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Zola Matuvanga T, Larivière Y, Lemey G, Isekah Osang'ir B, Mariën J, Milolo S, Meta R, Matangila J, Maketa V, Mitashi P, Van Geertruyden JP, Muhindo-Mavoko H, Van Damme P. Longitudinal assessment of an Ebola vaccine trial understanding among healthcare providers in the Democratic Republic of the Congo. Vaccine 2024; 42:481-488. [PMID: 38163747 DOI: 10.1016/j.vaccine.2023.12.076] [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: 10/04/2023] [Revised: 12/09/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The long-term retention of information disclosed during the informed consent in clinical trials lasting over a year cannot be guaranteed for all volunteers. This study aimed to assess the level of participants' retention and understanding of the trial information after two years of participation in a vaccine trial. METHODS In total, 699 health care providers (HCPs) and frontline workers were enrolled in the EBL2007 vaccine trial conducted between February 2019 and September 2022 in the Health District of Boende, Democratic Republic of the Congo (DRC). Individual scores obtained from a questionnaire (test of understanding, TOU), specifically designed to assess the understanding of the consent at baseline, were collected before the clinical trial started and at one-year and two-year intervals. RESULTS TOU scores were high in the beginning of the trial (median TOU = 10/10), but significantly decreased in both the first and second years following (median TOU = 8/10 in year 1 and median TOU = 9/10 in year 2, p-value < 0.0001). The decrease in scores was significantly higher among individuals with occupations requiring shorter education such as midwives (median TOU = 7/10 in year 1 and 8/10 in year 2, pvalue = 0.025). Furthermore, older participants exhibited poorer retention of information compared to younger individuals (median TOU = 8/10 vs 9/10, p-value = 0.007). CONCLUSION We observed a significant decline in the informational knowledge of informed consent, specifically in terms of basic knowledge on the study vaccine and trial procedures. As participant safety and understanding is a paramount ethical concern for researchers, it is crucial for participants to fully comprehend the study's objectives and potential risks. Therefore, our findings suggest the need for clinical researchers to re-explain participants to optimize the protection of their rights and wellbeing during the research.
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Affiliation(s)
- Trésor Zola Matuvanga
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium; Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Wilrijk, Belgium; Tropical Medicine Department, University of Kinshasa, Kinshasa, Congo.
| | - Ynke Larivière
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium; Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Wilrijk, Belgium
| | - Gwen Lemey
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium; Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Wilrijk, Belgium
| | - Bernard Isekah Osang'ir
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium; Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Wilrijk, Belgium
| | - Joachim Mariën
- Department of Biology, Evolutionairy Ecology group, University of Antwerp, Wilrijk, Belgium; Department of Biology, Royal Museum for Central Africa, Tervuren, Belgium
| | - Solange Milolo
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Congo
| | - Rachel Meta
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Congo
| | - Junior Matangila
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Congo
| | - Vivi Maketa
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Congo
| | - Patrick Mitashi
- Tropical Medicine Department, University of Kinshasa, Kinshasa, Congo
| | - Jean-Pierre Van Geertruyden
- Global Health Institute, Department of Family Medicine and Population Health, University of Antwerp, Wilrijk, Belgium
| | | | - Pierre Van Damme
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium
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Tiruneh G, Yilma M, Wakuma B, Abdisa E, Bayisa L, Nichols M, Bedeker A, Tiffin N. Compliance with research ethics in epidemiological studies targeted to conflict-affected areas in Western Ethiopia: validity of informed consent (VIC) by information comprehension and voluntariness (ICV). BMC Med Ethics 2024; 25:9. [PMID: 38238678 PMCID: PMC10795316 DOI: 10.1186/s12910-024-01003-5] [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: 10/04/2023] [Accepted: 01/12/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The conduct of research is critical to advancing human health. However, there are issues of ethical concern specific to the design and conduct of research in conflict settings. Conflict-affected countries often lack strong platform to support technical guidance and monitoring of research ethics, which may lead to the use of divergent ethical standards some of which are poorly elaborated and loosely enforced. Despite the growing concern about ethical issues in research, there is a dearth of information about ethical compliance in conflict areas. Valid and ethically informed decision-making is a premier pact with research participants in settling possible ethical issues before commencing the research, which is ensured by gaining informed consent from prospective participants of the research. AIMS This research aimed to explore compliance with research ethics and consent validity in community-based epidemiological research conducted previously. METHODS Research participants were recruited in the western part of Ethiopia in three districts subjected to conflicts. A community-based cross-sectional study design was utilized, and 338 residents were enrolled as study participants. All participants had previously been enrolled as research participants in epidemiological studies. Data was collected using a questionnaire that was pilot-tested before the commencement of the main data collection. The questionnaire focused on participants' experiences of the informed consent process followed when they were recruited for an epidemiological study and covered themes such as essential information provided, level of comprehension, and voluntarism of consent. RESULTS Over half of the study participants, 176 (52%), were not provided with essential information before consenting. And 135 (40%) of them did not comprehend the information provided to them. One hundred and ninety (56%) participants freely and voluntarily agreed to partake in one of these epidemiological studies, with over a quarter (97; 28.7%) of them reporting they were subjected to undue influence. Written consent was obtained from only 32 (9.4%) of the participants.
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Affiliation(s)
- Gemechu Tiruneh
- Department of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia.
| | - Mekdes Yilma
- Department of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Bizuneh Wakuma
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Eba Abdisa
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Lami Bayisa
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Michelle Nichols
- South African Medical Research Council Bioinformatics Unit, South African National Bioinformatics Institute, University of the Western Cape, Bellville, South Africa
| | - Anja Bedeker
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Nicki Tiffin
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Wu C, Wang N, Wang Q, Wang C, Wei Z, Wu Z, Yu S, Jiang X. Participants' understanding of informed consent in clinical trials: A systematic review and updated meta-analysis. PLoS One 2024; 19:e0295784. [PMID: 38166097 PMCID: PMC10760836 DOI: 10.1371/journal.pone.0295784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/29/2023] [Indexed: 01/04/2024] Open
Abstract
Obtaining written informed consent from participants before enrolment in a study is essential. A previous study showed that only 50% of the participants in clinical trials understood the components of informed consent, and the methods of participants' understanding of informed consent were controversial. This updated meta-analysis aimed to estimate the proportion of participants in clinical trials who understand the different informed consent components. PubMed, EMBASE, the Cochrane Library, and Scopus were searched till April 2023. Therapeutic misconception, ability to name one risk, knowing that treatments were being compared, and understanding the nature of the study, the purpose of the study, the risks and side-effects, the direct benefits, placebo, randomization, voluntariness, freedom to withdraw, the availability of alternative treatment if withdrawn from the trial, confidentiality, compensation, or comprehension were evaluated. This meta-analysis included 117 studies (155 datasets; 22,118 participants). The understanding of the risks and side-effects was investigated in the largest number of studies (n = 100), whereas comparehension was investigated in the smallest number (n = 11). The highest proportions were 97.5%(95% confidence interval (CI): 97.1-97.9) for confidentiality, 95.9% (95% confidence interval (CI): 95.4-96.4) for compensation, 91.4% (95% CI: 90.7-92.1) for the nature of study, 68.1% (95% CI: 51.6-84.6) for knowing that treatments were being compared, and 67.3% (95% CI: 56.6-78) for voluntary nature of participants. The smallest proportions were the concept of placebo (4.8%, 95%CI: 4.4-5.2) and randomization(39.4%, 95%CI: 38.3-40.4). Our findings suggested that most participants understood the fundamental components of informed consent (study confidentiality, nature, compensation, voluntariness, and freedom to withdraw). The understanding of other components, such as placebo and randomization was less satisfactory.
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Affiliation(s)
- Chengai Wu
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Na Wang
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Qianqian Wang
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Zhenjie Wei
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Zhimin Wu
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Shunan Yu
- Department of Molecular Orthopaedics, Beijing Research Institute of Traumatology and Orthopaedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Xieyuan Jiang
- Beijing Jishuitan Hospital, Capital Medical University, Beijing Research Institute of Traumatology and Orthopaedics, Beijing, China
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Gillette E, Nyandiko W, Chory A, Scanlon M, Aluoch J, Choudhury N, Lagat D, Ashimosi C, Biegon W, Munyoro D, Lidweye J, Nyagaya J, Wilets I, DeLong A, Kantor R, Vreeman R, Naanyu V. Ethical Considerations for Engaging Children and Adolescents Living with HIV in Research in African Countries: A Systematic Review. J Empir Res Hum Res Ethics 2023; 18:346-362. [PMID: 37872659 DOI: 10.1177/15562646231208991] [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] [Indexed: 10/25/2023]
Abstract
Research engaging children and adolescents living with HIV (CALWH) is critical for youth-friendly services and HIV care, and researchers need to ensure that such engagement is ethical. We conducted a systematic review to identify key ethical considerations for the engagement of CALWH in research. The review focused on primary research articles conducted in African countries that examined ethical issues in CALWH engaged in research. Ten studies met the inclusion criteria; the following seven key domains were extracted: 1) justifications for engaging CALWH in research; 2) community involvement; 3) informed consent/assent; 4) caregiver involvement; 5) perceptions of benefits; 6) perception of the risks of involvement; and 7) confidentiality. These domains can inform the ethical engagement of CALWH in research.
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Affiliation(s)
- Emma Gillette
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Winstone Nyandiko
- Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ashley Chory
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Scanlon
- Indiana University Center for Global Health, Indianapolis, Indiana, USA
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Nandini Choudhury
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Lagat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Whitney Biegon
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Dennis Munyoro
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Janet Lidweye
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jack Nyagaya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ilene Wilets
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Rachel Vreeman
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Violet Naanyu
- Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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Busisiwe N, Seeley J, Strode A, Parker M. Beyond translations, perspectives for researchers to consider to enhance comprehension during consent processes for health research in sub-saharan Africa: a scoping review. BMC Med Ethics 2023; 24:43. [PMID: 37344810 DOI: 10.1186/s12910-023-00920-1] [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: 05/24/2022] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Literature on issues relating to comprehension during the process of obtaining informed consent (IC) has largely focused on the challenges potential participants can face in understanding the IC documents, and the strategies used to enhance comprehension of those documents. In this review, we set out to describe the factors that have an impact on comprehension and the strategies used to enhance the IC process in sub-Saharan African countries. METHODS From November 2021 to January 2022, we conducted a literature search using a PRISMA tool. We searched electronic databases (PubMed, EMBASE, EBSCOHOST) to identify relevant peer reviewed studies. We then reviewed the references of these articles to find additional literature that might have been missed through the initial search. We were particularly interested in full text articles in English that focused on the IC process in SSA published between 2006 and 2020. We included systematic reviews, and studies from Western and Asian countries that included data about SSA. We excluded articles that focused on medical interventions and studies that did not require IC. RESULTS Out of the 50 studies included most were multi-country (n = 13) followed by single country studies in South Africa (n = 12); Kenya, Tanzania, Uganda (n = 5) each; Gambia, Ghana and Nigeria (n = 2)each ; and one each for Botswana, Malawi, Mali, Mozambique. We identified three areas of focus: (1) socio-cultural factors affecting IC; (2) gaps in the ethical and legal frameworks guiding the IC process; and (3) strategies used to improve participants' understanding of IC. CONCLUSION Our review showed wide recognition that the process of achieving IC in SSA is inherently challenging, and there are limitations in the strategies aimed at improving comprehension in IC. We suggest that there is a need for greater flexibility and negotiation with communities to ensure that the approach to IC is suited to the diverse socio-cultural contexts. We propose moving beyond the literal translations and technical language to understanding IC comprehension from the participants' perspectives and the researchers' views, while examining contextual factors that impact the IC process.
