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Giovannoni G, Hawkes CH, Lechner-Scott J, Levy M, Yeh EA, Pepper G, Schmierer K. Can placebo-controlled phase 2 disease-modifying therapy trials in MS still be justified? Mult Scler Relat Disord 2024; 87:105698. [PMID: 38850685 DOI: 10.1016/j.msard.2024.105698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Affiliation(s)
- Gavin Giovannoni
- The Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Christopher H Hawkes
- The Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Michael Levy
- Massachusetts General Hospital and Harvard Medical School, Massachusetts, USA
| | - E Ann Yeh
- Department of Paediatrics, Dalla Lana School of Public Health, University of Toronto
| | - George Pepper
- Shift.ms, Platform, New Station Street, LS1 4JB, United Kingdom
| | - Klaus Schmierer
- The Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
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Ali A, Clarke DF. Digital measures in epilepsy in low-resourced environments. Expert Rev Pharmacoecon Outcomes Res 2024; 24:705-712. [PMID: 37818647 DOI: 10.1080/14737167.2023.2270163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/09/2023] [Indexed: 10/12/2023]
Abstract
INTRODUCTION Digital measures and digital health-care delivery have been rarely implemented in lower-and-middle-income countries (LMICs), contributing to worsening global disparities and inequities. Sustainable ways to implement and use digital approaches will help to improve time to access, management, and quality of life in persons with epilepsy, goals that remain unreachable in under-resourced communities. As under-resourced environments differ in human and economic resources, no one approach will be appropriate to all LMICs. AREAS COVERED Digital health and tools to monitor and measure digital endpoints and metrics of quality of life will need to be developed or adapted to the specific needs of under-resourced areas. Portable technologies may partially address the urban-rural divide. Careful delineation of stakeholders and their engagement and alignment in all efforts is critically important if these initiatives are to be successfully sustained. Privacy issues, neglected in many regions globally, must be purposefully addressed. EXPERT OPINION Epilepsy care in under-resourced environments has been limited by the lack of relevant technologies for diagnosis and treatment. Digital biomarkers, and investigative technological advances, may finally make it feasible to sustainably improve care delivery and ultimately quality of life including personalized epilepsy care.
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Affiliation(s)
- Amza Ali
- Department of Medicine, Faculty of Medical Sciences, Mona, Kingston, Jamaica
| | - Dave F Clarke
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
- Department of Pediatric Epilepsy, Dell Children's Medical Center of Central Texas, Austin, TX, USA
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Yim IS, Ali NA, Dosani A, Lalani S, Babar N, Nausheen S, Premji SS. Strengthening Recruitment and Retention: Mitigation Strategies in Two Longitudinal Studies of Pregnant Women in Pakistan. Matern Child Health J 2024:10.1007/s10995-024-03957-9. [PMID: 38907181 DOI: 10.1007/s10995-024-03957-9] [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] [Accepted: 05/27/2024] [Indexed: 06/23/2024]
Abstract
PURPOSE Global health researchers have a responsibility to conduct ethical research in a manner that is culturally respectful and safe. The purpose of this work is to describe our experiences with recruitment and retention in Pakistan, a low-middle-income country. DESCRIPTION We draw on two studies with a combined sample of 2161 low-risk pregnant women who participated in a pilot (n = 300) and a larger (n = 1861) prospective study of psychological distress and preterm birth at one of four centers (Garden, Hyderabad, Kharadar, Karimabad) of the Aga Khan University Hospital in Karachi, Pakistan. ASSESSMENT Challenges we encountered include economic hardship and access to healthcare; women's position in the family; safety concerns and time commitment; misconceptions and mistrust in the research process; and concerns related to blood draws. To mitigate these challenges, we developed culturally acceptable study incentives, involved family members in the decision-making process about study participation, partnered with participants' obstetrician-gynecologists, accommodated off site study visits, combined research visits with regular prenatal care visits, and modified research participation related to blood draws for some women. CONCLUSION Implementation of these mitigation strategies improved recruitment and retention success, and we are confident that the solutions presented will support future scientists in addressing sociocultural challenges while embarking on collaborative research projects in Pakistan and other low-middle-income countries.
