Linguistic Strategies for Improving Informed Consent in Clinical Trials Among Low Health Literacy Patients

Informed proxy consent for ancient DNA research

Embracing the underlying principles and processes of informed proxy consent or relational autonomy consent in human ancient DNA research can transform research.

Reducing Health Disparities Among African American and Black Caribbean Patients by Improving the Communication Practices of Clinical Research Coordinators

This manuscript focuses on the communication factors that affect the willingness of African Americans and Black Caribbean patients to participate in clinical trials and research studies. Low rates of research participation by members of communities of color have long been linked to health disparities. While there are many factors that contribute to low rates of accrual of African American and Black patients to clinical trials, a lack of attention to communication factors that enhance or inhibit the recruitment process is central to the problem. In this study, we describe results from the analysis of six focus groups (N = 31) consisting of African American (k = 3) and Black Caribbean (k = 3) participants. Our analyses focus on verbal and nonverbal communication behaviors and how they affect participants' willingness to participate in clinical trials. Specifically, when clinical research coordinators (CRCs) had a professional appearance, made the effort to explain a study in detail, made eye contact, took the time to listen and answer questions patiently, and gave the sense that the CRC was being truthful and transparent, patients felt respected and valued. Additionally, participants emphasized the importance of the process of developing and maintaining a trusting relationship between study participants and CRCs. The results of this study will be used to develop a clinical trial communication training program designed to enhance the communication skills of clinical research coordinators who discuss research participation with African American and Caribbean Black patients.

Securing direct stakeholder feedback to inform clinical research in serious mental illness: Results of a patient and family perspectives survey

Mental illness research routinely includes unfamiliar or potentially frightening procedures like lumbar puncture (LP), contributing to low enrollment and retention. Previous studies related to LP acceptance have focused on older individuals, and little information on participant preferences for educational materials is available. We developed an online survey assessing existing knowledge, comfort and concerns, and preferences for educational materials in the context of our clinical study on schizophrenia spectrum conditions (SSCs). We found that participants were generally knowledgeable and interested in engaging with clinical SSC research. Frequency of engagement with research publications differed significantly by participant groups and age. Comfort levels were consistently highest for study procedures other than LP, though surprisingly the average number of informational needs per procedure was not significantly different for LP compared to other procedures. Preferences for format and source of educational materials varied across participant groups and age. Our results suggest that younger individuals with an SSC diagnosis are likely to have limited exposure to information, and proactively providing accessible and accurate educational materials may improve positive perceptions of LP. Providing content in a range of formats and sources will ensure that participants and their support networks have access to their preferred resources.

Beyond translations, perspectives for researchers to consider to enhance comprehension during consent processes for health research in sub-saharan Africa: a scoping review

BACKGROUND

Literature on issues relating to comprehension during the process of obtaining informed consent (IC) has largely focused on the challenges potential participants can face in understanding the IC documents, and the strategies used to enhance comprehension of those documents. In this review, we set out to describe the factors that have an impact on comprehension and the strategies used to enhance the IC process in sub-Saharan African countries.

METHODS

From November 2021 to January 2022, we conducted a literature search using a PRISMA tool. We searched electronic databases (PubMed, EMBASE, EBSCOHOST) to identify relevant peer reviewed studies. We then reviewed the references of these articles to find additional literature that might have been missed through the initial search. We were particularly interested in full text articles in English that focused on the IC process in SSA published between 2006 and 2020. We included systematic reviews, and studies from Western and Asian countries that included data about SSA. We excluded articles that focused on medical interventions and studies that did not require IC.

RESULTS

Out of the 50 studies included most were multi-country (n = 13) followed by single country studies in South Africa (n = 12); Kenya, Tanzania, Uganda (n = 5) each; Gambia, Ghana and Nigeria (n = 2)each ; and one each for Botswana, Malawi, Mali, Mozambique. We identified three areas of focus: (1) socio-cultural factors affecting IC; (2) gaps in the ethical and legal frameworks guiding the IC process; and (3) strategies used to improve participants' understanding of IC.

CONCLUSION

Our review showed wide recognition that the process of achieving IC in SSA is inherently challenging, and there are limitations in the strategies aimed at improving comprehension in IC. We suggest that there is a need for greater flexibility and negotiation with communities to ensure that the approach to IC is suited to the diverse socio-cultural contexts. We propose moving beyond the literal translations and technical language to understanding IC comprehension from the participants' perspectives and the researchers' views, while examining contextual factors that impact the IC process.

