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Stensland KD, Sales AE, Vedapudi VK, Damschroder LJ, Skolarus TA. Exploring implementation outcomes in the clinical trial context: a qualitative study of physician trial stakeholders. Trials 2023; 24:297. [PMID: 37106368 PMCID: PMC10142148 DOI: 10.1186/s13063-023-07304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Cancer clinical trials can be considered evidence-based interventions with substantial benefits, but suffer from poor implementation leading to low enrollment and frequent failure. Applying implementation science approaches such as outcomes frameworks to the trial context could aid in contextualizing and evaluating trial improvement strategies. However, the acceptability and appropriateness of these adapted outcomes to trial stakeholders are unclear. For these reasons, we interviewed cancer clinical trial physician stakeholders to explore how they perceive and address clinical trial implementation outcomes. METHODS We purposively selected 15 cancer clinical trial physician stakeholders from our institution representing different specialties, trial roles, and trial sponsor types. We performed semi-structured interviews to explore a previous adaptation of Proctor's Implementation Outcomes Framework to the clinical trial context. Emergent themes from each outcome were developed. RESULTS The implementation outcomes were well understood and applicable (i.e., appropriate and acceptable) to clinical trial stakeholders. We describe cancer clinical trial physician stakeholder understanding of these outcomes and current application of these concepts. Trial feasibility and implementation cost were felt to be most critical to trial design and implementation. Trial penetration was most difficult to measure, primarily due to eligible patient identification. In general, we found that formal methods for trial improvement and trial implementation evaluation were poorly developed. Cancer clinical trial physician stakeholders referred to some design and implementation techniques used to improve trials, but these were infrequently formally evaluated or theory-based. CONCLUSION Implementation outcomes adapted to the trial context were acceptable and appropriate to cancer clinical trial physician stakeholders. Use of these outcomes could facilitate the evaluation and design of clinical trial improvement interventions. Additionally, these outcomes highlight potential areas for the development of new tools, for example informatics solutions, to improve the evaluation and implementation of clinical trials.
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Affiliation(s)
- Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC, Building 16, 100S-12, Ann Arbor, MI, 48109, USA.
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- University of Missouri and Department of Family and Community Medicine, Sinclair School of Nursing, University of Missouri School of Medicine, Columbia, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan, NCRC, Building 16, 100S-12, Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Stensland KD, Sales AE, Damschroder LJ, Skolarus TA. Applying implementation frameworks to the clinical trial context. Implement Sci Commun 2022; 3:109. [PMID: 36217172 PMCID: PMC9552519 DOI: 10.1186/s43058-022-00355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Clinical trials advance science, benefit society, and provide optimal care to individuals with some conditions, such as cancer. However, clinical trials often fail to reach their endpoints, and low participant enrollment remains a critical problem with trial conduct. In these ways, clinical trials can be considered beneficial evidence-based practices suffering from poor implementation. Prior approaches to improving trials have had difficulties with reproducibility and limited impact, perhaps due to the lack of an underlying trial improvement framework. For these reasons, we propose adapting implementation science frameworks to the clinical trial context to improve the implementation of clinical trials. MAIN TEXT We adapted an outcomes framework (Proctor's Implementation Outcomes Framework) and a determinants framework (the Consolidated Framework for Implementation Research) to the trial context. We linked these frameworks to ERIC-based improvement strategies and present an inferential process model for identifying and selecting trial improvement strategies based on the Implementation Research Logic Model. We describe example applications of the framework components to the trial context and present a worked example of our model applied to a trial with poor enrollment. We then consider the implications of this approach on improving existing trials, the design of future trials, and assessing trial improvement interventions. Additionally, we consider the use of implementation science in the clinical trial context, and how clinical trials can be "test cases" for implementation research. CONCLUSIONS Clinical trials can be considered beneficial evidence-based interventions suffering from poor implementation. Adapting implementation science approaches to the clinical trial context can provide frameworks for contextual assessment, outcome measurement, targeted interventions, and a shared vocabulary for clinical trial improvement. Additionally, exploring implementation frameworks in the trial context can advance the science of implementation through both "test cases" and providing fertile ground for implementation intervention design and testing.
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Affiliation(s)
- Kristian D Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.,Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, NCRC Building 16, 100S-12, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Stensland KD, Damschroder LJ, Sales AE, Schott AF, Skolarus TA. Envisioning clinical trials as complex interventions. Cancer 2022; 128:3145-3151. [PMID: 35766902 PMCID: PMC9378578 DOI: 10.1002/cncr.34357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
Clinical trials are critical components of modern health care and infrastructure. Trials benefit society through scientific advancement and individual patients through trial participation. In fact, billions of dollars are spent annually in support of these benefits. Despite the massive investments, clinical trials often fail to accomplish their primary aims and trial enrollment rates remain low. Prior efforts to improve trial conduct and enrollment have had limited success, perhaps due to oversimplification of the complex, multilevel nature of trials. For these reasons, the authors propose applying implementation science to the clinical trials context. In this commentary, the authors posit clinical trials as complex, multilevel evidence-based interventions with significant societal and individual benefits yet with persistent gaps in implementation. An application of implementation science concepts to the clinical trials context as means to build common vocabulary and establish a platform for applying implementation science and practice to improve clinical trial conduct is introduced. Applying implementation science to the clinical trials context can augment improvement efforts and build capacity for better and more efficient evidence-based care for all patients and trial stakeholders throughout the clinical trials enterprise.
