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Naidoo K, Montgomery ET, Katz AWK, Garcia M, Naidoo S, Mansoor LE. Women's motivations for participating in the dapivirine vaginal ring open label extension study. AIDS Care 2024; 36:326-342. [PMID: 37734338 PMCID: PMC10922482 DOI: 10.1080/09540121.2023.2260145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
Open-Label Extension (OLE) studies are important in the drug development process and are used to further support the licensing applications and regulatory approvals of products. We aimed to understand why women chose to join the HOPE OLE study - where women were offered the dapivirine vaginal ring after two pivotal trials were completed - through data collected from individual in-depth interviews. Ten women at each of the six HOPE research sites in Lilongwe, Malawi; Durban (2 sites) and Johannesburg, South Africa; Kampala, Uganda; and Chitungwiza, Zimbabwe, were enrolled (n = 60). Access to an effective user-initiated HIV prevention product was one of the main reasons women joined HOPE. Although many participants worried that their male partners might expose them to HIV, they chose to remain in their relationships and avoid conflict or confrontation with their partners by discreetly using the ring to protect themselves. Other reasons for joining were quality healthcare, reimbursement and altruism. Researchers should better understand social and personal motivators behind research participation in order to recognize community sociocultural norms and its influences on product acceptability and adherence challenges.
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Affiliation(s)
- Kalendri Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Ariana W. K. Katz
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Morgan Garcia
- Global Health Population and Nutrition, FHI 360, Durham, NC, United States of America
| | - Sarita Naidoo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa (Present affiliation: The Aurum Institute, Johannesburg, South Africa)
| | - Leila E. Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
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Khoo EJ, Duenas DM, Wilfond BS, Gelinas L, Matheny Antommaria AH. Incentives in Pediatric Research in Developing Countries: When Are They Too Much? Pediatrics 2023; 151:e2021055702. [PMID: 36660851 PMCID: PMC9890390 DOI: 10.1542/peds.2021-055702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 01/21/2023] Open
Abstract
When incentives are offered to parents and their children to partake in research, there are concerns that parents may be unduly influenced by the incentives, and the children may be exploited. We present a case from a low- and middle-income country and consider the ethical issues that arise when the children are asked to participate in a multinational, double-blind, randomized, placebo-controlled trial of the effects of a nutritional supplement on growth. The first commenter, from Malaysia, notes that their residents might not share Americans' expectations regarding children's role in the consent process from a cultural perspective, which may alter the analysis of the concerns. The authors of the second commentary emphasize the use of incentives that benefit the child participant rather than their parent or are provided directly to the child participant to address the concerns. The third commentator discusses the importance of minimizing the study's risks and balancing the benefits and the risks, which attenuates the concerns.
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Affiliation(s)
- Erwin Jiayuan Khoo
- International Medical University, Kuala Lumpur, Malaysia
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts
| | - Devan M. Duenas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Luke Gelinas
- Advarra IRB, Columbia, Maryland
- Multi-Regional Clinical Trials Center of Brigham & Women’s Hospital and Harvard, Cambridge, Massachusetts
| | - Armand H. Matheny Antommaria
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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3
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Abrams EJ, Calmy A, Fairlie L, Mahaka IC, Chimula L, Flynn PM, Kinuthia J, Myer L, Khoo SH, Musoke P, Zwerski S, Zech JM, Lockman S, Siberry GK. Approaches to accelerating the study of new antiretrovirals in pregnancy. J Int AIDS Soc 2022; 25 Suppl 2:e25916. [PMID: 35851757 PMCID: PMC9294864 DOI: 10.1002/jia2.25916] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/28/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Women who are pregnant or who could become pregnant experience delayed access to or underinformed use of important new antiretroviral (ARV) drugs because of traditional drug development processes that ostensibly aim to reduce potential harm but effectively fail to ensure that timely information about safe and effective use in pregnancy is available. Discussion The World Health Organization and International Maternal, Pediatric, Adolescent Antiretroviral Clinical Trials Network convened a year‐long workshop on “Approaches to Enhance and Accelerate Study of New Drugs for HIV and Associated Infections in Pregnant Women.” Workshop participants were tasked with defining key principles and optimal approaches to including pregnant women in pre‐ and post‐licensure trials in order to accelerate the availability of pharmacokinetic and safety data for new ARV agents in pregnancy. ARV efficacy in pregnancy and ARV efficacy for prevention of vertical transmission can be extrapolated from proof of efficacy in non‐pregnant adults, provided that drug levels in pregnancy are similar. However, short‐term safety and pharmacokinetics must be studied directly in pregnant women and should be conducted and included in initial licensure for all new ARVs. Accelerating the timeline for completion of pre‐clinical studies is essential for pregnancy short‐term safety and pharmacokinetic studies to be safely completed by the time a drug is licensed. Composite key pregnancy, birth and neonatal outcomes are critical for drugs expected to have broad use, and studies should be initiated at or soon after drug licensure. Teratogenicity risk cannot be feasibly assessed before drug licensure and will depend on robust post‐marketing surveillance systems. With some modifications, these principles will apply to ARVs used for prevention, two‐drug regimens, long‐acting ARVs and ARVs administered through novel delivery systems. Conclusions Implementation of the proposed principles and framework will enhance and accelerate the study of new ARVs in pregnancy, resulting in more timely, equitable and informed access to new ARVs for pregnant women.
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Affiliation(s)
- Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Lee Fairlie
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Lameck Chimula
- University of North Carolina Project Malawi, Lilongwe, Malawi.,Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - John Kinuthia
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye H Khoo
- Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Philippa Musoke
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda.,Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sheryl Zwerski
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Jennifer M Zech
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Shahin Lockman
- Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - George K Siberry
- Office of HIV/AIDS, Bureau of Global Health, United States Agency for International Development (USAID), Washington, DC, USA
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Bloomfield LSP, Tracey C, Mbabazi E, Schultz RL, Henderson R, Bardosh K, Randolph S, Paige S. Research Participation Influences Willingness to Reduce Zoonotic Exposure in Uganda. ECOHEALTH 2022; 19:299-314. [PMID: 35674864 DOI: 10.1007/s10393-022-01589-5] [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: 06/10/2021] [Accepted: 04/15/2022] [Indexed: 06/15/2023]
Abstract
The majority of emerging and re-emerging infectious diseases in people are zoonotic. Despite substantial research in communities adjacent to protected areas with high levels of biodiversity, limited data exist on people's knowledge, attitudes, and practices to avoid exposure to infections from domestic and wild animals. We used a modified grounded-theory framework in QS NVivo to develop a Knowledge, Attitude, and Practices (KAP) survey administered at two time points, KAPT1 (April-July 2016) and KAPT2 (February-May 2018) to participants living at the edge of Kibale National Park, Uganda. We measured the difference in willingness to engage in protective behaviors around zoonotic exposure between an Intervention group (n = 61) and a Comparison group (n = 125). Prior to KAPT1, the Intervention group engaged in a human-centered design (HCD) activity identifying behaviors that reduce zoonotic exposure (March-May 2016). Using a difference-in-difference approach, we compared the Intervention and Comparison groups to assess sustained willingness and use of protective behaviors against domestic and wild animal exposures. At KAPT1, Comparison group participants had a significantly lower (p < 0.05) level of willingness to engage in behaviors that increase exposure to zoonoses from domestic animals; Intervention group participants had a significantly higher (p < 0.01) level of willingness to engage in behaviors that increase exposure to zoonoses from wild animals. At KAPT2, the treatment effect was significant (p < 0.01) for sustained willingness to engage in protective behaviors for domestic animal exposure in the Intervention group. There were no significant differences in practices to avoid domestic and wild animal zoonotic exposure between the Intervention and Comparison groups.
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Affiliation(s)
- Laura S P Bloomfield
- Stanford University School of Medicine, Stanford University, Stanford, CA, 94305, USA.
- Emmett Interdisciplinary Program in Environment and Resources, Stanford University, Stanford, CA, 94305, USA.
| | - Christopher Tracey
- Milken Institute School of Public Health, George Washington University, Washington, DC, 20052, USA
| | - Edith Mbabazi
- Makerere University Biological Field Station, Kibale National Park, Kibale, Uganda
| | - Rhiannon L Schultz
- Department of Anthropology, University of Georgia, Athens, GA, 30602, USA
| | - Rebecca Henderson
- Department of Anthropology, University of Florida, Gainesville, FL, 32607, USA
| | - Kevin Bardosh
- Center for One Health Research, School of Public Health, University of Washington, Seattle, WA, 98195, USA
| | - Shannon Randolph
- School of Humanities and Sciences, Stanford University, Stanford, CA, 94305, USA
| | - Sarah Paige
- Global Health Institute, University of Wisconsin-Madison, Madison, WI, 53706, USA
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Chi PC, Owino EA, Jao I, Bejon P, Kapulu M, Marsh V, Kamuya D. Ethical considerations around volunteer payments in a malaria human infection study in Kenya: an embedded empirical ethics study. BMC Med Ethics 2022; 23:46. [PMID: 35443642 PMCID: PMC9019790 DOI: 10.1186/s12910-022-00783-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Human Infection Studies (HIS) have emerged as an important research approach with the potential to fast track the global development of vaccines and treatments for infectious diseases, including in low resource settings. Given the high level of burdens involved in many HIS, particularly prolonged residency and biological sampling requirements, it can be challenging to identify levels of study payments that provide adequate compensation but avoid 'undue' levels of inducement to participate. Through this embedded ethics study, involving 97 healthy volunteers and other research stakeholders in a malaria HIS programme in Kenya, and using in-depth interviews, focus group discussions and observations during and after a malaria HIS, we give a grounded account of ethical issues emerging in relation to study payments in this setting. While careful community, national, international scientific and ethics review processes meant that risks of serious harm were highly unlikely, the levels of motivation to join HIS seen could raise concerns about study payments being too high. Particular value was placed on the reliability, rather than level, of study payment in this setting, where subsistence livelihoods are common. Study volunteers were generally clear about the study aims at the point of recruitment, and this knowledge was retained over a year later, although most reported experiencing more burdens than anticipated at enrolment. Strict study screening procedures, regular clinical and laboratory monitoring of volunteers, with prompt treatment with antimalarial at predetermined endpoints suggested that the risks of serious harm were highly unlikely. Ethical concerns emerged in relation to volunteers' attempts to conceal symptoms, hoping to prolong residency periods and increase study payments; and volunteers making decisions that compromised important family relationships and personal values. Our findings support an interpretation that, although study volunteers were keen to join the study to access cash payments, they also paid attention to other features of the study and the general clinical research landscape, including levels of risk associated with study participation. Overall, our analysis shows that the ethical concerns emerging from the study payments can be addressed through practical measures, hinged on reducing burdens and strengthening communication, raising important issues for research policy and planning.
