How the powerful decide: access to research participation by those at the margins

Disability rights and empowerment: Reflections on AJCP research and a call to action

People living with physical, sensory, intellectual, and/or developmental disabilities experience complex social, environmental, political, and cultural challenges along with stigma and marginalization in education, employment, and community life. These multiple and complex barriers often hinder their full and effective participation in society. In this reflection, we curated articles on physical, sensory, intellectual, and/or developmental disabilities published in the American Journal of Community Psychology from 1973 to 2022. We reviewed titles and abstracts to identify themes that grouped manuscripts in relevant community psychology core concepts and values. From our analysis, five themes emerged: (a) promoting empowerment and advocacy; (b) promoting organizations and settings that support people with disabilities; (c) including people with disabilities in knowledge production; (d) promoting social justice in disability research, and (e) promoting support networks of families of people with disabilities. We conclude this reflection with a discussion of recommendations for future research, practice, and a call to action.

A Call-In for Allyship and Anti-Ableism in Intellectual Disability Research

Provoked by decades of grassroots activism, anti-ableist work is underway to advance disability rights. Intellectual disability (ID) researchers can integrate these social changes into their work by interrogating and transforming the beliefs and practices that underpin ID research. We share actionable ideas to foster anti-ableism and allyship in ID research. These include: (1) Learn from and nurture long-term, mutual relationships with people with ID; (2) Amplify the voices of people with ID in institutional structures that influence research; (3) Infuse anti-ableist frameworks into our own research; and (4) Embody a career-long commitment to disability rights, reflexive practice, and growth.

Advancing the Personalization of Assessment and Intervention in Autistic Adolescents and Young Adults by Targeting Self-Determination and Executive Processes

As autistic adolescents and young adults navigate the transition to adulthood, there is a need to partner with them to identify strengths and needed supports to enable goal-directed actions. This article conceptually integrates research on self-determination, defined by Causal Agency Theory, and executive processes in autism to provide direction for future research and practice. We describe how integrating research on self-determination and executive processes could enable autistic adolescents and young adults to be engaged in the process of assessing executive processes and self-determination. We discuss how this can better inform personalization of supports for self-determination interventions by focusing on support needs related to executive processes, including inhibitory control and cognitive flexibility, from a strengths-based perspective. We discuss how this can enable self-determination interventions that promote outcomes aligned with the values of the autistic community.

Parental perspectives on research for Down syndrome

BACKGROUND

Down syndrome is the most common genetic disorder associated with intellectual and developmental disabilities. Research to improve health care outcomes in Down syndrome lags significantly behind other disease categories. Among these reasons are funding, recruitment and availability of research studies being conducted.

METHODS

We surveyed 228 parents of individuals with Down syndrome to understand their perceptions of research, study design, how they seek out information and topics they would like to see researched.

RESULTS

Parents with children 18 years and younger responded to our survey. Parents indicated their willingness to participate in research (72%), yet few have (36%). Parents identified barriers to participation, research they feel would help their child, and interests in seeing new therapies and drug studies.

CONCLUSION

These findings identify recommendations and insights from parents on future research agendas, studies and recruitment strategies that may help researchers improve outcomes for individuals with Down syndrome.

In Different Voices: The Views of People with Disabilities about Return of Results from Precision Medicine Research

PURPOSE

Returning genetic results to research participants is gaining momentum in the USA. It is believed to be an important step in exploring the impact of efforts to translate findings from research to bedside and public health benefits. Some also hope that this practice will incentivize research participation, especially among people from historically marginalized communities who are commonly underrepresented in research. However, research participants' interest in receiving nongenomic medical and nonmedical results that may emerge from precision medicine research (PMR) is understudied and no study to date has explored the views of people with disabilities about return of genomic and nongenomic results from PMR.

METHODS

In a national online survey of people with disabilities, participants were queried about their interest in receiving biological, environmental, and lifestyle results from PMR (n = 1,294). Analyses describe findings for all of the participants and comparisons for key demographic characteristics and disability subgroups.

RESULTS

The participants expressed high interest in biological and health-related results and less interest in other findings. However, the interest among the study participants was lower than that found in comparable studies of the general population. Moreover, this interest varied significantly across gender, race/ethnicity, and disability subgroups. Possible reasons for these differences are discussed.

CONCLUSION

Insofar as return of results from PMR may impact translational efforts, it is important to better understand the role of sociomedical marginalization in decisions about return of results from PMR and to develop strategies to address existing barriers.

