-and roles undertaken by-surgical trainees. RESULTS Interviews were undertaken with 34 clinicians (17 consultant surgeons, 17 surgical trainees) from 22 UK hospital trusts. Surgical trainees contributed to patient screening, approaches and randomisation, with a major contribution to the randomisation of patients from acute admissions. They were often encouraged to participate in the study by their centre principal investigator, and career development was a typical motivating factor for their participation in the study. The study was registered with the API scheme, and a majority of the trainees interviewed (n = 14) were participating in the scheme. CONCLUSION Surgical trainees can contribute substantial activity to a large-scale multi-centre RCT. Benefits of trainee engagement were identified for trainees themselves, for local sites and for the study as a whole. The API scheme provided a formal framework to acknowledge engagement. Ensuring that training and support for trainees are provided by the trial team is key to optimise success for all stakeholders.
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Affiliation(s)
- Marcus Jepson
- grid.5337.20000 0004 1936 7603QuinteT Research Group, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Michelle Lazaroo
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Samir Pathak
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Natalie Blencowe
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- grid.410421.20000 0004 0380 7336University Hospitals Bristol and Weston NHS Foundation Trust, Trust Headquarters, Marlborough St, Bristol, BS1 3NU UK
| | - Jane Collingwood
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Madeleine Clout
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Giles Toogood
- grid.443984.6Department of Hepatobiliary and Transplantation Surgery, St James’s University Hospital, Leeds, LS9 7TF UK
| | - Jane Blazeby
- grid.5337.20000 0004 1936 7603NIHR Biomedical Research Centre Bristol, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
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Langlois A, Armstrong S, Siriwardena AN. Do National and International Ethics Documents Accord With the Consent Substitute Model for Emergency Research? Acad Emerg Med 2021; 28:569-577. [PMID: 33247985 DOI: 10.1111/acem.14179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/09/2020] [Accepted: 11/21/2020] [Indexed: 12/01/2022]
Abstract
In 2010 Largent, Wendler, and Emanuel proposed the "consent substitute model" for emergency research with incapacitated participants. The model provides a means to enroll participants in emergency research without consent, if five conditions are met: 1) the research addresses the patients' urgent medical needs, 2) the risk-benefit ratio is favorable, 3) there are no known conflicts with patients' values or interests, 4) cumulative net risk is minimal, and 5) consent is given as soon as possible. We review national and international ethics laws, regulations, and guidelines to determine 1) whether they accord with the consent substitute model's five conditions and 2) the level of congruence across these documents. We find that only one document meets all five conditions and that there is significant disparity among the documents, particularly between national and international ones. These differences may have stymied international collaboration in emergency research. We recommend that the two international documents used most, the International Council for Harmonization's Guideline for Good Clinical Practice and the World Medical Association's Declaration of Helsinki, are revised to include more specific provisions on emergency medical research.
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Affiliation(s)
- Adèle Langlois
- From the School of Social and Political Sciences University of Lincoln LincolnUK
| | - Stephanie Armstrong
- and the Community and Health Research Unit College of Social Science University of Lincoln Lincoln UK
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McLeish J, Alderdice F, Robberts H, Cole C, Dorling J, Gale C. Challenges of a simplified opt-out consent process in a neonatal randomised controlled trial: qualitative study of parents' and health professionals' views and experiences. Arch Dis Child Fetal Neonatal Ed 2021; 106:244-250. [PMID: 33139313 PMCID: PMC8070626 DOI: 10.1136/archdischild-2020-319545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND More effective recruitment strategies like alternative approaches to consent are needed to facilitate adequately powered trials. Witholding Enteral feeds Around Transfusion was a multicentre, randomised, pilot trial that compared withholding and continuing feeds around transfusion. The primary clinical outcome was necrotising enterocolitis. The trial used simplified opt-out consent with concise parent information and no consent form. OBJECTIVE To explore the views and experiences of parents and health professionals on the acceptability and feasibility of opt-out consent in randomised comparative effectiveness trials. METHODS A qualitative, descriptive interview-based study nested within a randomised trial. Semistructured interview transcripts were analysed using inductive thematic analysis. SETTING Eleven neonatal units in England. PARTICIPANTS Eleven parents and ten health professionals with experience of simplified consent. RESULTS Five themes emerged: 'opt-out consent operationalised as verbal opt-in consent', 'opt-out consent normalises participation while preserving parental choice', 'opt-out consent as an ongoing process of informed choice', 'consent without a consent form' and 'choosing to opt out of a comparative effectiveness trial', with two subthemes: 'wanting "normal care"' and 'a belief that feeding is better'. CONCLUSION Introducing a novel form of consent proved challenging in practice. The principle of a simplified, opt-out approach to consent was generally considered feasible and acceptable by health professionals for a neonatal comparative effectiveness trial. The priority for parents was having the right to decide about trial participation, and they did not see opt-out consent as undermining this. Describing a study as 'opt-out' can help to normalise participation and emphasise that parents can withdraw consent.
