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Nzinga J, Oliwa J, Oluoch D, Jepkosgei J, Mbuthia D, Boga M, Musitia P, Ogola M, Muinga N, Muraya K, Hinga A, Kamuya D, Kelley M, Molyneux S. The hidden emotional labour behind ensuring the social value of research: Experiences of frontline health policy and systems researchers based in Kenya during COVID-19. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002116. [PMID: 37643165 PMCID: PMC10464993 DOI: 10.1371/journal.pgph.0002116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/23/2023] [Indexed: 08/31/2023]
Abstract
Health policy and systems research (HPSR) is a multi-disciplinary, largely applied field of research aimed at understanding and strengthening the performance of health systems, often with an emphasis on power, policy and equity. The value of embedded and participatory HPSR specifically in facilitating the collection of rich data that is relevant to addressing real-world challenges is increasingly recognised. However, the potential contributions and challenges of HPSR in the context of shocks and crises are not well documented, with a particular gap in the literature being the experiences and coping strategies of the HPSR researchers who are embedded in health systems in resource constrained settings. In this paper, we draw on two sets of group discussions held among a group of approximately 15 HPSR researchers based in Nairobi, Kenya, who were conducting a range of embedded HPSR studies throughout the COVID-19 pandemic. The researchers, including many of the authors, were employed by the KEMRI-Wellcome Trust Research Programme (KWTRP), which is a long-standing multi-disciplinary partnership between the Kenya Medical Research Institute and the Wellcome Trust with a central goal of contributing to national and international health policy and practice. We share our findings in relation to three inter-related themes: 1) Ensuring the continued social value of our HPSR work in the face of changing priorities; 2) Responding to shifting ethical procedures and processes at institutional and national levels; and 3) Protecting our own and front-line colleagues' well-being, including clinical colleagues. Our experiences highlight that in navigating research work and responsibilities to colleagues, patients and participants through the pandemic, many embedded HPSR staff faced difficult emotional and ethical challenges, including heightened forms of moral distress, which may have been better prevented and supported. We draw on our findings and the wider literature to discuss considerations for funders and research leads with an eye to strengthening support for embedded HPSR staff, not only in crises such as the on-going COVID-19 pandemic, but also more generally.
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Affiliation(s)
- Jacinta Nzinga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorothy Oluoch
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Joyline Jepkosgei
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Daniel Mbuthia
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mwanamvua Boga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peris Musitia
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Muthoni Ogola
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Naomi Muinga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Alex Hinga
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorcas Kamuya
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Maureen Kelley
- Nuffield Department of Population Health, Wellcome Centre for Ethics & Humanities, University of Oxford, Oxford, United Kingdom
| | - Sassy Molyneux
- Health Systems and Research Ethics Department, Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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2
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Chattopadhyay S, de Kok B. Making research ethics work for global health: towards a more agile and collaborative approach. BMJ Glob Health 2023; 8:e011415. [PMID: 37451687 PMCID: PMC10351231 DOI: 10.1136/bmjgh-2022-011415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/06/2023] [Indexed: 07/18/2023] Open
Abstract
In this reflective essay, we seek to engage in a constructive dialogue with scholars across medicine, public health and anthropology on research ethics practices. Drawing on anthropological research and ethical dilemmas that our colleagues and we encountered as medical anthropologists, we reflect on presumed and institutionalised 'best' practices such as mandatory written informed consent, and problematise how they are implemented in interdisciplinary global health research projects. We demonstrate that mandatory, individualised, written, informed consent may be unsuitable in many contexts and also identify reasons why tensions between professionals in interdisciplinary teams may arise when decisions about ethics procedures are taken. We propose alternatives to written informed consent that acknowledge research governance requirements and contextual realities and leave more room for ethnographic approaches. Beyond informed consent, we also explore the situatedness of ethical practices when working in contexts where decision-making around health is clearly a shared concern. We use vignettes based on our own and colleagues' experiences to illustrate our arguments, using the collective 'we' instead of 'I' in our vignettes to protect our research participants, partners and interlocutors. We propose a decolonial, plural and vernacular approach to informed consent specifically, and research ethics more broadly. We contend that ethics procedures and frameworks need to become more agile, decolonial, pluralised and vernacularised to enable achieving congruence between communities' ideas of social justice and institutional ethics. We argue that global health research can benefit from anthropology's engagement with situated ethics and consent that is relational, negotiated and processual; and accountability that is not only bureaucratic but also constructive. In doing so, we hope to broaden ethical praxis so that the best outcomes that are also just, fair and equitable can be achieved for all stakeholders.