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Affiliation(s)
- Ilona S Yim
- Department of Psychological Science, University of California, Irvine, 4201 Social and Behavioral Sciences Gateway, Irvine, CA, 92697-7085, USA.
| | - Naureen Akber Ali
- School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan
| | - Aliyah Dosani
- School of Nursing and Midwifery, Faculty of Health, Community & Education, Mount Royal University, Calgary, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Sharifa Lalani
- School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan
| | - Neelofur Babar
- Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan
| | - Sidrah Nausheen
- Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan
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Jamil H, Ranganathan S, Fissha AB, Vinck EE, Vervoort D. Low-Cost Innovations in Global Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241252441. [PMID: 38828943 DOI: 10.1177/15569845241252441] [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: 06/05/2024]
Abstract
Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, costing the lives of 18 million people annually, with up to one-third being attributable to cardiac surgical conditions. Approximately 6 billion people do not have access to safe, timely, and affordable cardiac surgery, predominantly affecting populations living in low-middle income countries. Cardiac surgical care is costly, resulting in few centers in variable-resource contexts operating continuously or with the resources observed in higher-resource environments. As a result, innovations may be formally developed or informally adopted to bypass resource constraints and ensure care delivery. Innovations have been observed across the cardiac surgical care continuum and across settings, potentially benefiting both high-income countries, where growing health care costs are becoming unsustainable, and low- and middle-income countries, where competing health agendas may limit investments into cardiac surgery. This narrative review attempts to address the costs associated with cardiac surgery, placing an emphasis on frugal innovations in the perioperative and postoperative care spectrum.
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Affiliation(s)
- Hera Jamil
- Life Sciences, Department of Biological Sciences, University of Toronto Scarborough, ON, Canada
| | | | - Aemon B Fissha
- College of Health Sciences, School of Medicine, Addis Ababa University, Ethiopia
| | - Eric E Vinck
- Division of Cardiac Surgery, Pontifical Bolivarian University, Medellín, Colombia
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
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Saleh M, Sharma K, Shamshudin A, Obayo I, Gondi S, Karimi N. Regulatory approval of clinical trials: is it time to reinvent the wheel? BMJ Glob Health 2024; 9:e013727. [PMID: 38267078 PMCID: PMC10823920 DOI: 10.1136/bmjgh-2023-013727] [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: 08/17/2023] [Accepted: 10/07/2023] [Indexed: 01/26/2024] Open
Abstract
Less than 1% of all clinical trials are conducted in Africa. In 2019, only six of 26 oncology clinical trials conducted in Africa were conducted in countries with subjects of African ancestry. There are multiple barriers that hinder the conduct of cancer clinical trials in Africa. Time to trial activation (TTA) is the administrative and regulatory process required before a study can be activated-an important metric and often a major barrier for site selection. In Kenya, TTA involves review by Institutional Review Board (IRB), Pharmacy and Poisons Board, National Commission for Science, Technology and Innovation and Ministry of Health, all in a sequential fashion. We performed a prospective review of TTA for all clinical trials initiated and began enrolment at the Aga Khan University-Clinical Research Unit between June 2020 and November 2022. TTA was defined as total time from submission of study documents (to regulatory bodies) to site activation by the sponsor. A total of 12 studies were submitted for regulatory review. Eleven (nine industry sponsored and two investigator initiated) were approved for activation. Three were COVID-19-related studies and eight were non-COVID-19-related studies. Mean TTA for COVID-related studies was 80 days (range 40-120). Mean TTA for non-COVID-related studies was 259 days (range 190-399). This TTA difference was statistically significant (p=0.02). TTA remains a significant barrier to the efficient regulatory approval of and subsequent conduct of clinical trials in Africa. COVID-19 pandemic revealed that parallel processing and expedited review of clinical trials allows efficient TTA without compromising human subject safety or data integrity. These lessons need to be applied to all clinical trials in order for African sites to become competitive and contribute data from African patients to global knowledge.
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Affiliation(s)
- Mansoor Saleh
- Hematology and Oncology, The Aga Khan University Hospital, Nairobi, Kenya
| | | | | | | | - Stacey Gondi
- The Aga Khan University Hospital, Nairobi, Kenya
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Fitzgerald TN, Zambeli-Ljepović A, Olatunji BT, Saleh A, Ameh EA. Gaps and priorities in innovation for children's surgery. Semin Pediatr Surg 2023; 32:151352. [PMID: 37976896 DOI: 10.1016/j.sempedsurg.2023.151352] [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] [Indexed: 11/19/2023]
Abstract
Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.
