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Gooden TE, Mkhoi ML, Mdoe M, Mwalukunga LJ, Senkoro E, Kibusi SM, Thomas GN, Nirantharakumar K, Manaseki-Holland S, Greenfield S. Barriers and facilitators of people living with HIV receiving optimal care for hypertension and diabetes in Tanzania: a qualitative study with healthcare professionals and people living with HIV. BMC Public Health 2023; 23:2235. [PMID: 37957584 PMCID: PMC10644467 DOI: 10.1186/s12889-023-17069-6] [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: 06/23/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND People living with HIV (PLWH) are at a higher risk for developing diabetes and hypertension. Often services are separate for HIV and non-communicable diseases (NCDs), but how this impacts NCD care among PLWH is unknown. We aimed to understand the barriers and facilitators for prevention, early diagnosis and safe effective care for diabetes and hypertension among PLWH. METHODS Semi-structured interviews (SSIs) were conducted with 10 healthcare professionals (HCPs) that care for PLWH, 10 HCPs that care for people with diabetes and hypertension and 16 PLWH with a comorbidity of diabetes and/or hypertension. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and purposively sampled based on age and sex. Interviews were conducted in Swahili using pre-developed topic guides, audio recorded then translated verbatim into English. An inductive thematic analysis was conducted using The Framework Method. RESULTS Three themes were found: organisational/healthcare system factors, individual factors and syndemic factors. Organisational/healthcare system factors comprised the only facilitators for prevention (education on lifestyle behaviours and counselling on adherence), but included the most barriers overall: fragmented services, no protocol for NCD screening and lack of access to diagnostic equipment were barriers for early diagnosis whereas the former plus lack of continuity of NCD care were barriers for safe effective care. Individual factors comprised four sub-themes, three of which were considered facilitators: HCPs' knowledge of NCDs for early diagnosis, self-monitoring of NCDs for safe effective care and HCPs' personal practice for both early diagnosis and safe effective care. HCPs' knowledge was simultaneously a barrier for prevention and PLWH knowledge was a barrier for prevention and safe effective care. Syndemic factors comprised three sub-themes; all were barriers for prevention, early diagnosis and/or safe effective care: poverty and mental health of PLWH and HIV stigma. CONCLUSIONS Organisational/healthcare system, individual and syndemic factors were found to be interlinked with barriers and facilitators that contribute to the prevention, early diagnosis and safe effective care of diabetes and hypertension among PLWH in Tanzania; these findings can inform future initiatives for making small and large health system changes to improve the health of aging PLWH.
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Affiliation(s)
- Tiffany E Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Mkhoi L Mkhoi
- Department of Microbiology and Parasitology, University of Dodoma, Dodoma, Tanzania
| | - Mwajuma Mdoe
- Department of Public Health, University of Dodoma, Dodoma, Tanzania
| | | | | | - Stephen M Kibusi
- Department of Public Health, University of Dodoma, Dodoma, Tanzania
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
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Prang KH, Mamani-Mategula E, Verbunt E, Chipeta E, Ataide R, Mwangi M, Phiri K, Pasricha SR, Kelaher M, Manda-Taylor L. An implementation research programme to support an intravenous iron intervention for pregnant women with moderate and severe anaemia in Malawi: study protocol. Implement Sci Commun 2022; 3:68. [PMID: 35729604 PMCID: PMC9210048 DOI: 10.1186/s43058-022-00299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/24/2022] [Indexed: 12/03/2022] Open
Abstract
Background Antenatal iron supplementation is critical to maternal and child health; however, access and adherence to oral iron are inconsistent in many low- and middle-income countries (LMICs). Modern intravenous (IV) iron products have become available in high-income clinical settings and provide an opportunity to deliver high doses of iron in a single-short infusion during pregnancy. However, there is limited knowledge of the drivers and barriers for such an intervention to be effectively delivered and upscaled in LMICs. In this study protocol, we describe the implementation research programme to support an IV iron intervention in Malawi for pregnant women with moderate and severe anaemia. Methods The implementation research programme has three phases, each guided by implementation science conceptual frameworks. In Phase 1, we will conduct formative research (context assessment of the health system with key informant interviews) to determine how IV iron can be effectively introduced into routine antenatal care. We will use the findings to co-develop potential strategies with end-users and healthcare providers to improve intervention implementation. In Phase 2, we will disseminate the implementation strategies to support the uptake and delivery of the intervention in the study settings. In Phase 3, the intervention will be implemented, and we will conduct formative evaluation (interviews with end-users, healthcare providers, and analysis of health services data) to investigate the feasibility and acceptability of the intervention and strategies. We will also identify processes and contextual factors that facilitate or impede the delivery and uptake of IV iron. Discussion In LMICs, modern IV iron products present a novel opportunity to rapidly cure moderate and severe anaemia in pregnancy, thereby improving maternal and child health outcomes. This implementation research programme will provide guidance and recommendations on how best an IV iron intervention for pregnant women with anaemia can be implemented in an LMIC setting like Malawi. We will develop locally relevant and culturally appropriate implementation strategies by engaging with key stakeholders (pregnant women, healthcare providers, and policymakers) and identifying factors likely to facilitate successful implementation. The findings of this research can guide the implementation of an IV iron intervention in Malawi and other LMICs.