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Affiliation(s)
| | - Bregje de Kok
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
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3
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Manguele A, Sidat M, IJsselmuiden C, Ferrinho P. Addressing conflicts of interest of ethical reviewers of health planning, management, policy and systems research proposals. Int J Health Plann Manage 2021; 36:2044-2047. [PMID: 34382265 DOI: 10.1002/hpm.3295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 11/05/2022] Open
Abstract
Steering health systems towards universal health coverage requires research on themes that are of particular interest to health planning, management, policy and systems researchers. Some issues, such as strikes regarded as illegal and health sector corruption, because of their social and political sensitivity have, for too long, remained outside adequate research inquiry. Their emergence in the research agenda raises some challenges for Human Research Ethics Committees, particularly related to their conflicts of interests as reviewers, that need clarification.
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Affiliation(s)
| | - Mohsin Sidat
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique.,Research Centre on Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Carel IJsselmuiden
- Council on Health Research for Development, Geneva, Switzerland.,School of Applied Human Sciences, Univ of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Paulo Ferrinho
- Research Centre on Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
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4
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Pratt B. Research for Health Justice: an ethical framework linking global health research to health equity. BMJ Glob Health 2021; 6:bmjgh-2020-002921. [PMID: 33589418 PMCID: PMC7887339 DOI: 10.1136/bmjgh-2020-002921] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/13/2020] [Accepted: 11/21/2020] [Indexed: 11/10/2022] Open
Abstract
Global health research should generate new knowledge to improve the health and well-being of those considered disadvantaged and marginalised. This goal motivates much of the global health research being undertaken today. Yet simply funding and conducting global health research will not necessarily generate the knowledge needed to help reduce health disparities between and within countries. Global health research grants programmes and projects must be structured in a particular way to generate that type of information. But how exactly should they be designed to do so? Through a programme of ethics research starting in 2009, an ethical framework called Research for Health Justice was developed that provides guidance to global health researchers and funders on how to design research projects and grants programmes to promote global health equity. It provides guidance on, for example, what research populations and questions ought to be selected, what research capacity strengthening ought to be performed and what post-study benefits ought to be provided. This paper describes how the ‘research for health justice’ framework was generated and pulls together a body of work spanning the last decade to provide a comprehensive and up-to-date version of its guidance.
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Affiliation(s)
- Bridget Pratt
- School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
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Rattani A, Hyder AA. Letter to the Editor. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:692-693. [PMID: 35006050 DOI: 10.1017/jme.2021.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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6
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Rattani A. Is Solidarity Possible in Global Health Policy and Systems Research? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:67-69. [PMID: 32364483 DOI: 10.1080/15265161.2020.1745943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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7
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Pratt B, Wild V, Barasa E, Kamuya D, Gilson L, Hendl T, Molyneux S. Justice: a key consideration in health policy and systems research ethics. BMJ Glob Health 2020. [PMCID: PMC7245410 DOI: 10.1136/bmjgh-2019-001942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Health policy and systems research (HPSR) is increasingly being funded and conducted worldwide. There are currently no specific guidelines or criteria for the ethical review and conduct of HPSR. Academic debates on HPSR ethics in the scholarly literature can inform the development of guidelines. Yet there is a deficiency of academic bioethics work relating to justice in HPSR. This gap is especially problematic for a field like HPSR, which can entail studies that intervene in ways affecting the social and health system delivery structures of society. In this paper, we call for interpreting the principle of justice in a more expansive way in developing and reviewing HPSR studies (relative to biomedical research). The principle requires advancing health equity and social justice at population or systems levels. Drawing on the rich justice literature from political philosophy and public health ethics, we propose a set of essential justice considerations to uphold this principle. These considerations are relevant for research funders, researchers, research ethics committees, policymakers, community organisations and others who are active in the HPSR field.