Development of the AASPIRE Web Accessibility Guidelines for Autistic Web Users

Websites figure predominantly in everyday life. However, many websites remain inaccessible to autistic people, and existing efforts to improve accessibility are in early stages, do not directly include autistic users in their development, or have not been empirically evaluated. The Academic Autism Spectrum Partnership in Research and Education (AASPIRE) used a community-based participatory research approach to create a website to improve health care access for autistic adults. We used the creation of that website as a "living laboratory" to develop the AASPIRE Web Accessibility Guidelines for Autistic Web Users. Our guidelines are grounded in accessibility theory, had autistic end-user involvement at all stages, and were empirically evaluated through a usability study and evaluation surveys. We incorporated what we learned into the design of the website, and compiled the accessibility information into a set of guidelines. The guidelines offer recommendations for increasing the physical, intellectual, and social acceptability of websites for use by autistic adults. In the evaluation of the website by 170 autistic end users, nearly all indicated it was easy to use (97%), easy to understand (95%), important (97%), and useful (96%). Ninety-two percent would recommend it to a friend, and 95% would recommend it to a health care provider. There were no significant associations between usability or understandability and education level, receipt of help using the site, browser type (e.g., IE or Safari), or device type (e.g., PC or tablet). We recommend using the guidelines to improve website accessibility for autistic Internet users.

Lay Summary

AASPIRE Web Accessibility Guideline: This guideline is a summary of the accessibility features we identified and implemented during the course of our study. None of these items were difficult or expensive for us to implement. They did not require special expertise beyond basic web programming and technical communications skills. We recommend that anyone seeking to create accessible websites for autistic users follow the Academic Autism Spectrum Partnership in Research and Education (AASPIRE) Web Accessibility Guideline in addition to broader web and communications standards and principles.Physical accessibility:Provide at least one low-contrast neutral color palette option to accommodate sensitive vision.Provide a selection of color palettes, including one with a dark background and one with a light background, again to accommodate color and contrast sensitivity.Provide a no-style option (i.e., no cascading style sheets (CSS) to accommodate browser customization and users who prefer no stylistic formatting.Provide simple consistent navigation and highly consistent site behavior for increased ease of operation.Avoid textured backgrounds, moving images, decorative elements that do not convey information, and other visual and/or sonic "clutter"; these types of elements may make the site difficult or impossible to comprehend.Provide smaller font sizes in addition to larger ones; large font sizes may make the page appear cluttered and difficult to read.Use a plain accessible sans-serif font (e.g., Arial) for ease of readability.Intellectual accessibility:Use the simplest interface possible for ease of understanding.Use simple concrete icons or images to communicate redundant information with text, and accommodate multiple ways of understanding information.Clearly label site elements with their purpose everywhere on the site, even if it seems redundant, to make navigation and site functionality easier to follow.Provide concrete examples where applicable to accommodate difficulties in understanding abstractions or generalizations.Minimize scrolling so the user does not need to rely on assumptions about content to guess what might be on the page.Show all important features and site navigation (as opposed to within combo box drop-down areas) so the user does not need to rely on assumptions to guess whether the item exists and how to access it. For example, completely visible list boxes or radio buttons can be used instead of combo boxes.Make content as short as possible without sacrificing precision and specificity, to reduce cognitive burden.Social accessibility:Be specific and precise in language use; avoid colloquialisms, idioms, and ambiguity to accommodate difficulties with language pragmatics.Explain the reason behind any nonstandard instructions or unusual information; provide additional pragmatic context to accommodate difficulties with language pragmatics.Provide alternatives to definitive response items on surveys and forms, for example, "do not know," "do not wish to say," or "not applicable," to reduce frustration for not being able to produce an exact answer.Use FAQ formats to organize complex information to enhance clarity as to why the information might be useful to the user and how it connects to their life.Define terms that might have different meanings depending on social context, or which might be jargon related to a specialized field (e.g., "drug interactions" and "health care providers"), to accommodate difficulties with language pragmatics.Be mindful of autistic culture and community preferences, including the language used to describe autism and how community-based symbols and history might influence content and perception of site credibility.

