The effect of format modifications and reading comprehension on recall of informed consent information by low-income parents: a comparison of print, video, and computer-based presentations

The Readability Study: A Randomised Trial of Health Information Written at Different Grade Reading Levels

BACKGROUND

Despite increasing attention on health literacy and the inclusion of grade reading level recommendations in guidelines, it remains unclear if lowering the grade reading level of written health information to specific target grades improves patient-related outcomes.

OBJECTIVE

To assess whether grade reading level of written information affects knowledge, perceived reading ease, acceptability and trustworthiness of information and, to explore whether information written at a lower grade reading level reduces disparities in outcomes across health literacy levels.

DESIGN

We conducted a 4-arm online randomized trial with a community sample of adults living in Australia from 31 July to 20 September 2023.

EXPERIMENTAL ARMS

Participants were randomised to one of four arms: Information about sciatica and knee osteoarthritis written at a grade 8, 10, 12 or 14 reading level. Readability was assessed using the SMOG Index and iteratively revised to each lower grade.

MEASURES

Primary outcome was knowledge of health conditions. Secondary outcomes were brief knowledge, perceived reading ease, acceptability (i.e., perceived usefulness and likelihood to recommend) and trustworthiness of information.

RESULTS

2235 participants were randomised and included in the analysis. Mean age was 41 years and 54.5% identified as female. Low health literacy was identified in 28.2% of participants. We found no evidence of a main effect of grade reading level on knowledge (grade 8: 9.0 (SD = 2.7), grade 10: 9.1 (SD = 2.6), grade 12: 8.9, grade 14: 9.1 (SD = 2.7). Participants with high health literacy had higher knowledge scores overall, however, there was no evidence that health literacy modified the effect of grade reading level. There were no significant differences in any of the secondary outcomes.

CONCLUSIONS

Our study showed no difference in knowledge when grade reading level was manipulated alone. Our findings indicate there is limited value in reducing grade reading level without attention to other health literacy principles.

ANZCTR TRIAL REGISTRY NUMBER

ACTRN12623000224628p.

A Pilot Evaluation of an Educational Video to Support Consent to a Pediatric Malignancy Biobank

Introduction: The collection of biological specimens is necessary to support basic and translational research. However, the complexity of biobanking introduces numerous ethical issues, particularly regarding informed consent. Objective: To evaluate the acceptability and perceived benefits of an educational video facilitating the consent process for the Children's Cancer Centre Biobank. Methods: We invited individuals who had previously consented to be (or their child to be) part of the Biobank, and health professionals who were involved in obtaining consent. Participants watched the video and completed a purpose-designed online survey. Results: A total of 16 health professionals (invited = 30) and 15 patients/caregivers (invited = 127) participated. Most patients/caregivers felt informed about the Biobank at consent, however, noted how overwhelmed they were at the time and that they did not engage with the written information. Overall, both patients/caregivers and health professionals rated the video favorably regarding the information provided and format. Participants valued that it was simple and clear, with several health professionals noting the need for linguistic translations to better support the families they work with. Most patients/caregivers agreed that the video provided enough information to begin considering participation. This aligned with the health professionals' feedback that the video was most effective when used as a conversation starter to help formalize the written consent. Conclusion: Our findings suggest that our video is an acceptable and beneficial tool to assist in the Biobank consenting process, from both the perspective of decision-makers and health professionals obtaining consent. It appears particularly valuable as a precursor to an interactive, formal consent discussion. Further work is required to determine whether our video has a significant impact on outcomes such as decision-making satisfaction and knowledge, and to determine the value to adolescents.

Adult orthodontic consultations in private dental practice: How much information do patients remember when they leave the surgery?

OBJECTIVE

With good communication and information retention being key aspects of valid consent, this study aimed to assess adult patient information recall immediately after an orthodontic consultation.

MATERIALS AND METHODS

Adults interested in bracket-based or clear aligners were invited to take part at a single private dental practice. A 45-minute consultation with one of three general dental practitioners (GDPs) primarily providing orthodontics took place. A participant self-completed questionnaire tested recall of 20 items from the consultation. Demographics such as gender, age, level of English, education level, previous orthodontic experience and having a close family member or friend who had orthodontic treatment were also recorded.

RESULTS

Forty-two participants completed the questionnaire, and the information recall rate was 75% (mean score = 15). Three of the 42 participants recalled all 20 items. No statistically significant differences (P < 0.05) were found between information recall and any demographic variable, however, older participants (36 years and over) scored less (mean = 13.83) than participants 18-25 years (mean = 15.6).

CONCLUSIONS

A quarter of information provided during an orthodontic consultation with a GDP in a private dental practice cannot be recalled immediately afterwards by patients and so it is recommended that any verbal or visual information is always supplemented with written information.

The effect of educational animation compared to leaflets on patients' knowledge regarding root canal treatment: a randomized controlled trial

BACKGROUND

Incorporating video as a tool for education offers a multitude of advantages. However, it is unknown what is the best educational tool to use for increasing public awareness, consequently reducing fear about root canal treatment. For this reason, this study aimed to compare the effectiveness of educational animation and leaflets as delivery methods for providing information on root canal treatment to patients and to assess their ability to retain the information.

METHODS

One hundred fifty adult volunteers were recruited via social media and Umm Al-Qura University Dental Hospital to participate in this randomized control trial study. The volunteers were divided into the study group (SG) and the control group (CG). The SG was provided with information through animations created by the research team, while the CG received the same information through a leaflet. Pre-intervention (T1), immediate post-intervention (T2), and one-month post-intervention (T3) validated questionnaires were completed by the participants to assess the changes in their knowledge. To evaluate the impact of the information delivery method, the knowledge scores of T2 and T3 were compared to T1 within each group using Paired T-tests. Additionally, the study compared the knowledge scores of the two groups using unpaired T-tests. The significance level was set at a P-value of less than 0.05.

RESULTS

A significant improvement in endodontic therapy knowledge among the participants in both groups (T1 compared to T2 in the same group) was noted (P < 0.050). However, when comparing T2 between groups, no significant difference was found in delivering the information and improving the knowledge (P = 0.080). Still, the mean differences between T1 and T2, as well as T1 and T3, were greater (P < 0.050) in the SG than in the CG. Furthermore, the total knowledge score in the SG at T3 was significantly higher than the CG.

CONCLUSION

Both educational animation and leaflets are practical tools to increase patients' awareness about root canal treatment. However, educational videos are more effective than leaflets in delivering and retaining information about root canal treatment.

TRIAL REGISTRATION

This study was retrospectively registered as a randomized control trial at the ISRCTN registry with the document number ISRCTN18413241, 15/05/2023.

Predictors of Health Literacy Levels in Patients Attending Anesthesia Outpatient Clinics for Preoperative Evaluation

INTRODUCTION

Health literacy significantly impacts healthcare outcomes, particularly in preoperative settings where patients' understanding of medical procedures, adherence to instructions, and surgical outcomes are influenced. Despite accessibility to medical information, challenges persist in comprehending healthcare details, affecting active patient participation in care. This study aims to assess health literacy among patients attending anesthesia outpatient clinics for preoperative evaluation and analyze associated factors.

METHODS

A sample size of 240 patients was determined using power analysis. The inclusion criteria encompassed informed, consenting patients with adequate mental capacity and primary education, aged 18-65 years, according to the American Society of Anesthesiologists (ASA I-II). Data were collected through a descriptive characteristics form and the Health Literacy Scale (HLS).