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No person left behind: Mapping the health policy landscape for genomics research in the Caribbean. LANCET REGIONAL HEALTH. AMERICAS 2022; 15:100367. [PMID: 36778076 PMCID: PMC9904062 DOI: 10.1016/j.lana.2022.100367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The Caribbean has long been an under-represented geographical region in the field of genomics research. Such under-representation may result in Caribbean people being underserved by precision medicine and other public health benefits of genomics. A collaboration among regional and international researchers aims to address this issue through the H3ECaribbean project (Human Heredity, Environment, and Health in the Caribbean), which builds on the lessons and success of H3Africa. The Caribbean project aims to target issues of social justice by encouraging the inclusion of diverse Caribbean communities in genomics research. This paper explores a framework for the ethical and socially acceptable conduct of genomics research in the Caribbean, taking account of the cultural peculiarities of the region. This is done in part by exploring research ethics issues identified in indigenous communities in North America, Small Island Developing States, and similar endeavours from the African continent. The framework provides guidance for interacting with local community leaders, as well as detailing steps for obtaining informed consent of all participants. Specifically, the authors outline the methods to ensure effective interaction and enforce full transparency with study participants to combat historical neglect when working with under-represented communities in the Caribbean.
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Mtande TK, Nair G, Rennie S. Ethics and regulatory complexities posed by a pragmatic clinical trial: a case study from Lilongwe, Malawi. Malawi Med J 2022; 34:213-219. [PMID: 36406092 PMCID: PMC9641616 DOI: 10.4314/mmj.v34i3.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Pragmatic clinical trials generally rely on real world data and have the potential to generate real world evidence. This approach arose from concerns that many trial results did not adequately inform real world practice. However, maintaining the real world setting during the conduct of a trial and ensuring adequate protection for research participants can be challenging. Best practices in research oversight for pragmatic clinical trials are nascent and underdeveloped, especially in developing countries. Methods We use the PRECIS-2 tool to present a case study from Lilongwe in Malawi to describe ethical and regulatory challenges encountered during the conduct of a pragmatic trial and suggest possible solutions. Results In this article, we highlight the following six issues: (1) one public facility hosting several pragmatic trials within the same period; (2) research participants refusing financial incentives; (3) inadequate infrastructure and high workload to conduct research; (4) silos among partner organisations involved in delivery of health care; (5) individuals influencing the implementation of revised national guidelines; (6) difficulties with access to electronic medical records. Conclusion Multiple stakeholder engagement is critical to the conduct of pragmatic trials, and even with careful stakeholder engagement, continuous monitoring by gatekeepers is essential. In the Malawian context, active engagement of the district research committees can complement the work of the research ethics committees (RECs).