Does the built environment moderate the relationship between having a disability and lower levels of physical activity? A systematic review

The relationship between the built environment and physical activity has been well documented. However, little is known about how the built environment affects physical activity among people with disabilities, who have disproportionately higher rates of physical inactivity and obesity. This study is the first systematic review to examine the role of the built environment as a moderator of the relationship between having a disability (physical, sensory or cognitive) and lower levels of physical activity. After conducting an extensive search of the literature published between 1990 and 2015, 2039 articles were screened, 126 were evaluated by abstract and 66 by full text for eligibility in the review. Data were abstracted using a predefined coding guide and synthesized from both qualitative and quantitative studies to examine evidence of moderation. Nine quantitative and six qualitative articles met the inclusion criteria. Results showed that most research to date has been on older adults with physical disabilities. People with disabilities described how aspects of the built environment affect neighborhood walking, suggesting a positive moderating role of features related to safety and aesthetic qualities, such as benches, lighting and stop light timing. There were mixed results among studies that examined the relationship quantitatively. Most of the studies were not designed to appropriately examine moderation. Future research should utilize valid and reliable built environment measures that are more specific to disability and should include people with and without disabilities to allow for testing of moderation of the built environment.

What's the Harm? Harms in Research With Adults With Intellectual Disability

Scientific advances can improve the lives of adults with intellectual disability, yet concerns that research participation may impose harm impede scientific progress. What counts as harmful can be subjective and perceptions of harm may vary among stakeholders. We studied perspectives on the harmfulness of research events among adults with intellectual disability, family members and friends, disability service providers, researchers, and Institutional Review Board members. We found considerable variance. For example, adults with intellectual disability see exclusion from research as more harmful, but most psychosocial harms as less significant than others. All stakeholders agree that having someone else make the participation decision is harmful. Findings provide insights into the concept of harm and ethical research with adults with intellectual disability.

Is Safety in the Eye of the Beholder? Safeguards in Research With Adults With Intellectual Disability

Human subjects research has a core commitment to participant well-being. This obligation is accentuated for once exploited populations such as adults with intellectual disability. Yet we know little about the public's views on appropriate safeguards for this population. We surveyed adults with intellectual disability, family members and friends, disability service providers, researchers, and Institutional Review Board (IRB) members to compare views on safeguards. We found many points of convergence of views, particularly for decision-making and participation. One trend is that adults with intellectual disability perceive greater safety in being engaged directly in recruitment, and recruitment by specific individuals. Researchers and IRB members need to consider community views to facilitate the safe and respectful inclusion of adults with intellectual disability.

Staff attitudes towards people with intellectual disabilities in Japan and the United States

BACKGROUND

Staff attitudes may affect choices available to persons with intellectual disabilities (ID). This study examined attitudes towards people with ID among staff working with people with ID in Japan and the United States.

METHOD

Attitudes of staff working with people with ID in Japan and the United States were compared using the Community Living Attitudes Scale, Intellectual Disabilities Form. Responses were examined via multivariate analysis of variance.

RESULTS

In unadjusted analyses, Japanese staff exhibited a greater tendency towards Sheltering and Exclusion of people with ID and lower endorsement of Empowerment and Similarity of people with ID. After controlling for covariates, the country effect was no longer significant for Sheltering and Exclusion. Age and education were significantly associated with attitudes in the adjusted model.

CONCLUSIONS

While attitudes in Japan appeared less supportive of community inclusion of people with ID, some of the differences between countries were attributable to other staff characteristics such as age and education. Findings provide new information about how attitudes of staff in each country compare with each other.

Ethics in pharmacologic research in the child with a disability

This article reviews the unique ethical concerns that face clinicians, researchers, and family members in the realm of research involving children and youth with childhood-onset disabilities. Presented are the contemporary legal and regulatory environments in which we work and a synopsis of relevant articles on bioethics in this sector of the scientific literature. The most important ethical themes that emerged for children with disabilities include justice in research, consent and assent, child-centered communication, child- and family-centered decision making, participation in multiple studies, and therapeutic misconception. Two publicly recorded clinical studies are profiled to illustrate common considerations and concerns that arise during our ethical review of drug studies involving children with disabilities. It is concluded that the balance of access to current research and treatments must be weighed against risk for all involved. Collaborative planning amongst those involved in the development, review, approval, conduct, and oversight of drug study protocols can lead to effective scientific inquiry within the context of core ethical principles and child- and family-centered care.