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Affiliation(s)
- Tamara N Fitzgerald
- Department of Surgery, Duke University, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA
| | - Alan Zambeli-Ljepović
- Philip R. Lee Institute for Health Policy Studies, University of California San Fransisco, USA
| | | | | | - Emmanuel A Ameh
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria.
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Giovannoni G, Hawkes CH, Lechner-Scott J, Levy M, Yeh EA. Is it ethical to use teriflunomide as an active comparator in phase 3 trials? Mult Scler Relat Disord 2023; 78:104911. [PMID: 37582327 DOI: 10.1016/j.msard.2023.104911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023]
Abstract
Ethical concerns have been raised about the practice of using teriflunomide, an oral licensed disease-modifying therapy, as an active comparator in phase 3 multiple sclerosis (MS) trials. The assumption is based on the perceived low efficacy of teriflunomide as judged by its effect on relapses and focal MRI activity. However, when you look beyond focal inflammation, teriflunomide has a robust impact on disability progression and a similar effect to the anti-CD20 monoclonal antibody therapies on slowing down the accelerated brain volume loss associated with MS. Teriflunomide is also more effective when used second or third line. The other classes of disease-modifying therapies have problems with their use as active comparators in clinical trials. Using a non-inferiority or equivalence trial design has its own unique set of regulatory and ethical challenges and is not necessarily a solution. There are also economic, altruistic and pragmatic reasons for continuing to use teriflunomide as an active comparator in MS clinical trials. An online survey indicates that the majority of the MS community feels it is still ethical to randomise subjects to teriflunomide and that procedures can be put in place to protect trial subjects randomised to teriflunomide. Therefore, we still have equipoise, and teriflunomide comparator trials are ethical.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - Christopher H Hawkes
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Michael Levy
- Massachusetts General Hospital and Harvard Medical School, MA, USA
| | - E Ann Yeh
- Department of Paediatrics, Dalla Lana School of Public Health, University of Toronto, Canada
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Johnston JC, Sartwelle TP, Zebenigus M, Arda B, Beran RG. Global Neurology: The Good, the Bad, and the Ugly. Neurol Clin 2023; 41:549-568. [PMID: 37407107 DOI: 10.1016/j.ncl.2023.03.008] [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: 07/07/2023]
Abstract
Global health programs engaging in isolated or short-term medical missions can and do cause harm, reinforce health care disparities, and impede medical care in the regions where it is so desperately needed. Related ethical, medical, and legal concerns are reviewed in this article. The authors recommend abandoning these ill-considered missions and focusing attention and resources on advancing neurology through ethically congruent, multisectoral, collaborative partnerships to establish sustainable, self-sufficient training programs within low- and middle-income countries.
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Affiliation(s)
- James C Johnston
- Auckland, New Zealand and San Antonio, TX, USA; Department of Neurology, Addis Ababa University School of Medicine, Ethiopia.
| | | | - Mehila Zebenigus
- Department of Neurology, Addis Ababa University School of Medicine, Ethiopia; Yehuleshet Higher Clinic, Addis Ababa, Ethiopia
| | - Berna Arda
- Department of Medical Ethics, Faculty of Medicine, Ankara University, Turkey
| | - Roy G Beran
- University of New South Wales, Sydney, Australia; Western Sydney University, Sydney, Australia; School of Medicine, Griffith University, Queensland, Australia
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Ahmed E. The Protection-Inclusion Dilemma: A Global Distributive Justice Perspective. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:120-121. [PMID: 37220355 DOI: 10.1080/15265161.2023.2201245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Eman Ahmed
- Suez Canal University Faculty of Medicine
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10