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Affiliation(s)
- Kristian D. Stensland
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Anne E. Sales
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Sinclair School of Nursing, University of Missouri and Department of Family and Community MedicineUniversity of MissouriColumbiaMissouriUSA
| | - Anne F. Schott
- University of Michigan Rogel Cancer CenterAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management Research, VA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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Stensland KD, Richesson RL, Vince RA, Skolarus TA, Sales AE. Evolving a national clinical trials learning health system. Learn Health Syst 2022; 7:e10327. [PMID: 37066100 PMCID: PMC10091198 DOI: 10.1002/lrh2.10327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/26/2022] [Accepted: 06/28/2022] [Indexed: 11/07/2022] Open
Abstract
Clinical trials generate key evidence to inform decision making, and also benefit participants directly. However, clinical trials frequently fail, often struggle to enroll participants, and are expensive. Part of the problem with trial conduct may be the disconnected nature of clinical trials, preventing rapid data sharing, generation of insights and targeted improvement interventions, and identification of knowledge gaps. In other areas of healthcare, a learning health system (LHS) has been proposed as a model to facilitate continuous learning and improvement. We propose that an LHS approach could greatly benefit clinical trials, allowing for continuous improvements to trial conduct and efficiency. A robust trial data sharing system, continuous analysis of trial enrollment and other success metrics, and development of targeted trial improvement interventions are potentially key components of a Trials LHS reflecting the learning cycle and allowing for continuous trial improvement. Through the development and use of a Trials LHS, clinical trials could be treated as a system, producing benefits to patients, advancing care, and decreasing costs for stakeholders.
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Affiliation(s)
| | - Rachel L. Richesson
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
| | - Randy A. Vince
- Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Ted A. Skolarus
- Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Anne E. Sales
- Department of Learning Health SciencesUniversity of MichiganAnn ArborMichiganUSA
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- Sinclair School of NursingUniversity of MissouriColumbiaMissouriUSA
- Department of Family and Community MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
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de Aguirre-Neto JC, de Camargo B, van Tinteren H, Bergeron C, Brok J, Ramírez-Villar G, Verschuur A, Furtwängler R, Howell L, Saunders D, Olsen O, Coulomb A, Vokuhl C, Godzinski J, Smets AM, Vujanic GM, van den Heuvel-Eibrink MM, Graf N, Pritchard-Jones K. International Comparisons of Clinical Demographics and Outcomes in the International Society of Pediatric Oncology Wilms Tumor 2001 Trial and Study. JCO Glob Oncol 2022; 8:e2100425. [PMID: 35537105 PMCID: PMC9126524 DOI: 10.1200/go.21.00425] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
International comparisons of patient demographics, tumor characteristics, and survival can shed light on areas for health care system improvement. The International Society of Pediatric Oncology Wilms Tumor 2001 trial/study registered patients through national clinical study groups in Western Europe and Brazil. This retrospective post hoc analysis of the International Society of Pediatric Oncology Wilms Tumor 2001 database aims to make visible and suggest reasons for any variations in outcomes. International variation in Wilms tumor survival parallels disease burden at diagnosis.![]()
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Affiliation(s)
| | | | - Harm van Tinteren
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Christophe Bergeron
- Centre Léon Bérard, Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France
| | - Jesper Brok
- Department of Paediatric Oncology and Haematology, Rigshospitalet, Copenhagen, Denmark
| | | | - Arnauld Verschuur
- Service d'hématologie-oncologie Pédiatrique, Hôpital de la Timone, Marseille, France
| | - Rhoikos Furtwängler
- Department of Pediatric Hematology and Oncology, Saarland University Hospital, Homburg, Germany
| | - Lisa Howell
- Paediatric Oncology, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Daniel Saunders
- Paediatric Radiotherapy, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Oystein Olsen
- Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Aurore Coulomb
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Armand Trousseau, Paris, France
| | | | - Jan Godzinski
- Department of Paed. Surgery, Marciniak Hospital, Wroclaw, Poland
| | - Anne M Smets
- Radiology, Amsterdam University Medical Centre-AMC, Amsterdam, the Netherlands
| | | | | | - Norbert Graf
- Department of Pediatric Hematology and Oncology, Saarland University Hospital, Homburg, Germany
| | - Kathy Pritchard-Jones
- UCL Great Ormond Street Institute of Child Health, Developmental Biology and Cancer Research and Teaching Department, University College London, London, United Kingdom
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Niranjan SJ, Wenzel JA, Martin MY, Fouad MN, Vickers SM, Konety BR, Durant RW. Perceived Institutional Barriers Among Clinical and Research Professionals: Minority Participation in Oncology Clinical Trials. JCO Oncol Pract 2021; 17:e666-e675. [PMID: 33974821 DOI: 10.1200/op.20.00970] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE In general, participation rates in cancer clinical trials are very low. However, participation rates are especially low among the socially disadvantaged and racial and ethnic minority groups. These groups have been historically under-represented in cancer clinical trials. Although many patient-related barriers have been studied, institutional factors that are essential for building clinical research infrastructure around the clinical trial enterprise in academic medical centers have been underexplored. MATERIALS AND METHODS We assessed perspectives of cancer center professional stakeholders on the institutional factors that can potentially influence racial and ethnic minority recruitment for cancer clinical trials. Ninety-one qualitative interviews were conducted at five US cancer centers among four stakeholder groups: cancer center leaders, principal investigators, referring clinicians, and research staff. Qualitative analyses examined response data focused on institutional factors related to minority recruitment for cancer clinical trials. RESULTS Four prominent themes emerged regarding institutional barriers among clinical and research professionals. (1) There are no existing programs currently being used to recruit or retain minorities to clinical trials. (2) Institutional efforts are needed to increase trial participation and are not specific to potential minority participants. (3) Access to cancer clinical trials and navigation within an Academic Medical Center need to be simplified to better facilitate recruitment of minority patients. (4) Community outreach by cancer centers will increase clinical research awareness in the community. CONCLUSION Our research highlights the need to address institutional barriers to improve the success of minority recruitment. To increase participation among minority populations, medical centers must address mutable institutional barriers such as setting specific minority recruitment goals for cancer clinical trials, ensuring that cancer clinical trials are accessible, especially to minority patients, and supporting sustained community outreach programs to increase clinical research awareness.
