Recruiting vulnerable populations for research: revisiting the ethical issues

Ethical inclusion: Risks and benefits of research from the perspective of perinatal people with opioid use disorders who have experienced incarceration

BACKGROUND

Research ethics guidelines and emphasis on representation in research guide the inclusion of marginalized groups, including people with perinatal opioid use disorders (OUD) and people experiencing incarceration in the United States. However, insights from participants regarding the risks and benefits of participation are not adequately considered. The aim of this study was to examine the risks and benefits of research participation from the perspective of pregnant/postpartum people with OUD who have experienced incarceration.

DESIGN

We recruited people who had experience with perinatal incarceration and were either currently pregnant or postpartum, and at least 18 years old. All participants met the clinical criteria for OUD. Our study did not have exclusion criteria based on gender, race, or ethnicity.

SETTING

Participants were either currently incarcerated at the North Carolina Correctional Institute for Women in Raleigh, North Carolina, United States or had previously experienced perinatal incarceration and were recruited from a perinatal substance use disorder treatment program located in North Carolina.

PARTICIPANTS

Between 9/2021-4/2022, we completed 12 interviews with pregnant/postpartum people with OUD, approximately half who were currently incarcerated and half with a recent history of perinatal incarceration.

INTERVENTION/MEASUREMENT

Interviews were conducted via Webex phone or video. The interviews followed a scripted interview guide and lasted one hour on average. Interview transcripts were analyzed using the Rigorous and Accelerated Data Reduction technique to produce an overarching thematic framework.

FINDINGS

Our analysis identified benefits, including the personal advantage of self-expression, helping others and contributing to change, and financial incentives. Risks included stigma and breach of confidentiality, misunderstanding of the distinction between research and advocacy, and limited ability to share their whole experience.

CONCLUSIONS

Participant-identified benefits of research mirrored those from other marginalized populations, though participant-identified risks were novel and nuanced. Recruitment and consent should move beyond normative research ethics committees protocol language to consider the perspectives of participants.

Helping themselves and helping others: how the passage of time influences why mothers with addictions take part in research

Introduction

Women with addiction issues are under-researched, despite previous evidence that women's needs are less understood than men's and that services can overlook gender-specific issues. The majority of women in treatment are mothers and a significant number have contact with child welfare services. The voices of these women are needed to shape and influence evidence-based treatment and service development.

Aim

To examine reasons and rationale for participation in research in mothers with addiction issues and involvement with the child welfare system.

Method

Reflexive thematic analysis was used on interview transcripts from two qualitative studies. Individual themes from each study were combined and analysed to develop themes covering both studies and at different timepoints in process of child welfare assessment or removal of child/ren.

Results

Three themes were identified (1) altruism; (2) personal benefit; and (3) empowerment. These mothers wanted to help with research. However, they also participated with the hope that this might facilitate the return of their children or help them to access support or services. A change over time was evident and, in those further down the line from child removal, there was a stronger want for their voices to be heard in order to advocate for other women and create change in services.

Gatekeepers in research: the experience of recruiting carers of people with chronic blood cancers

BACKGROUND

Gatekeepers play a crucial role in successfully recruiting participants to nurse-led qualitative research, particularly in clinical settings.

AIM

To present the authors' experience of recruiting and conducting qualitative interviews during the COVID-19 pandemic with the carers of patients who have chronic haematological malignancies, and the effects that gatekeepers had on recruitment.

DISCUSSION

The authors had to adapt and adjust their research plan because of difficulties in accessing their target population. Establishing and maintaining relationships with gatekeepers and a Patient and Public Involvement (PPI) panel was integral in successfully collecting data.

CONCLUSION

Ongoing reflexivity and feedback from supervisors, gatekeepers and PPI members in addition to developing research experience can help researchers to overcome challenges in recruiting difficult-to-access populations.

IMPLICATIONS FOR PRACTICE

Researchers need to be prepared for challenges to their research plans and carefully consider the options available for addressing these challenges. Reaching out to others is integral in expanding researchers' ideas.

Challenges and successes in the sustainment of Dutch community-level smoking cessation interventions for residents with a low socioeconomic position

BACKGROUND

When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position.

METHODS

We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically.

RESULTS

We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset.

CONCLUSIONS

The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders.

Gaining access to unspoken narratives of people living with dementia on a hospital ward-A new methodology

BACKGROUND

This is a methodological paper that aims to advance the conceptualisation of participatory research by focusing on the value of capturing and understanding movement as a vital means of communication for older people with dementia in a general hospital ward. Qualitative research involving people with dementia tends to be word-based and reliant upon verbal fluency. This article considers a method for capturing and understanding movement as a vital means of communication.

METHOD

This narrative enquiry is underpinned by the model of social citizenship that recognises people with dementia as citizens with narratives to share. The study focused on spontaneously produced conversations that were video recorded and analysed through a lens of mobility. This enabled each participant to share what was important to them in that moment of time without always using words.

FINDINGS

The study findings showed that people with dementia have narratives to share, but these narratives do not fit the bio-medically constructed model that is generally expected from patients. Utilising a mobilities lens enabled the narratives to be understood as containing layers of language. The first layer is the words; the second layer is gestures and movements that support the words; and the third layer is micro movements. These movements do not only support the words but in some cases tell a different story altogether.

CONCLUSION

This methodology brings attention to layers of communication that reveal narratives as a mobile process that require work from both the teller and the listener to share and receive. Movements are shown to be the physical manifestations of embodied language which when viewed through a lens of mobility enable a deeper understanding of the experience of living with dementia when an inpatient. Viewing narratives through a mobilities lens is important to the advancement of dementia and citizenship practices.