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von Gaudecker JR, Clarke DF, Perkins S, Ali A, Sanjuan D, Vidaurre J. Epilepsy care delivery during COVID-19 in resource-limited countries: A survey in collaboration with International Epilepsy Equity Group. Epilepsy Behav 2023; 138:108998. [PMID: 36436359 PMCID: PMC9690616 DOI: 10.1016/j.yebeh.2022.108998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The impact of pandemic has had worse effects in countries with already stretched healthcare resources. study's The study aimed to explore changes in epilepsy care delivery in resource-limited countries during and since the acute phase of the COVID-19 pandemic. METHOD A cross-sectional survey was conducted in 22 countries among healthcare providers (HCPs) caring for persons with epilepsy (PWE), in collaboration with newly formed global collaborators, the International Epilepsy Equity Group. Findings were compared based on the World Bank Ranking (WBR) and HCPs' practice type. Data were analyzed using Chi-square tests (α = 0.05) and pairwise multiple comparisons with α = 0.017 (Bonferroni adjustment). Open-ended responses were analyzed using thematic analysis. FINDINGS A total of 241 HCPs participated in the study. Of these, 8.30%, 65.98%, and 21.99% were from high-income (HIC), upper-middle-income (UMIC), and lower-middle-income countries (LMICs), respectively. Among HCPs, 31.12% were adult specialists, and 43.98% were pediatric specialists. During the acute phase of the pandemic, HCPs reported that the major barrier for PWE was difficulty reaching physicians/healthcare providers. Except for difficulty reaching physicians/healthcare providers (WBR P = 0.01 HIC < LMIC), no other significant differences in barriers during the acute phase were observed. Since the acute phase of the pandemic, the major concern for PWE was fear of getting infected with the SARS-CoV-2 virus. Significant differences in concerns since the acute phase included lockdowns (WBR: P = 0.03 UMIC < LMIC), fiscal difficulties (WBR: P < 0.001 UMICs < LMICs, UMICs < HIC; practice type: P = 0.006 adult < others, pediatrics < others), clinic closure (WBR: P = 0.003 UMIC < HIC; practice type: P =< 0.001 adult < others, pediatric < others), and long waiting times (WBR: P = 0.005, LMIC < UMIC, LMIC < HIC; practice type: P = 0.006 pediatric < adults). Diagnostic services, including EEG, MRI, CT (practice type: P < 0.001, adult < others; pediatric < others), and lab work (WBR: P = 0.01 UMIC < HIC), were restricted. The telephone was the most reported teleconsultation method used. Except for SMS/texting (WBR P = 0.02 UMIC < LMIC), there were no significant differences in teleconsultation methods used. DISCUSSION There is a high probability that the initial wave and consequent reduction of in-person care, restriction of health services, and fiscal difficulties affecting all involved in care delivery, led to the disruption of epilepsy care. Additional support are needed in resource-limited countries to cope with future pandemics.
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Affiliation(s)
- Jane R von Gaudecker
- Indiana University School of Nursing, Indiana University, Indianapolis, IN 46202, USA.
| | - Dave F Clarke
- Neurology and Pediatrics, Dell Medical School, University of Texas at Austin, USA; Pediatric Epilepsy, Dell Children's Medical Center of Central Texas, USA.
| | - Susan Perkins
- Department of Biostatistics, Indiana University School of Medicine, Indiana University, Indianapolis, IN 46202, USA.
| | - Amza Ali
- Epilepsy Centre of Jamaica, Jamaica; The University of the West Indies, Jamaica.
| | - Daniel Sanjuan
- National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
| | - Jorge Vidaurre
- Nationwide Children's Hospital - The Ohio State University, Columbus, OH, USA.
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11
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Rodriguez JJRB, Cuales JMD, Herrera MJB, Zubiri LAM, Muallil RM, Ishmael AI, Jimenez EB, Stoneking M, De Ungria MCA. Ethical challenges in genetic research among Philippine Indigenous Peoples: Insights from fieldwork in Zamboanga and the Sulu Archipelago. Front Genet 2022; 13:901515. [DOI: 10.3389/fgene.2022.901515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
The Philippines, with the recent discovery of an archaic hominin in Luzon and an extensive ethnolinguistic diversity of more than 100 Indigenous peoples, is crucial to understanding human evolution and population history in Island Southeast Asia. Advances in DNA sequencing technologies enable the rapid generation of genomic data to robustly address questions about origins, relatedness, and population movements. With the increased genetic sampling in the country, especially by international scientists, it is vital to revisit ethical rules and guidelines relevant to conducting research among Indigenous peoples. Our team led fieldwork expeditions between 2019 and February 2020 in Zamboanga and the Sulu Archipelago, a chain of islands connecting the Mindanao and Borneo landmasses. The trips concluded with a collection of 2,149 DNA samples from 104 field sites. We present our fieldwork experience among the mostly sea-oriented Sama-Bajaw and Tausug-speaking communities and propose recommendations to address the ethical challenges of conducting such research. This work contributes toward building an enabling research environment in the Philippines that respects the rights and autonomy of Indigenous peoples, who are the rightful owners of their DNA and all genetic information contained therein.