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Affiliation(s)
- Jenny McLeish
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | - Fiona Alderdice
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | | | - Christina Cole
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | - Jon Dorling
- Division of Neonatal–Perinatal Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chris Gale
- Academic Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Romano G, Mitchell E, Plachcinski R, Wakefield N, Walker K, Ayers S. The acceptability to women of techniques for managing an impacted fetal head at caesarean section and of randomised trials evaluating those techniques: a qualitative study. BMC Pregnancy Childbirth 2021; 21:103. [PMID: 33530956 PMCID: PMC7852117 DOI: 10.1186/s12884-021-03577-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/20/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study aimed to explore women's views on the acceptability of different techniques for managing an impacted fetal head at caesarean; and the feasibility and acceptability of conducting a trial in this area. METHODS Qualitative semi-structured interviews with a systematic sample of women who experienced second stage emergency caesarean section at a tertiary National Health Service (NHS) hospital in England, UK. Thematic analysis was used to extract women's views. RESULTS Women varied in their perceptions of the acceptability of different techniques for managing impacted fetal head. Trust in medical expertise and prioritising the safety of the baby were important contextual factors. Greater consensus was found around informed choice in trials where subthemes considered the timing of invitation, reduced capacity to give consent in emergency situations, and the importance of birth outcomes and having good rapport with healthcare professionals who invite women into trials. Finally, women reflected on the importance of supportive antenatal and postpartum education for impacted fetal head. CONCLUSIONS This research provides information on the acceptability of techniques and any trial to evaluate these techniques. Findings illustrate the importance of context and quality of care to both acceptability and approaching women to take part in a future trial.
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Affiliation(s)
- Gabriella Romano
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42 University Park, Nottingham, NG7 2RD, UK
| | | | - Natalie Wakefield
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42 University Park, Nottingham, NG7 2RD, UK
| | - Kate Walker
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42 University Park, Nottingham, NG7 2RD, UK.
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, Lenton, University of Nottingham, Nottingham, NG7 2RD, UK.
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
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Aberese-Ako M, Magnussen P, Gyapong M, Ampofo GD, Tagbor H. Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions. Malar J 2020; 19:347. [PMID: 32977827 PMCID: PMC7519547 DOI: 10.1186/s12936-020-03422-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015. METHODS This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and 12 communities for 12 months in two Administrative regions in Ghana. RESULTS Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5 + doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care. CONCLUSION For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.