How do clients with multiple problems and (in)formal caretakers coproduce integrated care and support? A longitudinal study on integrated care trajectories of clients with multiple problems

INTRODUCTION

Integrated care can create several advantages, such as better quality of care and better outcomes. These advantages apply especially to clients with multiple problems (CWMPs) who have multiple, interconnected needs that span health and social issues and require different health care (e.g., mental health care or addiction care), social care (e.g., social benefits) and welfare services at the same time. Integrated care is most often studied as a phenomenon taking place at the system, organizational, professional and clinical levels. Therefore, in many studies, clients seem to be implicitly conceptualized as passive recipients of care. Less research has been conducted on how clients and (in)formal caretakers coproduce integrated care.

METHODS

We performed a longitudinal study to investigate how CWPMs and (in)formal caretakers coproduce integrated care. Data were collected among CWMPs and their (in)formal caretakers in Rotterdam, the Netherlands. CWMPs' care trajectories were followed for 1-1.5 years. CWMPs were interviewed three times at an interval of 6 months (T0, T1, T2). Informal caretakers were interviewed three times (T0, T1, T2), and formal caretakers of 16 clients were interviewed twice (T1, T2). Data in the municipal record systems about participating CWMPs were also included.

RESULTS

Our study shows that the CWMPs' multidimensional needs, which should function as the organizing principle of integrated care, are rarely completely assessed at the start (first 6 weeks) of CWMPs' care trajectories. Important drivers behind this shortcoming are the urgent problems CWMPs enter the support trajectory with, their lack of trust in 'the government' and the complexity of their situations. We subsequently found two distinct types of cases. The highest level of integrated care is achieved when formal caretakers initiate an iterative process in which the CWMP's multidimensional needs are constantly further mapped out and interventions are attuned to this new information.

CONCLUSIONS

Our study indicates that integrated care is the joint product of formal caretakers and CWMPs. Integrated care however does not come naturally when CWMPs are 'put at the center'. Professionals need to play a leading role in engaging CWMPs to coproduce integrated care.

PATIENT CONTRIBUTION

CWMPs and their (in)formal caretakers participated in this study via interviews and contributed with their experiences of the process.

Rigor and Respect: Recruitment Strategies for Engaging Vulnerable Populations in Research

Engaging vulnerable populations in research is a critical focus for researchers seeking to find ways to improve safety and well-being for broader populations. Vulnerabilities often co-occur, meaning that individuals may experience vulnerabilities in multiple facets of their life (e.g., victim of abuse and mental health diagnoses). Unfortunately, many vulnerable populations remain underinvestigated due to difficulty reaching, engaging, and safely including such populations in research. While most researchers assert the importance of including vulnerable populations in research, few actively and successfully recruit them. Many vulnerable populations are understandably weary of research participation. Victims and survivors of domestic minor sex trafficking (DMST) are one such vulnerable population, in that identification may incur substantial risk for DMST victim's physical safety and well-being. In addition, DMST victims and survivors often experience co-occurring vulnerabilities including substance use, histories of abuse, delinquency, and poor mental health. Accordingly, they are notoriously difficult to recruit for research participation. The current paper uses a detailed case example to describe the recruitment and retention strategies used by one researcher to promote DMST survivor research participation. A candid account of challenges, successes, and lessons learned is offered in service of building methodological techniques for recruitment that both honor participant experiences while championing methodological rigor. Findings detail the importance of trust and a trauma-informed approach to qualitative data collection and analysis. Authors include specific strategies to promote comfort and candor amid traumatic response in ways that may empower research participants. A detailed discussion of how such strategies may be adapted for vulnerable populations beyond DMST victims and survivors is provided.

Safety hazards in patient seclusion events in psychiatric care: A video observation study

WHAT IS KNOWN ON THE SUBJECT?: Coercive measures such as seclusion are used to maintain the safety of patients and others in psychiatric care. The use of coercive measures can lead to harm among patients and staff. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first of its kind to rely on video observation to expose safety hazards in seclusion events that have not been reported previously in the literature. The actions that both patients and staff take during seclusion events can result in various safety hazards. IMPLICATIONS FOR PRACTICE?: Constant monitoring of patients during seclusion is important for identifying safety hazards and intervening to prevent harm. Nursing staff who use seclusion need to be aware of how their actions can contribute to safety hazards and how they can minimize their potential for harm ABSTRACT: Introduction Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices. Aim To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care. Method A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis. Results Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures. Discussion This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.

Inclusion of people living with Alzheimer's disease or related dementias who lack a study partner in social research: Ethical considerations from a qualitative evidence synthesis

BACKGROUND

Because use of a study partner (proxy decision-maker) to give informed consent on behalf of someone living with Alzheimer's disease or related dementias (ADRD) is common in nearly all clinical research, people living with ADRD who lack a study partner are regularly excluded from participation. Social research presents different opportunities and risks than clinical research. We argue that guidelines developed for the latter may be unduly restrictive for social research and, further, that the automatic exclusion of people living with ADRD presents separate ethical challenges by failing to support extant decision-making capacity and by contributing to underrepresentation in research.

PURPOSE

The study objective was to identify key components related to including cognitively vulnerable participants who lack a study partner in social research.

RESEARCH DESIGN/STUDY SAMPLE

We conducted an adaptive qualitative evidence synthesis (QES) and subsequent content analysis on 49 articles addressing capacity and research consent for potentially cognitively compromised individuals, to include people living with ADRD, who lack a study partner.

RESULTS

We identified four major topic areas: defining competency, capacity, and consent; aspects of informed consent; strategies to assess comprehension of risks associated with social research; and risks versus benefits.