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Affiliation(s)
- Tiwonge Kumwenda Mtande
- Centre for Bioethics in Eastern and Southern Africa (CEBESA), Kamuzu University of Health Sciences, Malawi, Centre for Medical Ethics and Law (CMEL), Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gonasagrie Nair
- Centre for Medical Ethics and Law (CMEL), Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stuart Rennie
- Centre for Medical Ethics and Law (CMEL), Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, UNC Bioethics Center, Department of Social Medicine, University of North Carolina at Chapel Hill, USA
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Lawrence DS, Ssali A, Moshashane N, Nabaggala G, Maphane L, Harrison TS, Meya DB, Jarvis JN, Seeley J. Decision making in a clinical trial for a life-threatening illness: Therapeutic expectation, not misconception. Soc Sci Med 2022; 305:115082. [PMID: 35649301 DOI: 10.1016/j.socscimed.2022.115082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 01/10/2023]
Abstract
Potential participants for clinical trials which aim to define treatments for life-threatening conditions are often extremely unwell. When exploring why individuals participate in clinical trials one common observation is a misplaced expectation of personal benefit - a therapeutic misconception. The care offered in some clinical trials is of a higher standard than is routinely available and this has led to criticism around the freedom of choice to enrol - structural coercion. We embedded an ethnographic study within a randomised controlled trial for HIV-associated cryptococcal meningitis in Gaborone, Botswana and Kampala, Uganda. We aimed to gain an understanding of decision-making around the trial and how this was impacted by the study design and broader social context. We conducted in-depth interviews with trial participants, surrogate decision makers and researchers, combined these with direct observations and analysed data using thematic analysis. Between January 2020 and June 2021 we interviewed 89 individuals. We found previous exposure to and awareness of clinical research was limited, as was understanding of the trial objectives and design. Through observations and engagement with healthcare facilities decision-makers were able to identify the trial as providing the best possible chance of survival. Hesitation and reluctance were mostly due to fear of lumbar punctures which was sometimes based on rumours but often based on tragic personal experience. Despite fear, and sometimes conviction that they would die, individuals agreed to consent, often against the wishes of family members. Reassurance and confidence came from trust in routine care staff and the research team but also from fellow participants and their surrogates. We argue that participants made informed decisions based on a therapeutic expectation from the trial and that rather than being the result of structural coercion this was an informed and voluntary choice.
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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, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.
| | - Agnes Ssali
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Georgina Nabaggala
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda
| | | | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK; Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK; MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Seeley
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Institute, Entebbe, Uganda; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
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Bungay V, Guta A, Slemon A, Varcoe C, Comber S. The Ethics of Financial Incentivization for Health Research Participation Among Sex Workers in a Canadian Context. QUALITATIVE HEALTH RESEARCH 2022; 32:942-955. [PMID: 35349393 DOI: 10.1177/10497323221089877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Research incentivization with sex workers is common, yet limited guidance exists for ethical incentives practice. We undertook a critical qualitative inquiry into how researchers (n = 17), community services staff (n = 17), and sex workers participating in research (n = 53) perceive incentives in a Canadian context. We employed an interpretive thematic approach informed by critical perspectives of relational autonomy for analysis. Four themes illustrate how (un)ethical use of incentives is situated in transactional micro-economies among groups experiencing severe marginalization: i) transactional research economy, ii) incentive type: assumptions and effects, iii) incentive amount: too much too little?, and iv) resistance, trauma, and research-related harm. Paternalistic assumptions about capacities of sex workers to act in their own best interests conflicted with participants' rights and abilities for self-determination; with researchers maintaining ultimate decision-making authority. Power differentials create conditions of harm. Safe, equitable approaches concerning research incentive use must redress relations of power that perpetuate oppression.