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Affiliation(s)
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Margaret Gyapong
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Gifty D Ampofo
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Harry Tagbor
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
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McMullan J, Droege C, Strilka CR, Lindsell C, Linke MJ. Food and Drug Administration and Institutional Review Board Approval of a Novel Prehospital Informed Consent Process for Emergency Research. PREHOSP EMERG CARE 2020; 25:512-518. [DOI: 10.1080/10903127.2020.1806969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brown P, Newham R, Hewison A. To explore the experience of research nurses who obtain consent from adults in emergency settings to participate in clinical trials, either prospectively or post enrolment. J Clin Nurs 2020; 29:3054-3063. [PMID: 32441860 DOI: 10.1111/jocn.15339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 12/01/2022]
Abstract
AIM To explore the understanding and experiences of research nurses who obtain informed consent from adult patients participating in emergency care research. DESIGN Qualitative phenomenographic descriptive study. METHODS Ten research nurses from six hospitals in England were recruited. Data were collected using semi-structured face-to-face and telephone interviews between January 2019 and March 2019. Interviews were transcribed verbatim and analysed thematically, informed by phenomenography. COREQ was followed. RESULTS Three main themes were identified: (a) emergency research is different, (b) protecting the patient, and (c) experience and confidence with recruitment. It was found that obtaining patient consent in emergency care research was challenging and timing of the process was crucial. Nurses with more experience of emergency care were more confident in approaching patients and their families. There was variability in out-of-hours recruitment which was a consequence of the range of informed consent processes used and the different levels of engagement of clinical teams. CONCLUSION There is a variety of organisational cultures, processes and procedures which affect the way consent is obtained in emergency care research. A team approach was evident in the hospitals where consent rates were high and was more successful than those reliant solely on the presence of a research nurse. Organisations were able to recruit successfully to emergency care research studies irrespective of size and configuration. Further investigation of their models of working and strategies for engagement is needed. Experienced research nurses made a positive difference to recruitment and were more likely to approach patients to obtain consent. RELEVANCE TO CLINICAL PRACTICE The understanding and experiences of recruitment to clinical trials in emergency care research by research nurses can help identify barriers to recruitment. This study provides useful insights for healthcare practitioners, clinical trials coordinators and sponsors about how best to develop protocols and policies to increase recruitment to emergency care research.
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Widmer M, Bonet M, Betrán AP. Would you like to participate in this trial? The practice of informed consent in intrapartum research in the last 30 years. PLoS One 2020; 15:e0228063. [PMID: 31978100 PMCID: PMC6980544 DOI: 10.1371/journal.pone.0228063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Informed consent is the cornerstone of the ethical conduct and protection of the rights and wellbeing of participants in clinical research. Therefore, it is important to identify the most appropriate moments for the participants to be informed and to give consent, so that they are able to make a responsible and autonomous decision. However, the optimal timing of consent in clinical research during the intrapartum period remains controversial, and currently, there is no clear guidance. OBJECTIVE We aimed to describe practices of informed consent in intrapartum care clinical research in the last three decades, as reported in uterotonics for postpartum haemorrhage prevention trials. METHODS This is a secondary analysis of the studies included in the Cochrane review entitled "Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis" published in 2018. All the reports included in the Cochrane network meta-analysis were eligible for inclusion in this analysis, except for those reported in languages other than English, French or Spanish. We extracted and synthesized data on the time each of the components of the informed consent process occurred. RESULTS We assessed data from 192 studies, out of 196 studies included in the Cochrane review. The majority of studies (59.9%, 115 studies) reported that women were informed about the study, without specifying the timing. When reported, most studies informed women at admission to the facility for childbirth. Most of the studies reported that consent was sought, but only 59.9% reported the timing, which in most of the cases, was at admission for childbirth. Among these, 32 studies obtained consent in the active phase of labour, 17 in the latent phase and in 10 studies the labour status was unknown. Women were consented antenatally in 6 studies and in 8 studies the consent was obtained indistinctly during antenatal care or at admission. Most of the studies did not specified who was the person who sought the informed consent. CONCLUSION Practices of informed consent in trials on use of uterotonics for prevention of postpartum haemorrhage showed variability and substandard reporting. Informed consent sought at admission for childbirth was the most frequent approach implemented in these trials.
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Affiliation(s)
- Mariana Widmer
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Mercedes Bonet
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Ana Pilar Betrán
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
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Aurich B, Vermeulen E, Elie V, Driessens MHE, Kubiak C, Bonifazi D, Jacqz-Aigrain E. Informed consent for neonatal trials: practical points to consider and a check list. BMJ Paediatr Open 2020; 4:e000847. [PMID: 33437878 PMCID: PMC7778778 DOI: 10.1136/bmjpo-2020-000847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/23/2020] [Accepted: 11/29/2020] [Indexed: 12/04/2022] Open
Abstract
Obtaining informed consent from parents of critically ill neonates can be challenging. The parental decision-making process is influenced by the severity of the child's condition, the benefit-risk balance, their emotional state and the quality of the relationship with the clinical team. Independent of local legislation, parents may prefer that consent is sought from both. Misconceptions about the absence of risks or unrealistic expectations about benefits should be openly addressed to avoid misunderstandings which may harm the relationship with the clinical team. Continuous consent can be sought where it is unclear whether the free choice of parental consent has been compromised. Obtaining informed consent is a dynamic process building on trusting relationships. It should include open and honest discussions about benefits and risks. Investigators may benefit from training in effective communication. Finally, involving parents in neonatal research including the development of the informed consent form and the process of obtaining consent should be considered standard practice.