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Affiliation(s)
| | | | | | - Mona N Fouad
- University of Alabama at Birmingham, Birmingham, AL
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Lalova T, Padeanu C, Negrouk A, Lacombe D, Geissler J, Klingmann I, Huys I. Cross-Border Access to Clinical Trials in the EU: Exploratory Study on Needs and Reality. Front Med (Lausanne) 2020; 7:585722. [PMID: 33195343 PMCID: PMC7642582 DOI: 10.3389/fmed.2020.585722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/14/2020] [Indexed: 11/26/2022] Open
Abstract
Objectives: To analyze the current situation of cross-border access to clinical trials in the EU with an overview of stakeholders' real-life experience, and to identify the needs, challenges, and potential for facilitation of cross-border access. Methods: We employed a mixed methods design. Semi-structured interviews and an online survey were conducted with a wide range of stakeholders: patient representatives, investigators/physicians, policy and regulatory experts, academic and commercial sponsor representatives, ethics committee members. Interviews underwent a framework analysis. The survey was analyzed descriptively. Results: Three hundred ninety six individuals responded to the survey. The majority were investigators/physicians (46%) and patient representatives (33%). Thirty eight individuals were interviewed. The majority were investigators/physicians (29%) and patient representatives (29%). All European regions were represented in the study. The highest response rate was received from residents of Western European countries (38% of survey respondents, 45% of interviewees), the lowest from Eastern Europe (9% of survey respondents, 5% of interviewees). The study suggested that cross-border participation in clinical trials occurs in practice, however very rarely. Ninety two percentage of survey respondents and the majority of interviewees perceived as needed the possibility to access clinical trials abroad. However, most interviewees also opined that patients ideally should not have to travel in order to access experimental treatment. The lack of access to treatment in the home country of the patient was described as the main motivation to participate in a clinical trial in another country. The logistical and financial burden for patients was perceived as the biggest challenge. Different stakeholders expressed diverging opinions regarding the allocation of financial and organizational responsibility for enabling cross-border access to clinical trials. Participants provided a number of proposals for improving the current system, which were carefully evaluated by the research team and informed future recommendations. Conclusions: Participation in clinical trials abroad is happening rarely but should be facilitated. There was a consensus on the need for reliable and accessible information regarding practical aspects, as well as multi-stakeholder, multi-national recommendations on existing options and best practice on cross-border access to clinical trials. Broader interdisciplinary research is recommended before discussing options in the EU legislative framework to enable clearly defined conditions for cross-border access to clinical trials.
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Affiliation(s)
- Teodora Lalova
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium.,Center for IT & IP law (CiTiP), KU Leuven, Leuven, Belgium
| | | | - Anastassia Negrouk
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Denis Lacombe
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | | | | | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
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Viana LS, Silva NDP, Balmant NV, Faria PA, Santos MO, Reis RS, Camargo BD. Challenges on participation in a cooperative group of childhood renal tumors in Brasil. Rev Assoc Med Bras (1992) 2020; 66:284-289. [PMID: 32520146 DOI: 10.1590/1806-9282.66.3.284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/01/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Children with renal tumors included in clinical trials have significantly better outcomes. In Brasil, the enrollment of patients in clinical trials remains challenging. Here we aimed to describe participation accrual in the Brazilian Wilms Tumor Study Group (BWTSG) and to identify barriers to trial registration of children with renal tumors. METHODS We determined the numbers of renal tumor diagnoses in 105 hospital-based cancer registries from 2001-2009. We then compared these totals with the numbers of renal tumor cases registered in the BWTSG from the same hospitals during the same time period. We also invited members of the Brazilian Pediatric Oncology Society to complete a 5-point Likert-type scale questionnaire regarding their opinions of the importance of participation in cooperative group trials. RESULTS The accrual rate of patient participation per hospital varied from 25% to 76%, and was highest in the South region. The accrual rate of hospital participation also varied according to the region (20-31%) and was highest in the Southeast region. For the questionnaire regarding the importance of participation in cooperative groups, the responses showed an agreement of >75% on 10 of the 13 statements. CONCLUSION Our results demonstrated low accrual of participation in a cooperative group trial in Brasil. We identified variations in registration rates according to geographic region and hospital, which may help targeted efforts to increase registration rates. The survey responses demonstrated that colleagues understand the importance of trial participation.
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Affiliation(s)
- Lucian S Viana
- . Centro de Pesquisa, Programa de Pós Graduação, Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Neimar de Paula Silva
- . Centro de Pesquisa, Programa de Pós Graduação, Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Nathalie V Balmant
- . Centro de Pesquisa, Programa de Pós Graduação, Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Paulo A Faria
- . Departamento de Patologias (Dipat), Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Marceli O Santos
- . Coordenação de Vigilância e Prevenção, Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Rejane S Reis
- . Fundação do Câncer, Hospital Fundação do Câncer, Rio de Janeiro, RJ, Brasil
| | - Beatriz de Camargo
- . Centro de Pesquisa, Programa de Pós Graduação, Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
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Degaga TS, Weston S, Tego TT, Abate DT, Aseffa A, Wayessa A, Price RN, Hailu A, Thriemer K. Disseminating clinical study results to trial participants in Ethiopia: insights and lessons learned. Malar J 2020; 19:205. [PMID: 32513176 PMCID: PMC7282093 DOI: 10.1186/s12936-020-03279-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/29/2020] [Indexed: 01/13/2023] Open
Abstract
International regulatory authorities and funders require that research be disseminated promptly and appropriately to all involved stakeholders. However, following completion of clinical trials participants often either do not receive any feedback or materials provided are not appropriate for the context. The investigators of a multicentre anti-malarial clinical trial (the IMPROV study) conducted a dissemination meeting at one of the study sites in Ethiopia; trial participants and medical staff were provided feedback on the study results. This report summarizes the dissemination strategies adopted by the investigators, including a plain language visual aid and simple communication techniques. Lessons learned are reported with a discussion on the operational challenges to dissemination of clinical trials in resource limited settings.