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Affiliation(s)
- Vicky Bungay
- School of Nursing, 8166University of British Columbia, Vancouver, BC, Canada
| | - Adrian Guta
- School of Social Work, 8637University of Windsor, Windsor, ON, Canada
| | - Allie Slemon
- School of Nursing, 8166University of British Columbia, Vancouver, BC, Canada
| | - Colleen Varcoe
- School of Nursing, 8166University of British Columbia, Vancouver, BC, Canada
| | - Scott Comber
- Rowe School of Business, 3688Dalhousie University, Halifax, NS, Canada
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Mussie KM, Pageau F, Merkt H, Wangmo T, Elger BS. Challenges in providing ethically competent health care to incarcerated older adults with mental illness: a qualitative study exploring mental health professionals' perspectives in Canada. BMC Geriatr 2021; 21:718. [PMID: 34922493 PMCID: PMC8683829 DOI: 10.1186/s12877-021-02687-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The population of incarcerated older adults is the fastest growing demographic in prisons. Older persons in custody have poorer health as compared with those in the community. The unmet and complex health care needs of incarcerated older adults with mental illness raise justice, safety, dignity and fairness in care as ethical concerns. As there exists research gap to better understand these concerns, the current study aimed at exploring the perspectives of mental health professionals on challenges in delivering ethically competent care to mentally ill incarcerated older adults in Canada. METHODS Thirty-four semi-structured interviews were conducted between August 2017 and November 2018 with prison mental health professionals in Canada who were selected using purposive and convenience sampling techniques. The audio recorded interviews were transcribed verbatim and analysed inductively to generate themes. RESULTS The results were distilled into three main categories and seven subcategories that related to ethical issues in the provision of health care for mentally ill incarcerated older adults. The main categories included imprisoned older persons with special care needs, lack of resources, and the peer-support program. CONCLUSIONS Results of this study showed that existing practices of care of mentally ill incarcerated older adults are characterised by challenges that increase their vulnerability to worse health conditions. It is imperative for local authorities, policy makers and representatives to prepare for and respond to the challenges that compromise ethically competent health care for, and healthy ageing of, mentally ill incarcerated older adults.
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Affiliation(s)
- Kirubel Manyazewal Mussie
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Félix Pageau
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Helene Merkt
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Center for Legal Medicine, University of Geneva, Geneva, Switzerland
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Shen FX, Wolf SM, Bhavnani S, Deoni S, Elison JT, Fair D, Garwood M, Gee MS, Geethanath S, Kay K, Lim KO, Lockwood Estrin G, Luciana M, Peloquin D, Rommelfanger K, Schiess N, Siddiqui K, Torres E, Vaughan JT. Emerging ethical issues raised by highly portable MRI research in remote and resource-limited international settings. Neuroimage 2021; 238:118210. [PMID: 34062266 PMCID: PMC8382487 DOI: 10.1016/j.neuroimage.2021.118210] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 11/18/2022] Open
Abstract
Smaller, more affordable, and more portable MRI brain scanners offer exciting opportunities to address unmet research needs and long-standing health inequities in remote and resource-limited international settings. Field-based neuroimaging research in low- and middle-income countries (LMICs) can improve local capacity to conduct both structural and functional neuroscience studies, expand knowledge of brain injury and neuropsychiatric and neurodevelopmental disorders, and ultimately improve the timeliness and quality of clinical diagnosis and treatment around the globe. Facilitating MRI research in remote settings can also diversify reference databases in neuroscience, improve understanding of brain development and degeneration across the lifespan in diverse populations, and help to create reliable measurements of infant and child development. These deeper understandings can lead to new strategies for collaborating with communities to mitigate and hopefully overcome challenges that negatively impact brain development and quality of life. Despite the potential importance of research using highly portable MRI in remote and resource-limited settings, there is little analysis of the attendant ethical, legal, and social issues (ELSI). To begin addressing this gap, this paper presents findings from the first phase of an envisioned multi-staged and iterative approach for creating ethical and legal guidance in a complex global landscape. Section 1 provides a brief introduction to the emerging technology for field-based MRI research. Section 2 presents our methodology for generating plausible use cases for MRI research in remote and resource-limited settings and identifying associated ELSI issues. Section 3 analyzes core ELSI issues in designing and conducting field-based MRI research in remote, resource-limited settings and offers recommendations. We argue that a guiding principle for field-based MRI research in these contexts should be including local communities and research participants throughout the research process in order to create sustained local value. Section 4 presents a recommended path for the next phase of work that could further adapt these use cases, address ethical and legal issues, and co-develop guidance in partnership with local communities.