Patient communication and experiences in cancer clinical drug trials: a mixed-method study at a specialist clinical trials unit

BACKGROUND

As cancer therapies increase in their complexity, effective communication among patients, physicians, and research staff is critical for optimal clinical trial management. Currently, we understand little about on-trial communication practices and patient trial experiences over time. This mixed-method study explored patient experiences of participating in a clinical drug trial at different time points, focussing on patient communication with trial staff.

METHODS

Patients enrolled in clinical drug trials conducted at the Parkville Cancer Clinical Trials Unit were invited to complete a tailored online survey and/or a qualitative interview. Patients were recruited to three cohorts based on time since the first trial treatment: new (≥ 1 to ≤ 13 weeks), mid- (≥ 14 to ≤ 26 weeks), and long-term (≥ 52 weeks) trial patients. Descriptive statistics were calculated for survey responses. Interview data were analysed thematically with a team-based approach. Survey and interview data were integrated at the intepretation stage.

RESULTS

From May to June 2021, 210 patients completed a survey (response rate 64%, 60% male), 20 completed interviews (60% male), and 18 completed both. More long-term trial patients (46%) participated than new (29%) and mid-trial patients (26%). Survey data showed high (> 90%) patient satisfaction with the provision of trial information and communication with trial staff across trial stages, and many reported trial experiences as above and beyond standard care. Interview data indicated that written trial information could be overwhelming, and verbal communication with the staff and physicians was highly valued, especially for enrolment and side effect management among long-term patients. Patients described the key points along the clinical trial trajectory that merit close attention: clear and well-communicated randomisation practices, reliable pathways for side effect reporting and prompt response from the trial staff, and end-of-trial transition management to avoid a sense of abandonment.

CONCLUSION

Patients reported high overall satisfaction with trial management but outlined key pinch points requiring improved communication practices. Establishing a range of effective communication practices among trial staff and physicians with patients in cancer clinical trials may have a wide range of positive effects on patient accrual, retention, and satisfaction.

Physicians' use of plain language during discussions of prostate cancer clinical trials with patients

OBJECTIVE

This study described physicians' use of plain language during patient-physician cancer clinical trial discussions.

METHODS

Video-recorded clinical interactions and accompanying transcripts were taken from a larger study of communication and clinical trials (PACCT). Interactions (n = 25) were selected if they included invitations to participate in a clinical trial. We used descriptive, qualitative discourse analysis, a method that identifies language patterns at or above the sentence level. We first excerpted discussions of clinical trials, then identified instances of plain language within those discussions. Finally, we inductively coded those instances to describe physicians' plain language practices.

RESULTS

The analysis identified four plain language practices. Lexical simplification replaced medical terminology with simpler words. Patient-centered definition named, categorized, and explained complex medical terminology. Metaphor explained medical terminology by comparing it with known concepts. Finally, experience-focused description replaced medical terminology with descriptions of patients' potential physical experiences.

CONCLUSION

These plain language practices hold promise as part of effective information exchange in discussions of cancer clinical trials. Testing is needed to identify patient preferences and the extent to which these practices address patient health literacy needs.

PRACTICE IMPLICATIONS

Pending further testing, these plain language practices may be integrated into physician clinical trial and other communication training.

Development and Evaluation of the Clinical Trial HEalth Knowledge and Beliefs Scale (CHEKS)

Patient health literacy is vital to clinical trial engagement. Knowledge and beliefs about clinical trials may contribute to patient literacy of clinical trials, influencing engagement, enrollment and retention. We developed and assessed a survey that measures clinical trial health knowledge and beliefs, known as the Clinical trial HEalth Knowledge and belief Scale (CHEKS). The 31 survey items in CHEKS represent knowledge and beliefs about clinical trial research (n = 409) in 2017. We examined item-scale correlations for the 31 items, eliminated items with item-scale correlations less than 0.30, and then estimated internal consistency reliability for the remaining 25 items. We used the comparative fit index (CFI) and the root mean squared error of approximation (RMSEA) to evaluate model fit. The average age of the sample was 34 (SD = 15.7) and 48% female. We identified 6 of the 31 items that had item-scale correlations (corrected for overlap) lower than 0.30. Coefficient alpha for the remaining 25 items was 0.93 A one-factor categorical confirmatory factor analytic model with 16 correlated errors was not statistically significant (chi-square = 10011.994, df = 300, p < 0.001) but fit the data well (CFI = 0.95 and RMSEA = 0.07). CHEKS can assess clinical trial knowledge and beliefs.