RESULTS

The mean health literacy score was 29.37±6.22, indicating a moderate level. Marital status, education level, employment status, book reading preference, comorbidities, and reason for clinic visits significantly influenced health literacy (p<0.001). Regression analysis revealed marital status (β=-1.915, p=0.047), employment (β=1.187, p=0.039), and book reading preference (β=3.76, p<0.001) as independent predictors of health literacy.

DISCUSSION

Health literacy levels were associated with various socio-demographic and health-related factors. Notably, being single or divorced, employed, and enjoying reading predicted higher health literacy. This underscores the impact of social support, occupation, and reading habits on health literacy. However, longitudinal studies with objective measures are warranted to further explore these associations.

CONCLUSION

This study underscores the importance of addressing health literacy levels in anesthesia outpatient clinics, highlighting key predictors such as marital status, education, and employment. While contributing to our understanding of preoperative health literacy, further research using longitudinal designs and objective measures is essential. Bridging the health literacy gap is crucial for empowering patients, refining decision-making, and elevating the quality of overall surgical experiences.

Parents' and adolescents' perspectives and understanding of information about childhood cancer precision medicine

BACKGROUND

Precision medicine is projected to become integral to childhood cancer care. As such, it is essential to support families to understand what precision medicine entails.

METHODS

A total of 182 parents and 23 adolescent patients participating in Precision Medicine for Children with Cancer (PRISM), an Australian precision medicine clinical trial for high-risk childhood cancer, completed questionnaires after study enrollment (time 0 [T0]). Of the parents, 108 completed a questionnaire and 45 completed an interview following return of precision medicine results (time 1 [T1]). We analyzed the mixed-methods data comprising measures exploring families' perceptions and understanding of PRISM's participant information sheet and consent form (PISCF), and factors associated with understanding.

RESULTS

Most parents were satisfied with the PISCF, rating it as at least "somewhat" clearly presented (n = 160/175; 91%) and informative (n = 158/175; 90%). Many suggested improvements including the use of clearer language and a more visually engaging format. Parents' actual understanding of precision medicine was low on average, but scores improved between T0 and T1 (55.8/100-60.0/100; p = .012). Parents from culturally and/or linguistically diverse backgrounds (n = 42/177; 25%) had lower actual understanding scores than those from a Western/European background whose first language was English (p = .010). There was little correlation between parents' perceived and actual understanding scores (p = .794; Pearson correlation -0.020; 95% CI, -0.169 to 0.116). Most adolescent patients read the PISCF either "briefly" or "not at all" (70%) and had a perceived understanding score of 63.6/100 on average.

CONCLUSIONS

Our study revealed gaps in families' understanding of childhood cancer precision medicine. We highlighted areas for potential intervention such as through targeted information resources.

PLAIN LANGUAGE SUMMARY

Precision medicine is projected to become part of the standard of care for children with cancer. Precision medicine aims to give the right treatment to the right patient and involves several complex techniques, many of which may be challenging to understand. Our study analyzed questionnaire and interview data from parents and adolescent patients enrolled in an Australian precision medicine trial. Findings revealed gaps in families' understanding of childhood cancer precision medicine. Drawing on parents' suggestions and the literature, we make brief recommendations about improving information provision to families, such as through targeted information resources.

The use of e-consent in surgery and application to neurosurgery: a systematic review and meta-analysis

INTRODUCTION

The integration of novel electronic informed consent platforms in healthcare has undergone significant growth over the last decade. Adoption of uniform, accessible, and robust electronic online consenting applications is likely to enhance the informed consent process and improve the patient experience and has the potential to reduce medico-legal ramifications of inadequate consent. A systematic review and meta-analysis was conducted to evaluate the utility of novel electronic means of informed consent in surgical patients and discuss its application to neurosurgical cohorts.

METHODS

A review of randomised controlled trials, non-randomised studies of health interventions, and single group pre-post design studies in accordance with the PRISMA statement. Random effects modelling was used to estimate pooled proportions of study outcomes. Patient satisfaction with the informed consent process and patients' gain in knowledge were compared for electronic technologies versus non-electronic instruments. A sub-group analysis was conducted to compare the utility of electronic technologies in neurosurgical cohorts relative to other surgical patients in the context of patient satisfaction and knowledge gain.

RESULTS

Of 1042 screened abstracts, 63 studies were included: 44 randomised controlled trials (n = 4985), 4 non-randomised studies of health interventions (n = 387), and 15 single group pre-post design studies (n = 872). Meta-analysis showed that electronic technologies significantly enhanced patient satisfaction with the informed consent process (P < 0.00001) and patients' gain in knowledge (P < 0.00001) compared to standard non-electronic practices. Sub-group analysis demonstrated that neurosurgical patient knowledge was significantly enhanced with electronic technologies when compared to other surgical patients (P = 0.009), but there was no difference in patient satisfaction between neurosurgical cohorts and other surgical patients with respect to electronic technologies (P = 0.78).

CONCLUSIONS

Novel electronic technologies can enhance patient satisfaction and increase patients' gain in knowledge of their surgical procedures. Electronic patient education tools can significantly enhance patient knowledge for neurosurgical patients. If used appropriately, these modalities can shorten and/or improve the consent discussion, streamlining the surgical process and improving satisfaction for neurosurgical patients.

A randomized implementation trial to increase adoption of evidence-informed consent practices

Introduction

Several evidence-informed consent practices (ECPs) have been shown to improve informed consent in clinical trials but are not routinely used. These include optimizing consent formatting, using plain language, using validated instruments to assess understanding, and involving legally authorized representatives when appropriate. We hypothesized that participants receiving an implementation science toolkit and a social media push would have increased adoption of ECPs and other outcomes.

Methods

We conducted a 1-year trial with clinical research professionals in the USA (n = 1284) who have trials open to older adults or focus on Alzheimer's disease. We randomized participants to receive information on ECPs via receiving a toolkit with a social media push (intervention) or receiving an online learning module (active control). Participants completed a baseline survey and a follow-up survey after 1 year. A subset of participants was interviewed (n = 43).

Results

Participants who engaged more with the toolkit were more likely to have tried to implement an ECP during the trial than participants less engaged with the toolkit or the active control group. However, there were no significant differences in the adoption of ECPs, intention to adopt, or positive attitudes. Participants reported the toolkit and social media push were satisfactory, and participating increased their awareness of ECPs. However, they reported lacking the time needed to engage with the toolkit more fully.

Conclusions

Using an implementation science approach to increase the use of ECPs was only modestly successful. Data suggest that having institutional review boards recommend or require ECPs may be an effective way to increase their use.

Understanding the Use of Optimal Formatting and Plain Language When Presenting Key Information in Clinical Trials

Recent revisions to the Common Rule require that consent documents begin with a focused presentation of the study's key information that is organized to facilitate understanding. We surveyed 1,284 researchers working with older adults or individuals with Alzheimer's disease, supplemented with 60 qualitative interviews, to understand current use and barriers to using evidence-based formatting and plain language in key information. Researchers reported using formatting in 42% of their key information sections, and plain language in 63% of their key information sections. Perceived barriers included lack of knowledge, Institutional Review Board, other members of their team, and the burden associated with implementation. Education and training are required to increase adoption of the practices.

