Ethical issues regarding recruitment to research studies within the primary care consultation

SWAT 84: effects of same-day consent vs delayed consent on the recruitment and retention of trial participants-an observational SWAT

BACKGROUND AND AIM

The recruitment process in a randomized trial can be challenging. Poor recruitment can have a negative impact on the allocated budget and estimated completion date of the study and may result in an underpowered study. We aimed to perform a Study Within A Trial (SWAT) to evaluate the impact of same-day consent or delayed consent on recruitment and retention in the host trial.

METHODS

This SWAT is designed as a prospective cohort design. The host trial was a randomized controlled trial evaluating the effectiveness of an intensive lifestyle modification programme in participants with peripheral arterial disease. Researchers screened the participants for inclusion and exclusion criteria. Informed consents were obtained from the participants who were willing to participate in the study on a standardized consent form. Participants were given the option to consent on the same day or to delay their consent. Following the consent, the participants were allocated to two groups (same-day consent vs. delayed consent) based on pre-determined criteria for SWAT. One hundred sixteen participants were consented to take part in the host trial. Seventy-five participants were randomized to the host trial. The primary outcome was the proportion of participants who withdrew consent at the recruitment phase. Secondary outcomes were reasons for consent withdrawal and dropout, attrition rate, and adherence with the host trial intervention.

RESULTS

There was a significantly lower consent-withdrawal rate in same-day consent (17.4%, n = 8/46), compared to the delayed consent group (47.1%, n = 33/70), p = 0.001. There was a significantly lower dropout rate in participants randomized following same-day consent (10.5%, n = 4/38), compared to those randomized after delayed consent (29.7%, n = 11/37), p = 0.038. Transport was the main reason mentioned for consent withdrawal and dropout. In participants randomized to the host trial intervention arm, there was a significant difference in adherence (percentage of the 12-week programme completed) between same-day consent (96.7% ± 4.9) and delayed consent participants (86.4% ± 11.2), p = 0.003, as well as number of weeks completed (mean difference =  - 1.547, 95% confidence intervals (- 2.237 to - 0.85)), p = 0.02.

CONCLUSION

This SWAT found evidence that participants who gave consent on the same day seemed to have better adherence and fewer-withdrawal and dropout rates.

SWAT REGISTRATION

The SWAT was registered on the Northern Ireland Network for Trials Methodology Research, SWAT 84.

Cross-sectional household transmission study of Cryptosporidium shows that C. hominis infections are a key risk factor for spread

BACKGROUND

Infection with the Cryptosporidium parasite causes over 4000 cases of diagnosed illness (cryptosporidiosis) in England and Wales each year. The incidence of sporadic disease has not been sufficiently established, and how frequently this arises from contact with other infected people is not well documented. This project aimed to explore potential transmission in the home and attempt to identify asymptomatic infections, which might play a role in transmission. Risk factors and characteristics associated with spread of infection in the home were described including any differences between Cryptosporidium species.

METHODS

The study identified cryptosporidiosis cases from North West England and Wales over a year and invited them and their household to take part. Each household was sent a study pack containing study information and a questionnaire, and stool sample kits to provide samples from consenting household members. Cryptosporidium-positive stool samples, identified by immunofluorescence microscopy, were characterised using molecular methods to help describe any patterns of transmission. Characteristics of households with and without additional cases were described, and compared using odds ratios (OR) and a multivariable logistic regression identified independent risk factors for household transmission. Data collection ran for one year, beginning in September 2018 with an initial pilot phase.

RESULTS

We enrolled 128 index cases and their households. Additional illness occurred in over a quarter of homes, each reporting an average of two additional cases. The majority of these were undiagnosed and unreported to surveillance. This burden was even greater in households where the index case was infected with C. hominis versus C. parvum, or the index case was under five years old, with mums and siblings most at risk of secondary infection. Only having an index case of C. hominis was independently associated with transmission in the multivariable model (OR 4.46; p = 0.01).

CONCLUSIONS

Cryptosporidium was a considerable burden in the home. At-risk homes were those where the index was less than five years old and/or infected with C. hominis. Of particular risk were female caregivers and siblings. Hygiene advice should be specifically directed here. This work provides evidence for humans as sources of C. hominis infection and that person-person is a key pathway. We recommend that all stools submitted for the investigation of gastrointestinal pathogens are tested for Cryptosporidium to better capture cases, inclusion of speciation data in routine surveillance, and the consideration of specific clinical advice on prevention for high-risk homes.