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Affiliation(s)
- Beate Aurich
- Department of Paediatric Clinical Pharmacology and Pharmacogenetics, Robert Debré Hospital, 48 Boulevard Sérurier, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Eric Vermeulen
- Dutch patient association for rare and genetic diseases (VSOP), Soest, The Netherlands
| | - Valéry Elie
- Department of Paediatric Clinical Pharmacology and Pharmacogenetics, Robert Debré Hospital, 48 Boulevard Sérurier, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | | | - Christine Kubiak
- The European Clinical Research Infrastructure Network (ECRIN), 5-7 Rue Watt, Paris, France
| | - Donato Bonifazi
- Consorzio per le Valutazioni Biologiche e Farmacologiche, Via Nicolo Putignani, Bari, Italy.,TEDDY European Network of Excellence for Paediatric Research, Via Luigi Porta 14, Pavia, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Clinical Phramcology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 Boulevard Sérurier, Paris, France.,Paris University, Paris, France
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Denison FC, Carruthers KF, Hudson J, McPherson G, Scotland G, Brook-Smith S, Clarkson C, Peace M, Brewin J, Chua GN, Hallowell N, Norman JE, Lawton J, Norrie J. Glyceryl trinitrate to reduce the need for manual removal of retained placenta following vaginal delivery: the GOT-IT RCT. Health Technol Assess 2019; 23:1-72. [PMID: 31912780 PMCID: PMC6970217 DOI: 10.3310/hta23700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Retained placenta is associated with postpartum haemorrhage and can lead to significant maternal morbidity if untreated. The only effective treatment is the surgical procedure of manual removal of placenta, which is costly, requires skilled staff, requires an operative environment and is unpleasant for women. Small studies suggest that glyceryl trinitrate may be an effective medical alternative. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of sublingual glyceryl trinitrate spray compared with placebo in reducing the need for manual removal of placenta in women with retained placenta after vaginal delivery following the failure of current management. DESIGN A group-sequential randomised double-blind placebo-controlled trial with a cost-effectiveness analysis. SETTING There were 29 obstetric units in the UK involved in the study. PARTICIPANTS There were 1107 women (glyceryl trinitrate group, n = 543; placebo group, n = 564) randomised between October 2014 and July 2017. INTERVENTIONS Glyceryl trinitrate spray was administered to 541 women in the intervention group, and a placebo was administered to 563 women in the control group. MAIN OUTCOME MEASURES Four primary outcomes were defined: (1) clinical - the need for manual removal of placenta, (2) safety - measured blood loss, (3) patient sided - satisfaction with treatment and side effects and (4) economic - cost-effectiveness of both treatments using the UK NHS perspective. Secondary clinical outcomes included a > 15% decrease in haemoglobin level, time from randomisation to delivery of placenta in theatre, the need for earlier manual removal of placenta than planned, increase in heart rate or decrease in blood pressure, requirement for blood transfusion, requirement for general anaesthesia, maternal pyrexia, and sustained uterine relaxation requiring additional uterotonics. RESULTS No difference was observed between the glyceryl trinitrate group and the control group for the placenta remaining undelivered within 15 minutes of study treatment (93.3% vs. 92%; odds ratio 1.01, 95% confidence interval 0.98 to 1.04; p = 0.393). There was no difference in blood loss of > 1000 ml between the glyceryl trinitrate group and the control group (22.2% vs. 15.5%; odds ratio 1.14, 95% confidence interval 0.88 to 1.48; p = 0.314). Palpitations were more common in the glyceryl trinitrate group than in the control group after taking the study drug (9.8% vs. 4.0%; odds ratio 2.60, 95% confidence interval 1.40 to 4.84; p = 0.003). There was no difference in any other measures of patient satisfaction between the groups. There was no difference in costs to the health service between groups (mean difference £55.30, 95% confidence interval -£199.20 to £309.79). Secondary outcomes revealed that a fall in systolic or diastolic blood pressure, or an increase in heart rate, was more common in the glyceryl trinitrate group than in the control group (odds ratio 4.9, 95% confidence interval 3.7 to 6.4; p < 0.001). The need for a blood transfusion was also more common in the glyceryl trinitrate group than in the control group (odds ratio 1.53, 95% confidence interval 1.04 to 2.25; p = 0.033). CONCLUSIONS Glyceryl trinitrate spray did not increase the delivery of retained placenta within 15 minutes of administration when compared with the placebo, and was not cost-effective for medical management of retained placenta. More participants reported palpitations and required a blood transfusion in the glyceryl trinitrate group. Further research into alternative methods of medical management of retained placenta is required. TRIAL REGISTRATION Current Controlled Trials ISRCTN88609453. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 70. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona C Denison