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Affiliation(s)
- Tamiru S. Degaga
- grid.442844.a0000 0000 9126 7261College of Medicine & Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Sophie Weston
- grid.271089.50000 0000 8523 7955Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT Australia
| | | | - Dagimawie T. Abate
- grid.442844.a0000 0000 9126 7261College of Medicine & Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Ashenafi Aseffa
- grid.452387.fEthiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Adugna Wayessa
- grid.452387.fEthiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ric N. Price
- grid.271089.50000 0000 8523 7955Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT Australia ,grid.10223.320000 0004 1937 0490Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Asrat Hailu
- grid.7123.70000 0001 1250 5688College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kamala Thriemer
- grid.271089.50000 0000 8523 7955Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT Australia
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Aguilera B, DeGrazia D, Rid A. Regulating international clinical research: an ethical framework for policy-makers. BMJ Glob Health 2020; 5:e002287. [PMID: 32461225 PMCID: PMC7259867 DOI: 10.1136/bmjgh-2020-002287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/03/2022] Open
Abstract
The global distribution of clinical trials is shifting to low-income and middle-income countries (LMICs), and adequate regulations are essential for protecting the rights and interests of research participants in these countries. However, policy-makers in LMICs can face an ethical trade-off: stringent regulatory protections for participants can lead researchers or sponsors to conduct their research elsewhere, potentially depriving the local population of the opportunity to benefit from international clinical research. In this paper, we propose a three-step ethical framework that helps policy-makers to navigate this trade-off. We use a recent set of regulatory protections in Chile to illustrate the practical value of our proposed framework, providing original ethical analysis and previously unpublished data from Chile obtained through freedom of information requests.
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Affiliation(s)
- Bernardo Aguilera
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - David DeGrazia
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
- Department of Philosophy, George Washington University, Washington, DC, USA
| | - Annette Rid
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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Razis E, Balogun J, Lushi M, Abdel Karim K, Kalapanida D, Kadzatsa W. Report from the Front: a Glimpse at Breast Cancer Research in Low- and Middle-Income Countries. CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-00329-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Ramaswami R, Paulino E, Barrichello A, Nogueira-Rodrigues A, Bukowski A, St Louis J, Goss PE. Disparities in Breast, Lung, and Cervical Cancer Trials Worldwide. J Glob Oncol 2019; 4:1-11. [PMID: 30241268 PMCID: PMC6223472 DOI: 10.1200/jgo.17.00226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Purpose As cancer burden has risen worldwide, physicians, patients, and their advocates have become aware that the clinical cancer trial research paradigm is not ubiquitous. Furthermore, the number and characteristics of trials that are registered in low- and middle-income countries (LMICs) compared with that in high-income countries (HICs) are unknown. Methods We collected retrospective data on trials for breast, lung, and cervical cancer registered in ClinicalTrials.gov or with the WHO International Clinical Trial Registry Platform between 2010 and 2017. The data were then classified as trials within LMICs or HICs using definitions from the World Bank. Results Included in these analyses were 6,710 trials, of which 3,164 (47%) were breast cancer trials, 3,283 (49%) were lung cancer trials, and 263 (4%) were cervical cancer trials. There were 1,951 (29%) trials from LMICs and 4,759 (71%) trials from HICs (P < .001). Although the proportion of phase III trials in HICs versus LMICs was similar (18% v 17%; P = .66), the number of phase I trials in LMICs was significantly lower than that of HICs (20% v 2%; P < .001). For several LMICs with the highest mortality-to-incidence ratios for breast, lung, or cervical cancer, there were no cancer trials registered in the registration data bases searched for this work. Conclusion There are differences in access to cancer clinical trials in LMICs compared with HICs. Several factors, such as excessive cost and a lack of infrastructure and expertise, may explain these differences.
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Affiliation(s)
- Ramya Ramaswami
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Eduardo Paulino
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Adriana Barrichello
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Angelica Nogueira-Rodrigues
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Alexandra Bukowski
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Jessica St Louis
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Paul E Goss
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
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Attar SG, Poustie VJ, Smye SW, Beety JM, Hawcutt DB, Littlewood S, Oni L, Pirmohamed M, Beresford MW. Working together to deliver stratified medicine research effectively. Br Med Bull 2019; 129:107-116. [PMID: 30753334 DOI: 10.1093/bmb/ldz003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/08/2019] [Accepted: 01/15/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION OR BACKGROUND Stratified medicine is an important area of research across all clinical specialties, with far reaching impact in many spheres. Despite recently formulated global policy and research programmes, major challenges for delivering stratified medicine studies persist. Across the globe, clinical research infrastructures have been setup to facilitate high quality clinical research. SOURCES OF DATA This article reviews the literature and summarizes views collated from a workshop held by the UK Pharmacogenetics and Stratified Medicine Network and the NIHR Clinical Research Network in November 2016. AREAS OF AGREEMENT Stratified medicine is an important area of clinical research and health policy, benefitting from substantial international, cross-sector investment and has the potential to transform patient care. However there are significant challenges to the delivery of stratified medicine studies. AREAS OF CONTROVERSY Complex methodology and lack of consistency of definition and agreement on key approaches to the design, regulation and delivery of research contribute to these challenges and would benefit from greater focus. GROWING POINTS Effective partnership and development of consistent approaches to the key factors relating to stratified medicine research is required to help overcome these challenges. AREAS TIMELY FOR DEVELOPING RESEARCH This paper examines the critical contribution clinical research networks can make to the delivery of national (and international) initiatives in the field of stratified medicine. Importantly, it examines the position of clinical research in stratified medicine at a time when pressures on the clinical and social services are mounting.