Patient and public involvement in research design and oversight

BACKGROUND

In recent years, the value of patient and public involvement (PPI) in developing research has become apparent. Patients and service users have insights that are essential to successfully developing and completing research. PPI collaborations may improve the scope, quality, relevance and impact of research. Nevertheless, there are challenges for nurse researchers in ensuring effective PPI is embedded in research proposals and practice.

AIM

To discuss the practical aspects of developing a PPI group, including one approach to convening a PPI group, and provide examples of where a PPI group has refined and improved the design of research.

DISCUSSION

Directly inviting patients and members of the public to collaborate in the research resulted in successful working relationships and tangible improvements to a study's methodology. None of the patients approached had considered collaborating in research before and so would not have been reached by any other means.

CONCLUSION

There are several approaches nurse researchers can take to convene a PPI group, including open forums and relevant charity groups. The authors' experience was broadly successful, although future research would involve collaboration with other teams to recruit more diverse groups.

IMPLICATIONS FOR PRACTICE

Nurse researchers are ideally placed to collaborate with patients and members of the public in designing and delivering research.

Opportunities and barriers for the use of Australian cancer registries as platforms for randomized clinical trials

It is well recognized that randomized controlled trials (RCTs) are a powerful tool to investigate causal relationships, and are considered the gold standard level of research evidence. However, RCTs can be expensive and time-consuming, and when they employ strict eligibility criteria, it results in an unrepresentative population and limited external validity. Recently, the registry-based randomized clinical trial (RRCT) has emerged as an alternative trial design. Utilizing registries to underpin such studies, RRCTs can have advantages including rapid recruitment, and enhanced generalizability. In Australia, legislated mandatory reporting of cancer diagnoses means that jurisdictional cancer registries are a rich source of systematically collected patient details, representing sound platforms for comprehensive data capture that can serve as a key tool for further research. We review the roles of cancer registries in Australia, discuss important considerations relevant to the design of RRCTs, and outline the opportunities provided by cancer registries to strengthen cancer research.

Attitudes and perceptions of next-of-kin/loved ones toward end-of-life HIV cure-related research: A qualitative focus group study in Southern California

As end-of-life (EOL) HIV cure-related research expands, understanding perspectives of participants’ next-of-kin (NOK) is critical to maintaining ethical study conduct. We conducted two small focus groups and two one-on-one interviews using focus group guides with the NOK of Last Gift study participants at the University of California, San Diego (UCSD). Participating NOK included six individuals (n = 5 male and n = 1 female), including a grandmother, grandfather, partner, spouse, and two close friends. Researchers double-coded the transcripts manually for overarching themes and sub-themes using an inductive approach. We identified six key themes: 1) NOK had an accurate, positive understanding of the Last Gift clinical study; 2) NOK felt the study was conducted ethically; 3) Perceived benefits for NOK included support navigating the dying/grieving process and personal growth; 4) Perceived drawbacks included increased sadness, emotional stress, conflicted wishes between NOK and study participants, and concerns around potential invasiveness of study procedures at the EOL; 5) NOK expressed pride in loved ones’ altruism; and 6) NOK provided suggestions to improve the Last Gift study, including better communication between staff and themselves. These findings provide a framework for ethical implementation of future EOL HIV cure-related research involving NOK.

Ontologies of transition(s) in healthcare practice: examining the lived experiences and representations of transgender adults transitioning in healthcare

In this article, we examine the ways transitions are constructed and represented within healthcare settings vis-à-vis lived experiences. Drawing on in-depth interviews with transgender people and data from a document analysis, we examine how transgender peoples' experiences fit within conceptualisations of transition(s) in healthcare guidance documents used in England. We take up Pearce's ([2018]. Understanding trans health. Bristol: Policy Press) suggestion to (re)think trans beyond 'condition', and rather as 'movement', to view being trans as a social identity rather than a defect. Our findings show how trans people and transitions are imagined through often linear narratives of movement in/out of transition. Through this framing, fluidity and gender liminal spaces are made invisible, where health care is imagined for certain transitions but not others. Our analysis attends to tensions that emerge in the complexity of transition(s) as well as the intricate ways in which transgender people are responding to often restrictive ontologies of medical transition. As a conceptual tool, 'trans as movement' can be used to create space for more expansive ontologies of gender that confront the harms and restrictions imposed by the gender binary, and offer alternative ways of (re)imagining multiplicity in transition trajectories and futures for both those in healthcare delivery, and for trans patients.