Ethical Considerations during the Informed Consent Process for Acute Ischemic Stroke in International Clinical Trials

We sought to investigate the experiences of researchers in existing active-control trials in acute ischemic stroke comparing investigational therapy to tissue plasminogen activator (tPA) in order to identify the approaches and challenges in obtaining informed consent. Out of 401 articles evaluated, 14 trials met inclusion criteria. Trial representatives were contacted to complete a survey concerning the consent process. None of the 14 trials published materials related to the informed consent process. Trials with 75% to 100% of patients directly consented had shorter door-to-treatment (DTT) times than trials that directly consented less than 50% of patients. Trials that had translators available (for recruiting participants who were not native speakers in the local language) and translated consent documents had longer DTT times. The study findings suggest that differences in the standards of informed consent internationally may allow more patients with moderate strokes to provide direct consent without delaying DTT time. Future trials should emphasize transparency to the public and scientific community in the informed consent process.

A Study of a Culturally and Contextually Situated Multimedia Approach to Recruit a Hard-to-Reach Spanish-Speaking Population for a Randomized Control Trial (RCT)

Study designs involving randomization can be difficult to communicate to participants, especially those with low literacy. The literature on strategies to explain research concepts is limited, especially for non-English speakers. We measured the effectiveness of a culturally and contextually situated multimedia approach to recruit a cohort of 60 female Mexican immigrants (FMI) to a randomized control trial (RCT) to reduce social isolation and depression. This strategy was designed to explain the concept of randomization, explain what participating in the research study entailed, and ensure informed consent. Potential participants viewed a presentation explaining the study and a video including animation with voice-over explaining the concept of randomization. We administered a pre/post survey. Respondents (N = 59) reported an increase in their understanding of randomization, intention to enroll, and attitude towards participating in research. We conclude that a culturally and contextually situated multimedia approach is an effective model when recruiting underrepresented populations with low literacy for RCTs.

A Web-Based Intervention to Increase Smokers' Intentions to Participate in a Cessation Study Offered at the Point of Lung Screening: Factorial Randomized Trial

BACKGROUND

Screen ASSIST is a cessation trial offered to current smokers at the point of lung cancer screening. Because of the unique position of promoting a prevention behavior (smoking cessation) within the context of a detection behavior (lung cancer screening), this study employed prospect theory to design and formatively evaluate a targeted recruitment video prior to trial launch.

OBJECTIVE

The aim of this study was to identify which message frames were most effective at promoting intent to participate in a smoking cessation study.

METHODS

Participants were recruited from a proprietary opt-in online panel company and randomized to a 2 (benefits of quitting vs risks of continuing to smoke at the time of lung screening; BvR) × 2 (gains of participating vs losses of not participating in a cessation study; GvL) message design experiment (N=314). The primary outcome was self-assessed intent to participate in a smoking cessation study. Message effectiveness and lung cancer risk perception measures were also collected. Analysis of variance examined the main effect of the 2 message factors and a least absolute shrinkage and selection operator (LASSO) approach identified predictors of intent to participate in a multivariable model. A mediation analysis was conducted to determine the direct and indirect effects of message factors on intent to participate in a cessation study.

RESULTS

A total of 296 participants completed the intervention. There were no significant differences in intent to participate in a smoking cessation study between message frames (P=.12 and P=.61). In the multivariable model, quit importance (P<.001), perceived message relevance (P<.001), and affective risk response (ie, worry about developing lung cancer; P<.001) were significant predictors of intent to participate. The benefits of quitting frame significantly increased affective risk response (Meanbenefits 2.60 vs Meanrisk 2.40; P=.03), which mediated the relationship between message frame and intent to participate (b=0.24; 95% CI 0.01-0.47; P=.03).

CONCLUSIONS

This study provides theoretical and practical guidance on how to design and evaluate proactive recruitment messages for a cessation trial. Based on our findings, we conclude that heavy smokers are more responsive to recruitment messages that frame the benefits of quitting as it increased affective risk response, which predicted greater intention to participate in a smoking cessation study.

Health Literacy in Adult Oncology: An Integrative Review

PROBLEM IDENTIFICATION

Patients with cancer face high expectations for performing health literacy activities necessary for self-management and decision making, but only 12% of adults in the United States are proficient in health literacy. This review explores evidence regarding what is known about functional, interactive, and critical health literacy in adult oncology populations.

LITERATURE SEARCH

The review was conducted by searching extensively in the CINAHL® Plus database.

DATA EVALUATION

Of 614 articles retrieved from the literature search, 22 were included in the final sample. Most were cross-sectional, descriptive, correlational studies.