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Affiliation(s)
- Primus Che Chi
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Esther Awuor Owino
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Irene Jao
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Melissa Kapulu
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Vicki Marsh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Dorcas Kamuya
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
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6
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Kaehler N, Adhikari B, Cheah PY, von Seidlein L, Day NPJ, Dondorp AM, Pell C. Community engagement for malaria elimination in the Greater Mekong Sub-region: a qualitative study among malaria researchers and policymakers. Malar J 2022; 21:46. [PMID: 35164770 PMCID: PMC8845385 DOI: 10.1186/s12936-022-04069-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community engagement has increasingly received attention in malaria research and programme interventions, particularly as countries aim for malaria elimination. Although community engagement strategies and activities are constantly developing, little is known about how those who implement research or programmes view community engagement. This article explores the perspectives of researchers and policy makers in the Greater Mekong Sub-region (GMS) on community engagement for malaria control and elimination. METHODS Semi-structured interviews were conducted among 17 policymakers and 15 senior researchers working in the field of malaria. All interviews were audio-recorded and transcribed in English. Transcribed data were analysed using deductive and inductive approaches in QSR NVivo. Themes and sub-themes were generated. RESULTS Researchers and policymakers emphasized the importance of community engagement in promoting participation in malaria research and interventions. Building trust with the community was seen as crucial. Respondents emphasized involving authority/leadership structures and highlighted the need for intense and participatory engagement. Geographic remoteness, social, cultural, and linguistic diversity were identified as barriers to meaningful engagement. Local staff were described as an essential 'connect' between researchers or policymakers and prospective participants. Sharing information with community members, using various strategies including creative and participatory methods were highlighted. CONCLUSIONS Policymakers and researchers involved in malaria prevention and control in the GMS viewed community engagement as crucial for promoting participation in research or programmatic interventions. Given the difficulties of the 'last mile' to elimination, sustained investment in community engagement is needed in isolated areas of the GMS where malaria transmission continues. Involving community-based malaria workers is ever more critical to ensure the elimination efforts engage hard-to-reach populations in remote areas of GMS.
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Affiliation(s)
- Nils Kaehler
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
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Vincent R, Adhikari B, Duddy C, Richardson E, Wong G, Lavery J, Molyneux S. 'Working relationships' across difference - a realist review of community engagement with malaria research. Wellcome Open Res 2022; 7:13. [PMID: 37621950 PMCID: PMC10444998 DOI: 10.12688/wellcomeopenres.17192.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 08/26/2023] Open
Abstract
Background: Community engagement (CE) is increasingly accepted as a critical aspect of health research, because of its potential to make research more ethical, relevant and well implemented. While CE activities linked to health research have proliferated in Low and Middle Income Countries (LMICs), and are increasingly described in published literature, there is a lack of conceptual clarity around how engagement is understood to 'work', and the aims and purposes of engagement are varied and often not made explicit. Ultimately, the evidence base for engagement remains underdeveloped. Methods: To develop explanations for how and why CE with health research contributes to the pattern of outcomes observed in published literature , we conducted a realist review of CE with malaria research - a theory driven approach to evidence synthesis. Results: We found that community engagement relies on the development of provisional 'working relationships' across differences, primarily of wealth, power and culture. These relationships are rooted in interactions that are experienced as relatively responsive and respectful, and that bring tangible research related benefits. Contextual factors affecting development of working relationships include the facilitating influence of research organisation commitment to and resources for engagement, and constraining factors linked to the prevailing 'dominant health research paradigm context', such as: differences of wealth and power between research centres and local populations and health systems; histories of colonialism and vertical health interventions; and external funding and control of health research. Conclusions: The development of working relationships contributes to greater acceptance and participation in research by local stakeholders, who are particularly interested in research related access to health care and other benefits. At the same time, such relationships may involve an accommodation of some ethically problematic characteristics of the dominant health research paradigm, and thereby reproduce this paradigm rather than challenge it with a different logic of collaborative partnership.
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Affiliation(s)
- Robin Vincent
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LG, UK
- Robin Vincent Learning and Evaluation Ltd, Sheffield, S89FH, UK
| | - Bipin Adhikari
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LG, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Claire Duddy
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
| | - Emma Richardson
- Health Research, Evidence and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Geoff Wong
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
| | - James Lavery
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, 30322, USA
- Center for Ethics, Emory University, Atlanta, Georgia, 30322, USA
| | - Sassy Molyneux
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LG, UK
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, University of Oxford, Kilifi, 80108, Kenya
| | - The REAL team: Mary Chambers, Phaik Yeong Cheah, Al Davies, Kate Gooding, Dorcas Kamuya, Vicki Marsh, Noni Mumba, Deborah Nyirenda, and Paulina Tindana.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LG, UK
- Robin Vincent Learning and Evaluation Ltd, Sheffield, S89FH, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
- Health Research, Evidence and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, 30322, USA
- Center for Ethics, Emory University, Atlanta, Georgia, 30322, USA
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, University of Oxford, Kilifi, 80108, Kenya
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8
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Joseph Davey DL, Bekker LG, Bukusi EA, Chi BH, Delany-Moretlwe S, Goga A, Lyerly AD, Mgodi NM, Mugo N, Myer L, Noguchi LM, Stranix-Chibanda L, Slack C, Pintye J. Where are the pregnant and breastfeeding women in new pre-exposure prophylaxis trials? The imperative to overcome the evidence gap. THE LANCET HIV 2022; 9:e214-e222. [DOI: 10.1016/s2352-3018(21)00280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/11/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
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Galea JT, Greene KY, Nguyen B, Polonijo AN, Dubé K, Taylor J, Christensen C, Zhang Z, Brown B. Evaluating the Impact of Incentives on Clinical Trial Participation: Protocol for a Mixed Methods, Community-Engaged Study. JMIR Res Protoc 2021; 10:e33608. [PMID: 34817381 PMCID: PMC8663586 DOI: 10.2196/33608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Monetary incentives in research are frequently used to support participant recruitment and retention. However, there are scant empirical data regarding how researchers decide upon the type and amount of incentives offered. Likewise, there is little guidance to assist study investigators and institutional review boards (IRBs) in their decision-making on incentives. Monetary incentives, in addition to other factors such as the risk of harm or other intangible benefits, guide individuals' decisions to enroll in research studies. These factors emphasize the need for evidence-informed guidance for study investigators and IRBs when determining the type and amount of incentives to provide to research participants. OBJECTIVE The specific aims of our research project are to (1) characterize key stakeholders' views on and assessments of incentives in biomedical HIV research; (2) reach consensus among stakeholders on the factors that are considered when choosing research incentives, including consensus on the relative importance of such factors; and (3) pilot-test the use of the guidance developed via aims 1 and 2 by presenting stakeholders with vignettes of hypothetical research studies for which they will choose corresponding incentive types. METHODS Our 2-year study will involve monthly, active engagement with a stakeholder advisory board of people living with HIV, researchers, and IRB members. For aim 1, we will conduct a nationwide survey (N=300) among people living with HIV to understand their views regarding the incentives used in HIV research. For aim 2, we will collect qualitative data by conducting focus groups with people living with HIV (n=60) and key informant interviews with stakeholders involved in HIV research (people living with HIV, IRB members, and biomedical HIV researchers: n=36) to extend and deepen our understanding of how incentives in HIV research are perceived. These participants will also complete a conjoint analysis experiment to gain an understanding of the relative importance of key HIV research study attributes and the impact that these attributes have on study participation. The data from the nationwide survey (aim 1) will be triangulated with the qualitative and conjoint analysis data (aim 2) to create 25 vignettes that describe hypothetical HIV research studies. Finally, individuals from each stakeholder group will select the most appropriate incentive that they feel should be used in each of the 25 vignettes (aim 3). RESULTS The stakeholder advisory board began monthly meetings in March 2021. All study aims are expected to be completed by December 2022. CONCLUSIONS By studying the role of incentives in HIV clinical trial participation, we will establish a decision-making paradigm to guide the choice of incentives for HIV research and, eventually, other types of similar research and facilitate the ethical recruitment of clinical research participants. TRIAL REGISTRATION ClinicalTrials.gov NCT04809636; https://clinicaltrials.gov/ct2/show/NCT04809636. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/33608.