Veterans Healthcare Administration providers' attitudes and perceptions regarding pragmatic trials embedded at the point of care

Background The Veterans Healthcare Administration (VA) is implementing an adaptation of a pragmatic trial program, Point of Care Research (POC-R). The goal of POC-R is to embed research into clinical practice, contributing to a Learning Healthcare System. Provider acceptance and participation in POC-R is essential to its successful implementation. The purpose of this study is to evaluate provider's perceptions and beliefs regarding the POC-R program. Methods Provider focus groups and interviews were conducted at seven VA medical facilities involving 62 providers. A semi-structured script was used that included descriptions of four use cases and targeted questions regarding perceptions, concerns, and attitudes about the POC-R program. Sessions were audio-taped, de-identified, transcribed, and analyzed using systematic qualitative techniques to create response categories and overarching themes. Results The emergent themes were as follows: (1) POC-R is a valuable component of evidence-based practice, providing an opportunity to base clinical practice on more generalizable evidence as well as providing tools to improve local practice; (2) POC-R highlights the tension between the need for autonomy of practice and compliance with protocols; (3) POC-R may create increased time and burden resulting from added research responsibilities; (4) concern about the scientific validity and reliability of results; (5) potential for a negative impact on the provider-patient relationship; and (6) uncertainty regarding what constitutes equipoise, given differences in provider knowledge and preferences. Despite substantive concerns, barriers were generally felt to be solvable. Implementation should include provider education, careful attention to workflow for all arms of the study, inclusion of the entire team, and adequate oversight. Limitations The study design is qualitative with limited implications for causal inference. Participants are from the VA and may not be representative of other clinicians. Conclusion VA providers are supportive of the importance and value of pragmatic trials in general and of POC-R in particular. However, providers have significant concerns regarding the burden, ethics, and evidence regarding equipoise. Results are discussed in terms of implementation recommendations.

Practice-based Research Network Research Good Practices (PRGPs): Summary of Recommendations

INTRODUCTION

Practice-based research networks (PBRNs) conduct research in community settings, which poses quality control challenges to the integrity of research, such as study implementation and data collection. A foundation for improving research processes within PBRNs is needed to ensure research integrity.

METHODS

Network directors and coordinators from seven U.S.-based PBRNs worked with a professional team facilitator during semiannual in-person meetings and monthly conference calls to produce content for a compendium of recommended research practices specific to the context of PBRNs. Participants were assigned to contribute content congruent with their expertise. Feedback on the draft document was obtained from attendees at the preconference workshop at the annual PBRN meeting in 2013. A revised document was circulated to additional PBRN peers prior to finalization.

RESULTS

The PBRN Research Good Practices (PRGPs) document is organized into four chapters: (1) Building PBRN Infrastructure; (2) Study Development and Implementation; (3) Data Management, and (4) Dissemination Policies. Each chapter contains an introduction, detailed procedures for each section, and example resources with information links.

CONCLUSION

The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings.

Comparison of underlying factors behind parental refusal or consent for lumbar puncture

BACKGROUND

Although lumbar puncture (LP) is a safe procedure in experienced hands, some parents fear having it performed on their children and refuse consent. The factors associated with this refusal are unclear, and any differences with consenting parents might provide clues as to how to address them. Therefore, we compared the underlying factors between the parents who refuse and those who consent to this procedure, as well as their children's outcomes.

METHODS

A prospective study of the two groups of parents was conducted by a face-to-face structured interview. Parents' demographic factors, knowledge, perceptions, beliefs and attitudes, as well as their children's outcomes, were compared. The odds ratio (OR) with 95% confidence intervals was calculated for significant associations.

RESULTS

Consent was declined by 24 out of 55 families (44%). Alternative options were offered more often to those refusing consent (OR=5.7). Significantly more parents who refused consent also refused bladder catheterization (OR=18), knowing someone with complications following LP (OR=8.7), felt that it was not needed (OR=7.9) or that it induced complications (OR=12.5). A significantly higher proportion of the consenting parents were aware that meningitis might cause convulsions (OR=4.6), deafness or blindness (OR=2.9).

CONCLUSION

The differences in the understanding, perceptions, beliefs and fears between the parents who refused consent and those who agreed, can provide clues to the developing of appropriate strategies when requesting consent for LP.