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Affiliation(s)
- Francis X Shen
- Professor of Law and Faculty Member, Graduate Program in Neuroscience, University of Minnesota; Instructor in Psychology, Harvard Medical School; Executive Director, MGH Center for Law, Brain & Behavior USA.
| | - Susan M Wolf
- McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; Chair, Consortium on Law and Values in Health, Environment & the Life Sciences, University of Minnesota USA
| | - Supriya Bhavnani
- Co-Principal Investigator, Child Development Group, Sangath, New Delhi, India
| | - Sean Deoni
- Associate Professor of Pediatrics (Research), Associate Professor of Diagnostic Imaging (Research), Brown University; Senior Program Officer, Maternal, Newborn & Child Health Discovery & Tools, Discovery & Translational Sciences, Bill & Melinda Gates Foundation USA
| | - Jed T Elison
- Associate Professor, Institute of Child Development, Department of Pediatrics, University of Minnesota USA
| | - Damien Fair
- Redleaf Endowed Director, Masonic Institute for the Developing Brain; Professor, Institute of Child Development, College of Education and Human Development; Professor, Department of Pediatrics, Medical School, University of Minnesota USA
| | - Michael Garwood
- Malcolm B. Hanson Professor of Radiology, Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota USA
| | - Michael S Gee
- Vice-Chair of Clinical Operations, Chief of Pediatric Radiology, Pediatric Imaging Research Center Director, Massachusetts General Hospital; Co-Director, Mass General Imaging Global Health Educational Programs USA
| | - Sairam Geethanath
- Associate Research Scientist, Columbia Magnetic Resonance Research Center, Columbia University USA
| | - Kendrick Kay
- Assistant Professor, Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota USA
| | - Kelvin O Lim
- Professor, Vice-Chair of Research, Drs. T. J. and Ella M. Arneson Land-Grant Chair in Human Behavior, Department of Psychiatry and Behavioral Sciences, University of Minnesota USA
| | - Georgia Lockwood Estrin
- Sir Henry Wellcome Postdoctoral Research Fellow, Centre for Brain and Cognitive Development, Department of Psychological Sciences, Birkbeck College, University of London UK
| | - Monica Luciana
- Professor, Department of Psychology; Adjunct Faculty Member, Institute of Child Development; Core Faculty Member, Center for Neurobehavioral Development, University of Minnesota USA
| | | | - Karen Rommelfanger
- Director, Neuroethics Program, Center for Ethics; Associate Professor, Departments of Neurology and Psychiatry and Behavioral Sciences, School of Medicine, Emory University USA
| | - Nicoline Schiess
- Technical Officer, Brain Health Unit, World Health Organization Switzerland
| | - Khan Siddiqui
- Chief Medical Officer and Chief Strategy Officer, Hyperfine USA
| | - Efraín Torres
- PhD Candidate in the Department of Biomedical Engineering, NSF GRFP Fellow, University of Minnesota; Garwood Lab member USA
| | - J Thomas Vaughan
- Professor in the Departments of Biomedical Engineering and Radiology, Director of the Columbia Magnetic Resonance Research Center; Principal and Investigator and MR Platform Director of the Zuckerman Institute, Columbia University; Director of the High Field Imaging Lab, Nathan Kline Institute USA
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Saleh S, Sambakunsi H, Nyirenda D, Kumwenda M, Mortimer K, Chinouya M. Participant compensation in global health research: a case study. Int Health 2021; 12:524-532. [PMID: 33165559 PMCID: PMC7651450 DOI: 10.1093/inthealth/ihaa064] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/11/2020] [Accepted: 08/25/2020] [Indexed: 01/19/2023] Open
Abstract
Background Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct. Methods We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field. Results Attention to careful researcher–participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of ‘ethics dumping’. Conclusions We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect.