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Affiliation(s)
- S G Attar
- Departments of Women's and Children's Health, and Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - V J Poustie
- Departments of Women's and Children's Health, and Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,NIHR Clinical Research Network (CRN) Coordinating Centre, 21 Queen's Street, Leeds, UK
| | - S W Smye
- NIHR Clinical Research Network (CRN) Coordinating Centre, 21 Queen's Street, Leeds, UK
| | - J M Beety
- NIHR Clinical Research Network (CRN) Coordinating Centre, 21 Queen's Street, Leeds, UK
| | - D B Hawcutt
- Departments of Women's and Children's Health, and Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - S Littlewood
- NIHR Clinical Research Network (CRN) Coordinating Centre, 21 Queen's Street, Leeds, UK
| | - L Oni
- Departments of Women's and Children's Health, and Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Pirmohamed
- Departments of Women's and Children's Health, and Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M W Beresford
- Departments of Women's and Children's Health, and Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,NIHR Clinical Research Network (CRN) Coordinating Centre, 21 Queen's Street, Leeds, UK
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14
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Wilson PT, Giessler K, Morris MC. Impact of a Clinical Trial in Two District Hospitals in Ghana: Perspectives of Ghanaian Researchers. J Empir Res Hum Res Ethics 2018; 13:486-493. [PMID: 30296898 DOI: 10.1177/1556264618804965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Conducting clinical trials in resource-poor settings may contribute to local capacity building. We describe the perspectives of local research personnel regarding the impact of collaborating in a clinical trial in rural Ghana. Forty-six Ghanaian research personnel were eligible to complete an anonymous survey, and 35 (76%) participated. Of the 35 respondents, 32 (91%) agreed that future patients will benefit because the hospital was part of the study. All 35 respondents reported a personal benefit derived from study involvement, most commonly citing skills or knowledge gained. Of the 35 individuals, 21 reported one or more burdens, most commonly citing nonspecific research responsibilities. Our data support the hypothesis that participation in clinical trials can contribute to capacity building in district hospitals in a lower middle-income country.
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15
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Smith MA, Joffe S. Will my child do better if she enrolls in a clinical trial? Cancer 2018; 124:3965-3968. [PMID: 30291807 DOI: 10.1002/cncr.31722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/17/2018] [Indexed: 11/08/2022]
Abstract
The question of whether children with cancer who enroll in clinical trials have superior outcomes compared with those who do not participate has been pursued for more than 4 decades, and recent studies have provided conflicting answers. Whether clinical trial participation influences outcome has important implications for how clinicians should present trial participation to patients and families. Methodological challenges limit generalizations about the impact of clinical trial participation on outcome compared with nonparticipation. Oncologists should inform patients and families that clinical trials are the engine for future progress because they identify more effective therapies and that clinical trial participation is a reasonable option to consider for children with cancer. However, as noted in by Truong and colleagues in this issue, the rationale for trial enrollment should not include an expectation of better outcomes compared with nonenrollment.
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Affiliation(s)
- Malcolm A Smith
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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Ramaswami R, Paulino E, Barrichello A, Nogueira-Rodrigues A, Bukowski A, St Louis J, Goss PE. Disparities in Breast, Lung, and Cervical Cancer Trials Worldwide. J Glob Oncol 2018. [PMID: 30241268 DOI: 10.1200/jgo.17.00226.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE As cancer burden has risen worldwide, physicians, patients, and their advocates have become aware that the clinical cancer trial research paradigm is not ubiquitous. Furthermore, the number and characteristics of trials that are registered in low- and middle-income countries (LMICs) compared with that in high-income countries (HICs) are unknown. METHODS We collected retrospective data on trials for breast, lung, and cervical cancer registered in ClinicalTrials.gov or with the WHO International Clinical Trial Registry Platform between 2010 and 2017. The data were then classified as trials within LMICs or HICs using definitions from the World Bank. RESULTS Included in these analyses were 6,710 trials, of which 3,164 (47%) were breast cancer trials, 3,283 (49%) were lung cancer trials, and 263 (4%) were cervical cancer trials. There were 1,951 (29%) trials from LMICs and 4,759 (71%) trials from HICs ( P < .001). Although the proportion of phase III trials in HICs versus LMICs was similar (18% v 17%; P = .66), the number of phase I trials in LMICs was significantly lower than that of HICs (20% v 2%; P < .001). For several LMICs with the highest mortality-to-incidence ratios for breast, lung, or cervical cancer, there were no cancer trials registered in the registration data bases searched for this work. CONCLUSION There are differences in access to cancer clinical trials in LMICs compared with HICs. Several factors, such as excessive cost and a lack of infrastructure and expertise, may explain these differences.
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Affiliation(s)
- Ramya Ramaswami
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Eduardo Paulino
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Adriana Barrichello
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Angelica Nogueira-Rodrigues
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Alexandra Bukowski
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Jessica St Louis
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
| | - Paul E Goss
- Ramya Ramaswami, Imperial College London, Hammersmith Hospital, London, United Kingdom; Eduardo Paulino, Adriana Barrichello, Angelica Nogueira-Rodrigues, Alexandra Bukowski, Jessica St. Louis, and Paul E. Goss, The Global Cancer Institute; and Massachusetts General Hospital, Boston, MA
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da Silva RE, Amato AA, Andrade DDBC, Leite e Silva AV, de Carvalho MR, Novaes MRCG. Research Priorities and Resource Allocation in the Investigation of New Drugs for Cancer in Least Developed Countries. JOURNAL OF ONCOLOGY 2018; 2018:8092702. [PMID: 30057606 PMCID: PMC6051037 DOI: 10.1155/2018/8092702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/03/2018] [Accepted: 05/27/2018] [Indexed: 12/14/2022]
Abstract
Cancer incidence has increased significantly in low- and middle-income countries. The priorities of international health research are not always aligned with the global burden of cancer. This study aims to analyze global tendencies in clinical trials in oncology and discuss research priorities and resource allocation in the investigation of new drugs for cancers that significantly affect the least developed countries. This was a retrospective and analytical study that included data collected from the World Health Organization's International Clinical Trials Registry Platform (ICTRP) in 2014. According to our results, there was a tendency for clinical trials involving breast and lung cancer to be conducted in countries with a lower level of economic development. On the other hand, cervical, stomach, and liver cancer, despite the significant burden that these place on middle- and low-income countries, were studied little among the countries selected. In conclusion, the organizations that most fund research to develop new drugs for cancer treatment continue to show little interest in prioritizing resources to fund research for certain types of cancer such as those of the cervix, stomach, and liver, which have a significant impact in low- and middle-income countries.