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Affiliation(s)
- Bridget Pratt
- Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Verina Wild
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Edwine Barasa
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Dorcas Kamuya
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Lucy Gilson
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Tereza Hendl
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Sassy Molyneux
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
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8
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Silva DS, Smith MJ, Norman CD. Systems thinking and ethics in public health: a necessary and mutually beneficial partnership. Monash Bioeth Rev 2019; 36:54-67. [PMID: 29948960 DOI: 10.1007/s40592-018-0082-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Systems thinking has emerged as a means of conceptualizing and addressing complex public health problems, thereby challenging more commonplace understanding of problems and corresponding solutions as straightforward explanations of cause and effect. Systems thinking tries to address the complexity of problems through qualitative and quantitative modeling based on a variety of systems theories, each with their own assumptions and, more importantly, implicit and unexamined values. To date, however, there has been little engagement between systems scientists and those working in bioethics and public health ethics. The goal of this paper is to begin to consider what it might mean to combine systems thinking with public health ethics to solve public health challenges. We argue that there is a role for ethics in systems thinking in public health as a means of elucidating implicit assumptions and facilitating ethics debate and dialogue with key stakeholders.
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Affiliation(s)
- Diego S Silva
- Faculty of Health Science, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
| | - Maxwell J Smith
- School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Cameron D Norman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,CENSE Research + Design, Toronto, Canada
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Mateus JC, Varela MT, Caicedo DM, Arias NL, Jaramillo CD, Morales LC, Palma GI. Does Resolution 8430 of 1993 respond to the current needs of ethics in health research with human beings in Colombia? BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2019; 39:448-463. [PMID: 31584760 PMCID: PMC7357356 DOI: 10.7705/biomedica.4333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/20/2019] [Indexed: 11/25/2022]
Abstract
Verifying the compliance with the ethical principles of health research legitimizes its exercise in the eyes of the society and allows for the resolution of ethical dilemmas that emerge from new research interests and methods. Resolution 8430 of 1993 is one of the main ethical guidelines governing health research on human beings in Colombia. Considering that the resolution has not been revised or updated since its promulgation it becomes necessary to evaluate its current validity and adequacy to address the potential ethical dilemmas in the existing country’s health research. Some gaps, contradictions, and aspects that require a deep review are detailed in this paper from a wide conception of health research areas and methods. After discussing the main weaknesses and inaccuracies, some alternatives are proposed to adjust the resolution to the present needs in health research with human beings.
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Affiliation(s)
- Julio Cesar Mateus
- Facultad de Salud, Universidad del Valle, Cali, Colombia; Doctorado en Salud, Escuela de Salud Pública, Facultad de Salud, Universidad del Valle, Cali, Colombia; Grupo iDIES, Fundación Universidad del Valle, Cali, Colombia.
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10
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Behera SK, Das S, Xavier AS, Selvarajan S, Anandabaskar N. Indian Council of Medical Research's National Ethical Guidelines for biomedical and health research involving human participants: The way forward from 2006 to 2017. Perspect Clin Res 2019; 10:108-114. [PMID: 31404208 PMCID: PMC6647898 DOI: 10.4103/picr.picr_10_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The Indian Council of Medical Research (ICMR) recently published the third revised guidelines "National Ethical Guidelines for Biomedical and Health-Related Research Involving Human Participants" in 2017. The changes to the guidelines were needed to acculturate the rapid advances in the research environment and advances in science and technology. The revised guidelines propose substantial changes/ modifications compared to the previous version. These include the introduction of broad consent, ethical issues related to deception, review of multi-centric research by a single ethics committee and ethical issues involved in implementation research and other issues related to public health research. The revised guidelines also incorporate modifications and minor changes to the previous version. Although most of the changes in the revised guidelines are in parallel to most of the international guidelines, we have also highlighted the minor differences compared to other international guidelines.