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Kathryn F Carruthers
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gladys McPherson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Sheonagh Brook-Smith
- Simpson's Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cynthia Clarkson
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Mathilde Peace
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Gin Nie Chua
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nina Hallowell
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane E Norman
- Tommy's Centre for Maternal and Fetal Health Research, Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Julia Lawton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit/Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Denison FC, Carruthers KF, Hudson J, McPherson G, Chua GN, Peace M, Brewin J, Hallowell N, Scotland G, Lawton J, Norrie J, Norman JE. Nitroglycerin for treatment of retained placenta: A randomised, placebo-controlled, multicentre, double-blind trial in the UK. PLoS Med 2019; 16:e1003001. [PMID: 31887169 PMCID: PMC6936786 DOI: 10.1371/journal.pmed.1003001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/22/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Retained placenta following vaginal delivery is a major cause of postpartum haemorrhage. Currently, the only effective treatments for a retained placenta are the surgical procedures of manual removal of placenta (MROP) and uterine curettage, which are not universally available, particularly in low- and middle-income countries. The objective of the trial was to determine whether sublingual nitroglycerin spray was clinically effective and cost-effective for medical treatment of retained placenta following vaginal delivery. METHODS AND FINDINGS A randomised, placebo-controlled, double-blind trial was undertaken between October 2014 and July 2017 at 29 delivery units in the UK (Edinburgh, Glasgow, Manchester, Newcastle, Preston, Warrington, Chesterfield, Crewe, Durham, West Middlesex, Aylesbury, Furness, Southampton, Bolton, Sunderland, Oxford, Nottingham [2 units], Burnley, Chertsey, Stockton-on-Tees, Middlesborough, Chester, Darlington, York, Reading, Milton Keynes, Telford, Frimley). In total, 1,107 women with retained placenta following vaginal delivery were recruited. The intervention was self-administered 2 puffs of sublingual nitroglycerin (800 μg; intervention, N = 543) or placebo spray (control, N = 564). The primary clinical outcome was the need for MROP, assessed at 15 minutes following administration of the intervention. Analysis was based on the intention-to-treat principle. The primary safety outcome was measured blood loss between study drug administration and transfer to the postnatal ward or other clinical area. The primary patient-sided outcomes were satisfaction with treatment and side-effect profile, assessed by questionnaires pre-discharge and 6 weeks post-delivery. Secondary clinical outcomes were measured at 5 and 15 minutes after study drug administration and prior to hospital discharge. There was no statistically significant or clinically meaningful difference in need for MROP by 15 minutes (primary clinical outcome, 505 [93.3%] for nitroglycerin versus 518 [92.0%] for placebo, odds ratio [OR] 1.01 [95% CI 0.98-1.04], p = 0.393) or blood loss (<500 ml: nitroglycerin, 238 [44.3%], versus placebo, 249 [44.5%]; 500 ml-1,000 ml: nitroglycerin, 180 [33.5%], versus placebo, 224 [40.0%]; >1,000 ml: nitroglycerin, 119 [22.2%], versus placebo, 87 [15.5%]; ordinal OR 1.14 [95% CI 0.88-1.48], p = 0.314) or satisfaction with treatment (nitroglycerin, 288 [75.4%], versus placebo, 303 [78.1%]; OR 0.87 [95% CI 0.62-1.22], p = 0.411) or health service costs (mean difference [£] 55.3 [95% CI -199.20 to 309.79]). Palpitations following drug administration were reported more often in the nitroglycerin group (36 [9.8%] versus 15 [4.0%], OR 2.60 [95% CI 1.40-4.84], p = 0.003). There were 52 serious adverse events during the trial, with no statistically significant difference in likelihood between groups (nitroglycerin, 27 [5.0%], versus