Video-augmentation of the informed consent process in mental health research: An exploratory study from India

Only around 50-75% of individuals fully understand the various aspects of informed consent in research. The aim of our study was to examine whether supplementing the conventional paper-based informed consent process with an audiovisual aid improves participants' understanding of the informed consent process and the information conveyed to them. Participants from two mental health/substance use intervention development studies were recruited for this study through consecutive sampling. They were then administered the traditional paper information and consenting process by itself or in combination with a video depicting the procedures of the study. Subsequently a bespoke questionnaire was administered to assess the participants' understanding of the information conveyed to them about the parent study. The various domains of the questionnaire were compared between those who were administered the two different consenting processes using the chi square test. 27 (58.7%) participants were administered the traditional consenting process and 19 were administered the video-supplemented consenting process. The video-supplemented consenting process was not superior to the traditional paper-based informed consent process on any of the domains examined. In settings with participants having a limited education, and in research involving people with mental health or substance use problems, further research is necessary to identify contextually relevant best practices for the informed consent process.

An App-Based Parenting Program to Promote Healthy Energy Balance-Related Parenting Practices to Prevent Childhood Obesity: Protocol Using the Intervention Mapping Framework

BACKGROUND

The family environment plays an important role in the development of children's energy balance-related behaviors. As a result, parents' energy balance-related parenting practices are important targets of preventive childhood obesity programs. Families with a lower socioeconomic position (SEP) may benefit from participating in such programs but are generally less well reached than families with a higher SEP.

OBJECTIVE

This paper describes the application of the Intervention Mapping Protocol (IMP) for the development of an app-based preventive intervention program to promote healthy energy balance-related parenting practices among parents of children (aged 0-4 years) with a lower SEP.

METHODS

The 6 steps of the IMP were used as a theory- and evidence-based framework to guide the development of an app-based preventive intervention program.

RESULTS

In step 1, behavioral outcomes for the app-based program (ie, children have a healthy dietary intake, sufficient sleep, and restricted screen time and sufficient physical activity) and sociocognitive (ie, knowledge, attitudes, and self-efficacy) and automatic (ie, habitual behaviors) determinants of energy balance-related parenting were identified through a needs assessment. In step 2, the behavioral outcomes were translated into performance objectives. To influence these objectives, in step 3, theory-based intervention methods were selected for each of the determinants. In step 4, the knowledge derived from the previous steps allowed for the development of the app-based program Samen Happie! through a process of continuous cocreation with parents and health professionals. In step 5, community health services were identified as potential adopters for the app. Finally, in step 6, 2 randomized controlled trials were designed to evaluate the process and effects of the app among Dutch parents of infants (trial 1) and preschoolers (trial 2). These trials were completed in November 2019 (trial 1) and February 2020 (trial 2).

CONCLUSIONS

The IMP allowed for the effective development of the app-based parenting program Samen Happie! to promote healthy energy balance-related parenting practices among parents of infants and preschoolers. Through the integration of theory, empirical evidence, and data from the target population, as well as the process of continued cocreation, the program specifically addresses parents with a lower SEP. This increases the potential of the program to prevent the development of obesity in early childhood among families with a lower SEP.

TRIAL REGISTRATION

Netherlands Trial Register NL6727, https://www.trialregister.nl/trial/6727; Netherlands Trial Register NL7371, https://www.trialregister.nl/trial/7371.

Randomized comparison of two interventions to enhance understanding during the informed consent process for research

BACKGROUND/AIMS

Many investigators have tested interventions to improve research participant understanding of information shared during the informed consent process, using a variety of methods and with mixed results. A valid criticism of most consent research is that studies are often conducted in simulated research settings rather than ongoing clinical studies. The present study rigorously tested two simple and easily adoptable strategies for presenting key consent information to participants eligible to enroll in six actual clinical trials (i.e. six parent studies).

METHODS

In collaboration with the study team from each parent study, we developed two consent interventions: a fact sheet and an interview-style video. The content of each of the intervention was based on the information shared in the consent form approved for each parent study. Participants were randomized to the standard consent process, or to one of the two interventions. Once exposed to the assigned consent mode, participants were asked to complete an assessment of understanding. The study was powered to determine whether those exposed to the fact sheet or video performed better on the consent assessment compared to those exposed to the standard consent. We also assessed participant satisfaction with the consent process.

RESULTS

A total of 284 participants were randomized to one of the three consent arms. Assessments of understanding were completed with a total of 273 participants from July 2017 to April 2019. Participants exposed to the video had better understanding scores compared to those exposed to the standard consent form process (p value = 0.020). Participants were more satisfied with the video when compared to the standard consent. Participants who received the fact sheet did not achieve higher overall understanding or satisfaction scores when compared to the standard consent process.

CONCLUSION

This randomized study of two novel consent interventions across six different clinical trials demonstrated a statistically significant difference in participant understanding based on overall scores among those exposed to the video intervention compared to those exposed to the standard consent.

Improving Surgical Informed Consent: Unanswered Questions

Objective

This study reviews randomized clinical trials that have attempted to improve the process of informed consent. Consent should be guided by the ethical imperatives of autonomy, beneficence, and social justice.

Summary Background

Informed consent is constantly evolving. Yet our review of the randomized trials done to improve the surgical informed consent process raises a number of questions: How does one define surgical informed consent? What interventions have been tried to measure and improve informed consent? Have the interventions in informed consent actually led to improvements? What efforts have been made to improve informed consent? And what steps can be taken to improve the process further?

Methods

A literature search for randomized controlled trials (RCTs)on informed consent identified 70 trials. Demographics, interventions, assessments, and a semi-quantitative summary of the findings were tabulated. The assessments done in the RCTs, show the surrogate for patient autonomy was comprehension; for beneficence, satisfaction and mental state (anxiety or depression); and, for social justice, language, literacy, learning needs, and cost.

Results

There were 4 basic categories of interventions: printed matter; non-interactive audiovisual tools; interactive multimedia; and a smaller group defying easy description. Improvement was documented in 46 of the 65 trials that studied comprehension. Thirteen of 33 trials showed improved satisfaction. Three of 30 studies showed an increase in anxiety. Few studies tried to assess primary language or literacy, and none looked at learning needs or cost.

Conclusions

No single study improved all 3 principles of informed consent. Validated interventions and assessments were associated with greater impact on outcomes. All 3 ethical principles should be assessed; autonomy (as comprehension), beneficence (as satisfaction, anxiety), and social justice. Not enough consideration has been given to social justice; appropriate language translation, standardized reading levels, assessment of learning needs, and cost to the individual are all important elements worthy of future study.

Digital tools in the informed consent process: a systematic review

Background

Providing understandable information to patients is necessary to achieve the aims of the Informed Consent process: respecting and promoting patients’ autonomy and protecting patients from harm. In recent decades, new, primarily digital technologies have been used to apply and test innovative formats of Informed Consent. We conducted a systematic review to explore the impact of using digital tools for Informed Consent in both clinical research and in clinical practice. Understanding, satisfaction and participation were compared for digital tools versus the non-digital Informed Consent process.

Methods

We searched for studies on available electronic databases, including Pubmed, EMBASE, and Cochrane. Studies were identified using specific Mesh-terms/keywords. We included studies, published from January 2012 to October 2020, that focused on the use of digital Informed Consent tools for clinical research, or clinical procedures. Digital interventions were defined as interventions that used multimedia or audio–video to provide information to patients. We classified the interventions into 3 different categories: video only, non-interactive multimedia, and interactive multimedia.

Results

Our search yielded 19,579 publications. After title and abstract screening 100 studies were retained for full-text analysis, of which 73 publications were included. Studies examined interactive multimedia (29/73), non-interactive multimedia (13/73), and videos (31/73), and most (34/38) studies were conducted on adults. Innovations in consent were tested for clinical/surgical procedures (26/38) and clinical research (12/38). For research IC, 21 outcomes were explored, with a positive effect on at least one of the studied outcomes being observed in 8/12 studies. For clinical/surgical procedures 49 outcomes were explored, and 21/26 studies reported a positive effect on at least one of the studied outcomes.