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Affiliation(s)
- Sepeedeh Saleh
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi.,Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Henry Sambakunsi
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
| | - Deborah Nyirenda
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
| | - Moses Kumwenda
- Malawi-Liverpool-Wellcome Trust, Queen Elizabeth Central Hospital, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Martha Chinouya
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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10
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Ellis GK, Manda A, Topazian H, Stanley CC, Seguin R, Minnick CE, Tewete B, Mtangwanika A, Chawinga M, Chiyoyola S, Chikasema M, Salima A, Kimani S, Kasonkanji E, Mithi V, Kaimila B, Painschab MS, Gopal S, Westmoreland KD. Feasibility of upfront mobile money transfers for transportation reimbursement to promote retention among patients receiving lymphoma treatment in Malawi. Int Health 2021; 13:297-304. [PMID: 33037426 PMCID: PMC8079308 DOI: 10.1093/inthealth/ihaa075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/22/2020] [Accepted: 09/28/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cancer outcomes in sub-Saharan Africa (SSA) remain suboptimal, in part due to poor patient retention. Many patients travel long distances to receive care, and transportation costs are often prohibitively expensive. These are well-known and established causes of delayed treatment and care abandonment in Malawi and across SSA. METHODS We sent visit reminder texts and offered upfront money to cover transportation costs through a mobile money transfer (MMT) platform to lymphoma patients enrolled in a prospective cohort in Malawi. The primary aim was to test the feasibility of upfront MMTs. RESULTS We sent 1034 visit reminder texts to 189 participating patients. Of these texts, 614 (59%) were successfully delivered, with 536 (52%) responses. 320/536 (60%) MMTs were sent to interested patients and 312/320 (98%) came to their appointment on time. Of 189 total patients, 120 (63%) were reached via text and 84 (44%) received MMTs a median of three times (IQR 2-5). Median age of reachable patients was 41 (IQR 30-50), 75 (63%) were male, 62 (52%) were HIV+ and 79 (66%) resided outside of Lilongwe. CONCLUSION MMTs were a feasible way to cover upfront transportation costs for patients reachable via text, however many of our patients were unreachable. Future studies exploring barriers to care, particularly among unreachable patients, may help improve the efficacy of MMT initiatives and guide retention strategies throughout SSA.
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Affiliation(s)
| | | | - Hillary Topazian
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | | | | | - Stephen Kimani
- UNC Project-Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Matthew S Painschab
- UNC Project-Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Satish Gopal
- National Cancer Institute, Center for Global Health, Rockville, MD, USA
| | - Katherine D Westmoreland
- UNC Project-Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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11
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Negash M, Chanyalew M, T Gebresilase T, Sintayehu B, Anteye T, Aseffa A, Newport MJ. Rapid ethical appraisal of stakeholder views on research prior to undertaking immunopathogenesis studies on podoconiosis in northeast Ethiopia during a period of social instability. Trans R Soc Trop Med Hyg 2021; 115:1026-1038. [PMID: 33570141 PMCID: PMC8417087 DOI: 10.1093/trstmh/trab003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/24/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022] Open
Abstract
Background Undertaking research and attaining informed consent can be challenging when there is political unrest and community mistrust. Rapid ethical appraisal (REA) is a tool that uses qualitative methods to explore sociocultural issues that may affect the ethical conduct of research. Methods We used REA in northeast Ethiopia shortly following a period of unrest, during which violence against researchers occurred, to assess stakeholder perceptions of research, researchers and the informed consent process. We held 32 in-depth interviews and 2 focus group discussions. Results Most community members had little awareness about podoconiosis or healthcare research. Convincing the community to donate blood for research is challenging due to association with HIV testing. The attack on researchers was mainly motivated by the community's mistrust of their intentions against the background of a volatile political situation. Social media contributed to the spread of misinformation. Lack of community engagement was also a key contributing factor. Conclusions Using REA, we identified potential barriers to the informed consent process, participant recruitment for data and specimen collection and the smooth conduct of research. Researchers should assess existing conditions in the study area and engage with the community to increase awareness prior to commencing their research activities.