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Affiliation(s)
- Sapan Kumar Behera
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Saibal Das
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Alphienes Stanley Xavier
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sandhiya Selvarajan
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
- IEC (Human Studies), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Nishanthi Anandabaskar
- Department of Pharmacology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
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11
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Mweemba C, Ali J, Hyder AA. Providing monetary and non-monetary goods to research participants: perspectives and practices of researchers and Research Ethics Committees in Zambia. Glob Bioeth 2018; 31:90-103. [PMID: 33343185 PMCID: PMC7734108 DOI: 10.1080/11287462.2018.1527672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/20/2018] [Indexed: 11/29/2022] Open
Abstract
There are disagreements among ethicists on what comprises an "appropriate" good to offer research participants. Debates often focus on the type, quantity, timing, and ethical appropriateness of such offers, particularly in settings where participants may be socio-economically vulnerable, such as in parts of Zambia. This was a Cross-sectional online survey of researchers and Research Ethics Committees (RECs) designed to understand practices, attitudes and policies associated with provision of goods to research participants. Of 122 responding researchers, 69 met eligibility criteria. Responses were also received from five of the six Zambian RECs involved in reviewing research proposals. Forty-nine researchers (71.0%) confirmed previous experience offering goods to participants. Of these, 21 (42.9%) offered participants money only, 18 (36.7%) offered non-monetary goods, while the rest offered both monetary and non-monetary goods. Generally, goods were offered and approved by RECs to compensate for time, lost wages and transportation. One REC and 34.8% of researchers reported being subject to an institutional policy on offering goods to participants. While reimbursement is the main reason for offering goods to participants in Zambia, caution is required when deciding on the type and quantity of goods to offer given the potential for community mistrust and manipulation.
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Affiliation(s)
- Chris Mweemba
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Joseph Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| | - Adnan A. Hyder
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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12
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Pratt B, Hyder AA. Linking Participatory Action Research on Health Systems to Justice in Global Health: A Case Study of the Maternal and Neonatal Implementation for Equitable Health Systems Project in Rural Uganda. J Empir Res Hum Res Ethics 2017; 13:74-87. [PMID: 29160115 DOI: 10.1177/1556264617741022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An ethical framework called "research for health justice" provides initial guidance on how to link health systems research in low- and middle-income countries to health equity. To further develop the largely conceptual framework, we tested its guidance against the experience of the Maternal and Neonatal Implementation for Equitable Health Systems (Manifest) project, which was performed in rural Uganda by researchers from Makerere University. We conducted 21 in-depth interviews with investigators and research implementers, directly observed study sites, and reviewed study-related documents. Our analysis identifies where alignment exists between the framework's guidance and the Manifest project, providing initial lessons on how that was achieved. It also identifies where nonalignment occurred and gaps in the framework's guidance. Suggestions are then made for revising and expanding "research for health justice."
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Affiliation(s)
- Bridget Pratt
- 1 University of Melbourne, Melbourne, Victoria, Australia.,2 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adnan A Hyder
- 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,3 Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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13
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Luyckx VA, Biller-Andorno N, Saxena A, Tran NT. Health policy and systems research: towards a better understanding and review of ethical issues. BMJ Glob Health 2017; 2:e000314. [PMID: 29225934 PMCID: PMC5717951 DOI: 10.1136/bmjgh-2017-000314] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/01/2017] [Accepted: 04/04/2017] [Indexed: 11/04/2022] Open
Abstract
Given the focus on health systems in the post-millennium development goal era and moving towards the sustainable development goals, there is a compelling need for a common framework for health policy and systems research ethics to guide researchers and facilitate review by research ethics committees. A consultation of global health policy and systems research and ethics experts was convened to identify ethical considerations relevant to health policy and systems research based on existing knowledge and to identify knowledge gaps through a scoping review and further expert deliberation. Health policy and systems research is highly complex and, in the absence of guidance documents, there is significant variability in ethics review. Although fundamental ethical principles pertain to both traditional clinical research and health policy and systems research, the application of these principles requires a comprehensive understanding of the nature of health policy and systems research with its distinct challenges. Such awareness must be raised among researchers and research ethics committees. Current research ethics committees lack familiarity with health policy and systems research and because health policy and systems research is conducted in real-world contexts, committees often have difficulties in determining whether a project is indeed research and/or requires ethical review. Given the strong current focus on health policy and systems research to rapidly improve health and health systems functioning globally, greater engagement and dialogue around the ethical concerns is required to optimise research review and research conduct in this rapidly evolving field.