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Affiliation(s)
- Jerome T Galea
- School of Social Work, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, United States
- College of Public Health, University of South Florida, Tampa, FL, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Karah Y Greene
- School of Social Work, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, United States
| | - Brandon Nguyen
- Department of Social Medicine, Population and Public Health, University of California, Riverside, Riverside, CA, United States
| | - Andrea N Polonijo
- Department of Sociology, University of California, Merced, Merced, CA, United States
| | - Karine Dubé
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jeff Taylor
- HIV+Aging Research Project-Palm Springs, Palm Springs, CA, United States
| | | | - Zhiwei Zhang
- Department of Statistics, University of California, Riverside, Riverside, CA, United States
| | - Brandon Brown
- Department of Social Medicine, Population and Public Health, University of California, Riverside, Riverside, CA, United States
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10
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Halpern SD, Chowdhury M, Bayes B, Cooney E, Hitsman BL, Schnoll RA, Lubitz SF, Reyes C, Patel MS, Greysen SR, Mercede A, Reale C, Barg FK, Volpp KG, Karlawish J, Stephens-Shields AJ. Effectiveness and Ethics of Incentives for Research Participation: 2 Randomized Clinical Trials. JAMA Intern Med 2021; 181:1479-1488. [PMID: 34542553 PMCID: PMC8453363 DOI: 10.1001/jamainternmed.2021.5450] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Incentivizing research participation is controversial and variably regulated because of uncertainty regarding whether financial incentives serve as undue inducements by diminishing peoples' sensitivity to research risks or unjust inducements by preferentially increasing enrollment among underserved individuals. OBJECTIVE To determine whether incentives improve enrollment in real randomized clinical trials (RCTs) or serve as undue or unjust inducements. DESIGN, SETTING, AND PARTICIPANTS Two RCTs of incentives that were embedded in 2 parent RCTs, 1 comparing smoking cessation interventions (conducted at smoking cessation clinics in 2 health systems) and 1 evaluating an ambulation intervention (conducted across wards of the Hospital of the University of Pennsylvania) included all persons eligible for the parent trials who did not have prior knowledge of the incentives trials. Recruitment occurred from September 2017 to August 2019 for the smoking trial and January 2018 through May 2019 for the ambulation trial; data were analyzed from January 2020 to July 2020. INTERVENTIONS Patients were randomly assigned to incentives of $0, $200, or $500 for participating in the smoking cessation trial and $0, $100, or $300 for the ambulation trial. MAIN OUTCOMES AND MEASURES The primary outcome of each incentive trial was the proportion of people assigned to each recruitment strategy that consented to participate. Each trial was powered to test the hypotheses that incentives served neither as undue inducements (based on the interaction between incentive size and perceived research risk, as measured using a 10-point scale, on the primary outcome), nor unjust inducements (based on the interaction between incentive size and participants' self-reported income). Noninferiority methods were used to test whether the data were compatible with these 2 effects of incentives and superiority methods to compare the primary and other secondary outcomes. RESULTS There were a total of 654 participants (327 women [50.0%]; mean [SD] age, 50.6 [12.1] years; 394 Black/African American [60.2%], 214 White [32.7%], and 24 multiracial individuals [3.7%]) in the smoking trial, and 642 participants (364 women [56.7%]; mean [SD] age, 46.7 [15.6] years; 224 Black/African American [34.9%], 335 White [52.2%], and 5 multiracial individuals [0.8%]) in the ambulation trial. Incentives significantly increased consent rates among those in the smoking trial in 47 of 216 (21.8%), 78 of 217 (35.9%), and 104 of 221 (47.1%) in the $0, $200, and $500 groups, respectively (adjusted odds ratio [aOR] for each increase in incentive, 1.70; 95% CI, 1.34-2.17; P < .001). Incentives did not increase consent among those in the ambulation trial: 98 of 216 (45.4%), 102 of 212 (48.1%), and 92 of 214 (43.0%) in the $0, $100, and $300 groups, respectively (aOR, 0.88; 95% CI, 0.64-1.22; P = .45). In neither trial was there evidence of undue or unjust inducement (upper confidence limits of ORs for undue inducement, 1.15 and 0.99; P < .001 showing noninferiority; upper confidence limits of ORs for unjust inducement, 1.21 and 1.26; P = .01 and P < .001, respectively). There were no significant effects of incentive size on the secondary outcomes in either trial, including time spent reviewing the risk sections of consent forms, perceived research risks, trial understanding, perceived coercion, or therapeutic misconceptions. CONCLUSIONS AND RELEVANCE In these 2 randomized clinical trials, financial incentives increased trial enrollment in 1 of 2 trials and did not produce undue or unjust inducement or other unintended consequences in either trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02697799.
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Affiliation(s)
- Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth Cooney
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Celine Reyes
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mitesh S Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ashley Mercede
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reale
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Frances K Barg
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Memory Center at the Penn Neuroscience Center, Philadelphia, Pennsylvania
| | - Alisa J Stephens-Shields
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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11
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Dotlic J, Jeremic Stojkovic V, Cummins P, Milic M, Gazibara T. Enhancing COVID-19 vaccination coverage using financial incentives: arguments to help health providers counterbalance erroneous claims. Epidemiol Health 2021; 43:e2021081. [PMID: 34645203 PMCID: PMC8859513 DOI: 10.4178/epih.e2021081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/06/2021] [Indexed: 11/22/2022] Open
Abstract
Financial reimbursements after receiving the coronavirus disease 2019 (COVID-19) vaccine have been criticized in the literature. This strategy has been described as payment to receive the vaccines, undue inducement, and unethical. We are aware that healthcare workers who work in primary healthcare, prevention, and public health may encounter similar reasons from people who refuse vaccination against COVID-19. For this reason, we are compelled to clarify these claims and provide arguments for all healthcare workers who might be challenged by such reasoning. In this critical review, we discuss why the claims against financial incentives that have been presented in the literature are erroneous.
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Affiliation(s)
- Jelena Dotlic
- University of Belgrade, Faculty of Medicine, Belgrade, Yugoslavia
| | | | - Paul Cummins
- Icahn School of Medicine at Mount Sinai, New York, United States
| | - Marija Milic
- Universty of Pristina temporarily settled in Kosovska Mitrovica, Kosovska Mitrovica, Yugoslavia
| | - Tatjana Gazibara
- University of Belgrade, Faculty of Medicine, Belgrade, Yugoslavia
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12
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Kakuhikire B, Satinsky EN, Baguma C, Rasmussen JD, Perkins JM, Gumisiriza P, Juliet M, Ayebare P, Mushavi RC, Burns BFO, Evans CQ, Siedner MJ, Bangsberg DR, Tsai AC. Correlates of attendance at community engagement meetings held in advance of bio-behavioral research studies: A longitudinal, sociocentric social network study in rural Uganda. PLoS Med 2021; 18:e1003705. [PMID: 34270581 PMCID: PMC8323877 DOI: 10.1371/journal.pmed.1003705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 07/30/2021] [Accepted: 06/21/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Community engagement is central to the conduct of health-related research studies as a way to determine priorities, inform study design and implementation, increase recruitment and retention, build relationships, and ensure that research meets the goals of the community. Community sensitization meetings, a form of community engagement, are often held prior to the initiation of research studies to provide information about upcoming study activities and resolve concerns in consultation with potential participants. This study estimated demographic, health, economic, and social network correlates of attendance at community sensitization meetings held in advance of a whole-population, combined behavioral, and biomedical research study in rural Uganda. METHODS AND FINDINGS Research assistants collected survey data from 1,630 adults participating in an ongoing sociocentric social network cohort study conducted in a rural region of southwestern Uganda. These community survey data, collected between 2016 and 2018, were linked to attendance logs from community sensitization meetings held in 2018 and 2019 before the subsequent community survey and community health fair. Of all participants, 264 (16%) attended a community sensitization meeting before the community survey, 464 (28%) attended a meeting before the community health fair, 558 (34%) attended a meeting before either study activity (survey or health fair), and 170 (10%) attended a meeting before both study activities (survey and health fair). Using multivariable Poisson regression models, we estimated correlates of attendance at community sensitization meetings. Attendance was more likely among study participants who were women (adjusted relative risk [ARR]health fair = 1.71, 95% confidence interval [CI], 1.32 to 2.21, p < 0.001), older age (ARRsurvey = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001; ARRhealth fair = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001), married (ARRsurvey = 1.74, 95% CI, 1.29 to 2.35, p < 0.001; ARRhealth fair = 1.41, 95% CI, 1.13 to 1.76, p = 0.002), and members of more community groups (ARRsurvey = 1.26 per group, 95% CI, 1.10 to 1.44, p = 0.001; ARRhealth fair = 1.26 per group, 95% CI, 1.12 to 1.43, p < 0.001). Attendance was less likely among study participants who lived farther from meeting locations (ARRsurvey = 0.54 per kilometer, 95% CI, 0.30 to 0.97, p = 0.041; ARRhealth fair = 0.57 per kilometer, 95% CI, 0.38 to 0.86, p = 0.007). Leveraging the cohort's sociocentric design, social network analyses suggested that information conveyed during community sensitization meetings could reach a broader group of potential study participants through attendees' social network and household connections. Study limitations include lack of detailed data on reasons for attendance/nonattendance at community sensitization meetings; achieving a representative sample of community members was not an explicit aim of the study; and generalizability may not extend beyond this study setting. CONCLUSIONS In this longitudinal, sociocentric social network study conducted in rural Uganda, we observed that older age, female sex, being married, membership in more community groups, and geographical proximity to meeting locations were correlated with attendance at community sensitization meetings held in advance of bio-behavioral research activities. Information conveyed during meetings could have reached a broader portion of the population through attendees' social network and household connections. To ensure broader input and potentially increase participation in health-related research studies, the dissemination of research-related information through community sensitization meetings may need to target members of underrepresented groups.
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Affiliation(s)
| | - Emily N. Satinsky
- Department of Psychology, University of Southern California, Los Angeles, California, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Justin D. Rasmussen
- Department of Psychology, Duke University, Durham, North Carolina, United States of America
| | - Jessica M. Perkins
- Peabody College, Vanderbilt University, Nashville, Tennessee, United States of America
| | | | - Mercy Juliet
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Rumbidzai C. Mushavi
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Bridget F. O. Burns
- Department of Urban Studies and Planning, Massachusetts Institute of Technology, Boston, Massachusetts, United States of America
| | - Claire Q. Evans
- Peabody College, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Mark J. Siedner
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - David R. Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda
- Oregon Health and Science University - Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Alexander C. Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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13
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The Claims of Biospecimen Donors to Credit and Compensation. Trends Genet 2020; 36:630-632. [PMID: 32660785 PMCID: PMC10107695 DOI: 10.1016/j.tig.2020.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 11/20/2022]
Abstract
The biorights movement argues that current treatment of biospecimen donors is unfair. To evaluate this claim, the present Science & Society article identifies the standards used to determine credit and compensation in research, and applies them to donors. This analysis suggests most donors deserve credit and, contrary to current practice, some deserve compensation.
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14
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Sullivan K, Mtande T, Jaffe E, Rosenberg N, Zimba C, Hoffman I, Little M, Faden R, Lyerly AD. Views among Malawian women about joining HIV prevention clinical trials when pregnant. AIDS Res Ther 2020; 17:27. [PMID: 32460804 PMCID: PMC7251879 DOI: 10.1186/s12981-020-00271-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pressing need to expand the biomedical HIV prevention evidence base during pregnancy is now increasingly recognized. Women's views regarding participation in such trials and initiating PrEP while pregnant are critical to inform evolving policy and best practices aimed at responsibly expanding evidence-based access for this population. METHODS We conducted 35 semi-structured interviews with reproductive-aged women in Malawi in the local language, Chichewa. Participants were HIV-negative and purposively sampled to capture a range of experience with research during pregnancy. Women's perspectives on enrolling in three hypothetical HIV prevention trial vignettes while pregnant were explored, testing: (1) oral PrEP (Truvada) (2) a vaginal ring (dapivirine), and (3) a randomized trial comparing the two. The vignettes were read aloud to participants and a simple visual was provided. Interviews were audio-recorded, transcribed, translated, and coded using NVivo 11. Thematic analysis informed the analytic approach. RESULTS A majority of women accepted participation in all trials. Women's views on research participation varied largely based on their assessment of whether participation or nonparticipation would best protect their own health and that of their offspring. Women interested in participating described power dynamics with their partner as fueling their HIV exposure concerns and highlighted health benefits of participation-principally, HIV protection and access to testing/treatment and ancillary care, and perceived potential risks of the vignettes as low. Women who were uninterested in participating highlighted potential maternal and fetal health risks of the trial, challenges of justifying prevention use to their partner, and raised some modality-specific concerns. Women also described ways their social networks, sense of altruism and adherence requirements would influence participation decisions. CONCLUSIONS The majority of participants conveyed strong interest in participating in biomedical HIV prevention research during pregnancy, largely motivated by a desire to protect themselves and their offspring. Our results are consistent with other studies that found high acceptance of HIV prevention products during pregnancy, and support the current direction of HIV research policies and practices that are increasingly aimed at protecting the health of pregnant women and their offspring through responsible research, rather than defaulting to their exclusion.