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Affiliation(s)
- Nkosi Busisiwe
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa.
- Institute for Global Health, University College London, London, UK.
- School of Law, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ann Strode
- School of Law, University of KwaZulu-Natal, Pietermaritzburg, South Africa
- South African Research Ethics Training Initiative, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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Gondwe MJ, Toto NM, Gunda C, Gmeiner M, MacCormick IJC, Lalloo D, Parker M, Desmond N. Guardians and research staff experiences and views about the consent process in hospital-based paediatric research studies in urban Malawi: A qualitative study. BMC Med Ethics 2022; 23:125. [PMID: 36471294 PMCID: PMC9720930 DOI: 10.1186/s12910-022-00865-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Obtaining consent has become a standard way of respecting the patient's rights and autonomy in clinical research. Ethical guidelines recommend that the child's parent/s or authorised legal guardian provides informed consent for their child's participation. However, obtaining informed consent in paediatric research is challenging. Parents become vulnerable because of stress related to their child's illness. Understanding the views held by guardians and researchers about the consent process in Malawi, where there are limitations in health care access and research literacy will assist in developing appropriate consent guidelines. METHODS We conducted 20 in-depth interviews with guardians of children and research staff who had participated in paediatric clinical trial and observational studies in acute and non-acute settings in the Southern Region of Malawi. Interviews were audio-recorded, transcribed verbatim, and thematically analysed. Interviews were compared across studies and settings to identify differences and similarities in participants' views about informed consent processes. Data analysis was facilitated by NVIVO 11 software. RESULTS All participants across study types and settings reported that they associated participating in research with therapeutic benefits. Substantial differences were noted in the decision-making process across study settings. Guardians from acute studies felt that the role of their spouses was neglected during consenting, while staff reported that they had problems obtaining consent from guardians when their partners were not present. Across all study types and settings, research staff reported that they emphasised the benefits more than the risks of the study to participants, due to pressure to recruit. Participants from non-acute settings were more likely to recall information shared during the consent process than participants in the acute setting. CONCLUSION The health care context, culture and research process influenced participants' understanding of study information across study types and settings. We advise research managers or principal investigators to define minimum requirements that would not compromise the consent process and conduct study specific training for staff. The use of one size fits all consent process may not be ideal. More guidance is needed on how these differences can be incorporated during the consent process to improve understanding and delivery of consent. Trial registration Not applicable.
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Affiliation(s)
- Mtisunge Joshua Gondwe
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi ,grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine, Liverpool, UK
| | - Neema Mtunthama Toto
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Charity Gunda
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Markus Gmeiner
- grid.10417.330000 0004 0444 9382Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ian J. C. MacCormick
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - David Lalloo
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine, Liverpool, UK
| | - Michael Parker
- grid.4991.50000 0004 1936 8948The Ethox Centre, University of Oxford, Oxford, UK
| | - Nicola Desmond
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi ,grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine, Liverpool, UK
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Sylvia N, Joseph O, David KM, Ian M, Janet N, Nelson NF, John B, Betty K, Charles I, Adelline T, Nelson S, Erisa Sabakaki M. Experiences and practices of key research team members in obtaining informed consent for pharmacogenetic research among people living with HIV: a qualitative study. RESEARCH ETHICS 2022; 18:193-209. [PMID: 36213304 PMCID: PMC9536131 DOI: 10.1177/17470161221076974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to explore experiences and practices of key research team members in obtaining informed consent for pharmacogenetics research and to identify the approaches used for enhancing understanding during the consenting process. Data collection involved 15 qualitative, in-depth interviews with key researchers who were involved in obtaining informed consent from HIV infected individuals in Uganda for participation in pharmacogenetic clinical trials. The study explored two prominent themes: approaches used to convey information and enhance research participants’ understanding and challenges faced during the consenting process. Several barriers and facilitators for obtaining consent were identified. Innovative and potentially effective consenting strategies were identified in this study that should be studied and independently verified.
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Affiliation(s)
| | | | | | | | | | | | - Barugahare John
- Makerere University College of Humanities and Social Sciences, Uganda
| | | | | | | | | | - Mwaka Erisa Sabakaki
- Makerere University College of Health Sciences, Uganda
- Infectious Diseases Institute, Uganda
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Contrasting Comprehension of HIV Research by Adolescents, Young Adults, and Caregivers in Western Kenya: A Cross-sectional Analysis. J Assoc Nurses AIDS Care 2022; 33:542-549. [PMID: 35767728 DOI: 10.1097/jnc.0000000000000336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Adolescent participation in research is critical to inform interventions that improve outcomes for this group. Adolescents and young adults living with HIV often present to care without caregivers, yet caregiver permission is typically required for those younger than 18 years. We evaluated whether understanding of key consent information differed between adolescents (n = 1,393) and caregiver adults (n = 169). Compared with caregivers, adolescents aged 10-14 years showed significantly lower understanding, whereas understanding for older adults living with HIV did not differ significantly from caregivers. Risks were the least understood consent information for all age groups. Our findings suggest that for low-risk research, waiving caregiver permission requirements will not compromise the ethical need to ensure understanding of research before enrollment and may allow adolescents greater access to potential research benefits.
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Nouvet E, Grandjean Lapierre S, Knoblauch A, Baril L, Andriamiadanarivo A, Raberahona M, Mattern C, Donelle L, Andriantsoa JR. Consent to Research in Madagascar: Challenges, Strategies, and Priorities for Future
Research. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1087201ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Appiah R. Gurus and Griots: Revisiting the research informed consent process in rural African contexts. BMC Med Ethics 2021; 22:98. [PMID: 34301252 PMCID: PMC8299170 DOI: 10.1186/s12910-021-00659-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Researchers conducting community-based participatory action research (CBPAR) in highly collectivistic and socioeconomically disadvantaged community settings in sub-Saharan Africa are confronted with the distinctive challenge of balancing universal ethical standards with local standards, where traditional customs or beliefs may conflict with regulatory requirements and ethical guidelines underlying the informed consent (IC) process. The unique ethnic, socioeconomic, and cultural diversities in these settings have important implications for the IC process, such as individual decisional autonomy, beneficence, confidentiality, and signing the IC document. MAIN TEXT Drawing on insights and field observations from conducting CBPARs across several rural, highly communal, low literate, and low-income communities in Ghana, we discuss some theoretical, ethico-cultural, and methodological challenges associated with applying the universal, Western individualistic cultural value-laden IC process in sub-Saharan Africa. By citing field situations, we discuss how local cultural customs and the socioeconomic adversities prevalent in these settings can influence (and disrupt) the information disclosure process, individual decisional authority for consent, and voluntariness. We review the theoretical assumptions of the Declaration of Helsinki's statement on IC and discuss its limitations as an ultimate guide for the conduct of social science research in the highly communal African context. We argue that the IC process in these settings should include strategies directed at preventing deception and coercion, in addition to ensuring respect for individual autonomy. We urge Universities, research institutions, and institutional review boards in Africa to design and promote the use of context-appropriate ethical IC guidelines that take into consideration both the local customs and traditional practices of the people as well as the scientific principles underpinning the universal IC standards. CONCLUSION We recommend that, rather than adopt a universal one-size-fits-all IC approach, researchers working in the rural, highly collectivistic, low literate, socioeconomically disadvantaged settings of sub-Saharan Africa should deeply consider the roles and influence of cultural values and traditional practices on the IC and the research process. We encourage researchers to collaborate with target communities and stakeholders in the design and implementation of context-appropriate IC to prevent ethics dumping and safeguard the integrity of the research process.
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Affiliation(s)
- Richard Appiah
- College of Health Sciences, University of Ghana, Korle-Bu, P. O. Box KB 143, Accra, Ghana.
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Sherman KA, Kilby CJ, Pehlivan M, Smith B. Adequacy of measures of informed consent in medical practice: A systematic review. PLoS One 2021; 16:e0251485. [PMID: 34043651 PMCID: PMC8159027 DOI: 10.1371/journal.pone.0251485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/28/2021] [Indexed: 11/19/2022] Open
Abstract
As a critical component of medical practice, it is alarming that patient informed consent does not always reflect (1) adequate information provision, (2) comprehension of provided information, and (3) a voluntary decision. Consequences of poor informed consent include low patient satisfaction, compromised treatment adherence, and litigation against medical practitioners. To ensure a well-informed, well-comprehended, and voluntary consent process, the objective and replicable measurement of these domains via psychometrically sound self-report measures is critical. This systematic review aimed to evaluate the adequacy of existing measures in terms of the extent to which they assess the three domains of informed consent, are psychometrically sound and acceptable for use by patients. Extensive searching of multiple databases (PsychINFO, PubMed, Sociological Abstracts, CINAHL, AMED) yielded 10,000 potential studies, with 16 relevant scales identified. No existing scale was found to measure all three consent domains, with most only narrowly assessing aspects of any one domain. Information provision was the most frequently assessed domain, followed by comprehension, and then voluntariness. None of the identified scales were found to have adequate evidence for either high quality psychometric properties or patient user acceptability. No existing scale is fit for purpose in comprehensively assessing all domains of informed consent. In the absence of any existing measure meeting the necessary criteria relating to information, comprehension and voluntariness, there is an urgent need for a new measure of medical consent to be developed that is psychometrically sound, spans all three domains and is acceptable to patients and clinicians alike. These findings provide the impetus and justification for the redesign of the informed consent process, with the aim to provide a robust, reliable and replicable process that will in turn improve the quality of the patient experience and care provided.
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Affiliation(s)
- Kerry A. Sherman
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia
- * E-mail:
| | | | - Melissa Pehlivan
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia
| | - Brittany Smith
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia
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Pietrzykowski T, Smilowska K. The reality of informed consent: empirical studies on patient comprehension-systematic review. Trials 2021; 22:57. [PMID: 33446265 PMCID: PMC7807905 DOI: 10.1186/s13063-020-04969-w] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/11/2020] [Indexed: 01/09/2023] Open
Abstract
Background Informed consent is a basic concept of contemporary, autonomy-based medical practice and facilitates a shared decision-making model for relations between physicians and patients. Thus, the extent to which patients can comprehend the consent they grant is essential to the ethical viability of medicine as it is pursued today. However, research on patients’ comprehension of an informed consent’s basic components shows that their level of understanding is limited. Methods Systemic searches of the PubMed and Web of Science databases were performed to identify the literature on informed consent, specifically patients’ comprehension of specific informed consent components. Results In total, 14 relevant articles were retrieved. In most studies, few clinical trial participants correctly responded to items that examined their awareness of what they consented to. Participants demonstrated the highest level of understanding (over 50%) regarding voluntary participation, blinding (excluding knowledge about investigators’ blinding), and freedom to withdraw at any time. Only a small minority of patients demonstrated comprehension of placebo concepts, randomisation, safety issues, risks, and side effects. Conclusions We found that participants’ comprehension of fundamental informed consent components was low, which is worrisome because this lack of understanding undermines an ethical pillar of contemporary clinical trial practice and questions the viability of patients’ full and genuine involvement in a shared medical decision-making process.