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Affiliation(s)
- Valerie Ann Luyckx
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zürich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, Universität Zürich, Zürich, Switzerland
| | - Abha Saxena
- Global Health Ethics Unit, World Health Organization, Geneva, Switzerland
| | - Nhan T Tran
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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14
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Pratt B, Paul A, Hyder AA, Ali J. Ethics of health policy and systems research: a scoping review of the literature. Health Policy Plan 2017; 32:890-910. [DOI: 10.1093/heapol/czx003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/12/2022] Open
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15
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Wild V, Pratt B. Health incentive research and social justice: does the risk of long term harms to systematically disadvantaged groups bear consideration? JOURNAL OF MEDICAL ETHICS 2017; 43:150-156. [PMID: 27738256 DOI: 10.1136/medethics-2015-103332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 08/12/2016] [Accepted: 09/19/2016] [Indexed: 06/06/2023]
Abstract
The ethics of health incentive research-a form of public health research-are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. 'Long term harms' are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects.
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Affiliation(s)
- Verina Wild
- Department of Philosophy, LMU, University of Munich, Germany
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Bridget Pratt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA
- School of Population and Global Health, University of Melbourne, Australia
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Gopichandran V, Luyckx VA, Biller-Andorno N, Fairchild A, Singh J, Tran N, Saxena A, Launois P, Reis A, Maher D, Vahedi M. Developing the ethics of implementation research in health. Implement Sci 2016; 11:161. [PMID: 27938400 PMCID: PMC5148832 DOI: 10.1186/s13012-016-0527-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/29/2016] [Indexed: 02/03/2023] Open
Abstract
Implementation research (IR) is growing in recognition as an important generator of practical knowledge that can be translated into health policy. With its aim to answer questions about how to improve access to interventions that have been shown to work but have not reached many of the people who could benefit from them, IR involves a range of particular ethical considerations that have not yet been comprehensively covered in international guidelines on health research ethics. The fundamental ethical principles governing clinical research apply equally in IR, but the application of these principles may differ depending on the IR question, context, and the nature of the proposed intervention. IR questions cover a broad range of topics that focus on improving health system functioning and improving equitable and just access to effective health care interventions. As such, IR designs are flexible and often innovative, and ethical principles cannot simply be extrapolated from their applications in clinical research. Meaningful engagement with all stakeholders including communities and research participants is a fundamental ethical requirement that cuts across all study phases of IR and links most ethical concerns. Careful modification of the informed consent process may be required in IR to permit study of a needed intervention. The risks associated with IR may be difficult to anticipate and may be very context-specific. The benefits of IR may not accrue to the same groups who participate in the research, therefore justifying the risks versus benefits of IR may be ethically challenging. The expectation that knowledge generated through IR should be rapidly translated into health policy and practice necessitates up-front commitments from decision-makers to sustainability and scalability of effective interventions. Greater awareness of the particular ethical implications of the features of IR is urgently needed to facilitate optimal ethical conduct of IR and uniform ethical review.
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Affiliation(s)
- Vijayaprasad Gopichandran
- Department of Community Medicine, ESIC Medical College and Postgraduate Institute of Medical Sciences and Research, KK Nagar, Chennai, 600078, India.