CONCLUSIONS

Based on findings, we suggest new and ethically appropriate ways to determine capacity to consent to social research, make consent processes accessible to a population experiencing cognitive challenges, and consider the risks of excluding a growing population from research that could benefit millions.

Ethical considerations for HIV remission clinical research involving participants diagnosed during acute HIV infection

HIV remission clinical researchers are increasingly seeking study participants who are diagnosed and treated during acute HIV infection—the brief period between infection and the point when the body creates detectable HIV antibodies. This earliest stage of infection is often marked by flu-like illness and may be an especially tumultuous period of confusion, guilt, anger, and uncertainty. Such experiences may present added ethical challenges for HIV research recruitment, participation, and retention. The purpose of this paper is to identify potential ethical challenges associated with involving acutely diagnosed people living with HIV in remission research and considerations for how to mitigate them. We identify three domains of potential ethical concern for clinicians, researchers, and ethics committee members to consider: 1) Recruitment and informed consent; (2) Transmission risks and partner protection; and (3) Ancillary and continuing care. We discuss each of these domains with the aim of inspiring further work to advance the ethical conduct of HIV remission research. For example, experiences of confusion and uncertainty regarding illness and diagnosis during acute HIV infection may complicate informed consent procedures in studies that seek to recruit directly after diagnosis. To address this, it may be appropriate to use staged re-consent procedures or comprehension assessment. Responsible conduct of research requires a broad understanding of acute HIV infection that encompasses its biomedical, psychological, social, and behavioral dimensions. We argue that the lived experience of acute HIV infection may introduce ethical concerns that researchers and reviewers should address during study design and ethical approval.

Dreaming the impossible dream? An exploratory study on the expectations of Dutch clients with multiple problems concerning the co-production of public services

Currently, many policymakers try to encourage client involvement during the public service delivery process and make it a co-production. Clients are encouraged to act as active agents and embrace an integrated approach to address their problems to empower them. However, different studies have raised questions regarding to what extent these ambitions are appropriate for clients with vulnerabilities, such as clients with multiple problems. Aiming to further explore this issue, we studied the expectations of clients with multiple problems concerning the co-production of public services. We interviewed 46 clients with multiple problems at the start of their support trajectory. All 46 participants lived in five districts in Rotterdam, the Netherlands, and were recruited via community-based primary care teams. Our study indicates that co-production ambitions might not resonate with clients with multiple problems. The study shows that these clients' expectations are driven by their feelings of being overwhelmed and stressed out by their situation, feelings of being a victim of circumstances, bad experiences with public services in the past, their evaluation of what counts as a problem and the envisioned solutions. These clients expect public service providers to take over, fix their main problem(s) and not interfere with other aspects of their lives (not an integrated approach). Although participants seek a 'normal' life with, e.g., a house, work, partner, children, holidays, a pet, and no stress (a white picket fence life) as ideal, they do not feel that this is attainable for them. More insight into the rationale behind these expectations could help to bridge the gap between policymakers' ambitions and clients' expectations.

OHSU Employees' Opinions of Receipt of Clinical Care and Participation in Clinical Research at Place of Employment

Academic medical centers conduct clinical research and provide patient care to the community and their workforce. Conflict may exist, as employees might expect benefits or feel pressured or coerced to participate in research studies or receive clinical care. Without evidence, some universities consider employees to be part of a vulnerable population for research consent at their institution, potentially restricting opportunities for employees to participate in clinical trials. At the same time, these universities encourage employees to receive health care at the same institution. We hypothesized that attitudes toward voluntary research participation and receipt of health care services at the site of employment are similar and favorable. To study this, we conducted a survey of employees at Oregon Health & Science University (OHSU) that asked parallel questions focusing on attitudes regarding concerns with participation in research and receipt of clinical care. We found the majority of respondents reported favorable and similar attitudes regarding employee participation in clinical care 596/688 (87%) or research 605/639 (95%) and personally comfortable with the idea (614/688 (90%) for clinical care, 582/639 (92%) for research participation). Our findings support efforts to remove barriers that restrict participation in clinical research by employees at academic medical centers.

Attitudes of legal guardians and legally supervised persons with and without previous research experience towards participation in research projects: A quantitative cross-sectional study

Background

Vulnerable groups, e.g. persons with mental illness, neurological deficits or dementia, are often excluded as participants from research projects because obtaining informed consent can be difficult and tedious. This may have the consequence that vulnerable groups benefit less from medical progress. Vulnerable persons are often supported by a legal guardian in one or more demands of their daily life. We examined the attitudes of legal guardians and legally supervised persons towards medical research and the conditions and motivations to participate in studies.

Methods

We conducted a cross-sectional study with standardized surveys of legal guardians and legally supervised persons. Two separate questionnaires were developed for the legal guardians and the supervised persons to asses previous experiences with research projects and the reasons for participation or non-participation. The legal guardians were recruited through various guardianship organizations. The supervised persons were recruited through their legal guardian and from a previous study among psychiatric patients. The data were analysed descriptively.

Results

Alltogether, 82 legal guardians and 20 legally supervised persons could be recruited. Thereof 13 legal guardians (15.6%) and 13 legally supervised persons (65.0%) had previous experience with research projects. The majority of the guardians with experience in research projects had consented the participation of their supervised persons (n = 12 guardians, 60.0%; in total n = 16 approvals). The possible burden on the participating person was given as the most frequent reason not to participate both by the guardians (n = 44, 54.4%) and by the supervised persons (n = 3, 30.0%). The most frequent motivation to provide consent to participate in a research study was the desire to help other patients by gaining new scientific knowledge (guardians: n = 125, 78.1%; supervised persons: n = 10, 66.6%).