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Affiliation(s)
- Tomasz Pietrzykowski
- Research Centre for Public Policy and Regulatory Governance, Faculty of Law and Administration, University of Silesia in Katowice, Katowice, Poland
| | - Katarzyna Smilowska
- Department of Neurology; Centre of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
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Palmeirim MS, Ross A, Obrist B, Mohammed UA, Ame SM, Ali SM, Keiser J. Informed consent procedure in a double blind randomized anthelminthic trial on Pemba Island, Tanzania: do pamphlet and information session increase caregivers knowledge? BMC Med Ethics 2020; 21:1. [PMID: 31906925 PMCID: PMC6945786 DOI: 10.1186/s12910-019-0441-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In clinical research, obtaining informed consent from participants is an ethical and legal requirement. Conveying the information concerning the study can be done using multiple methods yet this step commonly relies exclusively on the informed consent form alone. While this is legal, it does not ensure the participant's true comprehension. New effective methods of conveying consent information should be tested. In this study we compared the effect of different methods on the knowledge of caregivers of participants of a clinical trial on Pemba Island, Tanzania. METHODS A total of 254 caregivers were assigned to receive (i) a pamphlet (n = 63), (ii) an oral information session (n = 62) or (iii) a pamphlet and an oral information session (n = 64) about the clinical trial procedures, their rights, benefits and potential risks. Their post-intervention knowledge was assessed using a questionnaire. One group of caregivers had not received any information when they were interviewed (n = 65). RESULTS In contrast to the pamphlet, attending an information session significantly increased caregivers' knowledge for some of the questions. Most of these questions were either related to the parasite (hookworm) or to the trial design (study procedures). CONCLUSIONS In conclusion, within our trial on Pemba Island, a pamphlet was found to not be a good form of conveying clinical trial information while an oral information session improved knowledge. Not all caregivers attending an information session responded correctly to all questions; therefore, better forms of communicating information need to be found to achieve a truly informed consent.
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Affiliation(s)
- Marta S Palmeirim
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Amanda Ross
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Brigit Obrist
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Shaali M Ame
- Public Health Laboratory Ivo de Carneri, Chake Chake, Tanzania
| | - Said M Ali
- Public Health Laboratory Ivo de Carneri, Chake Chake, Tanzania
| | - Jennifer Keiser
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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Grantz KH, Claudot P, Kambala M, Kouyaté M, Soumah A, Boum Y, Juan-Giner A, Jemmy JP, Cummings DAT, Grais RF. Factors influencing participation in an Ebola vaccine trial among front-line workers in Guinea. Vaccine 2019; 37:7165-7170. [PMID: 31623917 DOI: 10.1016/j.vaccine.2019.09.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alongside the clinical aspects of the immunogenicity and safety trial of an Ebola vaccine deployed among front-line workers, a qualitative study was conducted to describe motivations behind individuals' decisions to participate - or not to participate - in the study. METHODS In July and August 2015, focus group discussions and semi-structured individual interviews were conducted in Conakry, Guinea. Individuals were eligible for the qualitative study if they met the inclusion criteria of the immunogenicity and safety study irrespective of their participation. Surveys were also conducted among several institution and department heads of staff included in the study as well as vaccine trial staff members. Discussion and interview transcripts were analyzed using content thematic analysis. RESULTS Interviews and focus groups were conducted among 110 persons, of whom about two-thirds (67%) participated in the vaccine trial. There was at least one group interview conducted at each participating trial site, along with numerous formal and informal interviews and conversations through the enrollment period. Participants were often motivated by a desire to save and protect themselves and others, contribute to scientific progress, or lead by example. Non-participants expressed concerns regarding the risk and costs of participation, particularly the fear of unknown side effects following vaccination, and distrust or fear of stigmatization. CONCLUSIONS Despite the unique nature of the 2014-2015 Ebola outbreak, front-line workers employed much of the same logic when choosing to participate as in other clinical trials in similar settings. Special consideration should be given to addressing perceived inequity, misunderstanding, and mistrust among the target populations in future trials. Clinical trial registry number: This trial is registered with the Pan African Clinical Trials Registry, number PACTR201503001057193.
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Affiliation(s)
- Kyra H Grantz
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32611, USA; Department of Biology, University of Florida, Gainesville, FL 32611, USA
| | | | - Micky Kambala
- Médecins Sans Frontières-Operational Center, Belgium
| | | | | | - Yap Boum
- Epicentre, 8 rue Saint Sabin, 75011 Paris, France
| | | | | | - Derek A T Cummings
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32611, USA; Department of Biology, University of Florida, Gainesville, FL 32611, USA
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Chen SY, Chang SCS, Lin CC, Lou Q, Anderson RM. Psychometric evaluation of the Informed Consent Process Scale in Chinese. Nurs Ethics 2019; 26:2456-2466. [PMID: 30614395 DOI: 10.1177/0969733018819126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Informed consent is essential for the ethical conduct of clinical research and is a culturally sensitive issue. But, a measurable Chinese version of the scale to evaluate the informed consent process has not yet been explored in the existing literature. RESEARCH OBJECTIVES This study aimed to develop and psychometrically test the Chinese version of the Informed Consent Process Scale. RESEARCH DESIGN Back-translation was conducted to develop the Chinese version of the questionnaire. A cross-sectional survey was administered, after which an exploratory factor analysis was conducted. PARTICIPANTS We recruited a total of 375 participants who had experience in signing an informed consent form within the previous 3 years in Taiwan. ETHICAL CONSIDERATIONS This study was approved by two Institutional Review Boards and the autonomy of the participants was respected. FINDINGS The Chinese version of the Informed Consent Process Scale is composed of three factors with 23 items showing evidence of acceptable reliability and validity. Three major factors were extracted and labeled: Factor 1 - 'Understanding of the research', Factor 2 - 'Trust and confidence' and Factor 3 - 'Doubt and uncertainty'. The three factors accounted for is 52.954 of the total variance with Cronbach's α of .917. DISCUSSION AND CONCLUSION The finding corroborates previous studies showing that participants had too little understanding on the informed consent forms they signed and implied the need to clarify the critical points in clinical research. The psychometric results indicated good internal consistency and validity for this newly constructed instrument, and it was found worthy of conducting further testing and application.
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Affiliation(s)
- Shu Yu Chen
- Changhua Christian Hospital; School of Nursing, Dayeh University
| | | | - Chiu-Chu Lin
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Ateudjieu J, Hurst S, Yakum MN, Tangwa GB. Biomedical research ethics in Cameroon: a survey to assess training needs of medical residents and students. BMC MEDICAL EDUCATION 2019; 19:5. [PMID: 30606193 PMCID: PMC6318839 DOI: 10.1186/s12909-018-1431-8] [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: 02/09/2018] [Accepted: 12/14/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Training curricula in research ethics for potential and future researchers should be implemented and constantly updated. This requires data regarding training needs. METHODS We conducted a cross-sectional survey on residents, fifth and sixth-year medical students registered in the 2006-2007 academic year at the Faculty of Medicine and Biomedical Sciences (FMBS) of the University of Yaounde 1, Cameroon. RESULTS Two-fifths (40.4%) of respondents (response rate 70.9%) reported training in research ethics. Less than half were aware of specific regulatory texts relevant to research ethics. Among those who reported conducting a research project 66.7% declared having obtained informed consent from participants and 32.9% having submitted their protocol to an Ethics Review Committee. Participants identified training priorities in research ethics and responsibilities of key actors in the protection of research participants. CONCLUSION There is a need to improve the training and attitude of medical students and residents in order to prepare them to respect and protect research participants.
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Affiliation(s)
- Jerome Ateudjieu
- M.A. SANTE (Meilleur Accès Aux Soins de Santé), Yaoundé, Cameroon
| | - Samia Hurst
- Geneva University Medical School, Institute for Biomedical Ethics, Geneva, Switzerland
| | | | - Godfrey B. Tangwa
- Department of Phylosophy, University of Yaounde 1, Yaounde, Cameroon
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Colom M, Rohloff P. Cultural considerations for informed consent in paediatric research in low/middle-income countries: a scoping review. BMJ Paediatr Open 2018; 2:e000298. [PMID: 30613801 PMCID: PMC6307601 DOI: 10.1136/bmjpo-2018-000298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Conducting research with children in low/middle-income countries (LMIC) requires consideration of socioeconomic inequalities and cultural and linguistic differences. Our objective was to survey the literature on informed consent in paediatric LMIC research, assessing for practical guidance for culturally and linguistically appropriate procedures. METHODS We conducted a scoping review on informed consent in paediatric LMIC research searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were published in English, from any date range, of any study design or format. RESULTS The search identified 2027 references, of which 50 were included in the analysis following full-text review. Reviewed guidelines emphasised individual, informed and voluntary consent from parents and caregivers. Reviewed articles provided detailed practical guidance on adapting these guiding principles to LMIC settings, including considerations for community engagement, verbal or other alternative consent procedures for low-literacy settings or less commonly spoken languages and guarding against therapeutic misconception by caregivers. There was uncertainty, however, on how to best protect individual autonomy, especially when influenced by gender dynamics, leadership hierarchies or the social status of researchers themselves. There was, furthermore, limited research discussing the special case of research involving adolescents or of procedures for documenting assent by participating children. CONCLUSIONS A scoping review of paediatric research in LMICs revealed substantial guidance on several features of culturally appropriate informed consent. However, additional research and guidance is needed, especially in the areas of gender imbalances, research with adolescents and children's own assent to participate in research.
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Affiliation(s)
- Marcela Colom
- Centre for Research in Indigenous Health, Wuqu’ Kawoq | Maya Health Alliance, Tecpán, Guatemala
| | - Peter Rohloff
- Centre for Research in Indigenous Health, Wuqu’ Kawoq | Maya Health Alliance, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Afolabi MO, Rennie S, Hallfors DD, Kline T, Zeitz S, Odongo FS, Amek NO, Luseno WK. An adapted instrument to assess informed consent comprehension among youth and parents in rural western Kenya: a validation study. BMJ Open 2018; 8:e021613. [PMID: 30002013 PMCID: PMC6082480 DOI: 10.1136/bmjopen-2018-021613] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 05/01/2018] [Accepted: 05/24/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To adapt and validate a questionnaire originally developed in a research setting for assessment of comprehension of consent information in a different cultural and linguistic research setting. DESIGN The adaptation process involved development and customisation of a questionnaire for each of the three study groups, modelled closely on the previously validated questionnaire. The three adapted draft questionnaires were further reviewed by two bioethicists and the developer of the original questionnaire for face and content validity. The revised questionnaire was subsequently programmed into an audio computerised format, with translations and back translations in three widely spoken languages by the study participants: Luo, Swahili and English. SETTING The questionnaire was validated among adolescents, their parents and young adults living in Siaya County, a rural region of western Kenya. PARTICIPANTS Twenty-five-item adapted questionnaires consisting of close-ended, multiple-choice and open-ended questions were administered to 235 participants consisting of 107 adolescents, 92 parents and 36 young adults. Test-retest was conducted 2-4 weeks after first questionnaire administration among 74 adolescents, young adults and parents. OUTCOME MEASURE Primary outcome measures included ceiling/floor analysis to identify questions with extremes in responses and item-level correlation to determine the test-retest relationships. Given the data format, tetrachoric correlations were conducted for dichotomous items and polychoric correlations for ordinal items. The qualitative validation assessment included face and content validity evaluation of the adapted instrument by technical experts. RESULTS Ceiling/floor analysis showed eight question items for which >80% of one or more groups responded correctly, while for nine questions, including all seven open-ended questions,<20% responded correctly. Majority of the question items had moderate to strong test-retest correlation estimates indicating temporal stability. CONCLUSIONS Our study demonstrates that cross-cultural adaptation and validation of an informed consent comprehension questionnaire is feasible. However, further research is needed to develop a tool which can estimate a quantifiable threshold of comprehension thereby serving as an objective indicator of the need for interventions to improve comprehension.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Bioethics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Denise Dion Hallfors
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, USA
| | - Tracy Kline
- Department of Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, USA
| | - Susannah Zeitz
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, USA
- Department of Health Behavior, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Frederick S Odongo
- Department of HIV Implementation Science and Services, Center for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Nyaguara O Amek
- Department of HIV Implementation Science and Services, Center for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Winnie K Luseno
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, USA
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Ossemane EB, Moon TD, Sacarlal J, Sevene E, Kenga D, Gong W, Heitman E. Assessment of Parents'/Guardians' Initial Comprehension and 1-Day Recall of Elements of Informed Consent Within a Mozambican Study of Pediatric Bacteremia. J Empir Res Hum Res Ethics 2018; 13:247-257. [PMID: 29667543 PMCID: PMC5993589 DOI: 10.1177/1556264618767780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Participants' understanding of key elements of a research protocol is essential to their ethical enrollment in the study. Ongoing participation should be based on continued comprehension and consent, which presumes a high degree of recall. Many obstacles can prevent full understanding of information about the research protocol. This study's aim was to evaluate the comprehension and 1-day recall of the elements of informed consent by the parents/guardians of children enrolled in a clinical study in Mozambique. We developed a 10-question test based on the study's informed consent document. We asked participants to answer questions shortly after being read the informed consent document and again the following day. Participants who did not demonstrate good or reasonable understanding at enrollment were provided the information again as a refresher. Overall high rates of initial comprehension demonstrate that attention to the informed consent process can result in Mozambicans' informed, voluntary participation in clinical trials.