The Convention on the Rights of Persons with Disabilities: a foundation for ethical disability and health research in developing countries

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) has foregrounded disability as a human rights and equity issue, elevating it to a priority global research area. Academics from Western universities are likely to play an increasing role in disability health research in developing countries. In such contexts, there is a need to bridge the gap between procedural ethics and the realities of disability research in cross-cultural contexts. We provide guidance on engaging in ethical disability health research that intersects with and upholds the CRPD. We highlight challenges and tensions in doing so, underscoring the need to be sensitive to the sociocultural and political context of disability that determines how ethical research should proceed. We conclude with 5 recommendations.

Where are persons with intellectual disabilities in medical research? A survey of published clinical trials

BACKGROUND

Persons with intellectual disabilities (ID) are exposed to the same medical interventions as everyone else. Given the unique health profiles of many persons with ID, it cannot be assumed that they will react to medical treatments the same as persons without ID. It is not clear if medical clinical trials routinely include persons with ID. The purpose of this research survey was to examine the inclusion of persons with ID in medical research trials, and to determine whether accommodations and/or study modifications could have been made to promote greater inclusion in medical research.

METHOD

Three hundred randomised control and clinical trials published between 2007 and 2011 in the six highest impact medical journals were randomly selected. Each study was reviewed for inclusion of persons with ID, and possible accommodations that could have been put in place without compromising research integrity. Corresponding authors received a follow-up survey to determine whether persons with ID were included, but were not mentioned in the article.

RESULTS

Only 6 (2%) of 300 randomly chosen studies clearly included persons with ID. Over 90% of studies were designed in ways that would automatically exclude persons with ID from participating. The author survey revealed three additional studies including persons with ID. Most persons with ID could have participated in at least 70% of the studies with simple accommodations and/or minor procedural modifications.

DISCUSSION

The findings highlight the exclusion of persons with ID in medical research. Efforts are needed to increase inclusion through research policy initiatives and education.

Paradigm shifts in disability and health: toward more ethical public health research

Disability is often considered a health outcome disproportionately experienced by minority groups. It is also possible to view people with disabilities as a minority group that itself experiences health disparities. Calls to reduce these disparities necessitate the inclusion of people with developmental disabilities in research, although resulting ethical issues can thwart scientific progress. Using disability rights principles can help address ethical challenges and promote safe, respectful public health research. Examples include applying human rights frameworks, providing accommodations, attending to power, countering legacies of deficits-based models of disability, and transforming access to science more broadly. Collectively, these strategies can encourage broader engagement in safe, respectful, inclusive public health research aimed at promoting the health and well-being of people with developmental disabilities.

Assessing Understanding and Obtaining Consent from Adults with Intellectual Disabilities for a Health Promotion Study

People with intellectual disabilities are often excluded from research, in part because they may be perceived as lacking capacity to provide informed consent. A requirement of informed decision making about research participation is ability to understand the study description and disclosures presented during the consent process. The authors' aims were to determine the extent to which study participants with intellectual disabilities were able to answer questions about key aspects of study disclosures, identify ways in which people who provided appropriate answers for all of the questions differed from those who had difficulty with one or more of the questions, and examine patterns of responses to see if certain issues were more difficult to understand than others. The authors piloted a short set of questions to assess the extent to which adults with intellectual disabilities were able to answer questions about key aspects of a health promotion study. More than half of study participants correctly answered all of the questions. For those not able to answer all questions, identifying potential risks of being in the study proved the most challenging. The findings indicate that many people with intellectual disabilities likely can provide their own consent to participate in low risk studies.

Participant experience of invasive research in adults with intellectual disability

Clinical research is a necessity if effective and safe treatments are to be developed. However, this may well include the need for research that is best described as 'invasive' in that it may be associated with some discomfort or inconvenience. Limitations in the undertaking of invasive research involving people with intellectual disabilities (ID) are perhaps related to anxieties within the academic community and among ethics committees; however, the consequence of this neglect is that innovative treatments specific to people with ID may not be developed. Such concerns are likely to continue while there is limited published knowledge regarding the actual experiences of people with ID who have participated in invasive clinical research. As part of a pilot study trialling the novel use of a surgically inserted device to curb overeating in people with Prader-Willi syndrome (PWS) we have investigated the experience of research through semistructured qualitative interviews involving three participants and their carers. Thematic analysis revealed that the adults with PWS and their family carers rated their participation positively, seeing it as a rewarding and enriching experience. This brief report discusses findings from our interview data in order to highlight strategies which may ensure that research is acceptable to participants, meets the necessary ethical standards and is able to achieve the aims set out by the researchers. To our knowledge, this is the first study to record experiences directly from people with PWS and their carers regarding their involvement in invasive clinical research.