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Affiliation(s)
- Mikias Negash
- Brighton and Sussex Centre for Global Health Research , Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK.,Armauer Hansen Research Institute, Addis Ababa, Ethiopia.,Addis Ababa University, College of Health Sciences, Department of Medical Laboratory Science, Addis Ababa, Ethiopia
| | | | - Tewodros T Gebresilase
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia.,Unit of Health Biotechnology, Institute of Biotechnology, College of Natural and Computational Sciences, Addis Ababa University, Ethiopia
| | | | | | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Melanie J Newport
- Brighton and Sussex Centre for Global Health Research , Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
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Bates MJ, Muula A, Gordon SB, Henrion MYR, Tomeny E, MacPherson P, Squire B, Niessen L. Study protocol for a single-centre observational study of household wellbeing and poverty status following a diagnosis of advanced cancer in Blantyre, Malawi - 'Safeguarding the Family' study. Wellcome Open Res 2020; 5:2. [PMID: 32161817 PMCID: PMC7047920 DOI: 10.12688/wellcomeopenres.15633.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Many households in low-and-middle income countries face the additional burden of crippling out-of-pocket expenditure when faced with a diagnosis of life-limiting illness. Available evidence suggests that receipt of palliative care supports cost-savings for cancer-affected households. This study will explore the relationship between receipt of palliative care, total household out-of-pocket expenditure on health and wellbeing following a first-time diagnosis of advanced cancer at Queen Elizabeth Central Hospital in Blantyre, Malawi. Protocol: Patients and their primary family caregivers will be recruited at the time of cancer diagnosis. Data on healthcare utilisation, related costs, coping strategies and wellbeing will be gathered using new and existing questionnaires (the Patient-and-Carer Cancer Cost Survey, EQ-5D-3L and the Integrated Palliative Care Outcome Score). Surveys will be repeated at one, three and six months after diagnosis. In the event of the patient’s death, a brief five-item questionnaire on funeral costs will be administered to caregivers not less than two weeks following the date of death. Descriptive and Poisson regression analyses will assess the relationship between exposure to palliative care and total household expenditure from baseline to six months. A sample size of 138 households has been calculated in order to detect a medium effect (as determined by Cohen’s f
2=0.15) of receipt of palliative care in a regression model for change in total household out-of-pocket expenditure as a proportion of annual household income. Ethics and dissemination: The study has received ethical approval. Results will be reported using STROBE guidelines and disseminated through scientific meetings, open access publications and a national stakeholder meeting. Conclusions: This study will provide data on expenditure for healthcare by households affected by advanced cancer in Malawi. We also explore whether receipt of palliative care is associated with a reduction in out-of-pocket expenditure at household level.
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Affiliation(s)
- Maya Jane Bates
- University of Malawi College of Medicine, P/Bag 360, Blantyre 3, Malawi.,Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Adamson Muula
- University of Malawi College of Medicine, P/Bag 360, Blantyre 3, Malawi
| | - Stephen B Gordon
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Malawi Liverpool Wellcome Trust, P O Box 30096, Blantyre 3, Malawi
| | - Marc Y R Henrion
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Malawi Liverpool Wellcome Trust, P O Box 30096, Blantyre 3, Malawi
| | - Ewan Tomeny
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Peter MacPherson
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Malawi Liverpool Wellcome Trust, P O Box 30096, Blantyre 3, Malawi.,London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Bertel Squire
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Louis Niessen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Bates MJ, Muula A, Gordon SB, Henrion MY, Tomeny E, MacPherson P, Squire B, Niessen L. Study protocol for a single-centre observational study of household wellbeing and poverty status following a diagnosis of advanced cancer in Blantyre, Malawi - ‘Safeguarding the Family’ study. Wellcome Open Res 2020; 5:2. [DOI: 10.12688/wellcomeopenres.15633.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Many households in low-and-middle income countries face the additional burden of crippling out-of-pocket expenditure when faced with a diagnosis of life-limiting illness. Available evidence suggests that receipt of palliative care supports cost-savings for cancer-affected households. This study will explore the relationship between receipt of palliative care, total household out-of-pocket expenditure on health and wellbeing following a first-time diagnosis of advanced cancer at Queen Elizabeth Central Hospital in Blantyre, Malawi. Protocol: Patients and their primary family caregivers will be recruited at the time of cancer diagnosis. Data on healthcare utilisation, related costs, coping strategies and wellbeing will be gathered using new and existing questionnaires (the Patient-and-Carer Cancer Cost Survey, EQ-5D-3L and the Integrated Palliative Care Outcome Score). Surveys will be repeated at one, three and six months after diagnosis. In the event of the patient’s death, a brief five-item questionnaire on funeral costs will be administered to caregivers not less than two weeks following the date of death. Descriptive and Poisson regression analyses will assess the relationship between exposure to palliative care and total household expenditure from baseline to six months. A sample size of 138 households has been calculated in order to detect a medium effect (as determined by Cohen’s f2=0.15) of receipt of palliative care in a regression model for change in total household out-of-pocket expenditure as a proportion of annual household income. Ethics and dissemination: The study has received ethical approval. Results will be reported using STROBE guidelines and disseminated through scientific meetings, open access publications and a national stakeholder meeting. Conclusions: This study will provide data on expenditure for healthcare by households affected by cancer in Malawi. We also explore whether receipt of palliative care is associated with a reduction in out-of-pocket expenditure at household level.
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