placebo, 26 [4.6%]; OR 1.13 [95% CI 0.54-2.38], p = 0.747). The main limitation of our study was the low return rate for the 6-week postnatal questionnaire. There were, however, no differences in questionnaire return rates between study groups or between women who did and did not have MROP, with the patient-reported use of outpatient and primary care services at 6 weeks accounting for only a small proportion (approximately 5%) of overall health service costs. CONCLUSIONS In this study, we found that nitroglycerin is neither clinically effective nor cost-effective as a medical treatment for retained placenta, and has increased side effects, suggesting it should not be used. Further research is required to identify an effective medical treatment for retained placenta to reduce the morbidity caused by this condition, particularly in low- and middle-income countries where surgical management is not available. TRIAL REGISTRATION ISRCTN.com ISRCTN88609453 ClinicalTrials.gov NCT02085213.
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Affiliation(s)
- Fiona C. Denison
- Tommy’s Centre for Maternal and Fetal Health, Medical Research Council Centre for Reproductive Health, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
| | - Kathryn F. Carruthers
- Tommy’s Centre for Maternal and Fetal Health, Medical Research Council Centre for Reproductive Health, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Gladys McPherson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Gin Nie Chua
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Mathilde Peace
- Tommy’s Centre for Maternal and Fetal Health, Medical Research Council Centre for Reproductive Health, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Nina Hallowell
- Wellcome Centre for Ethics and Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Graham Scotland
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Julia Lawton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Jane E. Norman
- Tommy’s Centre for Maternal and Fetal Health, Medical Research Council Centre for Reproductive Health, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
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Brown P, Hewison A, Newham R. What are research nurses' experiences of obtaining consent from or for patients participating in emergency care research? A qualitative review. J Clin Nurs 2019; 28:4155-4165. [PMID: 31241806 DOI: 10.1111/jocn.14984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/06/2019] [Accepted: 06/09/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION If studies are to be valid, recruitment of representative samples is essential. In 2012, 28% of UK emergency departments met the 80% standard for recruitment to trials set by the National Institute for Health Research. Research nurses play a vital role in the conduct of high-quality research, and it has been argued that dedicated research nurses are needed if clinical trials are to recruit successfully to target. REVIEW QUESTION What are research nurses' experiences of obtaining consent from or for patients participating in emergency care research? A qualitative evidence review. METHODS A qualitative integrative literature review with a narrative synthesis of the evidence. PRISMA guidelines for reporting systematic qualitative reviews (Appendix S1) were followed. A search of five electronic databases was performed in December 2018 along with a hand search which yielded 125 citations: 10 papers and one PhD thesis met the review eligibility criteria. Methodological quality of the selected studies was evaluated, and data were extracted and synthesised. RESULTS Three themes were identified: Access, Organisation and Timing. Research nurses encountered both general and specific barriers when seeking to obtain consent for participation in research. In particular, it was found there was lack of experience among staff of working in emergency research and with securing deferred consent. The distinction between nurse researchers with a clinical role and those dedicated to solely to research only is often not clear and warrants further investigation. CONCLUSION Nurse researchers with and without a clinical role can make a positive difference in recruitment to trials in emergency care. The involvement of dedicated research nurses in the consent process can increase recruitment to emergency care research. Experience of recruiting to clinical trials in nonemergency settings does not seem to help when recruiting for trials in emergency care. RELEVANCE TO CLINICAL PRACTICE There is a need for greater understanding of the experiences of dedicated research nurses in emergency care settings and in particular with regard to deferred consent.