Conclusions

Digital technologies for informed consent were not found to negatively affect any of the outcomes, and overall, multimedia tools seem desirable. Multimedia tools indicated a higher impact than videos only. Presence of a researcher may potentially enhance efficacy of different outcomes in research IC processes. Studies were heterogeneous in design, making evaluation of impact challenging. Robust study design including standardization is needed to conclusively assess impact.

Does a video clip enhance recruitment into a parenting trial? Learnings from a study within a trial

Background

Reaching recruitment targets in randomised controlled trials is a challenge. Media tools are increasingly used to engage participants, yet there is a paucity of research into the use of video to optimise recruitment. We therefore tested whether adding a participant information video clip to a standard participant information sheet improved recruitment into a parenting trial.

Methods

One hundred seven participants were randomised to receive either a participant information sheet (n = 51) or an informational video clip (n = 56) as part of an email contact following a screening phase. All participants went on to receive the information sheet as part of the existing consent procedure.

Results

The video condition did not increase the odds of recruitment into the trial, such that those in the video condition were significantly less likely to participate in the main trial (OR = 0.253, CI = 0.104–0.618, p = 0.003).

Conclusion

The introduction of a video clip into the recruitment stages of a parenting trial did not lead to an improvement in recruitment; however, the small sample size precludes definitive inferences. We offer reflections on challenges encountered in implementing the SWAT and suggestions for other researchers seeking to embed recruitment SWATs into similar trials.

Trial registration

Current controlled trials ISRCTN 58327365. Registered on 19 March 2015.

SWAT registration

SWAT 106; Effects of a video clip on recruitment into a randomised trial. Registered on 20 December 2016.

Using pictures to convey health information: A systematic review and meta-analysis of the effects on patient and consumer health behaviors and outcomes

OBJECTIVE

Assess the effect of pictorial health information on patients' and consumers' health behaviors and outcomes, evaluate these effects in lower health literacy populations, and examine the attributes of the interventions.

METHODS

We included randomized controlled trials (RCTs) that assessed the effect of pictorial health information on patient and consumer health behaviors and outcomes. We conducted a meta-analysis of RCTs that assessed knowledge/understanding, recall, or adherence, and a subgroup analysis of those outcomes on lower health literacy populations. We narratively reviewed characteristics of pictorial health interventions that significantly improved outcomes for lower health literacy populations.

RESULTS

From 4160 records, we included 54 RCTs (42 in meta-analysis). Pictorial health information moderately improved knowledge/understanding and recall overall, but largely increased knowledge/understanding for lower health literacy populations (n = 13), all with substantial heterogeneity. Icons with few words may be most helpful in conveying health information.

CONCLUSION

Our results support including pictures in health communication to improve patient knowledge. Our results should be interpreted with caution considering the significant heterogeneity of the meta-analysis outcomes.

PRACTICE IMPLICATIONS

Future research should assess which types and characteristics of pictures that best convey health information and are most useful and the implementation and sustainability in healthcare contexts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084743.

Parental Understanding of Research Consent Forms in the PICU: A Pilot Study

OBJECTIVES

To describe legal guardians' understanding of key concepts in a research consent form presented within 24 hours of their child's admission to the PICU and to explore legal guardians' opinions of the format (language, length) of the consent form and the overall consent process.

DESIGN

Single-center, exploratory pilot study.

SETTING

PICU at a tertiary-care hospital in Canada.

SUBJECTS

Forty-one English- and French-speaking legal guardians of children less than 18 years old, who had been admitted to the PICU within the past 24 hours and were expected to stay at least 48 hours, between October 2018 and February 2019.

INTERVENTIONS

The consent form from a previous PICU trial was given and explained to legal guardians within 24 hours of their child's admission to the PICU.

MEASUREMENTS AND MAIN RESULTS

Legal guardians' understanding of key concepts in the consent form was evaluated using a questionnaire the day after the form was explained, and opinions were collected verbally and using an additional survey. The median number of questions answered incorrectly was three of seven (interquartile range = 2-4). Participants best understood the topic of the study (5% incorrect), but 80% of participants were unable to recall a single risk. The median rating of the language in the form was five of five (very easy to understand; interquartile range = 4-5), and 88% of participants said it was a reasonable length.

CONCLUSIONS

Despite positive opinions of the consent form, most legal guardians did not understand all key components of the consent information provided to them orally and in writing within 24 hours of their child's PICU admission. Future studies are required to determine barriers to understanding and explore alternative approaches to obtaining consent in this setting.

The "Ought-Is" Problem: An Implementation Science Framework for Translating Ethical Norms Into Practice

We argue that once a normative claim is developed, there is an imperative to effect changes based on this norm. As such, ethicists should adopt an "implementation mindset" when formulating norms, and collaborate with others who have the expertise needed to implement policies and practices. To guide this translation of norms into practice, we propose a framework that incorporates implementation science into ethics. Implementation science is a discipline dedicated to supporting the sustained enactment of interventions. We further argue that implementation principles should be integrated into the development of specific normative claims as well as the enactment of these norms. Ethicists formulating a specific norm should consider whether that norm can feasibly be enacted because the resultant specific norm will directly affect the types of interventions subsequently developed. To inform this argument, we will describe the fundamental principles of implementation science, using informed consent to research participation as an illustration.

Healthcare-Associated Infections: Not Only a Clinical Burden, But a Forensic Point of View

BACKGROUND

Healthcare-associated infections (HCAIs) occur when patients receiving treatment in a health care setting develop an infection. They represent a major public health problem, requiring the integration of clinical medicine, pathology, epidemiology, laboratory sciences, and, finally, forensic medicine.

METHODS

The determination of cause of death is fundamental not only in the cases of presumed malpractice to ascertain the causal link with any negligent behavior both of health facilities and of individual professionals, but also for epidemiological purposes since it may help to know the global burden of HCAIs, that remains undetermined because of the difficulty of gathering reliable diagnostic data. A complete methodological approach, integrating clinical data by means of autopsy and histological and laboratory findings aiming to identify and demonstrate the host response to infectious insult, is mandatory in HCAIs related deaths.

RESULTS

Important tasks for forensic specialists in hospitals and health services centers are the promotion of transparency and open communication by health-care workers on the risk of HCAIs, thus facilitating patients' engagement and the implementation of educational interventions for professionals aimed to improve their knowledge and adherence to prevention and control measures.

CONCLUSION

HCAIs are a major problem for patient safety in every health-care facility and system around the world and their control and prevention represent a challenging priority for healthcare institution and workers committed to making healthcare safer. Clinicians are at the forefront in the war against HCAIs, however, also forensic pathologists have a remarkable role.

Iterative development of a web-based intervention for families of young children with type 1 diabetes: DIPPer Academy

Objective

A new diagnosis of Type 1 diabetes mellitus (T1D) can be stressful for families as they are expected to learn a large amount of information regarding disease management and treatment in a short period of time. Currently, parents complete diabetes education at the time of diagnosis. However, this format may not be sustainable as rates of T1D climb. The current study aimed to develop an online platform to provide educational material in the form of video micro-lectures using an iterative, user-centered, design process.

Methods

In the first stage of development, parents of young children with T1D identified information they felt most important to their child's T1D care. In the second stage, healthcare providers contributed qualitative and quantitative feedback regarding the educational material and video mock-ups. The third stage involved parents of young children with T1D providing feedback on the completed video micro-lectures.