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12
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Keddy KH, Saha S, Kariuki S, Kalule JB, Qamar FN, Haq Z, Okeke IN. Using big data and mobile health to manage diarrhoeal disease in children in low-income and middle-income countries: societal barriers and ethical implications. THE LANCET INFECTIOUS DISEASES 2022; 22:e130-e142. [DOI: 10.1016/s1473-3099(21)00585-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 12/28/2022]
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13
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Ponka D, Coffman M, Fraser-Barclay KE, Fortier RDW, Howe A, Kidd M, Lennon RP, Madaki JKA, Mash B, Mohd Sidik S, van Weel C, Zawaly K, Goodyear-Smith F. Fostering global primary care research: a capacity-building approach. BMJ Glob Health 2021; 5:bmjgh-2020-002470. [PMID: 32624501 PMCID: PMC7337619 DOI: 10.1136/bmjgh-2020-002470] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 01/15/2023] Open
Abstract
The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.
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Affiliation(s)
- David Ponka
- Besrour Centre for Global Family Medicine, College of Family Physicians of Canada, Mississauga, Ontario, Canada .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Megan Coffman
- Robert Graham Center Policy Studies in Family Medicine and Primary Care, Washington DC, District of Columbia, USA
| | | | - Richard D W Fortier
- General Practice, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand.,Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Amanda Howe
- Primary Care, University of East Anglia Norwich Medical School, Norwich, Norfolk, UK
| | - Michael Kidd
- Department of Family and Community Medicine, University of Toronto, Canada and Southgate Institute for Health, Toronto, Ontario, Canada
| | - Robert P Lennon
- Family and Community Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jeremiah K A Madaki
- Family Medicine, University of Jos, Jos, Plateau, Nigeria.,Family Medicine, Jos University Teaching Hospital, Jos, Plateau, Nigeria
| | - Bob Mash
- Family and Emergency Medicine, Stellenbosch University, Cape Town, South Africa.,Stellenbosch University, Cape Town, South Africa
| | - Sherina Mohd Sidik
- Psychiatry, Universiti Putra Malaysia Faculty of Medicine and Health Sciences, Serdang, Selangor, Malaysia
| | - Chris van Weel
- Department Primary and Community Care, Radboud Universiteit Nijmegen, Nijmegen, The Netherlands.,Department of Health Services Research and Policy, Australian National University, Acton, Australian Capital Territory, Australia
| | - Kristina Zawaly
- Family Medicine, McGill University, Montreal, Quebec, Canada.,General Practice and Primary Health Care, The University of Auckland, Auckland, New Zealand
| | - Felicity Goodyear-Smith
- General Practice, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
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14
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Grimwade O, Savulescu J, Giubilini A, Oakley J, Osowicki J, Pollard AJ, Nussberger AM. Payment in challenge studies: ethics, attitudes and a new payment for risk model. JOURNAL OF MEDICAL ETHICS 2020; 46:815-826. [PMID: 32978306 PMCID: PMC7719900 DOI: 10.1136/medethics-2020-106438] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/09/2020] [Accepted: 08/07/2020] [Indexed: 05/22/2023]
Abstract
Controlled Human Infection Model (CHIM) research involves the infection of otherwise healthy participants with disease often for the sake of vaccine development. The COVID-19 pandemic has emphasised the urgency of enhancing CHIM research capability and the importance of having clear ethical guidance for their conduct. The payment of CHIM participants is a controversial issue involving stakeholders across ethics, medicine and policymaking with allegations circulating suggesting exploitation, coercion and other violations of ethical principles. There are multiple approaches to payment: reimbursement, wage payment and unlimited payment. We introduce a new Payment for Risk Model, which involves paying for time, pain and inconvenience and for risk associated with participation. We give philosophical arguments based on utility, fairness and avoidance of exploitation to support this. We also examine a cross-section of the UK public and CHIM experts. We found that CHIM participants are currently paid variable amounts. A representative sample of the UK public believes CHIM participants should be paid approximately triple the UK minimum wage and should be paid for the risk they endure throughout participation. CHIM experts believe CHIM participants should be paid more than double the UK minimum wage but are divided on the payment for risk. The Payment for Risk Model allows risk and pain to be accounted for in payment and could be used to determine ethically justifiable payment for CHIM participants.Although many research guidelines warn against paying large amounts or paying for risk, our empirical findings provide empirical support to the growing number of ethical arguments challenging this status quo. We close by suggesting two ways (value of statistical life or consistency with risk in other employment) by which payment for risk could be calculated.