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Affiliation(s)
- Ricardo Eccard da Silva
- Office of Clinical Trials, Brazilian Health Regulatory Agency (ANVISA), Setor de Indústria Trecho 5, Área Especial 57, 71205-050, Brasília, Brazil
- Faculty of Health Sciences, University of Brasilia (UnB), Campus Universitário Darcy Ribeiro, 70910-900 Brasília, Brazil
| | - Angélica Amorim Amato
- Faculty of Health Sciences, University of Brasilia (UnB), Campus Universitário Darcy Ribeiro, 70910-900 Brasília, Brazil
| | | | - Alessandra Vanessa Leite e Silva
- Hospital de Base, Secretary of Health, Government of the Federal District, SMHS, Quadra 101, Área Especial, s/n, Asa Sul, 70330-150, Brasília, Brazil
| | - Marta Rodrigues de Carvalho
- School of Medicine, Health Science Education and Research Foundation (FEPECS), SMHN Quadra 03, Conjunto A, Bloco 1, Edifício FEPECS, 70.710-907 Brasília, Brazil
| | - Maria Rita Carvalho Garbi Novaes
- Faculty of Health Sciences, University of Brasilia (UnB), Campus Universitário Darcy Ribeiro, 70910-900 Brasília, Brazil
- School of Medicine, Health Science Education and Research Foundation (FEPECS), SMHN Quadra 03, Conjunto A, Bloco 1, Edifício FEPECS, 70.710-907 Brasília, Brazil
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18
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Mtove G, Kimani J, Kisinza W, Makenga G, Mangesho P, Duparc S, Nakalembe M, Phiri KS, Orrico R, Rojo R, Vandenbroucke P. Multiple-level stakeholder engagement in malaria clinical trials: addressing the challenges of conducting clinical research in resource-limited settings. Trials 2018; 19:190. [PMID: 29566732 PMCID: PMC5863846 DOI: 10.1186/s13063-018-2563-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/07/2018] [Indexed: 01/07/2023] Open
Abstract
Background Multinational clinical trials are logistically complex and require close coordination between various stakeholders. They must comply with global clinical standards and are accountable to multiple regulatory and ethical bodies. In resource-limited settings, it is challenging to understand how to apply global clinical standards to international, national, and local factors in clinical trials, making multiple-level stakeholder engagement an important element in the successful conduct of these clinical trials. Main body During the planning and implementation of a large multinational clinical trial for intermittent preventive treatment of malaria in pregnancy in resource-limited areas of sub-Saharan Africa, we encountered numerous challenges, which required implementation of a range of engagement measures to ensure compliance with global clinical and regulatory standards. These challenges included coordination with ongoing global malaria efforts, heterogeneity in national regulatory structures, sub-optimal healthcare infrastructure, local practices and beliefs, and perspectives that view healthcare providers with undue trust or suspicion. In addition to engagement with international bodies, such as the World Health Organization, the Malaria in Pregnancy Consortium, the Steve Biko Centre for Bioethics, and the London School of Hygiene and Tropical Medicine, in order to address the challenges just described, Pfizer Inc. and Medicines for Malaria Venture (the “Sponsoring Entities” for these studies) and investigators liaised with national- and district-level stakeholders such as health ministers and regional/local community health workers. Community engagement measures undertaken by investigators included local meetings with community leaders to explain the research aims and answer questions and concerns voiced by the community. The investigators also engaged with family members of prospective trial participants in order to be sensitive to local practices and beliefs. Conclusion Engagement with key stakeholders at international and national levels enabled the Sponsoring Entities to address challenges by aligning the study design with the requirements of health and regulatory agencies and to understand and address healthcare infrastructure needs prior to trial initiation. Local stakeholder engagement, including community members, study participants, and family enabled the investigators to address challenges by ensuring that study design and conduct were adapted to local considerations and ensuring accurate information about the study aims was shared with the public. Trial registration ClinicalTrials.gov, ID: NCT01103063. Registered on 7 April 2010.
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Affiliation(s)
- George Mtove
- National Institute for Medical Research, Amani Medical Research Centre, Muheza, Tanzania.