Why do some parents refuse consent for lumbar puncture on their child? A qualitative study

OBJECTIVE

Qualitative analysis of the attitudes, beliefs, and perceptions of parents who refuse consent for lumbar puncture (LP) on their child.

METHODS

We performed prospective, semistructured, face-to-face interviews with 24 families declining consent for LP in their child (aged between 1 month and 10 years of age), in 2 hospitals, over a 1-year period in the United Arab Emirates. The questionnaire included open-ended questions to allow parents to discuss their beliefs, concerns, and expectations. Content analysis of the transcripts was performed on how parents experienced the issue: their behavior, perceptions, and beliefs, as well as their opinions on what might have made them consent. Identified themes resulting from that analysis were labeled and coded before reducing them into categories and generating a Pareto chart.

RESULTS

Seven (29%) families were unfamiliar with LP indications and 3 had the impression that LP was also therapeutic. The emerged themes were fear of complications by 18 (75%), perception that LP was unnecessary by 5 (21%), and distrust of the motives behind the request for consent. Fear of paralysis and conviction that LP is unnecessary encompassed 80% of the causes for refusal. Eleven families (46%) stated that nothing would have made them consent, and 10 (42%) would agree only if the child looked unwell or deteriorated. CONCLUSIONS A better understanding of parents' perceptions, beliefs, and fears will help develop appropriate solutions to their refusal of LP consent.

Qualitative research ethics: enhancing evidence-based practice in physical therapy

BACKGROUND

Increasing challenges to health care systems and the prominence of patient-centered care and evidence-based practice have fostered the application of qualitative approaches in health care settings, prompting discussions of associated ethical issues in a range of disciplines.

OBJECTIVES

The purposes of this work were to identify and describe the application and value of qualitative health research for physical therapy and to identify ethical considerations in a qualitative research study.

DESIGN

This was a qualitative interview study with telephone follow-ups.

METHODS

Forty-six participants were interviewed about their early experiences with rheumatoid arthritis. They also were asked what motivated them to volunteer for the study. To inform the discussion of ethics in qualitative health research, this study drew on the in-depth interviews, took a descriptive approach to the data, and applied the traditional ethical principles of autonomy, justice, and beneficence to the study process.

RESULTS

Ethical issues emerged in this qualitative health research study that were both similar to and different from those that exist in a positivist paradigm (eg, clinical research). With flexibility and latitude, the traditional principle approach can be applied usefully to qualitative health research.

CONCLUSIONS

These findings build on previous research and discussion in physical therapy and other disciplines that urge a flexible approach to qualitative research ethics and recognize that ethics are embedded in an unfolding research process involving the role of the subjective researcher and an active participant. We suggest reflexivity as a way to recognize ethical moments throughout qualitative research and to help build methodological and ethical rigor in research relevant to physical therapist practice.

Do family doctors have an obligation to facilitate research?

In the third of a series of articles examining ethical issues in primary care research, we argue that family doctors, when considering what they ought to do in relation to research, have a positive obligation to participate in research and that one means of discharging this obligation is to collaborate in research studies by aiding recruitment. We offer three arguments in support of this obligation-arguments from fairness, reason and utility. We then go on to specify a series of conditions on this obligation which take into account that doctors have many other obligations. These are the conditions of financial remuneration, reciprocity and ability.

Offering payments, reimbursement and incentives to patients and family doctors to encourage participation in research

Sometimes researchers fail to meet their recruitment targets, and sometimes it is predicted that recruitment may prove difficult but it is not obvious what ethical latitude researchers have to boost participation by, for instance, paying participants to take part or by paying family doctors to recruit patients to participate. In this paper, we distinguish between payment, reimbursement and inducement. We look first at the ethics of paying research participants. We conclude that payment raises all kinds of ethical difficulties, but that reimbursement-whilst not completely unproblematic-is an ethical requirement. We then look at whether some inducement to participate is acceptable and conclude that it is. We continue by asking whether the same arguments can be applied to encouraging family doctors to recruit patients. We conclude that it is right for family doctors to be reimbursed for the costs of recruiting research participants and also argue that there are fewer problems with paying family doctors to recruit patients than there are with paying research participants. Given, however, that there is a fine line between reimbursement and payment, given the potential for conflicts of interests to arise, and given that even suspicion of such a conflict might undermine trust in doctors, systems of both payment and reimbursement need to be transparent.