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Affiliation(s)
- Olivia Grimwade
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Melbourne Law School, University of Melbourne, Melbourne, Victoria, Australia
| | - Alberto Giubilini
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
| | - Justin Oakley
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
| | - Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Koirala B, Amgai C, Davidson P. Conducting nursing research in low- and middle-income countries: experiences, challenges and solutions. Nurse Res 2020; 28:e1661. [PMID: 31894926 DOI: 10.7748/nr.2020.e1661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Conducting nursing research in low- and middle-income countries (LMICs) balances challenges and opportunities. Understanding the shared experiences of researchers who have completed studies in diverse cultural contexts using various methodologies is important, to advance global nursing research and to build health research capacity and sustainability strategies. AIM To provide a reflexive account using a case-study methodology of transactions and processes conducted during a study in a LMIC. DISCUSSION Lessons learned from the study include the importance of preplanning, being flexible and creative, engaging local collaborators early in planning, establishing good rapport and respectful relationships with gatekeepers and collaborators, having a backup plan, appreciating cultural differences, and sharing findings. CONCLUSION Conducting research in LMICs is complex, especially negotiating access and obtaining ethical approval. Understanding the issues will benefit future research and prepare nurse researchers who take on the challenges and rewards of conducting international research in LMICs. IMPLICATIONS FOR PRACTICE This paper provides a roadmap to help novice researchers conduct research in LMICs.
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Affiliation(s)
- Binu Koirala
- Johns Hopkins University School of Nursing, Baltimore, Maryland, US
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Nyangulu W, Mungwira R, Nampota N, Nyirenda O, Tsirizani L, Mwinjiwa E, Divala T. Compensation of subjects for participation in biomedical research in resource - limited settings: a discussion of practices in Malawi. BMC Med Ethics 2019; 20:82. [PMID: 31727044 PMCID: PMC6857211 DOI: 10.1186/s12910-019-0422-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 11/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Compensating participants of biomedical research is a common practice. However, its proximity with ethical concerns of coercion, undue influence, and exploitation, demand that participant compensation be regulated. The objective of this paper is to discuss the current regulations for compensation of research participants in Malawi and how they can be improved in relation to ethical concerns of coercion, undue influence, and exploitation. MAIN TEXT In Malawi, national regulations recommend that research subjects be compensated with a stipend of US$10 per study visit. However, no guidance is provided on how this figure was determined and how it should be implemented. While necessary to prevent exploitation, the stipend may expose the very poor to undue influence. The stipend may also raise the cost of doing research disadvantaging local researchers and may have implications on studies where income stipend is the intervention under investigation. We recommend that development and implementation of guidelines of this importance involve interested parties such as the research community and patient groups. CONCLUSION Compensating human research subjects is important but can also act as a barrier to voluntary participation and good research efforts. Deliberate measures need to be put in place to ensure fair compensation of research participants, avoid their exploitation and level the field for locally funded research.
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Affiliation(s)
- Wongani Nyangulu
- Public Health Nutrition Research Group (PHNG), College of Medicine, Blantyre, Malawi
| | - Randy Mungwira
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Nginanche Nampota
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Lufina Tsirizani
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Titus Divala
- Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
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Martellet L, Sow SO, Diallo A, Hodgson A, Kampmann B, Hirve S, Tapia M, Haidara FC, Ndiaye A, Diarra B, Ansah PO, Akinsola A, Idoko OT, Adegbola RA, Bavdekar A, Juvekar S, Viviani S, Enwere GC, Marchetti E, Chaumont J, Makadi MF, Pallardy F, Kulkarni PS, Preziosi MP, LaForce FM. Ethical Challenges and Lessons Learned During the Clinical Development of a Group A Meningococcal Conjugate Vaccine. Clin Infect Dis 2016; 61 Suppl 5:S422-7. [PMID: 26553670 PMCID: PMC4639500 DOI: 10.1093/cid/civ598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The group A meningococcal vaccine (PsA-TT) clinical development plan included clinical trials in India and in the West African region between 2005 and 2013. During this period, the Meningitis Vaccine Project (MVP) accumulated substantial experience in the ethical conduct of research to the highest standards. METHODS Because of the public-private nature of the sponsorship of these trials and the extensive international collaboration with partners from a diverse setting of countries, the ethical review process was complex and required strategic, timely, and attentive communication to ensure the smooth review and approval for the clinical studies. Investigators and their site teams fostered strong community relationships prior to, during, and after the studies to ensure the involvement and the ownership of the research by the participating populations. As the clinical work proceeded, investigators and sponsors responded to specific questions of informed consent, pregnancy testing, healthcare, disease prevention, and posttrial access. RESULTS Key factors that led to success included (1) constant dialogue between partners to explore and answer all ethical questions; (2) alertness and preparedness for emerging ethical questions during the research and in the context of evolving international ethics standards; and (3) care to assure that approaches were acceptable in the diverse community contexts. CONCLUSIONS Many of the ethical issues encountered during the PsA-TT clinical development are familiar to groups conducting field trials in different cultural settings. The successful approaches used by the MVP clinical team offer useful examples of how these problems were resolved. CLINICAL TRIALS REGISTRATION ISRCTN17662153 (PsA-TT-001); ISRTCN78147026 (PsA-TT-002); ISRCTN87739946 (PsA-TT-003); ISRCTN46335400 (PsA-TT-003a); ISRCTN82484612 (PsA-TT-004); CTRI/2009/091/000368 (PsA-TT-005); PACTR ATMR2010030001913177 (PsA-TT-006); PACTR201110000328305 (PsA-TT-007).