| | - Joshua Kimani
- College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - William Kisinza
- National Institute for Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Geofrey Makenga
- National Institute for Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Peter Mangesho
- National Institute for Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | | | | | - Kamija S Phiri
- College of Medicine, University of Malawi, Blantyre, Malawi
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Ward CL, Shaw D, Sprumont D, Sankoh O, Tanner M, Elger B. Good collaborative practice: reforming capacity building governance of international health research partnerships. Global Health 2018; 14:1. [PMID: 29310698 PMCID: PMC5759302 DOI: 10.1186/s12992-017-0319-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 12/29/2017] [Indexed: 02/01/2023] Open
Abstract
In line with the policy objectives of the United Nations Sustainable Development Goals, this commentary seeks to examine the extent to which provisions of international health research guidance promote capacity building and equitable partnerships in global health research. Our evaluation finds that governance of collaborative research partnerships, and in particular capacity building, in resource-constrained settings is limited but has improved with the implementation guidance of the International Ethical Guidelines for Health-related Research Involving Humans by The Council for International Organizations of Medical Sciences (CIOMS) (2016). However, more clarity is needed in national legislation, industry and ethics guidelines, and regulatory provisions to address the structural inequities and power imbalances inherent in international health research partnerships. Most notably, ethical partnership governance is not supported by the principal industry ethics guidelines - the International Conference on Harmonization Technical Requirements for Registration of Pharmaceutical for Human Use (ICH) Good Clinical Practice (ICH-GCP). Given the strategic value of ICH-GCP guidelines in defining the role and responsibility of global health research partners, we conclude that such governance should stipulate the minimal requirements for creating an equitable environment of inclusion, mutual learning, transparency and accountability. Procedurally, this can be supported by i) shared research agenda setting with local leadership, ii) capacity assessments, and iii) construction of a memorandum of understanding (MoU). Moreover, the requirement of capacity building needs to be coordinated amongst partners to support good collaborative practice and deliver on the public health goals of the research enterprise; improving local conditions of health and reducing global health inequality. In this respect, and in order to develop consistency between sources of research governance, ICH-GCP should reference CIOMS ethical guidelines as the established standard for collaborative partnership. Moreover, greater commitment and support should be given to co-ordinate, strengthen and enforce local laws requiring equitable research partnerships and health system strengthening.
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Affiliation(s)
- Claire Leonie Ward
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Dominique Sprumont
- Institut de Droit de la Santé, University of Neuchâtel, Neuchâtel, Switzerland
| | | | - Marcel Tanner
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Bernice Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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Jones C, Talisuna AO, Snow RW, Zurovac D. "We were being treated like the Queen": understanding trial factors influencing high paediatric malaria treatment adherence in western Kenya. Malar J 2018; 17:8. [PMID: 29304798 PMCID: PMC5756360 DOI: 10.1186/s12936-017-2164-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to anti-malarial medication is highly variable but frequently suboptimal. Numerous interventions with a variety of methodological approaches have been implemented to address the problem. A recently conducted, randomized, controlled trial in western Kenya evaluated the effects of short message service (SMS) reminders on paediatric adherence to artemether-lumefantrine (AL) and found over 97% adherence rates in both intervention and control arms. The current study was undertaken to explore participants' experiences in the trial and identify the factors contributing to the high adherence rates. METHODS In July 2016, 5 months after the trial completion, focus group discussions (FGDs) were undertaken with caregivers of children who had been treated in the intervention (n = 2) or control (n = 2) arms and who, post-trial, had received malaria treatment from the same facilities. The FGDs explored similarities and differences in perceptions and experiences of the care they received during and after the trial. RESULTS Intervention-arm participants reported that SMS messages were effective dosing reminders. Participants from both arms reported that trial instructions to keep empty AL packs for verification during a home visit by a health worker affected their dosing and adherence practices. Differences between trial and post-trial treatment experiences included: administration of the first AL dose by health workers with demonstration of dispersible tablets dilution; advice on what to do if a child vomited; clear instructions on timing of dosing with efforts made to ensure understanding; and, information that dose completion was necessary with explanation provided. Participants reported that after the trial AL was not available at facilities, constraining their ability to adhere to recommended malaria treatment. They emphasized receiving respectful and personal treatment from trial health workers contributing to perceptions of high quality care and enhanced readiness to adhere to dosing instructions. CONCLUSIONS This study highlights the complex range of factors that influence AL adherence. The results suggest that in addition to standardized definitions and measurement of adherence, and the influence of enrolment procedures, AL adherence trials need to take account of how intervention impact can be influenced by differences in the quality of care received under trial and routine conditions.
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Affiliation(s)
- Caroline Jones
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | - Robert W. Snow
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Dejan Zurovac
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Ward CL, Shaw D, Anane-Sarpong E, Sankoh O, Tanner M, Elger B. The Ethics of Health Care Delivery in a Pediatric Malaria Vaccine Trial: The Perspectives of Stakeholders From Ghana and Tanzania. J Empir Res Hum Res Ethics 2017; 13:26-41. [PMID: 29179625 DOI: 10.1177/1556264617742236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study explores ethical issues raised in providing medical care to participants and communities of low-resource settings involved in a Phase II/III pediatric malaria vaccine trial (PMVT). We conducted 52 key informant interviews with major stakeholders of an international multi-center PMVT (GSK/PATH-MVI RTS,S) (NCT00866619) in Ghana and Tanzania. Based on their stakeholder experiences, the responses fell into three main themes: (a) undue inducement, (b) community disparities, and (c) broad therapeutic misconceptions. The study identified the critical ethical aspects, from the perspectives of stakeholders, of delivering health care during a PMVT. The study showed that integrating research into health care services needs to be addressed in a manner that upholds the favorable risk-benefit ratio of research and attends to the health needs of local populations. The implementation of research should aim to improve local standards of care through building a collaborative agenda with local institutions and systems of health.