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Affiliation(s)
- Ezequiel B. Ossemane
- Vanderbilt Institute for Global Health, Nashville, Tennessee, USA
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Nashville, Tennessee, USA
- Vanderbilt University Medical Center Department of Pediatrics, Division of Infectious Diseases, Nashville, Tennessee, USA
| | - Jahit Sacarlal
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Esperança Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Darlene Kenga
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Wu Gong
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, Tennessee, USA
| | - Elizabeth Heitman
- Vanderbilt Institute for Global Health, Nashville, Tennessee, USA
- University of Texas South Western, Dallas, Texas, USA
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Jasińska KK, Guei S. Neuroimaging Field Methods Using Functional Near Infrared Spectroscopy (NIRS) Neuroimaging to Study Global Child Development: Rural Sub-Saharan Africa. J Vis Exp 2018. [PMID: 29443053 DOI: 10.3791/57165] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Portable neuroimaging approaches provide new advances to the study of brain function and brain development with previously inaccessible populations and in remote locations. This paper shows the development of field functional Near Infrared Spectroscopy (fNIRS) imaging to the study of child language, reading, and cognitive development in a rural village setting of Côte d'Ivoire. Innovation in methods and the development of culturally appropriate neuroimaging protocols allow a first-time look into the brain's development and children's learning outcomes in understudied environments. This paper demonstrates protocols for transporting and setting up a mobile laboratory, discusses considerations for field versus laboratory neuroimaging, and presents a guide for developing neuroimaging consent procedures and building meaningful long-term collaborations with local government and science partners. Portable neuroimaging methods can be used to study complex child development contexts, including the impact of significant poverty and adversity on brain development. The protocol presented here has been developed for use in Côte d'Ivoire, the world's primary source of cocoa, and where reports of child labor in the cocoa sector are common. Yet, little is known about the impact of child labor on brain development and learning. Field neuroimaging methods have the potential to yield new insights into such urgent issues, and the development of children globally.
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Affiliation(s)
- Kaja K Jasińska
- Linguistics and Cognitive Science Department, University of Delaware; Haskins Laboratories;
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Rennie S, Groves AK, Hallfors DD, Iritani BJ, Odongo FS, Luseno WK. The Significance of Benefit Perceptions for the Ethics of HIV Research Involving Adolescents in Kenya. J Empir Res Hum Res Ethics 2017; 12:269-279. [PMID: 28728497 DOI: 10.1177/1556264617721556] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Assessment of benefits is traditionally regarded as crucial to the ethical evaluation of research involving human participants. We conducted focus group discussions (FGDs) with health and other professionals engaged with adolescents, caregivers/parents, and adolescents in Siaya County, Kenya, to solicit opinions about appropriate ways of conducting HIV research with adolescents. Our data revealed that many focus group participants have a profoundly positive conception of participation in health research, including studies conferring seemingly few benefits. In this article, we identify and analyze five different but interrelated types of benefits as perceived by Kenyan adolescent and adult stakeholders in HIV research, and discuss their ethical significance. Our findings suggest that future empirical and conceptual research should concentrate on factors that may trigger researcher obligations to improve benefit perceptions among research participants.
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Affiliation(s)
- Stuart Rennie
- 1 The University of North Carolina at Chapel Hill, NC, USA
| | | | | | - Bonita J Iritani
- 3 Pacific Institute for Research and Evaluation, Chapel Hill, NC, USA
| | | | - Winnie K Luseno
- 3 Pacific Institute for Research and Evaluation, Chapel Hill, NC, USA
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Foe G, Larson EL. Reading Level and Comprehension of Research Consent Forms. J Empir Res Hum Res Ethics 2016; 11:31-46. [DOI: 10.1177/1556264616637483] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Consent forms continue to be at a higher reading level than the recommended sixth to eighth grade, making it difficult for participants to comprehend information before enrolling in research. To assess and address the extent of the problem regarding the level of literacy of consent forms and update previously published reports, we conducted an integrative literature review of English language research published between January 1, 2000, and December 31, 2013; 35 descriptive and eight intervention studies met inclusion criteria. Results confirmed that developing forms at eighth-grade level was attainable though not practiced. It was found that risks of participation was the section most poorly understood. There was also a lack of consensus regarding the most effective method to increase comprehension. Further research using standardized tools is needed to determine the best approach for improving consent forms and processes.
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Negussie H, Addissie T, Addissie A, Davey G. Preparing for and Executing a Randomised Controlled Trial of Podoconiosis Treatment in Northern Ethiopia: The Utility of Rapid Ethical Assessment. PLoS Negl Trop Dis 2016; 10:e0004531. [PMID: 26967654 PMCID: PMC4788215 DOI: 10.1371/journal.pntd.0004531] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/19/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Community-based randomized controlled trials are often complex pieces of research with significant challenges around the approach to the community, information provision, and decision-making, all of which are fundamental to the informed consent process. We conducted a rapid ethical assessment to guide the preparation for and conduct of a randomized controlled trial of podoconiosis treatment in northern Ethiopia. METHODS A qualitative study was carried out in Aneded woreda, East Gojjam Zone, Amhara Regional State from August to September, 2013. A total of 14 In-depth Interviews (IDIs) with researchers, experts, and leaders, and 8 Focus Group Discussions (FGDs) involving 80 participants (people of both gender, with and without podoconiosis), were conducted. Interviews were carried out in Amharic. Data analysis was started alongside collection. Final data analysis used a thematic approach based on themes identified a priori and those that emerged during the analysis. RESULTS Respondents made a range of specific suggestions, including that sensitisation meetings were called by woreda or kebele leaders or the police; that Health Extension Workers were asked to accompany the research team to patients' houses; that detailed trial information was explained by someone with deep local knowledge; that analogies from agriculture and local social organisations be used to explain randomisation; that participants in the 'delayed' intervention arm be given small incentives to continue in the trial; and that key community members be asked to quell rumours arising in the course of the trial. CONCLUSION Many of these recommendations were incorporated into the preparatory phases of the trial, or were used during the course of the trial itself. This demonstrates the utility of rapid ethical assessment preceding a complex piece of research in a relatively research-naive setting.
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Affiliation(s)
- Henok Negussie
- Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, United Kingdom
| | - Thomas Addissie
- School of Social Anthropology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Adamu Addissie
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, United Kingdom
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Linguistic and Cultural Challenges in Communication and Translation in US-Sponsored HIV Prevention Research in Emerging Economies. PLoS One 2015. [PMID: 26225759 PMCID: PMC4520713 DOI: 10.1371/journal.pone.0133394] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Linguistic and cultural differences can impede comprehension among potential research participants during the informed consent process, but how researchers and IRBs respond to these challenges in practice is unclear. We conducted in-depth interviews with 15 researchers, research ethics committee (REC) chairs and members from 8 different countries with emerging economies, involved in HIV-related research sponsored by HIV Prevention Trials Network (HPTN), regarding the ethical and regulatory challenges they face in this regard. In the interviews, problems with translating study materials often arose as major concerns. Four sets of challenges were identified concerning linguistic and cultural translations of informed consent documents and other study materials, related to the: (1) context, (2) process, (3) content and (4) translation of these documents. Host country contextual issues included low literacy rates, education (e.g., documents may need to be written below 5th grade reading level), and experiences with research, and different views of written documentation. Certain terms and concepts may not exist in other languages, or have additional connotations that back translations do not always reveal. Challenges arise because of not only the content of word-for-word, literal translation, but the linguistic form of the language, such as tone (e.g., appropriate forms of politeness vs. legalese, seen as harsh), syntax, manner of questions posed, and the concept of the consent); and the contexts of use affect meaning. Problems also emerged in bilateral communications--US IRBs may misunderstand local practices, or communicate insufficiently the reasons for their decisions to foreign RECs. In sum, these data highlight several challenges that have received little, if any, attention in past literature on translation of informed consent and study materials, and have crucial implications for improving practice, education, research and policy, suggesting several strategies, including needs for broader open-source multilingual lexicons, and more awareness of the complexities involved.
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Sippel D, Marckmann G, Ndzie Atangana E, Strech D. Clinical Ethics in Gabon: The Spectrum of Clinical Ethical Issues Based on Findings from In-Depth Interviews at Three Public Hospitals. PLoS One 2015; 10:e0132374. [PMID: 26161655 PMCID: PMC4498757 DOI: 10.1371/journal.pone.0132374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 06/13/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Unlike issues in biomedical research ethics, ethical challenges arising in daily clinical care in Sub-Saharan African countries have not yet been studied in a systematic manner. However this has to be seen as a distinct entity as we argue in this paper. Our aim was to give an overview of the spectrum of clinical ethical issues and to understand what influences clinical ethics in the Sub-Saharan country of Gabon. MATERIALS AND METHODS In-depth interviews with 18 health care professionals were conducted at three hospital sites in Gabon. Interview transcripts were analyzed using a grounded theory approach (open and axial coding), giving a qualitative spectrum of categories for clinical ethical issues. Validity was checked at a meeting with study participants and other health care experts in Gabon after analysis of the data. RESULTS Twelve main categories (with 28 further-specified subcategories) for clinical ethical issues were identified and grouped under three core categories: A) micro level: "confidentiality and information", "interpersonal, relational and behavioral issues", "psychological strain of individuals", and "scarce resources"; B) meso level: "structural issues of medical institutions", "issues with private clinics", "challenges connected to the family", and "issues of education, training and competence"; and C) macro level: "influence of society, culture, religion and superstition", "applicability of western medicine", "structural issues on the political level", and "legal issues". DISCUSSION Interviewees reported a broad spectrum of clinical ethical issues that go beyond challenges related to scarce financial and human resources. Specific socio-cultural, historical and educational backgrounds also played an important role. In fact these influences are central to an understanding of clinical ethics in the studied local context. Further research in the region is necessary to put our study into perspective. As many participants reported a lack of awareness of ethical issues amongst other health care professionals in daily clinical practice, we suggest that international organizations and national medical schools should consider infrastructure and tools to improve context-sensitive capacity building in clinical ethics for Sub-Saharan African countries like Gabon.