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Affiliation(s)
- Kristen Sullivan
- Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia Street, Campus Box 7240, Chapel Hill, NC, 27599, USA.
| | - Tiwonge Mtande
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Elana Jaffe
- Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia Street, Campus Box 7240, Chapel Hill, NC, 27599, USA
| | - Nora Rosenberg
- Department of Health Behavior, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 170 Rosenau Hall, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Chifundo Zimba
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599, USA
| | - Maggie Little
- The Kennedy Institute of Ethics, Georgetown University, 3700 O Street Northwest, Washington, DC, 20057, USA
| | - Ruth Faden
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Anne Drapkin Lyerly
- Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia Street, Campus Box 7240, Chapel Hill, NC, 27599, USA
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15
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Adhikari B, Pell C, Cheah PY. Community engagement and ethical global health research. Glob Bioeth 2019; 31:1-12. [PMID: 32002019 PMCID: PMC6968663 DOI: 10.1080/11287462.2019.1703504] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 12/06/2019] [Indexed: 11/27/2022] Open
Abstract
Community engagement is increasingly recognized as a critical element of medical research, recommended by ethicists, required by research funders and advocated in ethics guidelines. The benefits of community engagement are often stressed in instrumental terms, particularly with regard to promoting recruitment and retention in studies. Less emphasis has been placed on the value of community engagement with regard to ethical good practice, with goals often implied rather than clearly articulated. This article outlines explicitly how community engagement can contribute to ethical global health research by complementing existing established requirements such as informed consent and independent ethics review. The overarching and interlinked areas are (1) respecting individuals, communities and stakeholders; (2) building trust and social relationships; (3) determining appropriate benefits; minimizing risks, burdens and exploitation; (4) supporting the consent process; (5) understanding vulnerabilities and researcher obligations; (6) gaining permissions, approvals and building legitimacy and (7) achieving recruitment and retention targets.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,Kellogg College, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Churchill Hospital, Oxford, UK.,The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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16
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Interest in inducements: A psychophysiological study on sports betting advertising. Int J Psychophysiol 2019; 147:100-106. [PMID: 31760104 DOI: 10.1016/j.ijpsycho.2019.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 12/26/2022]
Abstract
Recent research has shown an association between the viewing of wagering advertising, which often presents inducements to gamble, and maladaptive sports-betting behaviours; however, the mechanism/s underlying the development of the intention to gamble remains relatively understudied. Eye-tracking and tonic electrodermal activity was recorded from 59 participants (including 49 regular gamblers and 10 non-gamblers), while they watched a series of advertisements. Following each advertisement, participants were asked to rate how likely they would be to take up the offer presented, therein. The number of fixations placed on each offer differed according to the type of inducement shown (p < .001), with reduced risk and cash back inducements being looked at more often than better odds and bonus bet inducements by all groups. Increased electrodermal activity while viewing the advertisements was associated with greater severity of gambling-related harm (p < .001), as well as greater ratings of desire for most advertisements. Rating of desire was, likewise, positively associated with gambling-related harm (p < .001). These results may suggest that, while the offers in gambling advertisements may be looked at by most viewers, unless there an attendant increase in arousal, it is quite unlikely that these inducements will elicit a desire to gamble. For individuals already at risk of gambling problems, exposure to these advertisements, especially those offering what is perceived to be safer betting options that minimise financial losses, may exacerbate existing harms. Such information may prove useful in guiding industry practice, government regulations, therapeutic interventions, and future research on this topic.
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17
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Bhattacharya S. Should we pay more to participants involved in research projects? Med Leg J 2019; 87:201-203. [PMID: 31697213 DOI: 10.1177/0025817219881971] [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: 11/15/2022]
Abstract
Inducements for research participants are considered controversial. Researchers face an ethical dilemma if they offer money as an inducement when enrolling volunteers for their study. Do these payments invalidate the consent process and make this unethical? Should the results of such studies be considered invalid? A recent publication by Persad and colleagues supports differential payment to volunteers, based upon their level of involvement, from an ethical perspective. Our current response to this article explores a few more areas of controversy and attempts to clarify them.
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18
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Brown B, Marg L, Zhang Z, Kuzmanović D, Dubé K, Galea J. Factors Associated With Payments to Research Participants: A Review of Sociobehavioral Studies at a Large Southern California Research University. J Empir Res Hum Res Ethics 2019; 14:408-415. [PMID: 31432735 DOI: 10.1177/1556264619869538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Along with a dearth of regulatory guidance, little empirical research has examined factors related to participant payment in research. We conducted a cross-sectional study of 100 institutional review board (IRB)-approved sociobehavioral human subjects research protocols at a large research university in Southern California. The proportion of studies that paid participants differed significantly by type of research (p < .001) and study population (p = .009). The average payment amount also differed significantly by study population (p < .001) and type of participation (in-person vs. remote; p < .001). In addition, studies that required more visits (p < .001) and more time (p = .011) paid significantly more than studies with fewer and shorter visits, respectively. These findings provide data to help inform future ethical payment practices.
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Affiliation(s)
| | - Logan Marg
- 1 University of California, Riverside, USA
| | | | | | - Karine Dubé
- 3 The University of North Carolina at Chapel Hill, USA
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Kurin M, Katz J, Kodish E, Lashner B. Informed Consent in IBD Trials: Where We Are and Where We Need to Go. Inflamm Bowel Dis 2019; 25:1115-1119. [PMID: 30989217 DOI: 10.1093/ibd/izz067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Indexed: 12/09/2022]
Abstract
Patient enrollment is increasingly recognized as a major limiting factor to inflammatory bowel disease (IBD) clinical trial completion. Many IBD trials will fail to enroll enough patients to adequately power their study. This has led to a renewed multifaceted effort to encourage more patients to enroll in clinical trials. Although this is of clear importance, it is also important to ensure that all efforts to enroll patients in clinical trials do not compromise the quality and validity of the patient's/study participant's informed consent. Informed consent has 4 components: disclosure, voluntariness, understanding, and capacity. The application of informed consent to IBD clinical trials for biologic agents has not been previously studied. Yet the nature of clinical trials for biologics in IBD creates certain challenges to properly fulfilling the requirements of informed consent in the recruitment process that should be examined. In the following commentary, the components of informed consent are reviewed, challenges to their fulfillment in IBD trials are reviewed, and practical advice is offered.
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Affiliation(s)
- Michael Kurin
- Division of Gastroenterology and Liver Diseases, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jeffry Katz
- Division of Gastroenterology and Liver Diseases, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Eric Kodish
- Pediatrics Institute and Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bret Lashner
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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20
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Sullivan KA, Little MO, Rosenberg NE, Zimba C, Jaffe E, Gilbert S, Coleman JS, Hoffman I, Mtande T, Anderson J, Gross MS, Rahangdale L, Faden R, Lyerly AD. Women's views about contraception requirements for biomedical research participation. PLoS One 2019; 14:e0216332. [PMID: 31067273 PMCID: PMC6505940 DOI: 10.1371/journal.pone.0216332] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/18/2019] [Indexed: 11/18/2022] Open
Abstract
The scientific and ethical importance of including women of reproductive age in biomedical research is widely acknowledged. Concerns about preventing fetal exposure to research interventions have motivated requirements for contraception among reproductive aged women in biomedical studies-often irrespective of risks and benefits or a woman's actual potential for pregnancy, raising important questions about when such requirements are appropriate. The perspectives of women themselves on these issues are largely unexplored. We conducted 140 interviews, 70 in the U.S. and 70 in Malawi, with women either living with or at-risk for HIV, exploring their views about the practice of requiring contraception in clinical trials. A majority of women interviewed from both countries indicated overall support for the practice, with seven themes characterizing advantages and disadvantages raised: reproductive control, health effects, prevention of fetal harm, burden on women, deferral to authority, autonomy regarding enrollment and birth control method, and relationship concerns. While women in the US frequently raised prevention of fetal harm as a key advantage, many other positives noted by women in both countries were related to contraception use in general, not specific to a trial context. With regard to disadvantages, U.S. women tended to focus on biomedical risks such as side effects and impact on fertility, whereas Malawian women focused on the social risks of contraception requirements, including violations of trust in marital relations and suspicions of potential infidelity. Given the potential benefits and burdens highlighted, contraception in research should be sensitive to actual fetal risk assessments; directed where justified at optimizing effective pregnancy prevention; responsive to women's reproductive preferences; and made available as an ancillary benefit even where risk thresholds do not justify requirement-in order to facilitate trials that are both ethical and robustly oriented around the interests and lives of women who will participate in them.
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Affiliation(s)
- Kristen A. Sullivan
- Center for Bioethics and Department of Social Medicine, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Margaret Olivia Little
- Kennedy Institute for Ethics, Georgetown University, Washington, D.C., United States of America
| | - Nora E. Rosenberg
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Elana Jaffe
- Center for Bioethics and Department of Social Medicine, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sappho Gilbert
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jenell S. Coleman
- Division of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Jean Anderson
- Division of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Marielle S. Gross
- Division of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ruth Faden
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Anne Drapkin Lyerly
- Center for Bioethics and Department of Social Medicine, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Singh H, Rao SV, Kakkar AK, Singh J, Manohar HD. Posttrial Access to Medical Interventions: Intricacies, Challenges, and Solutions. Int J Appl Basic Med Res 2019; 9:3-8. [PMID: 30820412 PMCID: PMC6385540 DOI: 10.4103/ijabmr.ijabmr_218_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 01/02/2019] [Indexed: 12/02/2022] Open
Abstract
With the recent increase in clinical trials, lower- and middle-income countries are preferred trial sites due to lower budgets and easy availability of potential participants. On trial completion, benefits to participants cease and it may affect their health adversely. Therefore, entitlement to posttrial access (PTA) of interventions is imperative. The Declaration of Helsinki and several other guidelines mandate that trial participants have access to experimentally proven efficacious drugs and that the research protocol should mention PTA provision mechanisms. A controversial question about PTA is whether, experimentally proven therapy should be made accessible to the control group as well as the community from which the participants were enrolled, especially if no satisfactory standard treatment exists. PTA has significant implications for various stakeholders - trial participants, investigators, sponsors, regulatory authorities, and governments and has been discussed and well addressed in recent guidelines issued by the Indian Council of Medical research. This article focuses on the PTA, guidelines related to PTA, disputes, different stakeholder perspectives, and practical difficulties in its implementation. It also looks at PTA from the Indian perspective and considers possible solutions to deal with the controversies.