| | - Valerie A Luyckx
- Institute of Biomedical Ethics and History of Medicine, Center for Medical Humanities, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, Center for Medical Humanities, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland
| | - Amy Fairchild
- Associate Dean of Academic Affairs, Texas A & M School of Public Health, College Station, Texas, USA
| | - Jerome Singh
- University of KwaZulu-Natal, Nelson Mandela School of Medicine, 719 Umbilo Road, Durban, 4001, South Africa
| | - Nhan Tran
- Alliance for Health Systems and Policy Research, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Abha Saxena
- Global Health Ethics Unit, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Pascal Launois
- Special Programme for Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
| | - Andreas Reis
- Global Health Ethics Unit, World Health Organization, 20, Avenue Appia, 1211, Geneva, Switzerland
| | - Dermot Maher
- Special Programme for Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
| | - Mahnaz Vahedi
- Special Programme for Research and Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
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Abstract
BACKGROUND Health systems research is increasingly being conducted in low and middle-income countries (LMICs). Such research should aim to reduce health disparities between and within countries as a matter of global justice. For such research to do so, ethical guidance that is consistent with egalitarian theories of social justice proposes it ought to (amongst other things) focus on worst-off countries and research populations. Yet who constitutes the worst-off is not well-defined. METHODS AND RESULTS By applying existing work on disadvantage from political philosophy, the paper demonstrates that (at least) two options exist for how to define the worst-off upon whom equity-oriented health systems research should focus: those who are worst-off in terms of health or those who are systematically disadvantaged. The paper describes in detail how both concepts can be understood and what metrics can be relied upon to identify worst-off countries and research populations at the sub-national level (groups, communities). To demonstrate how each can be used, the paper considers two real-world cases of health systems research and whether their choice of country (Uganda, India) and research population in 2011 would have been classified as amongst the worst-off according to the proposed concepts. CONCLUSIONS The two proposed concepts can classify different countries and sub-national populations as worst-off. It is recommended that health researchers (or other actors) should use the concept that best reflects their moral commitments-namely, to perform research focused on reducing health inequalities or systematic disadvantage more broadly. If addressing the latter, it is recommended that they rely on the multidimensional poverty approach rather than the income approach to identify worst-off populations.
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Affiliation(s)
- Bridget Pratt
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, 161 Barry Street Carlton, VIC 3053 Australia
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
| | - Adnan A. Hyder
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 USA
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205 USA
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Pratt B, Hyder AA. Governance of Transnational Global Health Research Consortia and Health Equity. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:29-45. [PMID: 27653398 DOI: 10.1080/15265161.2016.1214304] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Global health research partnerships are increasingly taking the form of consortia of institutions from high-income countries and low- and middle-income countries that undertake programs of research. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Although such consortia typically aim to reduce health disparities between and within countries, what is required for them to do so has not been clearly defined. This article takes a conceptual approach to explore how the governance of transnational global health research consortia should be structured to advance health equity. To do so, it applies an account called shared health governance to derive procedural and substantive guidance. A checklist based on this guidance is proposed to assist research consortia determine where their governance practices strongly promote equity and where they may fall short.
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Affiliation(s)
- Bridget Pratt
- a University of Melbourne and Johns Hopkins Bloomberg School of Public Health
| | - Adnan A Hyder
- b Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Berman Institute of Bioethics
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Tabernero P, Parker M, Ravinetto R, Phanouvong S, Yeung S, Kitutu FE, Cheah PY, Mayxay M, Guerin PJ, Newton PN. Ethical challenges in designing and conducting medicine quality surveys. Trop Med Int Health 2016; 21:799-806. [PMID: 27102573 PMCID: PMC4913736 DOI: 10.1111/tmi.12707] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In this paper we discuss the main ethical challenges related to the conduct of medicine quality surveys and make suggestions on how to address them. METHOD Most evidence-based information regarding medicine quality derives from surveys. However, existing research ethical guidelines do not provide specific guidance for medicine quality surveys. Hence, those conducting surveys are often left wondering how to judge what counts as best practice. A list of the main ethical challenges in the design and conduct of surveys is presented. RESULTS AND CONCLUSIONS It is vital that the design and conduct of medicine quality surveys uphold moral and ethical obligations and analyse the ethical implications and consequences of such work. These aspects include the impact on the local availability of and access to medicines; the confidentiality and privacy of the surveyors and the surveyed; questions as to whether outlet staff personnel should be told they are part of a survey; the need of ethical and regulatory approvals; and how the findings should be disseminated. Medicine quality surveys should ideally be conducted in partnership with the relevant national Medicine Regulatory Authorities. An international, but contextually sensitive, model of good ethical practice for such surveys is needed.