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Affiliation(s)
- Daniel Sippel
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies Dresden (CRTD), Technische Universität Dresden, Dresden, Germany
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Centre for Ethics and Law in the Life Sciences (CELLS), Hannover Medical School, Hannover, Germany
- * E-mail:
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Affiliation(s)
- Robert Klitzman
- Klitzman is Professor of Psychiatry and Director of the Masters of Bioethics Program at Columbia University, New York, NY
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Kengne-Ouafo JA, Millard JD, Nji TM, Tantoh WF, Nyoh DN, Tendongfor N, Enyong PA, Newport MJ, Davey G, Wanji S. Understanding of research, genetics and genetic research in a rapid ethical assessment in north west Cameroon. Int Health 2015; 8:197-203. [PMID: 25969503 PMCID: PMC4866326 DOI: 10.1093/inthealth/ihv034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/13/2015] [Indexed: 02/02/2023] Open
Abstract
Background There is limited assessment of whether research participants in low-income settings are afforded a full understanding of the meaning of medical research. There may also be particular issues with the understanding of genetic research. We used a rapid ethical assessment methodology to explore perceptions surrounding the meaning of research, genetics and genetic research in north west Cameroon. Methods Eleven focus group discussions (including 107 adults) and 72 in-depth interviews were conducted with various stakeholders in two health districts in north west Cameroon between February and April 2012. Results Most participants appreciated the role of research in generating knowledge and identified a difference between research and healthcare but gave varied explanations as to this difference. Most participants' understanding of genetics was limited to concepts of hereditary, with potential benefits limited to the level of the individual or family. Explanations based on supernatural beliefs were identified as a special issue but participants tended not to identify any other special risks with genetic research. Conclusion We demonstrated a variable level of understanding of research, genetics and genetic research, with implications for those carrying out genetic research in this and other low resource settings. Our study highlights the utility of rapid ethical assessment prior to complex or sensitive research.
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Affiliation(s)
- Jonas A Kengne-Ouafo
- Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
| | - James D Millard
- Wellcome Trust Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, Brighton BN1 9PX, UK
| | - Theobald M Nji
- Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon Department of Sociology and Anthropology, University of Buea, PO Box 63, Buea, Cameroon
| | - William F Tantoh
- Department of Sociology and Anthropology, University of Buea, PO Box 63, Buea, Cameroon
| | - Doris N Nyoh
- Department of Sociology, University of Douala, Cameroon
| | - Nicholas Tendongfor
- Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
| | - Peter A Enyong
- Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
| | - Melanie J Newport
- Wellcome Trust Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, Brighton BN1 9PX, UK
| | - Gail Davey
- Wellcome Trust Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, Brighton BN1 9PX, UK
| | - Samuel Wanji
- Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
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Halkoaho A, Pietilä AM, Ebbesen M, Karki S, Kangasniemi M. Cultural aspects related to informed consent in health research: A systematic review. Nurs Ethics 2015; 23:698-712. [PMID: 25904548 DOI: 10.1177/0969733015579312] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In order to protect the autonomy of human subjects, we need to take their culture into account when we are obtaining informed consent. OBJECTIVE AND RESEARCH DESIGN This study describes the cultural aspects related to informed consent in health research and is based on electronic searches that were conducted using the Scopus, PubMed, CINAHL, and Cochrane databases published between 2000 and 2013. A total of 25 articles were selected. FINDINGS Our findings indicate that cultural perspectives relating to the informed consent process are essential during the whole research process and particularly crucial in the planning phase of a study. Our study indicates that appropriate communication between different stakeholders plays a vital role in cultural understanding. DISCUSSION AND CONCLUSION The researchers' awareness of cultural differences and their ability to work in a culturally sensitive way are key factors in improving study participation and retention in a multicultural context. Taking cultural aspects into account during the whole research process improves the quality of research.
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Affiliation(s)
| | | | - Mette Ebbesen
- iPSYCH & Department of Culture and Society, Aarhus University, Denmark
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Tam NT, Huy NT, Thoa LTB, Long NP, Trang NTH, Hirayama K, Karbwang J. Participants' understanding of informed consent in clinical trials over three decades: systematic review and meta-analysis. Bull World Health Organ 2015; 93:186-98H. [PMID: 25883410 PMCID: PMC4371493 DOI: 10.2471/blt.14.141390] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To estimate the proportion of participants in clinical trials who understand different components of informed consent. METHODS Relevant studies were identified by a systematic review of PubMed, Scopus and Google Scholar and by manually reviewing reference lists for publications up to October 2013. A meta-analysis of study results was performed using a random-effects model to take account of heterogeneity. FINDINGS The analysis included 103 studies evaluating 135 cohorts of participants. The pooled proportion of participants who understood components of informed consent was 75.8% for freedom to withdraw at any time, 74.7% for the nature of study, 74.7% for the voluntary nature of participation, 74.0% for potential benefits, 69.6% for the study's purpose, 67.0% for potential risks and side-effects, 66.2% for confidentiality, 64.1% for the availability of alternative treatment if withdrawn, 62.9% for knowing that treatments were being compared, 53.3% for placebo and 52.1% for randomization. Most participants, 62.4%, had no therapeutic misconceptions and 54.9% could name at least one risk. Subgroup and meta-regression analyses identified covariates, such as age, educational level, critical illness, the study phase and location, that significantly affected understanding and indicated that the proportion of participants who understood informed consent had not increased over 30 years. CONCLUSION The proportion of participants in clinical trials who understood different components of informed consent varied from 52.1% to 75.8%. Investigators could do more to help participants achieve a complete understanding.
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Affiliation(s)
- Nguyen Thanh Tam
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Tien Huy
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Le Thi Bich Thoa
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Phuoc Long
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | | | - Kenji Hirayama
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki, Japan
| | - Juntra Karbwang
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
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Gazzinelli MF, Souza VDS, Campos ELW, Fernandes MM, Lobato L. Autonomous decision and behavior required in clinical trials: study with a socioeconomically vulnerable population. TEXTO & CONTEXTO ENFERMAGEM 2014. [DOI: 10.1590/0104-07072014002410013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Quasi-experimental study conducted to assess the effects of an educational intervention based on the Health Action Process Approach Model, in which autonomous decision-making and behaviors required for the participation in a clinical study were favored. This is an intervention study involving participants in a clinical trial conducted in the State of Minas Gerais, Brazil. The intervention was based on the social and cognitive variables of the Health Action Process Approach model and assessed by applying questionnaires before and after intervention. The results were compared using the McNemar test. The educational intervention favored knowledge on both the expectations about the results of the clinical trial and risk of infection by intestinal helminths, development of the ability to plan the behaviors required by the clinical trial and the necessary confidence to lead, keep, and retrieve them. Analysis of the results showed that the educational intervention favored both autonomous decision-making and the behavior required by clinical trials.
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Lobato L, Bethony JM, Pereira FB, Grahek SL, Diemert D, Gazzinelli MF. Impact of gender on the decision to participate in a clinical trial: a cross-sectional study. BMC Public Health 2014; 14:1156. [PMID: 25377601 PMCID: PMC4232621 DOI: 10.1186/1471-2458-14-1156] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 10/28/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND In order for Informed Consent to be ethical and valid each clinical trial participant must be able to make a voluntary decision to participate, free from pressure or coercion. Nonetheless, many factors may influence the decision reached, and such influences may be different for male and female volunteers. Being aware of these differences may help researches develop better processes for obtaining consent that safeguard the right of autonomy for all participants. The goal of this study was to evaluate potential gender-based differences in the factors influencing clinical trial participation. METHODS This cross-sectional study was conducted in the Northeast region of Minas Gerais, Brazil, in October 2011. A structured questionnaire was administered to 143 volunteers (48 male, 95 female) screened for participation in a clinical study of an investigational functional food with potential anthelminthic properties. Answers regarding their decision to participate in the study were compared, by gender, using chi-square and Mann Whitney tests. Odds ratios (OR) was used to measure association. RESULTS A majority of subjects (58% of males, 59% of females) listed the desire to collaborate with the development of a product against parasitic worms as their main reason for participation. Females were significantly more likely to report a decision influenced by friends, family, or researchers (OR 3.14, 3.45, and 3.46 respectively, p < 0.005). Females were also significantly more likely to report a decision influenced by general altruistic considerations (OR 8.45, p < 0.005). There was no difference, by gender, in the report of decisions influenced by informational meetings, understanding of the disease, or the availability of medical treatments or exams. There was also no difference in knowledge of the rights of research participants. CONCLUSION Study results indicate that there is a strong difference between male and female participants regarding social influences on the decision to participate in clinical research. Further research into the impact this may have on autonomy is warranted.
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Affiliation(s)
- Lucas Lobato
- />School of Nursing, Federal University of Minas Gerais, 190 Av. Alfredo Balena, Room 508, Belo Horizonte, MG 30130-100 Brazil
| | - Jeffrey Michael Bethony
- />Department of Microbiology, Immunology and Tropical Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC USA
| | - Fernanda Bicalho Pereira
- />School of Nursing, Federal University of Minas Gerais, 190 Av. Alfredo Balena, Room 508, Belo Horizonte, MG 30130-100 Brazil
| | - Shannon Lee Grahek
- />Department of Microbiology, Immunology and Tropical Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC USA
| | - David Diemert
- />Department of Microbiology, Immunology and Tropical Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC USA
| | - Maria Flávia Gazzinelli
- />School of Nursing, Federal University of Minas Gerais, 190 Av. Alfredo Balena, Room 508, Belo Horizonte, MG 30130-100 Brazil
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Kengne-Ouafo JA, Nji TM, Tantoh WF, Nyoh DN, Tendongfor N, Enyong PA, Newport MJ, Davey G, Wanji S. Perceptions of consent, permission structures and approaches to the community: a rapid ethical assessment performed in North West Cameroon. BMC Public Health 2014; 14:1026. [PMID: 25277694 PMCID: PMC4195877 DOI: 10.1186/1471-2458-14-1026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 09/23/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Understanding local contextual factors is important when conducting international collaborative studies in low-income country settings. Rapid ethical assessment (a brief qualitative intervention designed to map the ethical terrain of a research setting prior to recruitment of participants), has been used in a range of research-naïve settings. We used rapid ethical assessment to explore ethical issues and challenges associated with approaching communities and gaining informed consent in North West Cameroon. METHODS This qualitative study was carried out in two health districts in the North West Region of Cameroon between February and April 2012. Eleven focus group discussions (with a total of 107 participants) were carried out among adult community members, while 72 in-depth interviews included health workers, non-government organisation staff and local community leaders. Data were collected in English and pidgin, translated where necessary into English, transcribed and coded following themes. RESULTS Many community members had some understanding of informed consent, probably through exposure to agricultural research in the past. Participants described a centralised permission-giving structure in their communities, though there was evidence of some subversion of these structures by the educated young and by women. Several acceptable routes for approaching the communities were outlined, all including the health centre and the Fon (traditional leader). The importance of time spent in sensitizing the community and explaining information was stressed. CONCLUSIONS Respondents held relatively sophisticated understanding of consent and were able to outline the structures of permission-giving in the community. Although the structures are unique to these communities, the role of certain trusted groups is common to several other communities in Kenya and Ethiopia explored using similar techniques. The information gained through Rapid Ethical Assessment will form an important guide for future studies in North West Cameroon.