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Affiliation(s)
- Harmanjit Singh
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, India
| | - Sunil Vishwas Rao
- Department of Pharmacology, Karpaga Vinayaga Institute of Medical Sciences and Research Center, Kanchipuram, Tamil Nadu, India
| | - Ashish Kumar Kakkar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jagjit Singh
- Department of Pharmacology, Government Medical College and Hospital, Chandigarh, India
| | - Hasitha Daina Manohar
- Department of Pharmacology, Karpaga Vinayaga Institute of Medical Sciences and Research Center, Kanchipuram, Tamil Nadu, India
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Krutsinger DC, McMahon J, Stephens-Shields AJ, Bayes B, Brooks S, Hitsman BL, Lubitz SF, Reyes C, Schnoll RA, Ryan Greysen S, Mercede A, Patel MS, Reale C, Barg F, Karlawish J, Polsky D, Volpp KG, Halpern SD. Randomized evaluation of trial acceptability by INcentive (RETAIN): Study protocol for two embedded randomized controlled trials. Contemp Clin Trials 2019; 76:1-8. [PMID: 30414865 PMCID: PMC6354250 DOI: 10.1016/j.cct.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The most common and conceptually sound ethical concerns with financial incentives for research participation are that they may (1) represent undue inducements by blunting peoples' perceptions of research risks, thereby preventing fully informed consent; or (2) represent unjust inducements by encouraging enrollment preferentially among the poor. Neither of these concerns has been shown to manifest in studies testing the effects of incentives on decisions to participate in hypothetical randomized clinical trials (RCTs), but neither has been assessed in real RCTs. METHODS AND ANALYSES We are conducting randomized trials of real incentives embedded within two parent RCTs. In each of two trials conducted in parallel, we are randomizing 576 participants to one of three incentive groups. Following preliminary determination of patients' eligibility in the parent RCT, we assess patients' research attitudes, demographic characteristics, perceived research risks, time spent reviewing consent documents, ability to distinguish research from patient care, and comprehension of key trial features. These quantitative assessments will be supplemented by semi-structured interviews for a selected group of participants that more deeply explore patients' motivations for trial participation. The trials are each designed to have adequate power to rule out undue and unjust inducement. We are also exploring potential benefits of incentives, including possible increased attention to research risks and cost-effectiveness.
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Affiliation(s)
- Dustin C Krutsinger
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jacqueline McMahon
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alisa J Stephens-Shields
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Brooks
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian L Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Celine Reyes
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Mercede
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mitesh S Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Catherine Reale
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fran Barg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia, PA, United States
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Penn Memory Center at the Penn Neuroscience Center, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Polsky
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Gordon SB, Chinula L, Chilima B, Mwapasa V, Dadabhai S, Mlombe Y. A Malawi guideline for research study participant remuneration. Wellcome Open Res 2018; 3:141. [PMID: 30662959 PMCID: PMC6329041 DOI: 10.12688/wellcomeopenres.14668.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2018] [Indexed: 08/23/2023] Open
Abstract
Background: Research participant remuneration has been variable and inconsistent world-wide for many years owing to uncertainty regarding best practice and a lack of written guidelines for investigators and research ethics committees. Recent recommendations are that researchers and regulators should develop regionally appropriate written guidelines to define reasonable remuneration based on expense reimbursement, compensation for time and burden associated with participation. Incentives to motivate participation are acceptable in specific circumstances. Methods: We wished to develop regionally informed, precise and applicable guidelines in Malawi that might also be generally useful for African researchers and review committees. We therefore reviewed the current literature and developed widely applicable and specific remuneration tables using acceptable and evidence-based payment rationales. Results: There were good international guidelines and limited published regional guidelines. There were published examples of best practice and sufficient material to suggest a structured remuneration table. The rationale and method for the table were discussed at an inter-disciplinary workshop resulting in a reimbursement and compensation model with fixed rates. Payment is recommended pro rata and equally across a study. Conclusions: Transparent, fair remuneration of research participants is recommended by researchers and regulators in Malawi. The means to achieve this are now presented in the Malawi research participant remuneration table.
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Affiliation(s)
- Stephen B. Gordon
- Malawi LIverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Lameck Chinula
- University of North Carolina Research, University of North Carolina, Blantyre, Malawi
| | - Ben Chilima
- National Health Sciences Research Committee, Lilongwe, Malawi
| | - Victor Mwapasa
- Research Support Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | - Sufia Dadabhai
- JHU Research Project, Johns Hopkins University, Blantyre, Malawi
| | - Yohannie Mlombe
- College of Medicine Research Ethics Committee, University of Malawi College of Medicine, Blantyre, Malawi
| | - Malawi Research Ethics Workshop 2018 Participants
- Malawi LIverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
- University of North Carolina Research, University of North Carolina, Blantyre, Malawi
- National Health Sciences Research Committee, Lilongwe, Malawi
- Research Support Centre, University of Malawi College of Medicine, Blantyre, Malawi
- JHU Research Project, Johns Hopkins University, Blantyre, Malawi
- College of Medicine Research Ethics Committee, University of Malawi College of Medicine, Blantyre, Malawi
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24
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Gordon SB, Chinula L, Chilima B, Mwapasa V, Dadabhai S, Mlombe Y. A Malawi guideline for research study participant remuneration. Wellcome Open Res 2018; 3:141. [PMID: 30662959 PMCID: PMC6329041 DOI: 10.12688/wellcomeopenres.14668.2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Research participant remuneration has been variable and inconsistent world-wide for many years owing to uncertainty regarding best practice and a lack of written guidelines for investigators and research ethics committees. Recent recommendations are that researchers and regulators should develop regionally appropriate written guidelines to define reasonable remuneration based on expense reimbursement, compensation for time and burden associated with participation. Incentives to motivate participation are acceptable in specific circumstances. Methods: We wished to develop regionally informed, precise and applicable guidelines in Malawi that might also be generally useful for African researchers and review committees. We therefore reviewed the current literature and developed widely applicable and specific remuneration tables using acceptable and evidence-based payment rationales. Results: There were good international guidelines and limited published regional guidelines. There were published examples of best practice and sufficient material to suggest a structured remuneration table. The rationale and method for the table were discussed at an inter-disciplinary workshop resulting in a reimbursement and compensation model with fixed rates. Payment is recommended pro rata and equally across a study. Conclusions: Transparent, fair remuneration of research participants is recommended by researchers and regulators in Malawi. The means to achieve this are now presented in the Malawi research participant remuneration table.
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Affiliation(s)
- Stephen B Gordon
- Malawi LIverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Lameck Chinula
- University of North Carolina Research, University of North Carolina, Blantyre, Malawi
| | - Ben Chilima
- National Health Sciences Research Committee, Lilongwe, Malawi
| | - Victor Mwapasa
- Research Support Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | - Sufia Dadabhai
- JHU Research Project, Johns Hopkins University, Blantyre, Malawi
| | - Yohannie Mlombe
- College of Medicine Research Ethics Committee, University of Malawi College of Medicine, Blantyre, Malawi
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25
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Mweemba C, Ali J, Hyder AA. Providing monetary and non-monetary goods to research participants: perspectives and practices of researchers and Research Ethics Committees in Zambia. Glob Bioeth 2018; 31:90-103. [PMID: 33343185 PMCID: PMC7734108 DOI: 10.1080/11287462.2018.1527672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/20/2018] [Indexed: 11/29/2022] Open
Abstract
There are disagreements among ethicists on what comprises an "appropriate" good to offer research participants. Debates often focus on the type, quantity, timing, and ethical appropriateness of such offers, particularly in settings where participants may be socio-economically vulnerable, such as in parts of Zambia. This was a Cross-sectional online survey of researchers and Research Ethics Committees (RECs) designed to understand practices, attitudes and policies associated with provision of goods to research participants. Of 122 responding researchers, 69 met eligibility criteria. Responses were also received from five of the six Zambian RECs involved in reviewing research proposals. Forty-nine researchers (71.0%) confirmed previous experience offering goods to participants. Of these, 21 (42.9%) offered participants money only, 18 (36.7%) offered non-monetary goods, while the rest offered both monetary and non-monetary goods. Generally, goods were offered and approved by RECs to compensate for time, lost wages and transportation. One REC and 34.8% of researchers reported being subject to an institutional policy on offering goods to participants. While reimbursement is the main reason for offering goods to participants in Zambia, caution is required when deciding on the type and quantity of goods to offer given the potential for community mistrust and manipulation.
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Affiliation(s)
- Chris Mweemba
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Joseph Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| | - Adnan A. Hyder
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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26
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Thong MK, See-Toh Y, Hassan J, Ali J. Medical genetics in developing countries in the Asia-Pacific region: challenges and opportunities. Genet Med 2018; 20:1114-1121. [DOI: 10.1038/s41436-018-0135-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022] Open
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Brown B, Galea JT, Dubé K, Davidson P, Khoshnood K, Holtzman L, Marg L, Taylor J. The Need to Track Payment Incentives to Participate in HIV Research. ACTA ACUST UNITED AC 2018. [DOI: 10.1002/eahr.404002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Brandon Brown
- University of California; Center for Healthy Communities in the Division of Clinical Sciences in the School of Medicine; Riverside
| | - Jerome T. Galea
- Harvard Medical School; Department of Global Health and Social Medicine
| | - Karine Dubé
- University of North Carolina; Gillings School of Global Public Health; Chapel Hill
| | - Peter Davidson
- University of California; Division of Global Public Health; Department of Medicine; San Diego
| | | | - Lisa Holtzman
- Harvard TH Chan School of Public Health; Department of Global Health and Population
| | - Logan Marg
- University of California; Center for Healthy Communities in the School of Medicine; Riverside
| | - Jeff Taylor
- Collaboratory of AIDS Researchers for Eradication; Palm Springs, CA
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28
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Andanda P, Wathuta J. Human dignity as a basis for providing post-trial access to healthcare for research participants: a South African perspective. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:139-155. [PMID: 28601920 DOI: 10.1007/s11019-017-9782-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This paper discusses the need to focus on the dignity of human participants as a legal and ethical basis for providing post-trial access to healthcare. Debate about post-trial benefits has mostly focused on access to products or interventions proven to be effective in clinical trials. However, such access may be modelled on a broad fair benefits framework that emphasises both collateral benefits and interventional products of research, instead of prescribed post-trial access alone (Legal and ethical regulation of biomedical research in developing countries p. 134, 2016). The wording of the current version of the Declaration of Helsinki could in fact be interpreted to broaden the scope to include other collateral benefits by applying such a broad fair benefits framework. We argue that this possibility should be utilised by low and middle income countries' (LMICs) health research ethics committees (RECs) in order to ensure that research participants who enrol in clinical trials so as to receive medical care continue to access care after the trial is concluded, as befits their dignity. Although each LMIC has unique concerns, nonetheless there are common challenges based especially on emerging issues, such as post-trial access to healthcare. Accordingly, the South African perspective is used to draw lessons that can benefit other LMICs.