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Affiliation(s)
| | - Alistair Hewison
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | - Roger Newham
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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Houghton G, Kingdon C, Dower M, Shakur-Still H, Alfirevic Z. What women think about consent to research at the time of an obstetric emergency: a qualitative study of the views of a cohort of World Maternal Antifibrinolytic Trial participants. BJOG 2018; 125:1744-1753. [PMID: 29911309 PMCID: PMC6283048 DOI: 10.1111/1471-0528.15333] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 12/30/2022]
Abstract
Objective The World Maternal Antifibrinolytic (WOMAN) Trial was the first in the UK to use the option of waiver of informed consent at the time of an obstetric emergency. This qualitative study aimed to investigate participants’ views of the acceptability of the recruitment methods used. Design Qualitative study using in‐depth interviews with women who did and did not give consent at the time of their recruitment to the WOMAN Trial. Setting Highest UK recruitment site for the WOMAN Trial (129/569). Interviews were conducted in participants’ homes. Population About 40 of the 129 women who were recruited to the WOMAN Trial at one UK site were invited to take part, 15 women were interviewed. Methods Qualitative, interview study. Main outcome measures Facilitators and barriers to successful recruitment during obstetric emergencies. Guidance for future researchers. Results Findings revealed that what is important is not so much the consent process used or a signature on a form, but the way in which consent is obtained. Clinicians who successfully negotiate consent to research during childbirth emergencies engage in a ‘humane choreography’ of words and actions. This emphasises the importance of prompt decision‐making and treatment, while respecting the woman's personal situation and experience. Conclusions Our findings do not support a single pathway to consent in the context of an obstetric emergency. Women understand that consent to research in an emergency is complex. Clinicians’ skills in considering the clinical, ethical, and emotional aspects within the context of the clinical emergency can hamper or promote women's satisfaction. Tweetable abstract Study reports on women's views of consent to research in an obstetric emergency. Plain Language Summary Study reports on women's views of consent to research in an obstetric emergency.
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Affiliation(s)
- G Houghton
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - C Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - M Dower
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - H Shakur-Still
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Z Alfirevic
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool Women's NHS Foundation Trust, Liverpool, UK
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Tutton E, Achten J, Lamb SE, Willett K, Costa ML. Participation in a trial in the emergency situation: a qualitative study of patient experience in the UK WOLLF trial. Trials 2018; 19:328. [PMID: 29941030 PMCID: PMC6019785 DOI: 10.1186/s13063-018-2722-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 06/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients can struggle to make sense of trials in emergency situations. This study examines patient experience of participating in the United Kingdom, Wound management of Open Lower Limb Fractures (UK WOLLF) study, a trial of standard wound management versus Negative Pressure Wound Therapy (NPWT). METHODS The aim of the study was to understand the patient's lived experience of taking part in a trial of wound dressings. Interviews drawing on Phenomenology were undertaken with a purposive sample of 20 patients, on average 12 days into their hospital stay from July 2012-July 2013. RESULTS The participants were vulnerable due to the emotional and physical impact of injury. They expressed their trial experience through the theme of being compromised identified in categories of being dependent, being trusting, being grateful and being without experience. Participants felt dependent on and trusted the team to make the right decisions for them and not cause them harm. Their hopes for future recovery were also invested within the expertise of the team. Despite often not being well enough to consent to the study prior to surgery, they wished to be involved as much as possible. In agreeing to take part they expressed gratitude for their care, wanted to be helpful to others and considered the trial interventions to be a small component in relation to the enormity of their injury and broader treatment. In making sense of the trial they felt they could not understand the interventions without experience of them but if they received NPWT they developed a strong technological preference for this intervention. CONCLUSIONS Patients prefer to be involved in studies within the limits of their capacity, despite not being able to provide informed consent. A variety of sources of knowledge may enable participants to feel that they have a better understanding of the interventions. Professional staff need to be aware of the situated nature of decision making where participants invest their hopes for recovery in the team. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN33756652 . Registered on 24 February 2012.
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Affiliation(s)
- Elizabeth Tutton
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Kadoorie Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Juul Achten
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Sarah E. Lamb
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Keith Willett
- Kadoorie Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Matthew L. Costa
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
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