Conclusions

Overall, an open attitude towards medical research can be observed both among legal guardians and supervised persons. Perceived risks and no sense recognized in the study are reasons for not participating in medical research projects.

Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs.

The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

Vulnerability: An integrative bioethics review and a proposed taxonomy

BACKGROUND

Vulnerability is a concept frequently encountered in the bioethical literature, particularly in the context of research ethics. It can be said that the usage of the concept expanded in the 2000s and started to be used in many new contexts in the literature. However, there appears to be no systematic review that examines the definition of the concept of vulnerability.

OBJECTIVES

The rationale for this study constitutes the questions regarding how vulnerability is defined and which components are used to define the concept of vulnerability in the bioethics literature.

RESEARCH DESIGN

The integrative review method was conducted to reach various definitions of the concept of vulnerability in bioethics. Whittemore and Knafl's revised framework for integrative reviews guided the analysis. 'Vulnerability' and 'vulnerable' keywords, intercrossing with the words 'bioethics' and 'medical ethics', were searched in three different databases (PubMed, Web of Science and Scopus). Collected data were analysed thematically and a taxonomy was developed.

FINDINGS

A total of 1287 studies obtained through search were reduced to 123 that kept the definition of vulnerability. As a result of the review, a comprehensive taxonomy of vulnerability has been proposed. The proposed taxonomy of vulnerability has two categories, ontological and circumstantial, with three subcategories each, which might provide a multidimensional perspective.

DISCUSSION

Publication dates, origins and contexts of included publications were discussed. Specifications of the term vulnerability and components of its definition and factors that constitute these components provided from the view were evaluated and also discussed.

CONCLUSION

The proposed taxonomy provides a useful classification for assessing vulnerability in bioethics. It is hoped that the taxonomy we put forward as a result of the review will increase awareness on the issue and also take into account the factors that create vulnerability in the context of research, healthcare and nursing care policies.

ETHICAL CONSIDERATIONS

The review was conducted in accord with ethical and scientific standards.

Sustainable Food Consumption in Nursing Homes: Less Food Waste with the Right Plate Color?

The problem of unsustainable food consumption among vulnerable residents of nursing homes who suffer from dementia is often multifaceted. From an individual perspective, people with dementia who do not finish their meals are likely to encounter serious health issues associated with malnutrition. Moreover, at the institutional level, nursing homes generate tons of nonrecoverable food waste each year, impairing not only their economic position but also the natural and social environment at large. The purpose of this study is to explore the possibility of reducing food waste in Norwegian nursing homes by appraising how large this reduction could be as one replaces traditional dining white porcelain with plates with diverse color combinations. A quasi-experimental method was adopted. The results of the pilot study were extrapolated to the annual amount of food wasted at the national level. The findings indicate that, on average, 26% of food was thrown away when served on white plates compared to only 9% when served on one of the colored plate options tested. Nationally, approximately 992.6 tons of food per year could potentially be saved with only a single change, ultimately ameliorating the unsustainable food consumption problem among residents of nursing homes.

An under-represented and underserved population in trials: methodological, structural, and systemic barriers to the inclusion of adults lacking capacity to consent

BACKGROUND

There is increasing international recognition that populations included in trials should adequately represent the population treated in clinical practice; however, adults who lack the capacity to provide informed consent are frequently excluded from trials. Addressing the under-representation of groups such as those with impaired capacity to consent is essential to develop effective interventions and provide these groups with the opportunity to benefit from evidence-based care. While the spotlight has been on ensuring only appropriate and justifiable exclusion criteria are used in trials, barriers to the inclusion of adults lacking capacity are multifactorial and complex, and addressing their under-representation will require more than merely widening eligibility criteria. This commentary draws on the literature exploring the inclusion of adults lacking the capacity to consent in research and a number of recent studies to describe the methodological, structural, and systemic factors that have been identified.

MAIN TEXT

A number of potentially modifiable factors contributing to the under-representation of adults lacking the capacity to consent in trials have been identified. In addition to restrictive eligibility criteria, methodological issues include developing appropriate interventions and outcome measures for populations with impaired capacity. Structurally determined factors include the resource-intensive nature of these trials, the requirement for more appropriate research infrastructure, and a lack of interventions to inform and support proxy decision-makers. Systemic factors include the complexities of the legal frameworks, the challenges of ethical review processes, and paternalistic attitudes towards protecting adults with incapacity from the perceived harms of research.

CONCLUSIONS

Measures needed to address under-representation include greater scrutiny of exclusion criteria by those reviewing study proposals, providing education and training for personnel who design, conduct, and review research, ensuring greater consistency in the reviews undertaken by research ethics committees, and extending processes for advance planning to include prospectively appointing a proxy for research and documenting preferences about research participation. Negative societal and professional attitudes towards the inclusion of adults with impaired capacity in research should also be addressed, and the development of trials that are more person-centred should be encouraged. Further work to conceptualise under-representation in trials for such populations may also be helpful.

The association between method of solicitation and patient permissions for use of surplus tissues and contact for future research

OBJECTIVE

Obtaining patient permissions for research contact and for surplus tissue use as part of routine clinical practice can improve research participation. This study aims to investigate the difference in patient permissions for use of surplus tissues, and for direct contact for research, using 2 different methods of solicitation.

METHODS

An opt-in, population-based approach for gathering research permissions was implemented in 2 methods. The first method, applied a 2-item patient questionnaire delivered through the electronic health record patient portal. The questionnaire composed of 2 questions (1) whether de-identified surplus specimens may be used for research and (2) whether patients could be contacted about research. In the second method, the same questionnaire was physically presented in clinic within the clinical workflow. We used 1 to 1 propensity score matching and multivariate logistic regression to estimate the odds of obtaining permission and the difference between the 2 methods of solicitation.