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Affiliation(s)
- Pamela Andanda
- School of Law, University of the Witwatersrand, Johannesburg, South Africa.
- University of the Witwatersrand, Private Bag 3, WITS, Johannesburg, 2050, South Africa.
| | - Jane Wathuta
- School of Law, University of the Witwatersrand, Johannesburg, South Africa
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29
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Ward CL, Shaw D, Anane-Sarpong E, Sankoh O, Tanner M, Elger B. The Ethics of Health Care Delivery in a Pediatric Malaria Vaccine Trial: The Perspectives of Stakeholders From Ghana and Tanzania. J Empir Res Hum Res Ethics 2017; 13:26-41. [PMID: 29179625 DOI: 10.1177/1556264617742236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study explores ethical issues raised in providing medical care to participants and communities of low-resource settings involved in a Phase II/III pediatric malaria vaccine trial (PMVT). We conducted 52 key informant interviews with major stakeholders of an international multi-center PMVT (GSK/PATH-MVI RTS,S) (NCT00866619) in Ghana and Tanzania. Based on their stakeholder experiences, the responses fell into three main themes: (a) undue inducement, (b) community disparities, and (c) broad therapeutic misconceptions. The study identified the critical ethical aspects, from the perspectives of stakeholders, of delivering health care during a PMVT. The study showed that integrating research into health care services needs to be addressed in a manner that upholds the favorable risk-benefit ratio of research and attends to the health needs of local populations. The implementation of research should aim to improve local standards of care through building a collaborative agenda with local institutions and systems of health.
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Koen J, Wassenaar D, Mamotte N. The 'over-researched community': An ethics analysis of stakeholder views at two South African HIV prevention research sites. Soc Sci Med 2017; 194:1-9. [PMID: 29035778 DOI: 10.1016/j.socscimed.2017.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 11/16/2022]
Abstract
Health research in resource-limited, multi-cultural contexts raises complex ethical concerns. The term 'over-researched community' (ORC) has been raised as an ethical concern and potential barrier to community participation in research. However, the term lacks conceptual clarity and is absent from established ethics guidelines and academic literature. In light of the concern being raised in relation to research in low- and middle-income countries (LMICs), a critical and empirical exploration of the meaning of ORC was undertaken. Guided by Emanuel et al.'s (2004) eight principles for ethically sound research in LMICs, this study examines the relevance and meaning of the terms 'over-research' and 'over-researched community' through an analysis of key stakeholder perspectives at two South African research sites. Data were collected between August 2007 and October 2008. 'Over-research' was found to represent a conglomeration of ethical concerns often used as a proxy for standard research ethics concepts. 'Over-research' seemed fundamentally linked to disparate positions and perspectives between different stakeholders in the research interaction, arising from challenges in inter-stakeholder relationships. 'Over-research' might be interpreted to mean exploitation. However, exploitation itself could mean different things. Using the term may lead to obscured understanding of real or perceived ethical concerns, making it difficult to identify and address the underlying concerns. It is recommended that the term be carefully and critically interrogated for clarity when used in research ethics discourse. Because it represents other legitimate concerns, it should not be dismissed without careful exploration.
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Affiliation(s)
- Jennifer Koen
- HIV AIDS Vaccines Ethics Group, Discipline of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, Private Bag X01 Scottsville, Pietermaritzburg, 3209, South Africa.
| | - Douglas Wassenaar
- South African Research Ethics Training Initiative, School of Applied Human Sciences, University of KwaZulu-Natal, Private Bag X01 Scottsville, Pietermaritzburg, 3209 South Africa.
| | - Nicole Mamotte
- South African Research Ethics Training Initiative, School of Applied Human Sciences, University of KwaZulu-Natal, Private Bag X01 Scottsville, Pietermaritzburg, 3209 South Africa.
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31
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Healy J, Hope R, Bhabha J, Eyal N. Paying for antiretroviral adherence: is it unethical when the patient is an adolescent? JOURNAL OF MEDICAL ETHICS 2017; 43:145-149. [PMID: 27645199 DOI: 10.1136/medethics-2015-103359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 07/13/2016] [Accepted: 08/11/2016] [Indexed: 06/06/2023]
Abstract
With the expansion of antiretroviral treatment programmes, many children and adolescents with HIV in sub-Saharan Africa could expect to live healthy lives. Yet adolescents have the highest levels of poor antiretroviral adherence and of loss to follow-up compared with other age groups. This can lead to increased morbidity and mortality, to the development of drug-resistant strains, and to high societal costs. While financial incentives have been extensively used to promote medication adherence among adults, their use among adolescents remains rare. And while there is a large body of ethical literature exploring financial incentives among adults, little philosophical thought has gone into their use among adolescents. This paper explores three oft-mentioned ethical worries about financial incentives for health behaviours and it asks whether these concerns are more serious in the context of incentives for improving adolescent adherence. The three worries are that such incentives would unduly coerce adolescents' decision-making, would compromise distributive justice and would crowd out intrinsic motivations and non-monetary values. Our tentative conclusion is that more empirical investigation of these concerns is necessary, and that at this point they are not compelling enough to rule out trials in which adolescents are incentivised for antiretroviral adherence.
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Affiliation(s)
| | | | - Jacqueline Bhabha
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Nir Eyal
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
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Hing N, Sproston K, Brook K, Brading R. The Structural Features of Sports and Race Betting Inducements: Issues for Harm Minimisation and Consumer Protection. J Gambl Stud 2016; 33:685-704. [DOI: 10.1007/s10899-016-9642-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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33
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Rasiah R, Manikam R, Chandrasekaran SK, Naghavi N, Mubarik S, Mustafa R, Pushparajan S. Deceased Donor Organs: What Can Be Done to Raise Donation Rates Using Evidence From Malaysia? Am J Transplant 2016; 16:1540-7. [PMID: 26602367 DOI: 10.1111/ajt.13603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/02/2015] [Accepted: 10/31/2015] [Indexed: 01/25/2023]
Abstract
Organ donation rates have continued to fall seriously short of needs worldwide, with the lowest rates recorded among developing economies. This study seeks to analyze evidence from a developing economy to explore the usefulness of social psychological theory to solve the problem. The study deployed a large survey (n = 10 412) using a convenience sampling procedure targeted at increasing the number of Malaysians registered with the Ministry of Health, Malaysia who are willing to donate organs upon death. Structural equation modeling was deployed to estimate simultaneously the relative influence of cognitive and noncognitive variables on willingness to donate deceased organs. The cognitive factors of donation perception, socioeconomic status and financial incentives, and the noncognitive factors of demography and fear showed a high statistically significant (1%) relationship with willingness to donate organs after death. While financial incentives were significant, cash rewards showed the least impact. Donation perception showed the highest impact, which shows that the development of effective pedagogic programs with simultaneous improvements to the quality of services provided by medical personnel engaged in retrieving and transplanting deceased donor organs can help raise organ donation rates.
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Affiliation(s)
- R Rasiah
- Faculty of Economics and Administration, University of Malaya, Kuala Lumpur, Malaysia
| | - R Manikam
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - N Naghavi
- Faculty of Economics and Administration, University of Malaya, Kuala Lumpur, Malaysia
| | - S Mubarik
- Faculty of Economics and Administration, University of Malaya, Kuala Lumpur, Malaysia
| | - R Mustafa
- Malaysian Qualifying Agency, Kuala Lumpur, Malaysia
| | - S Pushparajan
- Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
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Dal-Ré R, Rid A, Emanuel E, Wendler D. The potential exploitation of research participants in high income countries who lack access to health care. Br J Clin Pharmacol 2016; 81:857-64. [PMID: 26743927 PMCID: PMC4834591 DOI: 10.1111/bcp.12879] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/25/2015] [Accepted: 01/03/2016] [Indexed: 11/30/2022] Open
Abstract
There are millions of individuals living in North America and the European Union who lack access to healthcare services. When these individuals participate in research, they are at increased risk of being exposed to the risks and burdens of clinical trials without realizing the benefits that result from them. The mechanisms that have been proposed to ensure that research participants in low- and middle-income countries are not exploited are unlikely to protect participants in high-income countries. The present manuscript argues that one way to address concerns about exploitation in high-income countries would be to require sponsors to provide targeted benefits such as medical treatment during the trial, or the study drug after the trial. The latter could be achieved through extension studies, expanded access programs, or named-patient programs. Sponsors also might provide non-medical benefits, such as education or social support. Ethical and regulatory guidance should be revised to ensure that research participants in high-income countries who lack access to healthcare services receive sufficient benefits.
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Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM + CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Madrid, Spain
| | - Annette Rid
- Department of Social Science, Health and Medicine, King's College, London, UK
| | - Ezekiel Emanuel
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania,, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
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Thaker SJ, Figer BH, Gogtay NJ, Thatte UM. An audit of consent refusals in clinical research at a tertiary care center in India. J Postgrad Med 2016; 61:257-63. [PMID: 26440397 PMCID: PMC4943370 DOI: 10.4103/0022-3859.166515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND RATIONALE Ensuring research participants' autonomy is one of the core ethical obligations of researchers. This fundamental principle confers on every participant the right to refuse to take part in clinical research, and the measure of the number of consent refusals could be an important metric to evaluate the quality of the informed consent process. This audit examined consent refusals among Indian participants in clinical studies done at our center. MATERIALS AND METHODS The number of consent refusals and their reasons in 10 studies done at our center over a 5-year period were assessed. The studies were classified by the authors according to the type of participant (healthy vs patients), type of sponsor (investigator-initiated vs pharmaceutical industry), type of study (observational vs interventional), level of risk [based on the Indian Council of Medical Research (ICMR) "Ethical Guidelines for Biomedical Research on Human Participants"], available knowledge of the intervention being studied, and each patient's disease condition. RESULTS The overall consent refusal rate was 21%. This rate was higher among patient participants [23.8% vs. healthy people (14.9%); P = 0.002], in interventional studies [33.6% vs observational studies (7.5%); P < 0.0001], in pharmaceutical industry-sponsored studies [34.7% vs investigator-initiated studies (7.2%); P < 0.0001], and in studies with greater risk (P < 0.0001). The most common reasons for consent refusals were multiple blood collections (28%), inability to comply with the study protocol (20%), and the risks involved (20%). CONCLUSION Our audit suggests the adequacy and reasonable quality of the informed consent process using consent refusals as a metric.