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Affiliation(s)
- Jonas A Kengne-Ouafo
- />Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon
- />Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
| | - Theobald M Nji
- />Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
- />Department of Sociology and Anthropology, University of Buea, PO Box 63, Buea, Cameroon
| | - William F Tantoh
- />Department of Sociology and Anthropology, University of Buea, PO Box 63, Buea, Cameroon
| | - Doris N Nyoh
- />Department of Sociology, University of Douala, Douala, Cameroon
| | - Nicholas Tendongfor
- />Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon
- />Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
| | - Peter A Enyong
- />Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon
- />Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
| | - Melanie J Newport
- />Wellcome Trust Centre for Global Health Research, Brighton & Sussex Medical School, Falmer Campus, Brighton, BN1 9PX UK
| | - Gail Davey
- />Wellcome Trust Centre for Global Health Research, Brighton & Sussex Medical School, Falmer Campus, Brighton, BN1 9PX UK
| | - Samuel Wanji
- />Department of Microbiology and Parasitology, University of Buea, PO Box 63, Buea, Cameroon
- />Research Foundation in Tropical Diseases and Environment, PO Box 474, Buea, Cameroon
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MacQueen KM, Chen M, Ramirez C, Nnko SEA, Earp KM. Comparison of closed-ended, open-ended, and perceived informed consent comprehension measures for a mock HIV prevention trial among women in Tanzania. PLoS One 2014; 9:e105720. [PMID: 25157899 PMCID: PMC4144899 DOI: 10.1371/journal.pone.0105720] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 07/28/2014] [Indexed: 11/19/2022] Open
Abstract
Verifying participant comprehension continues to be a difficult ethical and regulatory challenge for clinical research. An increasing number of articles assessing methods to improve comprehension have been published, but they use a wide range of outcome measures including open-ended, closed-ended, and self-perceived measures of comprehension. Systematic comparisons of different measures have rarely been reported. This study evaluated the likely direction of bias observed when using open-ended, closed-ended, and perceived ease of comprehension measures among women administered a mock informed consent process in Mwanza, Tanzania. Participants were randomized to either a closed-ended or an open-ended assessment of comprehension, administered the consent process for a hypothetical HIV prevention trial in Kiswahili, and then administered a comprehension assessment, per their randomization. They were then asked how easy or hard it was to understand each of the informed consent components measured in the comprehension assessment. Women in the closed-ended arm had significantly higher overall comprehension scores than in the open-ended arm. Perceived scores were significantly higher when compared to both open-ended and close-ended scores within arms but were similar between arms. Findings highlight the importance of comprehension assessments in complex clinical trials that go beyond asking participants if they understand or have any questions. They also indicate the need for continued exploration of objective measures of comprehension in international clinical research settings, so that points in need of clarification can be efficiently and effectively identified and addressed. Such measures would reduce burdens on both staff and participants that result from well-intentioned but potentially unnecessary time spent explaining in unwarranted detail things already understood.
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Affiliation(s)
- Kathleen M. MacQueen
- Global Health, Population and Nutrition, FHI 360, Durham, North Carolina, United States of America
- * E-mail:
| | - Mario Chen
- Global Health, Population and Nutrition, FHI 360, Durham, North Carolina, United States of America
| | - Catalina Ramirez
- Global Health, Population and Nutrition, FHI 360, Durham, North Carolina, United States of America
| | - Soori E. A. Nnko
- Sexual and Reproductive Health, National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | - Kelly M. Earp
- Global Health, Population and Nutrition, FHI 360, Durham, North Carolina, United States of America
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Synnot A, Ryan R, Prictor M, Fetherstonhaugh D, Parker B. Audio-visual presentation of information for informed consent for participation in clinical trials. Cochrane Database Syst Rev 2014; 2014:CD003717. [PMID: 24809816 PMCID: PMC6599866 DOI: 10.1002/14651858.cd003717.pub3] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented, for example, on the Internet or on DVD) are one such method. We updated a 2008 review of the effects of these interventions for informed consent for trial participation. OBJECTIVES To assess the effects of audio-visual information interventions regarding informed consent compared with standard information or placebo audio-visual interventions regarding informed consent for potential clinical trial participants, in terms of their understanding, satisfaction, willingness to participate, and anxiety or other psychological distress. SEARCH METHODS We searched: the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 6, 2012; MEDLINE (OvidSP) (1946 to 13 June 2012); EMBASE (OvidSP) (1947 to 12 June 2012); PsycINFO (OvidSP) (1806 to June week 1 2012); CINAHL (EbscoHOST) (1981 to 27 June 2012); Current Contents (OvidSP) (1993 Week 27 to 2012 Week 26); and ERIC (Proquest) (searched 27 June 2012). We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or verbal information), with standard forms of information provision or placebo audio-visual information, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to consider participating in a real or hypothetical clinical study. (In the earlier version of this review we only included studies evaluating informed consent interventions for real studies). DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. We synthesised the findings using meta-analysis, where possible, and narrative synthesis of results. We assessed the risk of bias of individual studies and considered the impact of the quality of the overall evidence on the strength of the results. MAIN RESULTS We included 16 studies involving data from 1884 participants. Nine studies included participants considering real clinical trials, and eight included participants considering hypothetical clinical trials, with one including both. All studies were conducted in high-income countries.There is still much uncertainty about the effect of audio-visual informed consent interventions on a range of patient outcomes. However, when considered across comparisons, we found low to very low quality evidence that such interventions may slightly improve knowledge or understanding of the parent trial, but may make little or no difference to rate of participation or willingness to participate. Audio-visual presentation of informed consent may improve participant satisfaction with the consent information provided. However its effect on satisfaction with other aspects of the process is not clear. There is insufficient evidence to draw conclusions about anxiety arising from audio-visual informed consent. We found conflicting, very low quality evidence about whether audio-visual interventions took more or less time to administer. No study measured researcher satisfaction with the informed consent process, nor ease of use.The evidence from real clinical trials was rated as low quality for most outcomes, and for hypothetical studies, very low. We note, however, that this was in large part due to poor study reporting, the hypothetical nature of some studies and low participant numbers, rather than inconsistent results between studies or confirmed poor trial quality. We do not believe that any studies were funded by organisations with a vested interest in the results. AUTHORS' CONCLUSIONS The value of audio-visual interventions as a tool for helping to enhance the informed consent process for people considering participating in clinical trials remains largely unclear, although trends are emerging with regard to improvements in knowledge and satisfaction. Many relevant outcomes have not been evaluated in randomised trials. Triallists should continue to explore innovative methods of providing information to potential trial participants during the informed consent process, mindful of the range of outcomes that the intervention should be designed to achieve, and balancing the resource implications of intervention development and delivery against the purported benefits of any intervention.More trials, adhering to CONSORT standards, and conducted in settings and populations underserved in this review, i.e. low- and middle-income countries and people with low literacy, would strengthen the results of this review and broaden its applicability. Assessing process measures, such as time taken to administer the intervention and researcher satisfaction, would inform the implementation of audio-visual consent materials.
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Affiliation(s)
| | | | - Megan Prictor
- School of Public Health and Human Biosciences, La Trobe UniversityCochrane Consumers and Communication Review GroupBundooraAustralia3086
| | - Deirdre Fetherstonhaugh
- La Trobe UniversityAustralian Centre for Evidence Based Aged Care (ACEBAC)BundooraAustralia3086
| | - Barbara Parker
- La Trobe UniversityAustralian Institute for Primary Care & Ageing, Faculty of Health SciencesBundooraAustralia3086
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Addissie A, Davey G, Newport MJ, Addissie T, MacGregor H, Feleke Y, Farsides B. A mixed-methods study on perceptions towards use of Rapid Ethical Assessment to improve informed consent processes for health research in a low-income setting. BMC Med Ethics 2014; 15:35. [PMID: 24885049 PMCID: PMC4055294 DOI: 10.1186/1472-6939-15-35] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 04/24/2014] [Indexed: 11/16/2022] Open
Abstract
Background Rapid Ethical Assessment (REA) is a form of rapid ethnographic assessment conducted at the beginning of research project to guide the consent process with the objective of reconciling universal ethical guidance with specific research contexts. The current study is conducted to assess the perceived relevance of introducing REA as a mainstream tool in Ethiopia. Methods Mixed methods research using a sequential explanatory approach was conducted from July to September 2012, including 241 cross-sectional, self-administered and 19 qualitative, in-depth interviews among health researchers and regulators including ethics committee members in Ethiopian health research institutions and universities. Results In their evaluation of the consent process, only 40.2% thought that the consent process and information given were adequately understood by study participants; 84.6% claimed they were not satisfied with the current consent process and 85.5% thought the best interests of study participants were not adequately considered. Commonly mentioned consent-related problems included lack of clarity (48.1%), inadequate information (34%), language barriers (28.2%), cultural differences (27.4%), undue expectations (26.6%) and power imbalances (20.7%). About 95.4% believed that consent should be contextualized to the study setting and 39.4% thought REA would be an appropriate approach to improve the perceived problems. Qualitative findings helped to further explore the gaps identified in the quantitative findings and to map-out concerns related to the current research consent process in Ethiopia. Suggestions included, conducting REA during the pre-test (pilot) phase of studies when applicable. The need for clear guidance for researchers on issues such as when and how to apply the REA tools was stressed. Conclusion The study findings clearly indicated that there are perceived to be correctable gaps in the consent process of medical research in Ethiopia. REA is considered relevant by researchers and stakeholders to address these gaps. Exploring further the feasibility and applicability of REA is recommended.
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Afolabi MO, Okebe JU, McGrath N, Larson HJ, Bojang K, Chandramohan D. Informed consent comprehension in African research settings. Trop Med Int Health 2014; 19:625-642. [PMID: 24636078 DOI: 10.1111/tmi.12288] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Previous reviews on participants' comprehension of informed consent information have focused on developed countries. Experience has shown that ethical standards developed on Western values may not be appropriate for African settings where research concepts are unfamiliar. We undertook this review to describe how informed consent comprehension is defined and measured in African research settings. METHODS We conducted a comprehensive search involving five electronic databases: Medline, Embase, Global Health, EthxWeb and Bioethics Literature Database (BELIT). We also examined African Index Medicus and Google Scholar for relevant publications on informed consent comprehension in clinical studies conducted in sub-Saharan Africa. 29 studies satisfied the inclusion criteria; meta-analysis was possible in 21 studies. We further conducted a direct comparison of participants' comprehension on domains of informed consent in all eligible studies. RESULTS Comprehension of key concepts of informed consent varies considerably from country to country and depends on the nature and complexity of the study. Meta-analysis showed that 47% of a total of 1633 participants across four studies demonstrated comprehension about randomisation (95% CI 13.9-80.9%). Similarly, 48% of 3946 participants in six studies had understanding about placebo (95% CI 19.0-77.5%), while only 30% of 753 participants in five studies understood the concept of therapeutic misconception (95% CI 4.6-66.7%). Measurement tools for informed consent comprehension were developed with little or no validation. Assessment of comprehension was carried out at variable times after disclosure of study information. No uniform definition of informed consent comprehension exists to form the basis for development of an appropriate tool to measure comprehension in African participants. CONCLUSIONS Comprehension of key concepts of informed consent is poor among study participants across Africa. There is a vital need to develop a uniform definition for informed consent comprehension in low literacy research settings in Africa. This will be an essential step towards developing appropriate tools that can adequately measure informed consent comprehension. This may consequently suggest adequate measures to improve the informed consent procedure.