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Affiliation(s)
- Patricia Tabernero
- Lao‐Oxford‐Mahosot Hospital‐Wellcome Trust Research UnitMahosot HospitalVientianeLao PDR
- WorldWide Antimalarial Resistance NetworkOxfordUK
- Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
| | | | - Raffaella Ravinetto
- Department of Clinical SciencesInstitute of Tropical MedicineAntwerpBelgium
- Department of Pharmaceutical and Pharmacological SciencesKU LeuvenBelgium
| | - Souly Phanouvong
- United States PharmacopeiaPromoting the Quality of Medicines ProgramUnited States Pharmacopeial ConventionRockvilleMDUSA
| | - Shunmay Yeung
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Freddy E. Kitutu
- Pharmacy Department and School of Public HealthMakerere University College of Health SciencesKampalaUganda
- International Maternal and Child Health UnitDepartment of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Phaik Yeong Cheah
- Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
- The Ethox CentreUniversity of OxfordOxfordUK
- Mahidol Oxford Tropical Medicine Research UnitMahidol UniversityBangkokThailand
| | - Mayfong Mayxay
- Lao‐Oxford‐Mahosot Hospital‐Wellcome Trust Research UnitMahosot HospitalVientianeLao PDR
- Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
- Faculty of Postgraduate StudiesUniversity of Health SciencesVientianeLao PDR
| | - Philippe J. Guerin
- WorldWide Antimalarial Resistance NetworkOxfordUK
- Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
| | - Paul N. Newton
- Lao‐Oxford‐Mahosot Hospital‐Wellcome Trust Research UnitMahosot HospitalVientianeLao PDR
- WorldWide Antimalarial Resistance NetworkOxfordUK
- Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
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Wassenaar D, Rattani A. What Makes Health Systems Research in Developing Countries Ethical? Application of the Emanuel Framework for Clinical Research to Health Systems Research. Dev World Bioeth 2016; 16:133-139. [DOI: 10.1111/dewb.12101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Tam NT, Huy NT, Thoa LTB, Long NP, Trang NTH, Hirayama K, Karbwang J. Participants' understanding of informed consent in clinical trials over three decades: systematic review and meta-analysis. Bull World Health Organ 2015; 93:186-98H. [PMID: 25883410 PMCID: PMC4371493 DOI: 10.2471/blt.14.141390] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To estimate the proportion of participants in clinical trials who understand different components of informed consent. METHODS Relevant studies were identified by a systematic review of PubMed, Scopus and Google Scholar and by manually reviewing reference lists for publications up to October 2013. A meta-analysis of study results was performed using a random-effects model to take account of heterogeneity. FINDINGS The analysis included 103 studies evaluating 135 cohorts of participants. The pooled proportion of participants who understood components of informed consent was 75.8% for freedom to withdraw at any time, 74.7% for the nature of study, 74.7% for the voluntary nature of participation, 74.0% for potential benefits, 69.6% for the study's purpose, 67.0% for potential risks and side-effects, 66.2% for confidentiality, 64.1% for the availability of alternative treatment if withdrawn, 62.9% for knowing that treatments were being compared, 53.3% for placebo and 52.1% for randomization. Most participants, 62.4%, had no therapeutic misconceptions and 54.9% could name at least one risk. Subgroup and meta-regression analyses identified covariates, such as age, educational level, critical illness, the study phase and location, that significantly affected understanding and indicated that the proportion of participants who understood informed consent had not increased over 30 years. CONCLUSION The proportion of participants in clinical trials who understood different components of informed consent varied from 52.1% to 75.8%. Investigators could do more to help participants achieve a complete understanding.