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Affiliation(s)
| | | | | | - U M Thatte
- Department of Clinical Pharmacology, Seth GS Medical College, King Edward Memorial (KEM) Hospital, Mumbai, Maharashtra, India
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Mngadi KT, Frohlich J, Montague C, Singh J, Nkomonde N, Mvandaba N, Ntombeka F, Luthuli L, Abdool Karim Q, Mansoor L. Challenges with participant reimbursement: experiences from a post-trial access study. JOURNAL OF MEDICAL ETHICS 2015; 41:909-913. [PMID: 26392172 DOI: 10.1136/medethics-2013-101899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 08/30/2015] [Indexed: 06/05/2023]
Abstract
Reimbursement of trial participants remains a frequently debated issue, with specific guidance lacking. Trials combining post-trial access and implementation science may necessitate new strategies and models. CAPRISA 008, a post-trial access study testing the feasibility of using family planning services to rollout a prelicensure HIV prevention intervention, tried to balance the real-life scenario of no reimbursement for attendance at public sector clinics with that of a trial including some visits that focused on research procedures and others that focused on standard of care procedures. A reduced reimbursement was offered for 'standard of care' visits, meant primarily to cover transport costs to and from the clinic only. This impacted negatively on accrual, retention and participant morale, primarily due to the protracted delay in regulatory approval, during which time, the costs of living, including travel costs had increased. Relevant guidelines were reviewed and institutional policy was updated to incorporate the South African National Health Research Ethics Committee guidelines on reimbursement (taking into account participant time, travel and inconvenience). The reimbursement amount for 'standard of care' visits was increased accordingly. The question remains whether a trial that combines post-trial access with implementation science, with clear benefits for the participants and the provision of above standard medical care, should have reimbursement rates that approach those of a proof-of-concept trial, for 'standard of care' visits.
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Affiliation(s)
- Kathryn Therese Mngadi
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa School of Laboratory Medicine and Medical Sciences, University of Kwazulu Natal, South Africa
| | - Janet Frohlich
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
| | - Carl Montague
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
| | - Jerome Singh
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa Department of HIV Prevention, Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, Alberta, Canada
| | - Nelisiwe Nkomonde
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
| | - Nomzamo Mvandaba
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
| | - Fanelesibonge Ntombeka
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
| | - Londiwe Luthuli
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
| | - Quarraisha Abdool Karim
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa Department if Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, USA
| | - Leila Mansoor
- Department of HIV Prevention, Centre for the AIDS Program of Research in South Africa, University of Kwazulu Natal, Durban, Kwazulu Natal, South Africa
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Mastroleo I. Post-trial obligations in the Declaration of Helsinki 2013: classification, reconstruction and interpretation. Dev World Bioeth 2015; 16:80-90. [PMID: 26481322 DOI: 10.1111/dewb.12099] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The general aim of this article is to give a critical interpretation of post-trial obligations towards individual research participants in the Declaration of Helsinki 2013. Transitioning research participants to the appropriate health care when a research study ends is a global problem. The publication of a new version of the Declaration of Helsinki is a great opportunity to discuss it. In my view, the Declaration of Helsinki 2013 identifies at least two clearly different types of post-trial obligations, specifically, access to care after research and access to information after research. The agents entitled to receive post-trial access are the individual participants in research studies. The Declaration identifies the sponsors, researchers and host country governments as the main agents responsible for complying with the post-trial obligations mentioned above. To justify this interpretation of post-trial obligations, I first introduce a classification of post-trial obligations and illustrate its application with examples from post-trial ethics literature. I then make a brief reconstruction of the formulations of post-trial obligations of the Declaration of Helsinki from 2000 to 2008 to correlate the changes with some of the most salient ethical arguments. Finally I advance a critical interpretation of the latest formulation of post-trial obligations. I defend the view that paragraph 34 of 'Post-trial provisions' is an improved formulation by comparison with earlier versions, especially for identifying responsible agents and abandoning ambiguous 'fair benefit' language. However, I criticize the disappearance of 'access to other appropriate care' present in the Declaration since 2004 and the narrow scope given to obligations of access to information after research.
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Resnik DB. Bioethical Issues in Providing Financial Incentives to Research Participants. ACTA ACUST UNITED AC 2015; 5:35-41. [PMID: 26807399 DOI: 10.2147/mb.s70416] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Offering research subjects financial incentives for their participation is a common practice that boosts recruitment but also raises ethical concerns, such as undue inducement, exploitation, and biased enrollment. This article reviews the arguments for providing participants with financial incentives, ethical concerns about payment, and approaches to establishing appropriate compensation levels. It also makes recommendations for investigators, institutions, and oversight committees.
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Affiliation(s)
- David B Resnik
- National Institute of Environmental Health Sciences, National Institutes of Health, 111 Alexander Drive, Box 12233, Mail Drop CU 03, Research Triangle Park, NC, USA
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Fisher JS, Butt Z, Friedewald J, Fry-Revere S, Hanneman J, Henderson ML, Ladin K, Mysel H, Preczewski L, Sherman LA, Thiessen C, Gordon EJ. Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation. Am J Transplant 2015; 15:1180-6. [PMID: 25833728 DOI: 10.1111/ajt.13234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 12/15/2014] [Accepted: 12/25/2015] [Indexed: 01/25/2023]
Abstract
New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.
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Affiliation(s)
- J S Fisher
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic/Green Hospital, La Jolla, CA
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Abstract
The conceptual complexity of the term voluntariness has resulted in relatively few empirical studies of the voluntariness component of consent to research. As the call for a formal assessment of voluntariness to be incorporated into the consent process intensifies, more researchers are responding to the challenge of developing a valid and reliable measure of voluntariness. The purpose of this article was to summarize and describe the empirical literature on voluntariness of consent. As part of a broader study on the voluntariness of consent to research, existing empirical studies of voluntariness of consent to research were reviewed to establish how voluntariness of consent to research has been assessed to date. Fifteen studies using different voluntariness assessment instruments were identified and included in the review. The review found that little attempt has been made to systematically collect data on the reliability and validity of voluntariness assessment instruments. No two instruments reviewed were found to be based on a shared conceptualization of voluntary consent to research.
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Gordon EJ, Patel CH, Sohn MW, Hippen B, Sherman LA. Does financial compensation for living kidney donation change willingness to donate? Am J Transplant 2015; 15:265-73. [PMID: 25425398 DOI: 10.1111/ajt.13004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 08/26/2014] [Accepted: 08/28/2014] [Indexed: 01/25/2023]
Abstract
The potential use of financial compensation to increase living kidney donation rates remains controversial in potentially introducing undue inducement of vulnerable populations to donate. This cross-sectional study assessed amounts of financial compensation that would generate motivation and an undue inducement to donate to family/friends or strangers. Individuals leaving six Departments of Motor Vehicles were surveyed. Of the 210 participants who provided verbal consent (94% participation rate), respondents' willingness to donate would not change (70%), or would increase (29%) with compensation. Median lowest amounts of financial compensation for which participants would begin to consider donating a kidney were $5000 for family/friends, and $10,000 for strangers; respondents reporting $0 for family/friends (52%) or strangers (26%) were excluded from analysis. Median lowest amounts of financial compensation for which participants could no longer decline (perceive an undue inducement) were $50,000 for family/friends, and $100,000 for strangers; respondents reporting $0 for family/friends (44%) or strangers (23%) were excluded from analysis. The two most preferred forms of compensation included: direct payment of money (61%) and paid leave (21%). The two most preferred uses of compensation included: paying off debt (38%) and paying nonmedical expenses associated with the transplant (29%). Findings suggest tolerance for, but little practical impact of, financial compensation. Certain compensation amounts could motivate the public to donate without being perceived as an undue inducement.
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Affiliation(s)
- E J Gordon
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL; Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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Kamuya DM, Marsh V, Njuguna P, Munywoki P, Parker M, Molyneux S. "When they see us, it's like they have seen the benefits!": experiences of study benefits negotiations in community-based studies on the Kenyan Coast. BMC Med Ethics 2014; 15:90. [PMID: 25539983 PMCID: PMC4391117 DOI: 10.1186/1472-6939-15-90] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 12/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benefit sharing in health research has been the focus of international debates for many years, particularly in developing countries. Whilst increasing attention is being given to frameworks that can guide researchers to determine levels of benefits to participants, there is little empirical research from developing countries on the practical application of these frameworks, including in situations of extreme poverty and vulnerability. In addition, the voices of those who often negotiate and face issues related to benefits in practice - frontline researchers and fieldworkers (FWs) - are rarely included in these debates. Against this background, this paper reports on experiences of negotiating research participation and benefits as described by fieldworkers, research participants and researchers in two community based studies. METHODS The findings reported here are from a broader social science study that explored the nature of interactions between fieldworkers and participants in two community based studies on the Kenyan Coast. Between January and July 2010, data were collected using participant observation, and through group discussions and in-depth interviews with 42 fieldworkers, 4 researchers, and 40 study participants. RESULTS Participants highly appreciated the benefits provided by studies, particularly health care benefits. Fieldworkers were seen by participants and other community members as the gatekeepers and conduits of benefits, even though those were not their formal roles. Fieldworkers found it challenging to ignore participant and community requests for more benefits, especially in situations of extreme poverty. However, responding to requests by providing different sorts and levels of benefits over time, as inadvertently happened in one study, raised expectations of further benefits and led to continuous negotiations between fieldworkers and participants. CONCLUSIONS Fieldworkers play an important intermediary role in research; a role imbued with multiple challenges and ethical dilemmas for which they require appropriate support. Further more specific empirical research is needed to inform the development of guidance for researchers on benefit sharing, and on responding to emergency humanitarian needs for this and other similar settings.