The influence of participation, gender and organizational sense of community on psychological empowerment: the moderating effects of income

This study explored the influence of participation, gender and organizational sense of community (SOC) on both the intrapersonal and interactional components of psychological empowerment (PE). Participants were residents (n = 562) involved in community organizing efforts in five U.S. communities. Measures of participation and SOC were tailored to community organization contexts. SOC assessed three dimensions: (1) connection of members to the organization; (2) perceptions about the organization as a bridge to other groups and organizations in the broader community; and (3) bond or attachment to the community at large. Income (low, middle and high-income) was tested as a moderator of these relationships. Results showed significant moderating effects of income on the relationship between participation, gender and SOC on both components of PE. Participation was positively related with intrapersonal empowerment across income levels, but positively related with interactional empowerment only for low-income individuals. Gender was only associated with intrapersonal empowerment, and only for low-income individuals. SOC, as expressed through bridging to the broader community, was positively related with interactional PE for all income levels, but with intrapersonal PE for only low and middle-income individuals. In contrast, member connection to the organization was not related to interactional empowerment and significantly related to intrapersonal empowerment only for individuals with higher income. The importance of participation, gender and SOC for different types of empowerment and the impact of income on the SOC-empowerment relationship are discussed.

A neuroimaging proof of principle study of Down's syndrome and dementia: ethical and methodological challenges in intrusive research

BACKGROUND

Research into specific illnesses and the development of new treatments may only become possible as new technologies become available. When used for research, such technologies may best be described as 'intrusive', in that they require a considerable willingness and commitment on the part of the participants. This has increasingly been the case for brain disorders and illnesses where novel neuroimaging techniques, often combined with clinical and psychological assessments, have the potential to result in new understanding. People with intellectual disabilities (ID) have a history of under-representation as participants in research using such technologies and are therefore at risk of not receiving equal access to state-of-the-art treatments. We propose that 'intrusive' biomedical research is both possible and ethical in ID, and explore some of the methodological challenges by reference to a recent proof of principle study that used a relatively new ligand-based brain scanning technique in a group of volunteers with Down's syndrome.

METHODS

Five overlapping stages of the study methodology were identified and evaluated for their acceptability to volunteers with mild to moderate ID through discussion, reflection, and analysis of structured feedback in the context of key policy documents, ethical guidelines and relevant legislation.

RESULTS

Identification of key ethical and methodological challenges from reflective practice and participant feedback facilitated the emergence of strategies that permitted continual refinement of the study design. Important areas considered included (1) being clear about the purpose and scientific justification for the study; (2) reconciling the potential risks and benefits with relevant ethical guidelines and legislation; (3) identifying and implementing effective recruitment strategies; (4) optimising and assessing capacity to consent; and (5) making the 'intrusive' procedures as acceptable as possible to people with ID.

CONCLUSION

We were able to demonstrate that a proof of principle study incorporating a novel brain scanning technique in a group of volunteers with ID was feasible, safe and well tolerated, despite the vulnerabilities of the study cohort and the intrusive nature of the research. We consider the study within an ethical and historical discourse about the principles that define current 'best practice' in ID research and propose a number of key recommendations for making intrusive research acceptable in people with ID.

The human rights context for ethical requirements for involving people with intellectual disability in medical research

BACKGROUND

The history of ethical guidelines addresses protection of human rights in the face of violations. Examples of such violations in research involving people with intellectual disabilities (ID) abound. We explore this history in an effort to understand the apparently stringent criteria for the inclusion of people with ID in research, and differences between medical and other research within a single jurisdiction.

METHOD

The history of the Helsinki Declaration and informed consent within medical research, and high-profile examples of ethical misconduct involving people with ID and other groups are reviewed. The UN Convention on the Rights of Persons with Disabilities is then examined for its research implications. This background is used to examine a current anomaly within an Australian context for the inclusion of people with ID without decisional capacity in medical versus other types of research.

RESULTS

Ethical guidelines have often failed to protect the human rights of people with ID and other vulnerable groups. Contrasting requirements within an Australian jurisdiction for medical and other research would seem to have originated in early deference to medical authority for making decisions on behalf of patients.

CONCLUSIONS

Stringent ethical requirements are likely to continue to challenge researchers in ID. A human rights perspective provides a framework for engaging both researchers and vulnerable participant groups.