Results

Providers and parents reported that the videos were highly useful, important to T1D care, and the majority would recommend them to other parents.

Conclusions

The iterative design process used by the research team incorporated multiple perspectives and ultimately developed educational resources that were well-received by providers, researchers, and parents.

Implications for Impact Statement

This study used an iterative, user-centered design to develop a series of web-based videos for parents of young children with type 1 diabetes. Primary stakeholders, both healthcare providers and parents, described videos as highly important, useful, enjoyable, and would recommend these resources to others. Parents rated videos highly across a variety of presentations that ranged in development time and cost, indicating that researchers can feasibly and cost-effectively create web-based resources for parents.

Patients' Acceptability of Computer-Based Information on Hypodontia: A Randomized Controlled Trial

OBJECTIVES

To compare patients' acceptability of a hypodontia-specific interactive computer-based education material (ICB-EM) versus a British Orthodontic Society (BOS) hypodontia leaflet.

TRIAL DESIGN

Two-arm parallel randomized controlled trial, 1:1 allocation ratio.

METHODS

The study was conducted at a specialized secondary care facility in the Greater London area. Ninety-six new hypodontia patients aged 14 y and older were randomly assigned to the control group ( n = 49) receiving the BOS leaflet or the intervention group ( n = 47) receiving the ICB-EM. The main outcome measure was patients' evaluation of the intervention measured by the treatment evaluation inventory.

RESULTS

The analyzed sample comprised 76 participants: control group ( n = 38) and intervention group ( n = 38). The mean age of the sample was 19 y (SD = 7.24) and 20.3 y (SD = 6.9) for the control and intervention group, respectively. The intervention group was significantly more satisfied with the ICB-EM than individuals who received the BOS leaflet ( t = -3.53, P = 0.001).

CONCLUSION

Patients preferred the computer-based information.

KNOWLEDGE TRANSFER STATEMENT

Patients attending dental care in the 21st century are adept in the use of computerised facilities for obtaining information. The results of the study will provide valuable evidence for clinicians on the level of acceptability of the patients toward interactive computer based health education as opposed to traditional paper leaflets.

Does pictorial health information improve health behaviours and other outcomes? A systematic review protocol

INTRODUCTION

Most health information is verbal or written, yet words alone may not be the most effective way to communicate health information. Lower health literacy is prevalent in the US and is linked to limited understanding of one's medical condition and treatment. Pictures increase comprehension, recall, adherence and attention in health settings. This is called pictorial superiority. No systematic review has examined the impact of pictorial health information among patients and consumers, including those with lower health literacy.

METHODS AND ANALYSIS

This systematic review and meta-analysis will assess the characteristics and effectiveness of pictorial health information on patient and consumer health behaviours and outcomes, as well as differentially among individuals of lower literacy/lower health literacy. We will conduct a systematic search across selected databases, as well as grey literature, from inception until June 2018. We will include randomised controlled trials in all languages with all types of participants that assess the effect of pictorial health information on patients' and consumers' health behaviours and outcomes. Two independent reviewers will conduct the primary screening of articles and data extraction for the selected articles with a third individual available to resolve conflicts. We will assess the quality of all included studies using the Cochrane risk of bias tool. We will combine all selected studies and do a test of heterogeneity. If there is sufficient homogeneity, we will pool studies into a meta-analysis. Independent of the heterogeneity of included studies, we will also conduct a narrative synthesis.

ETHICS AND DISSEMINATION

No ethics approval is required. The results will be published in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42018084743.

The Acceptability of Biobehavioral Research With Latino Youth in the United States

In this study, we explored Latinx adolescents’ knowledge and perceptions of biobehavioral research and their willingness to participate in such studies. We conducted four focus groups in the summer of 2014 with Latinx adolescents in Texas between the ages of 12 and 17 years ( n = 17; 53% male; M age = 14.6 years [ SD = 1.66]) who were recruited from a community-based clinic. Five themes emerged from our content analysis: (a) protection of human subjects is important to participants, (b) comfort with providing different types of biological data varies depending on different factors, (c) engagement in biobehavioral research should be grounded in a cultural lens, (d) providing bilingual research staff is essential, and (e) adolescents have various motivations for participating. Findings highlighted how various factors could serve as both barriers and facilitators to participation. Our study provides insight into strategies for conducting biobehavioral research with Latinxs, who are the fastest growing group of adolescents in the United States and experience disparities in health-risk behaviors that can be better understood through research approaches that integrate biological and psychological measures. Without considering the perspectives of historically marginalized or understudied populations, we jeopardize the quality and validity of research findings, and risk harming participants.

Exploratory study of personal health information management using health literacy model

Purpose

The purpose of this paper is to empirically test whether individuals’ internal factors (prior knowledge, resources, and capability) and environmental factors (stimuli, limitation) have any influence on the development of personal health information management (PHIM) literacy skills and which constructs are statistically associated with general health-related outcomes.

Design/methodology/approach

Survey responses were collected from Amazon’s Mechanical Turk (mTurk), a crowdsourcing internet service, in December 2013. A total of 578 responses were analyzed using partial-least squares structural equation modeling technique.

Findings

The model as a whole exhibited 62.8 percent of variance in health-related outcomes. The findings suggest that prior knowledge has a direct effect on health literacy (HL) skills (H3: β=0.212, p<0.001). The PHIM stimuli (H4: β=0.475, p<0.001) have a direct impact on HL skills, and they have an indirect effect on the comprehension of stimuli (H6: β=0.526, p<0.001) through the mediator of stimuli and the knowledge variable.

Research limitations/implications

One possible limitation of this study is that the study may include a highly technology literate group, as survey respondents were recruited from the online service mTurk.

Practical implications

The study poses implications for further research and practice. This research was an exploratory work for further model development so future studies should investigate deeper into real personal health record (PHR) user groups (e.g. patients and caregivers). For example, studies by White and Horvitz (2009a, b) conducted real-time user studies that the authors could apply to the authors’ future PHR studies. Since the findings cannot be generalizable to these specific groups, similar research may be conducted. Using caregiver groups of PHR users in comparison to patient groups could determine the similarities and differences of their PHIM activities and related outcomes for optimal design of self-care management.

Social implications

Further, it is suggested to conduct large scale, real-time-based studies using a PHR transaction log analysis to achieve conclusiveness and generalizability. Additionally, future studies should address not only diverse real-time user groups, but also various PHR data sources and their presentation issues.

Originality/value

This study model offers an important perspective on PHIM and its causal pathway for use not only by patient educators and healthcare providers but also information providers, personal health record (PHR) system developers, and PHR users.

Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.

A cognitive approach for design of a multimedia informed consent video and website in pediatric research

OBJECTIVE

Poor participant comprehension of research procedures following the conventional face-to-face consent process for biomedical research is common. We describe the development of a multimedia informed consent video and website that incorporates cognitive strategies to enhance comprehension of study related material directed to parents and adolescents.

MATERIALS AND METHODS

A multidisciplinary team was assembled for development of the video and website that included human subjects professionals; psychologist researchers; institutional video and web developers; bioinformaticians and programmers; and parent and adolescent stakeholders. Five learning strategies that included Sensory-Modality view, Coherence, Signaling, Redundancy, and Personalization were integrated into a 15-min video and website material that describes a clinical research trial.