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Lins MM, Santos MDO, de Albuquerque MDFPM, de Castro CCL, Mello MJG, de Camargo B. Incidence and survival of childhood leukemia in Recife, Brazil: A population-based analysis. Pediatr Blood Cancer 2017; 64. [PMID: 28000427 DOI: 10.1002/pbc.26391] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/05/2016] [Accepted: 11/10/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Leukemia is the most common pediatric cancer with incidence rates of around 48 per million for children under 15 years of age. The median age-adjusted incidence rate (AAIR) in children aged 0-14 years in Brazil is 53.3 per million. While overall survival rates for children with leukemia have improved significantly, data for incidence, trends, and relative survival among children and adolescents with leukemia in Recife, Brazil, remain incomplete, which hampers our analyses and provision of the best healthcare. The objective of this report is to provide that data. METHODS Data from the Population-Based Cancer Registry of Recife were analyzed from 1998 to 2007. Our analyses included frequencies and AAIR, together with age-specific incidence rates for all leukemias, acute lymphoblastic leukemia, and acute myeloid leukemia. To evaluate incidence trends, joinpoint regression, including annual average percent change, were analyzed. Relative survival was calculated using the life-table method. RESULTS One hundred seventy-five cases were identified, 51% in females. The review reduced the not otherwise specified (NOS) leukemia category by 50% and diagnosis by death certificate only from 5.7% to 1.1%. The AAIR for leukemia was 41.1 per million, with a peak among children aged 1-4 (78.3 per million). Incidence trends during the period were stable. The five-year relative survival rate was 69.8%. CONCLUSIONS These data represent the incidence rate and survival of childhood leukemia in Recife, located in the northeast region of Brazil, using a high-quality database.
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Affiliation(s)
- Mecneide Mendes Lins
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, PE, Brazil.,Instituto Nacional de Cancer, Rio de Janeiro, Brazil.,Pediatric Oncology Unit, Instituto de Medicina Integral Prof. Fernando Figueira-IMIP, Recife, PE, Brazil
| | - Marceli de Oliveira Santos
- Divisão de Vigilância e Análise de Situação Coordenação de Prevenção e Vigilância (Surveilance Division and Surveilance and Prevention Coordination Situation of Analysis) at Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | | | | | - Maria Julia Gonçalves Mello
- Pediatric Research Center, Instituto de Medicina Integral Prof. Fernando Figueira - IMIP, Recife, PE, Brazil
| | - Beatriz de Camargo
- Pediatric Hematology and Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
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Ssali A, Nunn A, Mbonye M, Anywaine Z, Seeley J. Reasons for participating in a randomised clinical trial: The volunteers' voices in the COSTOP trial in Uganda. Contemp Clin Trials Commun 2017; 7:44-47. [PMID: 29696167 PMCID: PMC5898547 DOI: 10.1016/j.conctc.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 05/05/2017] [Accepted: 05/11/2017] [Indexed: 01/03/2023] Open
Abstract
Introduction The reasons why research participants join clinical trials remains an area of inquiry especially in low and middle income countries. Methods We conducted exit interviews with participants who took part in a trial which aimed to evaluate whether long term prophylaxis with cotrimoxazole can be safely discontinued among adults who have been stabilised on antiretroviral therapy (ART). Participants were all reported to be stable on ART and had been participating in the trial for between 12 and 36 months; at the end of the trial participants were interviewed using a semi-structured questionnaire. One of the objectives of the exit interview was to find out what motivated the participants to join the research. Results Participants gave personal reasons for joining the trial, frequently linked to their health and well-being as well as reduction of pill burden. Conclusion We conclude that underlying reasons for joining clinical trials may extend beyond or can be different from the rationale given to the participants before enrolment by the research team. The reasons that motivate enrolment to clinical trials and research in general require further investigation in different settings. Trial registration number ISRCTN44723643.
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Affiliation(s)
- Agnes Ssali
- Medical Research Council/UVRI Uganda Research Unit on AIDS, Uganda
- Corresponding author.
| | - Andrew Nunn
- Medical Research Council Clinical Trials Unit at University College, London, UK
| | - Martin Mbonye
- Medical Research Council/UVRI Uganda Research Unit on AIDS, Uganda
| | | | - Janet Seeley
- Medical Research Council/UVRI Uganda Research Unit on AIDS, Uganda
- London School of Hygiene and Tropical Medicine, UK
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Asante KP, Jones C, Sirima SB, Molyneux S. Clinical Trials Cannot Substitute for Health System Strengthening Initiatives or Specifically Designed Health Policy and Systems Research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:24-26. [PMID: 27216095 PMCID: PMC6616026 DOI: 10.1080/15265161.2016.1170242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | - Caroline Jones
- b University of Oxford and KEMRI Wellcome Trust Research Programme
| | | | - Sassy Molyneux
- b University of Oxford and KEMRI Wellcome Trust Research Programme
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25
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Barrios CH. The Good Example: Potential of Clinical Research to Expand Quality Care in Low- and Middle-Income Countries. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:22-23. [PMID: 27216094 DOI: 10.1080/15265161.2016.1170246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos H Barrios
- a PUCRS School of Medicine , Hospital do Câncer Mãe de Deus , and Latin American Cooperative Group (LACOG)
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Rennie S. The Infrastructure Effect: Scientific Conjecture or Wishful Thinking? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:12-13. [PMID: 27216090 DOI: 10.1080/15265161.2016.1170245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Dranseika V, Gefenas E, Waligora M. Broadening the "Infrastructure Effect": Lessons from the Early Development of Research Ethics in Eastern Europe. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:26-28. [PMID: 27216096 DOI: 10.1080/15265161.2016.1170243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Pinxten W, Ravinetto R, Buvé A. Never Look a Gift Horse in the Mouth? Four Reasons Not to Blur the Line Between Research and Care in Low- and Middle-Income Countries. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:17-19. [PMID: 27216092 DOI: 10.1080/15265161.2016.1170244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Haire BG. "Reasonable Availability" Criterion Remains Salient. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:19-21. [PMID: 27216093 DOI: 10.1080/15265161.2016.1170239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Pratt B, Ali J, Hyder AA. If Research Is a Pillar of Health System Development, Why Only Focus on Clinical Trials? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:14-17. [PMID: 27216091 DOI: 10.1080/15265161.2016.1170241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Bridget Pratt
- a Nossal Institute of Global Health, University of Melbourne
| | - Joseph Ali
- b Johns Hopkins Berman Institute of Bioethics
| | - Adnan A Hyder
- c Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health
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