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Affiliation(s)
- Dorcas M Kamuya
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, United Kingdom. .,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Vicki Marsh
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, United Kingdom. .,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
| | | | | | - Michael Parker
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, United Kingdom.
| | - Sassy Molyneux
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, United Kingdom. .,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
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What are fair study benefits in international health research? Consulting community members in Kenya. PLoS One 2014; 9:e113112. [PMID: 25470596 PMCID: PMC4254456 DOI: 10.1371/journal.pone.0113112] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/20/2014] [Indexed: 11/25/2022] Open
Abstract
Background Planning study benefits and payments for participants in international health research in low- income settings can be a difficult and controversial process, with particular challenges in balancing risks of undue inducement and exploitation and understanding how researchers should take account of background inequities. At an international health research programme in Kenya, this study aimed to map local residents' informed and reasoned views on the effects of different levels of study benefits and payments to inform local policy and wider debates in international research. Methods and Findings Using a relatively novel two-stage process community consultation approach, five participatory workshops involving 90 local residents from diverse constituencies were followed by 15 small group discussions, with components of information-sharing, deliberation and reflection to situate normative reasoning within debates. Framework Analysis drew inductively and deductively on voice- recorded discussions and field notes supported by Nvivo 10 software, and the international research ethics literature. Community members' views on study benefits and payments were diverse, with complex contextual influences and interplay between risks of giving ‘too many’ and ‘too few’ benefits, including the role of cash. While recognising important risks for free choice, research relationships and community values in giving ‘too many’, the greatest concerns were risks of unfairness in giving ‘too few’ benefits, given difficulties in assessing indirect costs of participation and the serious consequences for families of underestimation, related to perceptions of researchers' responsibilities. Conclusions Providing benefits and payments to participants in international research in low-income settings is an essential means by which researchers meet individual-level and structural forms of ethical responsibilities, but understanding how this can be achieved requires a careful account of social realities and local judgment. Concerns about undue inducement in low-income communities may often be misplaced; we argue that greater attention should be placed on avoiding unfairness, particularly for the most-poor.
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Abstract
Social scientists undertaking studies of transnational medical research in developing countries focus on 'trial communities': networks of funders, institutions, researchers, clinical staff, fieldworkers and study participants. They relate these to the political economy that brings powerful research resources to poor settings. Whereas bioethicists tend to consider universal ethical requirements, social scientists examine how ethics are practiced in given situations in the light of the concerns and interests held by different parties involved in medical research. In conditions of poverty, high morbidity and weak public health services, research subjects are heavily induced by the prospect of high quality medical care and other benefits that researchers seem to offer. Studies of medical research undertaken by well-established internationally funded institutions in Africa show that parents are keen to have their children 'join' projects at these organisations. They assess benefits and risks less in terms of specific research projects and more in terms of their overall trust in the care these institutions are known to have provided previously for others in the community. Bioethics should widen its scope beyond concern with protecting individual subjects from the risks of specific research projects. It should recognise that clinical and research functions are indistinguishable for many participants, who want information on results of clinical investigations and sustained support for improving the health of their children.
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Dal-Ré R, Ndebele P, Higgs E, Sewankambo N, Wendler D. Protections for clinical trials in low and middle income countries need strengthening not weakening. BMJ 2014; 349:g4254. [PMID: 24996885 PMCID: PMC4688422 DOI: 10.1136/bmj.g4254] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, E-28049 Madrid, Spain
| | - Paul Ndebele
- Medical Research Council of Zimbabwe, Causeway, Harare, Zimbabwe
| | - Elizabeth Higgs
- Division of Clinical Research, Office of the Director, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | | | - David Wendler
- Unit on Vulnerable Populations, Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
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Abstract
BACKGROUND Injection drug use continues to significantly contribute to new infections with HIV. Moreover, conducting HIV prevention research with people who inject drugs (PWIDs) can be complicated for an array of practical, social, legal, and ethical reasons. It is critical that these research efforts are sensitive to the particular vulnerabilities associated with injection drug use as well as those related to being at risk of acquiring HIV so as to minimize harm to participants in research. PURPOSE To describe how we addressed some of these ethical challenges during the course of a large-scale multinational randomized HIV prevention trial involving PWIDs, which was successfully completed. METHODS The ethical issues encountered during the life cycle of the trial were cataloged by the principal investigator, study coordinator, and ethicist working on the trial. Relevant study documents were then reviewed to provide pertinent details. The ethical issues unique to the trial were then described. RESULTS Before implementation, the trial faced particularly complex challenges related to the vulnerability of PWIDs, where HIV seroincidence rates in the population were high and legal policies and stigma regarding injection drug use was severe. Accordingly, a rapid policy assessment was commissioned, and a series of community engagement activities were conducted. During the trial, in addition to using careful standard operating procedures regarding all aspects of trial conduct and extensive staff training, the trial standardized informed consent procedures and assessed them. Furthermore, social harms were monitored along with physical harms and adverse events. Following the decision to close the study, it was critical to develop an orderly and safe process for closing it. The issue of post-trial access to the study medication and a complex intervention also surfaced for consideration. LIMITATIONS The issues described in this article are necessarily limited to how they manifested themselves within the context of a particular trial that was conducted in two countries. In addition, other stakeholders may have divergent views on the ethical issues described and may also have identified additional ethical issues that would warrant examination. CONCLUSIONS Adopting similar approaches to addressing ethical issues in future research promises to facilitate this work so that needed strategies to prevent HIV infection among PWIDs can be safely and appropriately tested. Future trials enrolling PWIDs who are at risk of detainment should identify ways of mapping closely their experiences and perceptions in order to better apprehend some of the ethical issues at stake. In addition, scholarly and policy work needs to address the ethical issues related to post-trial access to multi-modal interventions that may be desired by participants, but are not shown to be effective in achieving the primary outcomes of the study.
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Affiliation(s)
- Jeremy Sugarman
- Johns Hopkins University, Berman Institute of Bioethics and Department of Medicine, 1809 Ashland Ave, Deering Hall, Baltimore, MD, United States
| | - Scott M. Rose
- FHI360, 2224 East Highway 54, Durham, NC 27713, United States
| | - David Metzger
- University of Pennsylvania, School of Medicine, HIV Prevention Research Division, Department of Psychiatry, 3535 Market Street, Suite 4000, Philadelphia, PA 19104, United States
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Chakrapani V, Newman PA, Singhal N, Nelson R, Shunmugam M. "If It's Not Working, Why Would They Be Testing It?": mental models of HIV vaccine trials and preventive misconception among men who have sex with men in India. BMC Public Health 2013; 13:731. [PMID: 23919283 PMCID: PMC3750469 DOI: 10.1186/1471-2458-13-731] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 08/01/2013] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Informed consent based on comprehension of potential risks and benefits is fundamental to the ethical conduct of clinical research. We explored mental models of candidate HIV vaccines and clinical trials that may impact on the feasibility and ethics of biomedical HIV prevention trials among men who have sex with men (MSM) in India. METHODS A community-based research project was designed and implemented in partnership with community-based organizations serving MSM in Chennai and Mumbai. We conducted 12 focus groups (n=68) with diverse MSM and 14 key informant interviews with MSM community leaders/service providers using a semi-structured interview guide to explore knowledge and beliefs about HIV vaccines and clinical trials. Focus groups (60-90 minutes) and interviews (45-60 minutes) were conducted in participants' native language (Tamil in Chennai; Marathi or Hindi in Mumbai), audio-taped, transcribed and translated into English. We explored focus group and interview data using thematic analysis and a constant comparative method, with a focus on mental models of HIV vaccines and clinical trials. RESULTS A mental model of HIV vaccine-induced seropositivity as "having HIV" resulted in fears of vaccine-induced infection and HIV stigma. Some participants feared inactivated vaccines might "drink blood" and "come alive". Pervasive preventive misconception was based on a mental model of prevention trials as interventions, overestimation of likely efficacy of candidate vaccines and likelihood of being assigned to the experimental group, with expectations of protective benefits and decreased condom use. Widespread misunderstanding and lack of acceptance of placebo and random assignment supported perceptions of clinical trials as "cheating". Key informants expressed concerns that volunteers from vulnerable Indian communities were being used as "experimental rats" to benefit high-income countries. CONCLUSIONS Evidence-informed interventions that engage with shared mental models among potential trial volunteers, along with policies and funding mechanisms that ensure local access to products that demonstrate efficacy in trials, may support the safe and ethical implementation of HIV vaccine trials in India.
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Affiliation(s)
- Venkatesan Chakrapani
- Centre for Sexuality and Health Research and Policy (C-SHaRP), 38 (Old No. 167), Ground Floor, Rangarajapuram Main Road, Kodambakkam, Chennai 600024, India
| | - Peter A Newman
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario M5S 1V4 Canada
| | - Neeti Singhal
- The Humsafar Trust, III floor, Manthan Plaza, Nehru Road, Vakola, Santacruz (East), Mumbai 400 055 India
| | - Ruban Nelson
- Centre for Sexuality and Health Research and Policy (C-SHaRP), 38 (Old No. 167), Ground Floor, Rangarajapuram Main Road, Kodambakkam, Chennai 600024, India
| | - Murali Shunmugam
- Centre for Sexuality and Health Research and Policy (C-SHaRP), 38 (Old No. 167), Ground Floor, Rangarajapuram Main Road, Kodambakkam, Chennai 600024, India
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Doshi MS, Kulkarni SP, Ghia CJ, Gogtay NJ, Thatte UM. Evaluation of factors that motivate participants to consent for non-therapeutic trials in India. JOURNAL OF MEDICAL ETHICS 2013; 39:391-396. [PMID: 23475804 DOI: 10.1136/medethics-2012-100755] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND RATIONALE Several factors that motivate individuals to participate in non-therapeutic studies have been identified. This study was conducted as limited data is available regarding these motivations from developing countries. METHODS This was a single-centre study conducted over 4 months in which a questionnaire was administered to 102 healthy participants and 16 patient participants who had earlier taken part in non-therapeutic studies at our centre. Descriptive statistics and univariate analysis were used to analyse data. RESULTS The most common motivation among healthy participants was financial reward (65%) followed by altruism, free medical check up, curiosity and personal health benefit. Patient participants, however, most commonly said they consented to take part in the trial as they were 'invited to participate by the treating physician' (88%). In comparison with the patient participants, healthy participants were more likely to be satisfied with the financial reward (p=0.02), and recommend participation in studies to friends or relatives (p=0.0013). CONCLUSIONS The most common motivating factor to participate in non-therapeutic studies appears to be different for healthy participants (financial reward) and patient participants (invitation to participate by the physician). Participants also felt that adequate information and care was given to them during the trial, and that they would participate in future clinical studies, and would also recommend such studies to their friends.
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Affiliation(s)
- Maulik Sumantbhai Doshi
- Department of Clinical Pharmacology, 1st Floor, MSB, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra 400012, India.
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Salaam AO, Brown J. Ethical Dilemmas in Psychological Research with Vulnerable Groups in Africa. ETHICS & BEHAVIOR 2013. [DOI: 10.1080/10508422.2012.728478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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