RESULTS

A diverse team collaborated extensively over 15months to design and build a multimedia platform for obtaining parental permission and adolescent assent for participant in as asthma clinical trial. Examples of the learning principles included, having a narrator describe what was being viewed on the video (sensory-modality); eliminating unnecessary text and graphics (coherence); having the initial portion of the video explain the sections of the video to be viewed (signaling); avoiding simultaneous presentation of text and graphics (redundancy); and having a consistent narrator throughout the video (personalization).

DISCUSSION

Existing conventional and multimedia processes for obtaining research informed consent have not actively incorporated basic principles of human cognition and learning in the design and implementation of these processes. The present paper illustrates how this can be achieved, setting the stage for rigorous evaluation of potential benefits such as improved comprehension, satisfaction with the consent process, and completion of research objectives.

CONCLUSION

New consent strategies that have an integrated cognitive approach need to be developed and tested in controlled trials.

Video-Assisted Informed Consent for Cataract Surgery: A Randomized Controlled Trial

Purpose. To investigate whether adding video assistance to traditional verbal informed consent advisement improved satisfaction among cataract surgery patients. Methods. This trial enrolled 80 Chinese patients with age-related cataracts scheduled to undergo unilateral phacoemulsification surgery. Patients were randomized into two groups: the video group watched video explaining cataract-related consent information and rewatched specific segments of the video at their own discretion, before receiving traditional verbal consent advisement; the control group did not watch the video. Outcomes included patient satisfaction, refusal to consent, time to complete the consent process, and comprehension measured by a ten-item questionnaire. Results. All 80 enrolled patients signed informed consent forms. Compared with the control group, members of the video group exhibited greater satisfaction (65% versus 86%, p = 0.035) and required less time to complete the consent process (12.3 ± 6.7 min versus 5.6 ± 5.4 min, p < 0.001), while also evincing levels of comprehension commensurate with those reported for patients who did not watch the video (accuracy rate, 77.5% versus 80.2%, p = 0.386). Conclusion. The video-assisted informed consent process had a positive impact on patients' cataract surgery experiences. Additional research is needed to optimize patients' comprehension of the video.

The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults

Inadequate health literacy (HL) is associated with impaired healthcare choices leading to poor quality-of-care. Our primary purpose was to estimate the prevalence of inadequate HL among two populations of AARP^® Medicare Supplement insureds: sicker and healthier populations; to identify characteristics of inadequate HL; and to describe the impact on patient satisfaction, preventive services, healthcare utilization, and expenditures. Surveys were mailed to insureds in 10 states. Multivariate regression models were used to identify characteristics and adjust outcomes. Among respondents (N = 7334), 23% and 16% of sicker and healthier insureds, respectively, indicated inadequate HL. Characteristics of inadequate HL included male gender, older age, more comorbidities, and lower education. Inadequate HL was associated with lower patient satisfaction, lower preventive service compliance, higher healthcare utilization and expenditures. Inadequate HL is more common among older adults in poorer health, further compromising their health outcomes; thus they may benefit from expanded educational or additional care coordination interventions.

Smoking Education for Low-Educated Adolescents

This study aims to provide insight into which modality is most effective for educating low-educated adolescents about smoking. It compares the persuasive effects of print and audiovisual smoking education materials. We conducted a field experiment with two conditions (print vs. video) and three measurement times (Time 1, Time 2, and Time 3). A total of 221 high school students in the second year of the lowest levels of education in the Netherlands participated at all three time points of the study. Results showed that participants in both conditions had more negative beliefs about smoking after being exposed to the smoking education than before, but there were no differences between the print and video version in this effect. However, the video version did make the attitude toward smoking more negative at Time 3 compared to baseline, whereas the text version did not, which suggests that the video version was more effective for educating low-educated adolescents about smoking.

Effects of a pain self-management intervention combining written and video elements on health-related quality of life among people with different levels of education

Combining written and video material could increase the impact of health education for people with less education, but more evidence is needed about the impact of combined materials in different formats, especially in the context of chronic pain self-management. This study tested the impact of combining written information about self-managing chronic joint pain, which used language at a high reading level, with a DVD containing narrative video material presented directly by patients, using language at a lower reading level. Physical and mental health-related quality of life (36-Item Short Form Health Survey) was measured among 107 men with hemophilia before and 6 months after being randomly assigned to receive an information booklet alone or the booklet plus the DVD. Analysis of covariance was used to compare health outcomes between randomized groups at follow-up, using the baseline measures as covariates, with stratified analyses for groups with different levels of education. The DVD significantly improved mental health-related quality of life among those with only high school education. Video material could therefore supplement written information to increase its impact on groups with less education, and combined interventions of this type could help to achieve health benefits for disadvantaged groups who are most in need of intervention.

A pilot study of simple interventions to improve informed consent in clinical research: feasibility, approach, and results

BACKGROUND

Research suggests that participants do not always adequately understand studies. While some consent interventions increase understanding, methodologic challenges have been raised in studying consent outside of actual trial settings. This study examined the feasibility of testing two consent interventions in actual studies and measured effectiveness of interventions in improving understanding.

METHODS

Participants enrolling in any of eight ongoing clinical trials were sequentially assigned to one of three different informed consent strategies for enrollment in their clinical trial. Control participants received standard consent procedures for their trial. Participants in the first intervention arm received a bulleted fact sheet summarizing key study information. Participants in the second intervention arm received the bulleted fact sheet and also engaged in a feedback Q&A session. Later, patients answered closed- and open-ended questions to assess patient understanding and literacy. Descriptive statistics, Wilcoxon -Mann -Whitney and Kruskal-Wallis tests were generated to assess correlations; regression analysis determined predictors of understanding.

RESULTS

144 participants enrolled. Using regression analysis, participants receiving the second intervention scored 7.6 percentage points higher (p = .02) on open-ended questions about understanding than participants in the control, although unadjusted comparisons did not reach statistical significance.

CONCLUSIONS

Our study supports the hypothesis that patients receiving both bulleted fact sheets and a Q&A session had higher understanding compared to standard consent. Fact sheets and short structured dialog are quick to administer and easy to replicate across studies and should be tested in larger samples.

Audio-visual presentation of information for informed consent for participation in clinical trials

BACKGROUND

Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented, for example, on the Internet or on DVD) are one such method. We updated a 2008 review of the effects of these interventions for informed consent for trial participation.

OBJECTIVES

To assess the effects of audio-visual information interventions regarding informed consent compared with standard information or placebo audio-visual interventions regarding informed consent for potential clinical trial participants, in terms of their understanding, satisfaction, willingness to participate, and anxiety or other psychological distress.

SEARCH METHODS

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 6, 2012; MEDLINE (OvidSP) (1946 to 13 June 2012); EMBASE (OvidSP) (1947 to 12 June 2012); PsycINFO (OvidSP) (1806 to June week 1 2012); CINAHL (EbscoHOST) (1981 to 27 June 2012); Current Contents (OvidSP) (1993 Week 27 to 2012 Week 26); and ERIC (Proquest) (searched 27 June 2012). We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or verbal information), with standard forms of information provision or placebo audio-visual information, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to consider participating in a real or hypothetical clinical study. (In the earlier version of this review we only included studies evaluating informed consent interventions for real studies).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. We synthesised the findings using meta-analysis, where possible, and narrative synthesis of results. We assessed the risk of bias of individual studies and considered the impact of the quality of the overall evidence on the strength of the results.