RESULTS

The propensity score model matched 8044 observations (4114 submissions in each group). Among the in-clinic submission group, 70.13% provided permission for surplus tissue compared with 66.65% in the patient portal submission group (odds ratio [OR] = 1.20; 95% confidence interval [CI] 1.09-1.32; P < 0.001). Permission for future research contact was similar among in-clinic (65.07%) and patient portal submission (66.65%) groups (OR = 0.94; 95% CI 0.85-1.03; P = 0.175). These trends were consistent among European Americans and African American patients. However, among patients of other race, higher permission for both future contact (OR = 0.58; 95% CI 0.39-0.86; P < 0.007) and surplus tissue use (OR = 0.65; 95% CI 0.43-0.97; P = 0.036) was observed among patient portal submission.

DISCUSSION

Our findings suggest that in-clinic solicitation of patient permissions may provide the same opportunity to patients who do not use patient portals and may be associated with higher permission rate for surplus tissue. However, this was primary true for European American and African Americans patients. Patients of other race minorities might respond better to online approaches.

CONCLUSION

Adopting a patient-centric approach that combines in-clinic and portal-based administration may be feasible and promising. Further research is required in this area.

Ethical understandings of proxy decision making for research involving adults lacking capacity: A systematic review (framework synthesis) of empirical research

BACKGROUND

Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies' authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the development of a conceptual framework of proxy decision-making for research.

METHODS

A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework.

RESULTS

Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and 'something else', and the active elements of proxy decision-making: 'knowing the person', patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated.

CONCLUSIONS

The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy's authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed.

Doing Research with Vulnerable Populations: The Case of Intravenous Drug Users

This review article considers ethical concerns when doing research on potentially vulnerable people who inject drugs (PWID) in a Canadian context. The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans broadly addresses many of the traditional ethical principles of research on vulnerable persons, but does so at the cost of clarity and precision. Vulnerability is contextual rather than absolute. When doing research with vulnerable persons, informed consent should be obtained from an independent person, and comprehension should be checked using questioning. Participants can be vulnerable due to many factors, including addiction, chronic disease, socioeconomic and racial status, and lack of education. The ability of PWID to give informed consent can be compromised by undue influence or intoxication, but existing research shows that neither the mode nor the magnitude of compensation has a significant effect on new rates of drug use. Compensation can also help dispel the therapeutic misconception. Intoxication rather than undue influence is the main concern when obtaining informed consent from PWID. The stigmatization of PWID as incapable of consent should be avoided. Paternalistic exclusion from research can harm PWID and exacerbate their vulnerability by reducing our knowledge of and ability to specifically treat them. As such, we must collect better data about the effects of research ethics policies. Studies to this effect should focus on experiences, perspectives and needs of potentially vulnerable research participants. Research ethics boards in Canada should adopt an evidence-based approach when applying discretionary power to proposals for clinical research.

Rethinking vulnerable groups in clinical research

Vulnerable groups are often excluded from clinical research on the basis of scientific, ethical and practical reasons. Although intended to protect vulnerable people and maintain study integrity, exclusion of vulnerable groups from research through use of standard exclusion criteria may not always be necessary and may result in findings that are not generalisable. Achieving a balance between the competing needs to protect vulnerable people and to make progress in our understanding of disorders and their management through research requires a reconsideration of exclusion criteria and consent processes to ensure vulnerable people are appropriately represented in clinical research. Reasons for development of broad exclusion criteria include both concrete barriers and intangible discouraging factors. This paper examines this situation and its consequences, perceived and real barriers to inclusion of vulnerable people in research, and suggests methods for overcoming these barriers and applying thoughtful exclusion criteria.

Photo-elicitation with adolescents in qualitative research: an example of its use in exploring family interactions in adolescent psychiatry

BACKGROUND

Photo-elicitation is a method used increasingly often in qualitative health research, and its positive effect on the research process is well established today. Photo-elicitation appears to facilitate verbalization and insight and to improve relationships between the researcher and participants, thereby enriching the quality of the data collected. Nonetheless, it is barely used at all in the field of adolescent psychiatry. With the aim of exploring the potential of these methods for research with adolescents receiving psychiatric care, we conducted a qualitative photo-elicitation data collection study with this population, asking them about family interactions around food.

METHODS

The data were collected from 15 adolescents and 17 parents during semi-structured interviews in which a photo taken by the adolescent served as the focus of discussion. Data were explored through inductive thematic analysis.

RESULTS

Photo-elicitation played a threefold role in this study: (1) it induced the teens' interest, thought, and pleasure, (2) it played a mediating function during the interviews, and (3) it enabled family interactions to be viewed from the adolescent's perspective. Three themes concerning family interactions were found: (1) parent-child relationship patterns, (2) the functioning of the family group, and (3) the adolescent's individual relation with food, that is, the issue of the adolescent's autonomy.

CONCLUSIONS

Photo-elicitation proved to be an innovative technique in qualitative research in the area of adolescent psychiatry, one that enriched the data and enabled the emergence of new themes in this field, related in particular to the process by which adolescents develop autonomy.

A screening tool for predicting gatekeeping behaviour

AIM

To develop a typology and screening tool for gatekeeping behaviours by nurses responsible for recruitment in palliative care research.

DESIGN

Concurrent analysis.

METHOD

Two focus groups were conducted in 2015 with nine qualified hospice community nurses involved in recruitment to a trial in palliative care. The literature was searched for research into gatekeeping from 2000-2016. All narrative examples of gatekeeping activity were coded using gerunds. Common codes were then grouped and interpreted as a social process.