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Affiliation(s)
- Nguyen Thanh Tam
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Tien Huy
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Le Thi Bich Thoa
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Phuoc Long
- Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | | | - Kenji Hirayama
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki, Japan
| | - Juntra Karbwang
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
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22
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Pratt B, Hyder AA. Global justice and health systems research in low- and middle-income countries. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2015; 43:143-161. [PMID: 25846045 DOI: 10.1111/jlme.12202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Scholarship focusing on how international research can contribute to justice in global health has primarily explored requirements for the conduct of clinical trials. Yet health systems research in low- and middle-income countries (LMICs) has increasingly been identified as vital to the reduction of health disparities between and within countries. This paper expands an existing ethical framework based on the health capability paradigm - research for health justice - to externally-funded health systems research in LMICs. It argues that a specific form of health systems research in LMICs is required if the enterprise is to advance global health equity. "Research for health justice" requirements for priority setting, research capacity strengthening, and post-study benefits in health systems research are derived in light of the field's distinctive characteristics. Specific obligations are established for external research actors, including governments, funders, sponsors, and investigators. How these framework requirements differ from those for international clinical research is discussed.
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Affiliation(s)
- Bridget Pratt
- Research fellow in the Department of International Health at Johns Hopkins Bloomberg School of Public Health and at the Johns Hopkins Berman Institute of Bioethics
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23
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Hyder AA, Pratt B, Ali J, Kass N, Sewankambo N. The ethics of health systems research in low- and middle-income countries: a call to action. Glob Public Health 2014; 9:1008-22. [PMID: 25104051 PMCID: PMC4198578 DOI: 10.1080/17441692.2014.931998] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The increasing conduct of health systems research (HSR) in low- and middle-income countries (LMICs) has not been matched by concurrent work to clarify the field's ethical dimensions. To begin to address this gap, a two-day workshop on the ethics of HSR in LMICs was convened at Johns Hopkins University in June 2013. Participants included health systems researchers, philosophers, lawyers, bioethicists and institutional review board members from Botswana, Uganda, the UK, USA and Zambia. Based on discussions from the workshop, the paper affirms that, while HSR in LMICs raises ethical issues in relation to constructs (i.e. consent, risk, equipoise) common to international clinical research, the nature of the issues that arise often differ between the two fields. Three salient features of HSR and the ethical considerations associated with each of them in LMICs are described to demonstrate this point. Recommendations for institutional review boards' oversight of HSR in LMICs are presented. Finally, a call is made for further action to develop thinking and guidance around the ethics of HSR in resource-poor settings.
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Affiliation(s)
- Adnan A. Hyder
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
| | - Bridget Pratt
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
- Nossal Institute of Global Health, The University of Melbourne, Victoria, Australia
| | - Joseph Ali
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
| | - Nancy Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
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Lange MM. Vulnerability as a concept for health systems research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:41-43. [PMID: 24521337 DOI: 10.1080/15265161.2014.872437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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25
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Dereli T, Coşkun Y, Kolker E, Güner O, Ağırbaşlı M, Ozdemir V. Big data and ethics review for health systems research in LMICs: understanding risk, uncertainty and ignorance -- and catching the black swans? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:48-50. [PMID: 24521341 DOI: 10.1080/15265161.2013.868955] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Pratt B. Connecting health systems research ethics to a broader health equity agenda. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:1-3. [PMID: 24521324 DOI: 10.1080/15265161.2014.881213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Bridget Pratt
- a Johns Hopkins Bloomberg School of Public Health and Nossal Institute of Global Health, University of Melbourne
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27
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Olson NW. Conceptualizing ancillary care obligations in health systems research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:46-47. [PMID: 24521340 DOI: 10.1080/15265161.2013.868959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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28
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Gupta S. Ethical review of health systems research in low- and middle-income countries: research-treatment distinction and intercultural issues. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:44-46. [PMID: 24521339 DOI: 10.1080/15265161.2013.872314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Shivam Gupta
- a Johns Hopkins Bloomberg School of Public Health
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29
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Bamford R. Ethical review of health systems research: vulnerability and the need for philosophy in research ethics. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:38-39. [PMID: 24521335 DOI: 10.1080/15265161.2013.868954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Hurst SA. Simplicity as progress: implications for fairness in research with human participants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:40-41. [PMID: 24521336 DOI: 10.1080/15265161.2014.872392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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