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Affiliation(s)
- Muhammed O Afolabi
- Medical Research Council Unit, Fajara, The Gambia.,London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Heidi J Larson
- London School of Hygiene and Tropical Medicine, London, UK
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Chima SC. Evaluating the quality of informed consent and contemporary clinical practices by medical doctors in South Africa: an empirical study. BMC Med Ethics 2013; 14 Suppl 1:S3. [PMID: 24564932 PMCID: PMC3878312 DOI: 10.1186/1472-6939-14-s1-s3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Informed consent is a legal and ethical doctrine derived from the principle of respect for autonomy. Generally two rights derived from autonomy are accorded legal protection. The constitutional right to bodily integrity followed by the right to bodily well-being, protected by professional negligence rules. Therefore healthcare professionals treating patients' without valid consent may be guilty of infringing patients' rights. Many challenges are experienced by doctors obtaining informed consent in complex multicultural societies like South Africa. These include different cultural ethos, multilingualism, poverty, education, unfamiliarity with libertarian rights based autonomy, and power asymmetry between doctors and patients. All of which could impact on the ability of doctors to obtain legally valid informed consent. METHODS The objective of this study was to evaluate whether the quality of informed consent obtained by doctors practicing in South Africa is consistent with international ethical standards and local regulations. Responses from 946 participants including doctors, nurses and patients was analyzed, using a semi-structured self-administered questionnaire and person triangulation in selected public hospitals in Durban, KwaZulu-Natal, South Africa. RESULTS The median age of 168 doctors participating was 30 years with 51% females, 28% interns, 16% medical officers, 26% registrars, 30% consultant/specialists. A broad range of clinical specialties were represented. Challenges to informed consent practice include language difficulties, lack of interpreters, workload, and time constraints. Doctors spent 5-10 minutes on consent, disclosed most information required to patients, however knowledge of essential local laws was inadequate. Informed consent aggregate scores (ICAS) showed that interns/registrars scored lower than consultants/specialists. ICAS scores were statistically significant by specialty (p = 0.005), with radiologists and anaesthetists scoring lowest, while internists, GPs and obstetricians/gynaecologists scored highest. Comparative ICAS scores showed that professional nurses scored significantly lower than doctors (p ≤ 0.001). CONCLUSIONS This study shows that though doctors had general knowledge of informed consent requirements, execution in practice was inadequate, with deficiency in knowledge of basic local laws and regulations. Remedying identified deficiencies may require a 'corps' of interpreters in local hospitals to assist doctors in dealing with language difficulties, and continuing education in medical law and ethics to improve informed consent practices and overall quality of healthcare service delivery.
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Affiliation(s)
- Sylvester C Chima
- Programme of Bio & Research Ethics and Medical Law, Nelson R Mandela School of Medicine and School of Nursing and Public Health College of Health Sciences, University of KwaZulu Natal Durban, South Africa
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Abstract
Consent and community engagement (CE) in health research are two aspects of a single concern-that research is carried out in a respectful manner where social value is maximized. There are important overlaps and interdependencies between consent and CE; for example, CE can provide insights into how best to tailor consent to context and can be an important component of consent processes. Engaging communities can also have intrinsic and instrumental value beyond consent; for example, as a means of showing respect and identifying appropriate ways of working respectfully. In this paper we critically examine how CE and consent processes are characterized, conducted, and evaluated in diverse health research contexts, and propose a preliminary research agenda to support future learning in these critical areas.
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Mack N, Ramirez CB, Friedland B, Nnko S. Lost in translation: assessing effectiveness of focus group questioning techniques to develop improved translation of terminology used in HIV prevention clinical trials. PLoS One 2013; 8:e73799. [PMID: 24040075 PMCID: PMC3769359 DOI: 10.1371/journal.pone.0073799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 07/23/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction Achieving participant comprehension has proven to be one of the most difficult, practical, and ethical challenges of HIV prevention clinical trials. It becomes even more challenging when local languages do not have equivalent scientific and technical vocabularies, rendering communication of scientific concepts in translated documents extremely difficult. Even when bilingual lexicons are developed, there is no guarantee that participants understand the terminology as translated. Methods We conducted twelve focus groups with women of reproductive age in Mwanza, Tanzania to explore the effectiveness of four questioning techniques for: (1) assessing participants' familiarity with existing technical terms and concepts, (2) generating a list of acceptable technical and non-technical terms, (3) testing our definitions of technical terms, and (4) verifying participants' preferences for terms. Focus groups were transcribed, translated, and qualitatively analyzed. Results and Discussion A translation process that uses all four questioning techniques in a step-wise approach is an effective way to establish a baseline understanding of participants' familiarity with research terms, to develop and test translatable definitions, and to identify participants' preferred terminology for international HIV clinical research. This may help to ensure that important concepts are not “lost in translation.” The results emphasize the importance of using a variety of techniques depending on the level of participant familiarity with research concepts, the existence of colloquial or technical terms in the target language, and the inherent complexity of the terms.
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Affiliation(s)
- Natasha Mack
- Social and Behavioral Health Sciences, FHI 360, Durham, North Carolina, United States of America
- * E-mail:
| | - Catalina B. Ramirez
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Barbara Friedland
- HIV and AIDS Program, Population Council, New York, New York, United States of America
| | - Soori Nnko
- National Institute for Medical Research, Mwanza, Tanzania
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Abstract
IRBs have been criticized for long and complicated consent forms, but how IRBs make decisions about these issues hasn't been examined. I contacted leaders of 60 IRBs, and interviewed IRB leaders from 34 (response rate = 55%), and 13 members and administrators. IRBs confront challenges and dilemmas regarding these documents: what and how much these forms should include (e.g., how "perfect" forms should be). While IRBs generally seek to decrease the length and complexity, institutions and industry funders often want these forms to be legal documents. IRBs may also "nitpick" these documents without realizing the costs. This study, the first to explore how IRBs view and make decisions about consent forms, suggests underlying tensions, ambiguities, and subjectivities that have important implications for future policy, practice, education, and research.
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Joglekar NS, Deshpande SS, Sahay S, Ghate MV, Bollinger RC, Mehendale SM. Correlates of lower comprehension of informed consent among participants enrolled in a cohort study in Pune, India. Int Health 2013; 5:64-71. [PMID: 24029848 PMCID: PMC3889625 DOI: 10.1093/inthealth/ihs009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 06/19/2012] [Accepted: 07/23/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optimum comprehension of informed consent by research participants is essential yet challenging. This study explored correlates of lower comprehension of informed consent among 1334 participants of a cohort study aimed at estimating HIV incidence in Pune, India. METHODS As part of the informed consent process, a structured comprehension tool was administered to study participants. Participants scoring ≥90% were categorised into the 'optimal comprehension group', whilst those scoring 80-89% were categorised into the 'lower comprehension group'. Data were analysed to identify sociodemographic and behavioural correlates of lower consent comprehension. RESULTS The mean ± SD comprehension score was 94.4 ± 5.00%. Information pertaining to study-related risks was not comprehended by 61.7% of participants. HIV-negative men (adjusted OR [AOR] = 4.36, 95% CI 1.71-11.05) or HIV-negative women (AOR = 13.54, 95% CI 6.42-28.55), illiteracy (AOR= 1.65, 95% CI 1.19-2.30), those with a history of multiple partners (AOR = 1.73, 95% CI 1.12-2.66) and those never using condoms (AOR = 1.35, 95% CI 1.01-1.82) were more likely to have lower consent comprehension. CONCLUSIONS We recommend exploration of domains of lower consent comprehension using a validated consent comprehension tool. Improved education in these specific domains would optimise consent comprehension among research participants.
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Affiliation(s)
- Neelam S. Joglekar
- National AIDS Research Institute, Indian Council of Medical Research, Pune, India
| | - Swapna S. Deshpande
- National AIDS Research Institute, Indian Council of Medical Research, Pune, India
| | - Seema Sahay
- National AIDS Research Institute, Indian Council of Medical Research, Pune, India
| | - Manisha V. Ghate
- National AIDS Research Institute, Indian Council of Medical Research, Pune, India
| | | | - Sanjay M. Mehendale
- National Institute of Epidemiology, Indian Council of Medical Research, Chennai, India
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Vreeman R, Kamaara E, Kamanda A, Ayuku D, Nyandiko W, Atwoli L, Ayaya S, Gisore P, Scanlon M, Braitstein P. A qualitative study using traditional community assemblies to investigate community perspectives on informed consent and research participation in western Kenya. BMC Med Ethics 2012; 13:23. [PMID: 23009744 PMCID: PMC3515354 DOI: 10.1186/1472-6939-13-23] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 09/03/2012] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND International collaborators face challenges in the design and implementation of ethical biomedical research. Evaluating community understanding of research and processes like informed consent may enable researchers to better protect research participants in a particular setting; however, there exist few studies examining community perspectives in health research, particularly in resource-limited settings, or strategies for engaging the community in research processes. Our goal was to inform ethical research practice in a biomedical research setting in western Kenya and similar resource-limited settings. METHODS We sought to use mabaraza, traditional East African community assemblies, in a qualitative study to understand community perspectives on biomedical research and informed consent within a collaborative, multinational research network in western Kenya. Analyses included manual, progressive coding of transcripts from mabaraza to identify emerging central concepts. RESULTS Our findings from two mabaraza with 108 community members revealed that, while participants understood some principles of biomedical research, they emphasized perceived benefits from participation in research over potential risks. Many community members equated health research with HIV testing or care, which may be explained in part by the setting of this particular study. In addition to valuing informed consent as understanding and accepting a role in research activities, participants endorsed an increased role for the community in making decisions about research participation, especially in the case of children, through a process of community consent. CONCLUSIONS Our study suggests that international biomedical research must account for community understanding of research and informed consent, particularly when involving children. Moreover, traditional community forums, such as mabaraza in East Africa, can be used effectively to gather these data and may serve as a forum to further engage communities in community consent and other aspects of research.