RESULTS

Gatekeeping is normal and should be expected. A continuum typology emerged, ranging from unintentional to active disengagement. Justification ranged from forgetting to deliberately not mentioning the study for fear of burdening patients. Viewing gatekeeping as a continuum allowed for the creation of a screening tool designed to collaboratively discuss and hence mitigate specific types of gatekeeping behaviour before they occur. This is a unique international contribution to this persistent issue.

Research involving adults lacking capacity to consent: the impact of research regulation on 'evidence biased' medicine

BACKGROUND

Society is failing in its moral obligation to improve the standard of healthcare provided to vulnerable populations, such as people who lack decision making capacity, by a misguided paternalism that seeks to protect them by excluding them from medical research. Uncertainties surround the basis on which decisions about research participation is made under dual regulatory regimes, which adds further complexity. Vulnerable individuals' exclusion from research as a result of such regulation risks condemning such populations to poor quality care as a result of 'evidence biased' medicine.

MAIN TEXT

This paper explores the research regulation provisions for proxy decision making for those unable to provide informed consent for themselves, and the subsequent legal and practical difficulties for decision-makers. There are two separate regulatory regimes governing research involving adults who lack capacity to consent in England and Wales. The Mental Capacity Act 2005 governs how incapacitated adults can be involved in research, however clinical trials of medicinal products are separately regulated by the Medicines for Human Use (Clinical Trials) Regulations 2004. There are significant differences under these dual regimes in the provisions for those lacking capacity to participate in medical research. The level of risk permitted differs, with a greater requirement for justification for participation in a clinical trial than other types of research. Who acts as proxy decision maker, how much information is provided to the person lacking capacity, and whether they retain the power of veto also significantly differs.

CONCLUSION

The development of two separate regulatory regimes has resulted in significant differences between the provisions for clinical trials and other forms of research, and from usual medical practice. The resulting uncertainty has reinforced the tendency of those approving and conducting research to exclude adults lacking capacity to avoid difficult decisions about seeking consent for their participation. Future developments, such as the incoming EU Regulations, may address some of these differences, however the justification and level of risk permitted requires review to ensure that requirements are appropriate and proportionate to the burdens and risks for the individual, and also to the benefits for the wider population represented.

Personal Stigma in Suicide Attempters

The aim of this study was to explore suicide attempters' experiences of personal stigma. This qualitative study included a focus group of 7 experienced clinicians and semi-structured interviews with 8 suicide attempters. Thematic analysis of the data yielded four main themes: seriousness, care, "badness," and avoidance. Experiences of stigma pervaded all contexts, but were most emotionally upsetting to the participants in interpersonal relationships. The findings show the importance of evaluating stigma for suicide attempters during suicide risk assessment and the need for specifically tailored interventions to combat suicide stigma at the individual level.

The SALOME study: recruitment experiences in a clinical trial offering injectable diacetylmorphine and hydromorphone for opioid dependency

BACKGROUND

The Study to Assess Long-term Opioid Medication Effectiveness (SALOME) is a two-stage phase III, single site (Vancouver, Canada), randomized, double blind controlled trial designed to test if hydromorphone is as effective as diacetylmorphine for the treatment of long-term illicit opioid injection. Recruiting participants for clinical trials continues to be a challenge in medical and addiction research, with many studies not being able to reach the planned sample size in a timely manner. The aim of this study is to describe the recruitment strategies in SALOME, which offered appealing treatments but had limited clinic capacity and no guaranteed post-trial continuation of the treatments.

METHODS

SALOME included chronic opioid-dependent, current illicit injection opioid users who had at least one previous episode of opioid maintenance treatment. Regulatory approvals were received in June 2011 and recruitment strategies were implemented over the next 5 months. Recruitment strategies included ongoing open communication with the community, a consistent and accessible team and participant-centered screening. All applicants completed a pre-screening checklist to assess prerequisites. Applicants meeting these prerequisites were later contacted to commence the screening process.

RESULTS

A total of 598 applications were received over the two-year recruitment period; 130 were received on the first day of recruitment. Of these applicants, 485 met prerequisites; however, many could not be found or were not reached before recruitment ended. For the 253 candidates who initiated the screening process, the average time lapse between application and screening date was 8.3 months (standard deviation [SD] = 4.44) and for the 202 randomized to the study, the average processing time from initial screen to randomization was 25.9 days (SD = 37.48; Median = 15.0).

CONCLUSIONS

As in prior trials offering injectable diacetylmorphine within a supervised model, recruiting participants for this study took longer than planned. The recruitment challenges overcome in SALOME were due to the high number of applicants compared with the limited number that could be randomized and treated. Our study emphasizes the value of integrating these strategies into clinical addiction research to overcome study-specific barriers.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01447212.

Recruitment and retention of older adolescent and young adult female survivors of childhood cancer in longitudinal research

PURPOSE/OBJECTIVES

To describe the challenges encountered in the recruitment and retention of a sample of older adolescent and young adult female survivors of childhood cancer for a longitudinal study testing a targeted psychosocial intervention aimed at enhancing hope.

DATA SOURCES

Published literature on constructing longitudinal intervention studies and strategies in the recruitment and retention of childhood cancer survivors in research was used to develop the protocol of this study.

DATA SYNTHESIS

Using empirical literature to construct the study's design resulted in achieving certain goals for the design, but not in the recruitment and retention of study participants. Using online technology to deliver the intervention and collect data was efficient and effective. Traditional approaches to recruitment and retention of those survivors, however, were not effective. Use of more novel approaches to enroll study participants demonstrated only modest success.

CONCLUSIONS

Additional research is needed on strategies to successfully recruit and retain older adolescents and young adult female survivors of childhood cancer in longitudinal intervention studies.