MAIN RESULTS

We included 16 studies involving data from 1884 participants. Nine studies included participants considering real clinical trials, and eight included participants considering hypothetical clinical trials, with one including both. All studies were conducted in high-income countries.There is still much uncertainty about the effect of audio-visual informed consent interventions on a range of patient outcomes. However, when considered across comparisons, we found low to very low quality evidence that such interventions may slightly improve knowledge or understanding of the parent trial, but may make little or no difference to rate of participation or willingness to participate. Audio-visual presentation of informed consent may improve participant satisfaction with the consent information provided. However its effect on satisfaction with other aspects of the process is not clear. There is insufficient evidence to draw conclusions about anxiety arising from audio-visual informed consent. We found conflicting, very low quality evidence about whether audio-visual interventions took more or less time to administer. No study measured researcher satisfaction with the informed consent process, nor ease of use.The evidence from real clinical trials was rated as low quality for most outcomes, and for hypothetical studies, very low. We note, however, that this was in large part due to poor study reporting, the hypothetical nature of some studies and low participant numbers, rather than inconsistent results between studies or confirmed poor trial quality. We do not believe that any studies were funded by organisations with a vested interest in the results.

AUTHORS' CONCLUSIONS

The value of audio-visual interventions as a tool for helping to enhance the informed consent process for people considering participating in clinical trials remains largely unclear, although trends are emerging with regard to improvements in knowledge and satisfaction. Many relevant outcomes have not been evaluated in randomised trials. Triallists should continue to explore innovative methods of providing information to potential trial participants during the informed consent process, mindful of the range of outcomes that the intervention should be designed to achieve, and balancing the resource implications of intervention development and delivery against the purported benefits of any intervention.More trials, adhering to CONSORT standards, and conducted in settings and populations underserved in this review, i.e. low- and middle-income countries and people with low literacy, would strengthen the results of this review and broaden its applicability. Assessing process measures, such as time taken to administer the intervention and researcher satisfaction, would inform the implementation of audio-visual consent materials.

Achieving new levels of recall in consent to research by combining remedial and motivational techniques

INTRODUCTION

Research supports the efficacy of both a remedial consent procedure (corrected feedback (CF)) and a motivational consent procedure (incentives) for improving recall of informed consent to research. Although these strategies were statistically superior to standard consent, effects were modest and not clinically significant. This study examines a combined incentivised consent and CF procedure that simplifies the cognitive task and increases motivation to learn consent information.

METHODS

We randomly assigned 104 individuals consenting to an unrelated host study to a consent as usual (CAU) condition (n=52) or an incentivised CF (ICF) condition (n=52). All participants were told they would be quizzed on their consent recall following their baseline assessment and at 4 monthly follow-ups. ICF participants were also informed that they would earn $5 for each correct answer and receive CF as needed.

RESULTS

Quiz scores in the two conditions did not differ at the first administration (p=0.39, d=0.2); however, ICF scores were significantly higher at each subsequent administration (second: p=0.003, Cohen's d=0.6; third: p<0.0001, d=1.4; fourth: p<0.0001, d=1.6; fifth: p<0.0001, d=1.8).

CONCLUSIONS

The ICF procedure increased consent recall from 72% to 83%, compared with the CAU condition in which recall decreased from 69% to 59%. This supports the statistical and clinical utility of a combined remedial and motivational consent procedure for enhancing recall of study information and human research protections.

Enhancing patient understanding of medical procedures: evaluation of an interactive multimedia program with in-line exercises

INTRODUCTION

Standard print and verbal information provided to patients undergoing treatments are often difficult to understand and may impair their ability to be truly informed. This study examined the effect of an interactive multimedia informational program with in-line exercises and corrected feedback on patients' real-time understanding of their cardiac catheterization procedure.

METHODS

151 adult patients scheduled for diagnostic cardiac catheterization were randomized to receive information about their procedure using either the standard institutional verbal and written information (SI) or an interactive iPad-based informational program (IPI). Subject understanding was evaluated using semi-structured interviews at baseline, immediately following catheterization, and 2 weeks after the procedure. In addition, for those randomized to the IPI, the ability to respond correctly to several in-line exercises was recorded. Subjects' perceptions of, and preferences for the information delivery were also elicited.

RESULTS

Subjects randomized to the IPI program had significantly better understanding following the intervention compared with those randomized to the SI group (8.3±2.4 vs 7.4±2.5, respectively, 0-12 scale where 12=complete understanding, P<0.05). First-time correct responses to the in-line exercises ranged from 24.3% to 100%. Subjects reported that the in-line exercises were very helpful (9.1±1.7, 0-10 scale, where 10=extremely helpful) and the iPad program very easy to use (9.0±1.6, 0-10 scale, where 10=extremely easy) suggesting good clinical utility.

DISCUSSION

Results demonstrated the ability of an interactive multimedia program to enhance patients' understanding of their medical procedure. Importantly, the incorporation of in-line exercises permitted identification of knowledge deficits, provided corrected feedback, and confirmed the patients' understanding of treatment information in real-time when consent was sought.

Why or why not? A qualitative analysis of low-income parents' reasons for accepting or rejecting simulated research enrollment for their children

A simulation of enrollment in a high- or low-risk research study was conducted with low-income, mostly minority parents. Simulation participants were provided scenarios based on actual low-risk research involving premature babies or actual high-risk research involving devices designed as bridges to heart transplants when all other therapies had failed. Their understanding of the procedures, risks, and benefits was based only the information gained from consent materials for the high- or low-risk protocol. After reviewing the consent information, participants were asked to state their own decision as to whether to enroll their simulated child in the described study. The low-income sample of parents who participated in this simulation were overwhelmingly positive about enrolling a child in the two studies; 66% of those considering the high-risk study and 91% in the low-risk study indicated they would enroll a child. Parents in both conditions cited the value of learning ways to improve the health care of others as a primary reason for agreeing; they also valued knowledge for its own sake. Reasons for refusal varied according to the risk level. Many were unwilling to accept the risks involved in the high-risk study; parents considering the low-risk study of premature infants were concerned about possible discomforts for the infant. More of them also cited the length of the study and the need for repetitious follow-up visits. Information gained from the stated rationales gives insights into ways that researchers can enhance consent materials and the recruitment process.

A rural community's involvement in the design and usability testing of a computer-based informed consent process for the Personalized Medicine Research Project

Many informed consent studies demonstrate that research subjects poorly retain and understand information in written consent documents. Previous research in multimedia consent is mixed in terms of success for improving participants' understanding, satisfaction, and retention. This failure may be due to a lack of a community-centered design approach to building the interventions. The goal of this study was to gather information from the community to determine the best way to undertake the consent process. Community perceptions regarding different computer-based consenting approaches were evaluated, and a computer-based consent was developed and tested. A second goal was to evaluate whether participants make truly informed decisions to participate in research. Simulations of an informed consent process were videotaped to document the process. Focus groups were conducted to determine community attitudes towards a computer-based informed consent process. Hybrid focus groups were conducted to determine the most acceptable hardware device. Usability testing was conducted on a computer-based consent prototype using a touch-screen kiosk. Based on feedback, a computer-based consent was developed. Representative study participants were able to easily complete the consent, and all were able to correctly answer the comprehension check questions. Community involvement in developing a computer-based consent proved valuable for a population-based genetic study. These findings may translate to other types of informed consents, including those for trials involving treatment of genetic disorders. A computer-based consent may serve to better communicate consistent, clear, accurate, and complete information regarding the risks and benefits of study participation. Additional analysis is necessary to measure the level of comprehension of the check-question answers by larger numbers of participants. The next step will involve contacting participants to measure whether understanding of what they consented to is retained over time.

Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials

Background

Obtaining informed consent is a cornerstone of biomedical research, yet participants comprehension of presented information is often low. The most effective interventions to improve understanding rates have not been identified.

Purpose

To systematically analyze the random controlled trials testing interventions to research informed consent process. The primary outcome of interest was quantitative rates of participant understanding; secondary outcomes were rates of information retention, satisfaction, and accrual. Interventional categories included multimedia, enhanced consent documents, extended discussions, test/feedback quizzes, and miscellaneous methods.

Methods

The search spanned from database inception through September 2010. It was run on Ovid MEDLINE, Ovid EMBASE, Ovid CINAHL, Ovid PsycInfo and Cochrane CENTRAL, ISI Web of Science and Scopus. Five reviewers working independently and in duplicate screened full abstract text to determine eligibility. We included only RCTs. 39 out of 1523 articles fulfilled review criteria (2.6%), with a total of 54 interventions. A data extraction form was created in Distiller, an online reference management system, through an iterative process. One author collected data on study design, population, demographics, intervention, and analytical technique.

Results

Meta-analysis was possible on 22 interventions: multimedia, enhanced form, and extended discussion categories; all 54 interventions were assessed by review. Meta-analysis of multimedia approaches was associated with a non-significant increase in understanding scores (SMD 0.30, 95% CI, -0.23 to 0.84); enhanced consent form, with significant increase (SMD 1.73, 95% CI, 0.99 to 2.47); and extended discussion, with significant increase (SMD 0.53, 95% CI, 0.21 to 0.84). By review, 31% of multimedia interventions showed significant improvement in understanding; 41% for enhanced consent form; 50% for extended discussion; 33% for test/feedback; and 29% for miscellaneous.Multiple sources of variation existed between included studies: control processes, the presence of a human proctor, real vs. simulated protocol, and assessment formats.

Conclusions

Enhanced consent forms and extended discussions were most effective in improving participant understanding. Interventions of all categories had no negative impact on participant satisfaction or study accrual. Identification of best practices for studies of informed consent interventions would aid future systematic comparisons.

Traditional nurse instruction versus 2 session nurse instruction plus DVD for teaching ostomy care: a multisite randomized controlled trial

PURPOSE

This randomized controlled trial compared 2 methods of ostomy care instruction to determine their effect on patients' knowledge, skills, and confidence related to postoperative ostomy care.

SUBJECTS AND SETTING

Eighty-eight adults with newly created ostomies were randomly assigned to 1 of 2 groups. Of the 88 enrolled patients, 68 completed the study: 10 patients were discharged from the hospital prior to completion of the study interventions; 10 others were withdrawn because they no longer met study inclusion criteria. The remaining subjects, who were equally split between men and women, ranged in age from 23 to 84 years. There were 23 colostomy and 45 ileostomy patients in our sample. The study setting was 2 acute care hospitals within a large tertiary health care system in the midwestern United States.

METHODS

We used a posttest-only experimental design to compare 2 methods of postoperative ostomy education. Traditional education comprised 3 WOC nurse-led instruction sessions and the experimental intervention comprised 2 nurse-led instruction sessions plus DVD instruction that could be accessed in between nurse-led sessions. All patients received one-on-one instruction from certified WOC nurse at their bedside. Patients completed a written test of ostomy knowledge, a self-care skills demonstration, and a Visual Analog Scale rating their confidence with ostomy self-care.

RESULTS

There were no significant differences between the 2 teaching methods or type of ostomy with regard to knowledge of ostomy care (F3,64 5 1.308, P 5 0.28), ostomy care skills (F3,64 5 0.163, P 5 0.92), or confidence in performing ostomy self-care (F3,64 5 0.629, P 5 0.59). Differences between the study groups' self-reported learning style, education level, age, room type, and gender also did not significantly impact their knowledge, skills, or confidence.

CONCLUSION

When teaching first-time ostomy patients postoperative self-care, a Nurse Instruction plus DVD method is as effective as Nurse Instruction alone.

Can video aids increase the validity of patient consent?

The objective of this study is to identify the value of using video to communicate and share information with patients, and assess the role of video in aiding decision-making and consent in urogynaecological surgery. The patients with the need for urogynaecological surgery who were seen in Weston Hospital from November 2003 to December 2008 were offered a video of the proposed procedure to watch prior to decision-making and consenting. Patients were then sent a questionnaire assessing the role of the video in their understanding of the need for and method of the procedure, and the impact of this on their decision-making. A total of 96 questionnaires were sent out, and 71 forms were returned and analysed. Our study shows that women's understanding of the method and purpose of their operation was significantly increased by using the video.

How Informed is "Informed Consent" for Robotic Cardiothoracic Surgery?

OBJECTIVE

: The education of patients in the informed consent process remains a challenge for many surgeons. In cardiothoracic surgery, emerging minimally invasive techniques including robotics add another level of complexity to the patient education process. We sought to evaluate our patients' perceptions and informed knowledge after robotic-assisted cardiothoracic surgery.

METHODS

: A survey containing questions designed to elicit patients' perceptions about robotic cardiothoracic surgery was given postoperatively by telephone 1 month to 12 months after surgery. The survey included questions about the type of procedure, function of the organ operated on, purpose of the operation, primary "surgeon" (robot vs. human), patients' opinion about robotic-assisted surgery, educational level, and socioeconomic background. Continuous variables are reported as mean ± SD. Continuous and categorical variables were compared using the Student t test and Pearson χ test, respectively. Ordinal variables were compared using the Mann-Whitney U test. P values of <0.05 were considered significant.

RESULTS

: Between 2002 and 2007, 198 patients underwent robotic cardiothoracic surgery. One hundred fifty patients (76%) were contacted and 89 (45%) fully completed the survey. Of the respondents, there were 31 coronary artery bypasses, 33 pacemaker lead implantations, esophageal resections, 8 thymectomies, and 9 others. The mean age of the patients was 61.1 ± 15 years (range, 23-87) and there were 52 men (58.4%). A total of 96.6% of patients were satisfied with the information provided by the surgeon and 92.1% felt that they understood the information. The diagnosis, target organ, and procedure were correctly identified by 81 (91.0%), 83 (93.3%), and 76 (85.4%) of the patients, respectively. A total of 80 (89.9%) knew a robot was involved and 73.8% understood the role of the robot in the surgery. These results were independent of age, income, and education level achieved.

CONCLUSIONS

: Overall, patients demonstrated an understanding of the role of the robot in their cardiothoracic surgery. Despite the increasing complexity of robotics, preoperative patient education can result in patients who are both satisfied and well educated about their cardiothoracic surgery procedures.

Two methods of obtaining informed consent in a genetic epidemiological study: effects on understanding

THIS STUDY EVALUATED THE EFFECT ON participant understanding and participation rates of two different approaches to obtaining informed consent, using 2,192 actual research subjects in a genetic cohort study. One group received the routine approach consisting of written materials and an oral explanation. The other group received a more intense approach consisting of educational lectures and group meetings in addition to the routine approach. Subjects in the intense approach group were relatively more likely to read some or all of the explanatory material. Those in the intense group who did not read the material were more likely than those in the routine group to express uncertainty about their understanding of the research. Those in the intense group who read the material perceived that they had a higher level of understanding of the research and this was associated with a higher frequency of volunteering to participate. In contrast, subjects in the routine group were less likely to read the written material, but ironically more likely to assume that they understood what the research was about. These rather paradoxical findings raised questions about what motivates potential research subjects to become sufficiently engaged to seek actual understanding of the research before volunteering.