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Affiliation(s)
- Rachel Vreeman
- Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5900, Indianapolis, IN, 46202, USA
- USAID - Academic Model Providing Access to Healthcare (AMPATH) Partnership, P.O. Box 4606, Eldoret, 30100, Kenya
- Regenstrief Institute, Inc., 410 W. 10th St., Suite 2000, Indianapolis, IN, 46202-3012, USA
- Children’s Health Services Research, Health Information and Translational Sciences Building, Suite #1000, 410 W. 10th St., Indianapolis, IN, 46202, USA
| | - Eunice Kamaara
- Departments of Philosophy and Religious Studies, Moi University, P.O. Box 3990, Eldoret, 30100, Kenya
| | - Allan Kamanda
- Moi Teaching and Referral Hospital, Nandi Road, P.O. Box 3, Eldoret, 30100, Kenya
| | - David Ayuku
- Department of Behavioural Sciences, School of Medicine, Moi University College of Health Sciences, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Winstone Nyandiko
- USAID - Academic Model Providing Access to Healthcare (AMPATH) Partnership, P.O. Box 4606, Eldoret, 30100, Kenya
- Department of Child Health and Paediatrics, School of Medicine, Moi University College of Health Sciences, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Lukoye Atwoli
- USAID - Academic Model Providing Access to Healthcare (AMPATH) Partnership, P.O. Box 4606, Eldoret, 30100, Kenya
- Department of Mental Health, School of Medicine, Moi University College of Health Sciences, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Samuel Ayaya
- USAID - Academic Model Providing Access to Healthcare (AMPATH) Partnership, P.O. Box 4606, Eldoret, 30100, Kenya
- Department of Child Health and Paediatrics, School of Medicine, Moi University College of Health Sciences, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Peter Gisore
- USAID - Academic Model Providing Access to Healthcare (AMPATH) Partnership, P.O. Box 4606, Eldoret, 30100, Kenya
- Department of Child Health and Paediatrics, School of Medicine, Moi University College of Health Sciences, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Michael Scanlon
- Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5900, Indianapolis, IN, 46202, USA
| | - Paula Braitstein
- USAID - Academic Model Providing Access to Healthcare (AMPATH) Partnership, P.O. Box 4606, Eldoret, 30100, Kenya
- Regenstrief Institute, Inc., 410 W. 10th St., Suite 2000, Indianapolis, IN, 46202-3012, USA
- Department of Medicine, Indiana University School of Medicine, 545 Barnhill Drive, EH 317, Indianapolis, IN, 46202, USA
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Kiguba R, Kutyabami P, Kiwuwa S, Katabira E, Sewankambo NK. Assessing the quality of informed consent in a resource-limited setting: a cross-sectional study. BMC Med Ethics 2012; 13:21. [PMID: 22906301 PMCID: PMC3478970 DOI: 10.1186/1472-6939-13-21] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Accepted: 08/13/2012] [Indexed: 11/20/2022] Open
Abstract
Background The process of obtaining informed consent continues to be a contentious issue in clinical and public health research carried out in resource-limited settings. We sought to evaluate this process among human research participants in randomly selected active research studies approved by the School of Medicine Research and Ethics Committee at the College of Health Sciences, Makerere University. Methods Data were collected using semi-structured interviewer-administered questionnaires on clinic days after initial or repeat informed consent procedures for the respective clinical studies had been administered to each study participant. Results Of the 600 participants interviewed, two thirds (64.2%, 385/600) were female. Overall mean age of study participants was 37.6 (SD = 7.7) years. Amongst all participants, less than a tenth (5.9%, 35/598) reported that they were not given enough information before making a decision to participate. A similar proportion (5.7%, 34/597) reported that they had not signed a consent form prior to making a decision to participate in the study. A third (33.7%, 201/596) of the participants were not aware that they could, at any time, voluntarily withdraw participation from these studies. Participants in clinical trials were 50% less likely than those in observational studies [clinical trial vs. observational; (odds ratio, OR = 0.5; 95% CI: 0.35-0.78)] to perceive that refusal to participate in the parent research project would affect their regular medical care. Conclusions Most of the participants signed informed consent forms and a vast majority felt that they received enough information before deciding to participate. On the contrary, several were not aware that they could voluntarily withdraw their participation. Participants in observational studies were more likely than those in clinical trials to perceive that refusal to participate in the parent study would affect their regular medical care.
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Affiliation(s)
- Ronald Kiguba
- Makerere University College of Health Sciences, Kampala, Uganda.
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Osei A. Challenges of clinical trials in low- and middle-income countries. Int Psychiatry 2012. [DOI: 10.1192/s1749367600003039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Clinical trials have been conducted almost wholly in high-income countries until recently, yet their results may not always be valid or applicable in middle- and low-income countries. Clinical trials are now, though, increasingly being done in less wealthy countries. While this is welcome, there is a need to ensure the profit motive does not override the benefits. Partnership with local counterparts while adhering to international standards should help to maintain high-quality output from clinical trials.
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Abstract
UNLABELLED Increasingly, US-sponsored research is carried out in developing countries, but how US Institutional Review Boards (IRBs) approach the challenges they then face is unclear. METHODS I conducted in-depth interviews of about 2 hours each, with 46 IRB chairs, directors, administrators and members. I contacted the leadership of 60 IRBs in the United States (US) (every fourth one in the list of the top 240 institutions by National Institutes of Health (NIH) funding), and interviewed IRB leaders from 34 (55%). RESULTS US IRBs face ethical and logistical challenges in interpreting and applying principles and regulations in developing countries, given economic and health disparities, and limited contextual knowledge. These IRBs perceive wide variations in developing world IRBs/RECs' quality, resources and training; and health systems in some countries may have long-standing practices of corruption. These US IRBs often know little of local contexts, regulations and standards of care, and struggle with understandings of other cultures' differing views of autonomy, and risks and benefits of daily life. US IRBs thus face difficult decisions, including how to interpret principles, how much to pay subjects and how much sustainability to require from researchers. IRB responses and solutions include trying to maintain higher standards for developing world research, obtain cultural expertise, build IRB infrastructure abroad, communicate with foreign IRBs, and 'negotiate' for maximum benefits for participants and fearing 'worst-case scenarios'. CONCLUSIONS US and foreign IRBs confront a series of tensions and dilemmas in reviewing developing world research. These data have important implications for increased education of IRBs/RECs and researchers in the US and abroad, and for research and practice.
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Affiliation(s)
- Robert L Klitzman
- Columbia University College of Physicians and Surgeons - Psychiatry, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA.
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Bull S, Farsides B, Tekola Ayele F. Tailoring information provision and consent processes to research contexts: the value of rapid assessments. J Empir Res Hum Res Ethics 2012; 7:37-52. [PMID: 22378133 PMCID: PMC3427649 DOI: 10.1525/jer.2012.7.1.37] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Guidance requires that consent processes for research be appropriately tailored to their cultural context. This paper discusses the use of rapid assessments to identify cultural and ethical issues arising when explaining research in studies in The Gambia and Ethiopia. The assessments provided insights into appropriate ways of providing information to minimize the risk of stigmatizing vulnerable research populations; research participants' views about the most important information to provide about research and their understandings of research; and perceived constraints upon reaching voluntary decisions about participation. These insights demonstrate that rapid assessments are a relatively quick and inexpensive intervention that can provide valuable information to assist in the tailoring of information provision and consent processes to research context while maintaining and enhancing participants' fundamental protections.
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Affiliation(s)
- Susan Bull
- The Ethox Centre, Division of Public Health, University of Oxford, Old Road Campus, Headington, Oxford, United Kingdom.
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Corneli AL, Sorenson JR, Bentley ME, Henderson GE, Bowling JM, Nkhoma J, Moses A, Zulu C, Chilima J, Ahmed Y, Heilig CM, Jamieson DJ, van der Horst C. Improving participant understanding of informed consent in an HIV-prevention clinical trial: a comparison of methods. AIDS Behav 2012; 16:412-21. [PMID: 21656146 PMCID: PMC3923514 DOI: 10.1007/s10461-011-9977-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Empirical research on informed consent has shown that study participants often do not fully understand consent information. This study assessed participant understanding of three mock consent approaches describing an HIV-prevention clinical trial in Lilongwe, Malawi prior to trial implementation. Pregnant women (n = 297) were systematically selected from antenatal-care waiting lines and sequentially allocated to receive an enhanced standard consent form (group 1), a context-specific consent form (group 2), or context-specific counseling cards (group 3). Understanding of research concepts and study procedures was assessed immediately postintervention and at 1-week follow-up. At postintervention, participants in groups 2 and 3 understood more about research concepts and study procedures compared with group 1. Group 3 participants also understood more about study procedures compared with group 2. At follow-up, participants in groups 2 and 3 continued to understand more about research concepts and study procedures. Context-specific approaches improved understanding of consent information in this study.
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Affiliation(s)
- Amy L Corneli
- Department of Health Behavior and Health Education, The University of North Carolina at Chapel Hill, USA.
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Abstract
This article highlights a number of ethical challenges I face in obtaining informed consent from very sick subjects with suspected pulmonary tuberculosis (TB). Some of the subjects with TB have an associated human immunodeficiency virus (HIV) infection. From my experience in administering informed consent and health surveys, I found the subjects to be generally mentally stable but physically exhausted. Many of the very sick subjects cough excessively and cannot tolerate a 45-minute conversation with the study staff in order for them to administer consent and conduct a survey after the routine clinical evaluation. In this situation, the administration of a qualitative consent that preserves the subject's right and autonomy becomes a challenge.
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Affiliation(s)
- Gambo G Aliyu
- Institute of Human Virology University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Kass NE, Chaisson L, Taylor HA, Lohse J. Length and complexity of US and international HIV consent forms from federal HIV network trials. J Gen Intern Med 2011; 26:1324-8. [PMID: 21748435 PMCID: PMC3208469 DOI: 10.1007/s11606-011-1778-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 05/18/2011] [Accepted: 06/14/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Informed consent is required in most clinical research with humans. While federal regulations state consent information should be understandable to participants, concerns have been raised that consent forms are overly long and complex. DESIGN Consent forms from 2006 HIV network trials sponsored by the National Institutes of Health (NIH), Division of AIDS (DAIDS), were analyzed for complexity and length. Comparisons were made between US and international sites, template and site forms, adult and pediatric trials, and trial type. How randomization and placebos were explained was examined as these are frequently misunderstood. RESULTS One hundred twenty-four consent forms (21 template and 103 site forms) were reviewed. Median readability was 9.2 grade level, although confidentiality sections were 12.35 median grade level. International sites' forms had lower readability than US forms (p = 0.025), template forms had lower readability than site forms (p = 0.046), and adult forms were less complex than pediatric (parent) forms (p < 0.0001). Median length of all forms was 22.4 pages; the 85 forms from adult studies had a median length of 27.4 pages. Sections describing randomization were a median length of 53 words. CONCLUSIONS Consent forms are extremely long, exceeding recommendations for how much information readily can be processed. Networks should consider providing shorter consent templates, consistent with federal recommendations, given that sites' forms are based on these models. Further research should examine whether forms emphasizing key information (rather than providing details about all aspects of the research) improve understanding of research.
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Affiliation(s)
- Nancy E Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA.
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Chaisson LH, Kass NE, Chengeta B, Mathebula U, Samandari T. Repeated assessments of informed consent comprehension among HIV-infected participants of a three-year clinical trial in Botswana. PLoS One 2011; 6:e22696. [PMID: 22046230 PMCID: PMC3203064 DOI: 10.1371/journal.pone.0022696] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 07/05/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Informed consent (IC) has been an international standard for decades for the ethical conduct of clinical trials. Yet frequently study participants have incomplete understanding of key issues, a problem exacerbated by language barriers or lack of familiarity with research concepts. Few investigators measure participant comprehension of IC, while even fewer conduct interim assessments once a trial is underway. METHODS AND FINDINGS We assessed comprehension of IC using a 20-question true/false quiz administered in 6-month intervals in the context of a placebo-controlled, randomized trial for the prevention of tuberculosis among HIV-infected adults in Botswana (2004-2009). Quizzes were offered in both Setswana and English. To enroll in the TB trial, participants were required to have ≥ 16/20 correct responses. We examined concepts understood and the degree to which understanding changed over three-years. We analyzed 5,555 quizzes from 1,835 participants. The participants' highest education levels were: 28% primary, 59% secondary, 9% tertiary and 7% no formal education. Eighty percent of participants passed the enrollment quiz (Quiz1) on their first attempt and the remainder passed on their second attempt. Those having higher than primary education and those who took the quiz in English were more likely to receive a passing score on their first attempt (adjusted odds ratios and 95% confidence intervals, 3.1 (2.4-4.0) and 1.5 (1.2, 1.9), respectively). The trial's purpose or procedures were understood by 90-100% of participants, while 44-77% understood randomization, placebos, or risks. Participants who failed Quiz1 on their initial attempt were more likely to fail quizzes later in the trial. Pass rates improved with quiz re-administration in subsequent years. CONCLUSIONS Administration of a comprehension quiz at enrollment and during follow-up was feasible in a large, international collaboration and efficiently determined IC comprehension by trial participants. Strategies to improve understanding of concepts like placebos and randomization are needed. Comprehension assessments throughout a study may reinforce key concepts.
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Affiliation(s)
- Lelia H. Chaisson
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Nancy E. Kass
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Unami Mathebula
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Taraz Samandari
- Botswana-USA Partnership, Gaborone and Francistown, Botswana
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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