IMPLICATIONS FOR NURSING

The improvement in the psychological well-being of female survivors of childhood cancer remains an important outcome in ongoing care. The need to continue to identify creative and effective ways to recruit and retain those survivors is warranted.

Challenges in recruiting participants in a multi-centre study on symptom experiences and self care strategies of bowel symptoms following colo-rectal surgery

Aim: the purpose of this paper is to present some of the challenges found to be problematic in recruiting individuals following sphincter-saving surgery for rectal cancer for a multi-centre study. While the focus of the study is on symptom experience and self-care strategies of bowel symptoms following colo-rectal surgery, the paper will concentrate solely on the challenges experienced in recruiting a sample for the study.

Background: recruitment of an adequate number of participants is a challenge for researchers in any area of research involving patients. Enrolment of patients treated for rectal cancer poses particular challenges, because the total population of this group in a given country can be small. The use of multiple centres was required to obtain the required number of participants for the current study.

Findings: in multi-centre studies, researchers can encounter substantial challenges in obtaining ethical approval, accessing clinical sites and gaining direct access to patients. These challenges are embedded in a convoluted process involving many systems of communication, which can vary from one centre to another.

Conclusions: the process of obtaining ethical approval is prolonged in the absence of a central ethical review committee. A central review process based on a standard application for researchers seeking ethical approval for multi-centred studies is necessary. Establishing and maintaining access to clinical sites requires co-operation from many individuals during the development of the proposal and continuing throughout the data collection process.

Serum concentrations of opioids when comparing two switching strategies to methadone for cancer pain

PURPOSE

Our aim was to compare pharmacological aspects of two switching strategies from morphine/oxycodone to methadone; the stop and go (SAG) strategy in which methadone is started directly after the initial opioid has been stopped, and the 3-days switch (3DS), in which morphine/oxycodone is gradually changed to methadone by cross-tapering over 3 days.

METHODS

Forty-two cancer patients with pain and/or opioid side effects were assessed in this randomised trial. Trough serum concentrations of methadone, morphine, morphine-6-glucuronide (M6G), and oxycodone were measured on days 1, 2, 3, 4, 7, and 14. Primary outcome was number of patients with methadone concentrations in apparent C(SS) on day 4. Secondary outcomes were exposure to opioids during the first 3 days, interindividual variation of opioid concentrations, and correlation between methadone concentrations and pain intensity (PI) day 3.

RESULTS

Thirty-five patients received methadone (16 in the SAG group, 19 in the 3DS group). The median preswitch morphine equivalent doses were 620 (range 350-2000) mg/day in the SAG group and 800 (range 90-3600) mg/day in the 3DS group (p = 0.43);42% reached C(SS) for methadone in the SAG group on day 4 compared with 22% in the 3DS group (p = 0.42). The SAG group was significantly less exposed to morphine/M6G/oxycodone and significantly more exposed to methadone in the first 3 days. Methadone showed a low correlation with PI. More patients dropped out after intervention in the SAG group than in the 3DS group (38% vs. 5%; p = 0.032). One SAG patient suffered from respiratory depression on day 5.

CONCLUSION

The SAG group was initially more exposed to methadone and less to the replaced opioids but without observed clinical benefit and with a higher dropout rate. Patients switched to methadone should be followed closely for the first 5 days, regardless of switching strategy.

Ethical aspects of researching subjective experiences in early-stage dementia

This article is based on a qualitative longitudinal study that followed the subjective experiences of both people living with dementia and their family members during the early stages of the illness. The purpose of this article is to describe and reflect on the ethical and methodological issues that occurred during data collection. The article focuses on the situation of the person with dementia and the family member and the role of the researcher when conducting the research interviews. Based on the results of this study, conducting research interviews with people with dementia and their family members poses several ethical and methodological challenges that must be addressed. In doing so, ethically sound dementia-specific research methods will be actively developed enhancing our understanding of living with dementia and providing new insights into the care of people with dementia and their family members.

Factors that promote and prohibit access to participants in the clinical setting: a review of response rates from a health communication intervention study

OBJECTIVE

This report examines the factors that influence researchers' abilities to recruit participants into health communication studies conducted within the clinical setting.

METHOD

Review of response rates over a 15 month data collection period for an intervention study on patient-physician communication, low health literacy, and diabetes management.

RESULTS

Most patients were willing to participate (73%). The challenge was not fostering interest in the study, but rather being able to approach potential participants. Over the course of the study, patients with diabetes visited the clinic 1263 times yet interviewers were only able to approach patients 196 times for potential inclusion in the study. Confounding factors that affected recruiting participants included the interviewers' availability and clinic schedule, as well as patient chief complaint and no show or rescheduling rates.

CONCLUSION

Researchers must engage in collaborative efforts with clinic staff during the research design phase, maximize their availability to approach potential patients, and capitalize on the insights of clinic staff to approach those patients who fit the study criteria and would be most willing to participate in the research project.

PRACTICE IMPLICATIONS

Researchers must learn about the clinic, reduce research burden, and be flexible to work within the constraints of the clinic setting.

CQ Sources/Bibliography

These CQ Sources were compiled by Bette Anton.

Challenges and costs related to recruitment of female adolescents for clinical research

Addressing health issues in adolescents is a national priority. However, recruitment of adolescents into research studies can be challenging and costly. The purpose of this article was to compare procedures, costs, and challenges in recruiting female adolescents from two hospitals and two high schools in an urban area of the southern United States. Three studies will be described. The findings indicate that the choice of recruitment procedures and sites has major implications for study budget in terms of personnel time as well as for the timeline of the study.