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Affiliation(s)
| | - Samba O. Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Aldiouma Diallo
- Institut pour la Recherche et le Développement, Niakhar, Senegal
| | - Abraham Hodgson
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit, Basse, The Gambia
| | - Siddhivinayak Hirve
- Shirdi Sai Baba Hospital, Vadu/King Edward Memorial Hospital Research Centre, Rasta Peth, Pune, India
| | - Milagritos Tapia
- Department of Pediatrics, Center for Vaccine Development, University of Maryland School of Medicine, Baltimore
| | | | - Assane Ndiaye
- Institut pour la Recherche et le Développement, Niakhar, Senegal
| | - Bou Diarra
- Institut pour la Recherche et le Développement, Niakhar, Senegal
| | | | - Adebayo Akinsola
- Vaccines and Immunity Theme, Medical Research Council Unit, Basse, The Gambia
| | - Olubukola T. Idoko
- Vaccines and Immunity Theme, Medical Research Council Unit, Basse, The Gambia
| | | | - Ashish Bavdekar
- Shirdi Sai Baba Hospital, Vadu/King Edward Memorial Hospital Research Centre, Rasta Peth, Pune, India
| | - Sanjay Juvekar
- Shirdi Sai Baba Hospital, Vadu/King Edward Memorial Hospital Research Centre, Rasta Peth, Pune, India
| | | | | | | | - Julie Chaumont
- Meningitis Vaccine Project, PATH, Ferney-Voltaire, France
| | | | - Flore Pallardy
- Meningitis Vaccine Project, PATH, Ferney-Voltaire, France
| | | | - Marie-Pierre Preziosi
- Meningitis Vaccine Project, PATH, Ferney-Voltaire, France
- Meningitis Vaccine Project, Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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Nair SC, Ibrahim H. Informed consent form challenges for genetic research in a developing Arab country with high risk for genetic disease. J Genet Couns 2014; 24:294-9. [PMID: 25228356 DOI: 10.1007/s10897-014-9763-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 08/20/2014] [Indexed: 12/16/2022]
Abstract
The prevalence of genetic disease is high in the Middle East, particularly in the United Arab Emirates. Our study assesses the information provided in, and the readability ease of, informed consent forms (ICF) for genetic research studies. A multicenter retrospective cross-sectional review of 54 ICFs was conducted to assess compliance by comparing them with standard good clinical practice guidelines for developing consent forms. Readability of the forms was determined using the Flesch-Kincaid scale. Overall Good Clinical Practice compliance for the ICFs averaged at 63 %. Information regarding privacy, confidentiality, specimen collection and storage were absent from the majority of the ICFs. Readability ease score was low (36.7 ± 4.6) and required college-level (11.8 ± 1.4) reading skills to understand the information. Our study highlights the need to improve the readability and information contained in the ICFs for genetic research studies in our setting. Our findings may be generalized to similar cultures in the Middle East and Asia.
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Affiliation(s)
- Satish Chandrasekhar Nair
- Department of Academic Affairs, Medical Affairs, Tawam Hospital-In Affiliation with Johns Hopkins Medicine (USA), Post Box 15258, Al Ain, United Arab Emirates,
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