Research involving prisoners: consensus and controversies in international and European regulations

This article examines international and European regulations on research involving prisoners for consensus, differences, and their consequences, and offers a critical evaluation of the various approaches. Agreement exists that prisoners are at risk of coercion, which might interfere with their ability to provide voluntary informed consent to research. Controversy exists about the magnitude of this risk and the consequences that should follow from this risk. Two strategies are proposed for a method of protecting prisoners that does not lead to discrimination: first, more caution to assure non-coerced consent and second, restrictions on the type of research. Most regulations stress the importance of the principle of equivalence of healthcare in places of detention as part of an efficient protection against research risks and discrimination. All the presented approaches have shortcomings. While 'over-use' of prisoners for research as compared to the general population is ethically unjustified, not granting prisoners access to studies beneficial to their own health because of over-strict regulations is equally unjustified. A middle solution should be preferred, one that grants a minimum of protection together with the lowest possible barriers. Research that does not entail a direct benefit for the individual detainee should be restricted to types of research that have a benefit for detainees as a group and that are of low risk. What will ultimately protect prisoners best, while producing the greatest benefit for them, is access to the same healthcare available to members of the community including research as a true option.

The childbearing health and related service needs of newcomers (CHARSNN) study protocol

BACKGROUND

Refugee and asylum-seeking women in Canada may have significant harmful childbearing health outcomes and unmet health and social care needs. The most vulnerable of these women are: those who have left their countries by force (e.g., war, rape or abuse histories), are separated from their families, have limited knowledge of the host country languages, and are visible minorities. Asylum-seekers face additional stresses related to their unknown future status and are marginalized with regards to access to provincial health care systems. The prevalence and severity of health issues in this population is not known nor is the extent of response from social service and health care systems (including variation in provincial service delivery). Understanding the magnitude of health and social concerns of newcomers requires data from a representative sample of childbearing refugee and asylum-seeking women resettling in Canada to permit comparisons to be made with non-refugee immigrant and Canadian-born women. Our research questions are: (1) Do refugee or asylum-seeking women and their infants, experience a greater number or a different distribution of harmful health events during pregnancy, at birth, and during the postpartum period than non-refugee immigrant or Canadian-born women? (2) Are the harmful health events experienced postpartum by asylum-seeking women and their infants, addressed less often (compared to refugees, non-refugee immigrants, and Canadian-born women) by the Canadian health care system as delivered in each of the three major receiving cities for newcomers?

METHODS/DESIGN

This is a four-year multi-site prospective cohort study (pregnancy to 4 months postpartum). We will seek to recruit 2400 women [200 in each of 4 groups (refugees, asylum-seekers, non-refugee immigrants, and Canadian-born) from 1 of 12 postpartum hospital units across the 3 largest receiving cities for newcomers to Canada - Montreal, Toronto, and Vancouver].

DISCUSSION

Knowledge of the extent of harmful health events occurring to asylum-seeking, refugee, immigrant, and Canadian-born women, and the response of the health care system to those events and group differences, if they exist, will inform immigration and health policy makers as well as providers of services.

Lessons learned from a pilot study on the health status of children from itinerant populations

The pilot study is used to guide development of a research design or to test an already developed plan; however, results of pilot work often are not reported. Pilot work can yield many valuable lessons and provide investigative training to the principal investigator and as well as evidence to funding agencies that the research is feasible and worthwhile. The pilot study described here is preliminary work on health disparities in two itinerant populations: carnival and migrant farmworker children. This pilot study had three aims: (a) identify the most productive methods to recruit subjects from these two "invisible" populations; (b) test feasibility of the research protocol; and (c) collect preliminary data on the children's health status for future research proposals.

Quality of life in terminal care—with special reference to age, gender and marital status

OBJECTIVES

This study was conducted to explore symptoms, other quality of life (QoL) aspects and impact of age, gender, marital status, cancer diagnosis and time of survival in patients with advanced cancer admitted to palliative care.

PATIENTS AND METHODS

A cross-sectional study of 278 cancer patients completing the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 at referral to palliative care.

MAIN RESULTS

Gynaecological and gastro-intestinal tract cancers were the most common. Mean age was 67 years; 62% were female. Median survival was 43 days and 39% lived less than 30 days. Patients reported impaired general QoL and high occurrence of symptoms (44 and 100% for diarrhoea and fatigue, respectively). Fatigue, appetite loss and dyspnoea were reported as most severe (mean values of 80, 59 and 51, respectively, 0-100 scales). Married/cohabiting patients and younger patients reported lower functional abilities and more symptoms. No impact of diagnoses on QoL parameters was found. Patients closest to death did not differ significantly from those with longer time to live in social functioning.

CONCLUSION

Young and married patients may be at higher risk for perceived low quality of life at the end of life. EORTC QLQ-C30 could be used as a clinical tool for screening of symptoms and reduced functioning in palliative care, but may not be appropriate for use in the most severely ill patients. Limitations of the instrument and the need for robust measurements of patient mix are discussed. Proxy ratings of physical symptoms and nurse responsibility to include QoL assessment in daily practice would increase attrition and decrease selection bias.

Conceptualizing nursing research with offenders: another look at vulnerability

In this article, vulnerability is examined as it applies to the conduct of nursing research with offenders. As a group, offenders present with a multitude of acute and chronic physical and mental health care needs; they are subject to discrimination, stigmatization, and marginalization; and as such, they often experience dual, multiple, or overlapping vulnerabilities. As research participants, they are especially vulnerable to coercion, as a direct consequence of their dependency status within the correctional system. Embracing a research agenda that focuses on offenders as a vulnerable population is fraught with ambiguities not generally encountered in other settings. The ethical conduct of research with vulnerable populations reflects a contemporary research problem that requires ongoing discourse within the nursing community and the health care community at large.