SYNTHESIS

Health literacy research in the United States focuses primarily on functional health literacy, but studies that include interactive and/or critical health literacy indicate their applicability in adult oncology populations.

IMPLICATIONS FOR RESEARCH

Additional research is needed to clarify the role of health literacy in cancer care to develop effective interventions that facilitate self-management and decision making.

Partnering With Patients to Bridge Gaps in Consent for Acute Care Research

Clinical trials for acute conditions such as myocardial infarction and stroke pose challenges related to informed consent due to time limitations, stress, and severe illness. Consent processes should be sensitive to the context in which trials are conducted and to needs of patients and surrogate decision-makers. This manuscript describes a collaborative effort between ethicists, researchers, patients, and surrogates to develop patient-driven, patient-centered approaches to consent for clinical trials in acute myocardial infarction and stroke.Our group identified important ways in which existing consent processes and forms for clinical trials fail to meet patients' and surrogates' needs in the acute context. We collaborated to create model forms and consent processes that are substantially shorter and, hopefully, better-matched to patients' and surrogates' needs and expectations from the perspective of content, structure, and tone. These changes, however, challenge some common conventions regarding consent.

Perceptions of Clinical Trial Participation Among Women of Varying Health Literacy Levels

PURPOSE

To understand the perceptions of risk, benefit, and the informed consent process after enrolling in and completing a phase 2 clinical trial using intraoperative radiation therapy (IORT) for early-stage breast cancer, and to determine how perceptions varied based on women's health literacy levels.

PARTICIPANTS & SETTING

20 participants who had already completed a phase 2 IORT clinical trial for early-stage breast cancer at an academic medical center.

METHODOLOGIC APPROACH

A qualitative descriptive study was conducted using structured interviews consisting of questions aimed to elicit responses from participants regarding experiences of informed consent and the research process. A validated brief health literacy questionnaire was used to determine health literacy levels of participants. The authors analyzed themes using inductive thematic analysis.

FINDINGS

Women with lower levels of health literacy reported feeling confident enough in the provider to make the decision to enroll in the clinical trial during the initial consultation, and, in general, women reported relying heavily on provider recommendation for enrolling in the clinical trial.

IMPLICATIONS FOR NURSING

Tailored approaches for patients with limited health literacy are needed during the clinical trial consent process. Additional longitudinal research with a larger sample size can extend study results and provide insight into the most effective way to modify the informed consent process for patients with limited health literacy.

Communication strategies for designing Facebook advertising campaigns to recruit rural participants to develop healthcare delivery interventions

Background:

Little is known about designing research recruitment campaigns that connect with underserved, geographically isolated rural populations. A theoretically informed process is needed to assist research teams and practitioners in their evaluation of Facebook’s feasibility as a recruitment tool and development of online materials for recruiting rural adults into healthcare delivery intervention development studies.

Methods:

We drew from research and theory in communication and incorporated process analysis techniques to develop replicable procedures for designing and evaluating Facebook campaigns for rural recruitment. We describe our process and illustrate using two case studies.

Results:

Campaigns received approximately 1000 link clicks from the target rural demographic and successfully enrolled participants using Facebook as a primary method of recruitment. The rural tobacco intervention development study received a total of 477 link clicks, cost only $155.80, and enrolled three (23%) of its 13 participants from Facebook. The rural mental health intervention development study received a total of 518 link clicks, cost only $233.28, and enrolled 178 participants.

Conclusions:

Our process yielded two successful recruitment campaigns. Facebook was an affordable and efficacious strategy for enrolling adults in behavioral research studies on tobacco and mental health. Future work should apply these theoretical techniques to additional study topics and evaluate specific message features associated with recruitment.

Factors associated with refusal or acceptance of older patients (≥ 65 years) to provide consent to participate in clinical research in cardiology: a qualitative study

BACKGROUND

Clinical research is an essential step in the successful translation of knowledge from basic research into concrete clinical applications, yet many people are reluctant to provide consent when actually approached to actively participate in clinical trials.

AIMS

We investigated the factors that influence older patient's (≥ 65 years) decisions to accept or refuse to participate in a prospective randomized clinical trial in secondary prevention after acute coronary syndrome.

METHODS

Qualitative approach based on individual semi-structured interviews with patients who were approached for consent to participate in a currently ongoing clinical trial was adopted. Patients were interviewed after the consent process (8 accepted; 8 refused the trial). Interviews were analysed using grounded theory methodology.

RESULTS

Sixteen patients aged ≥ 65 years participated. The main concept to emerge from these interviews is that the actual trial itself does not appear to be the primary determinant in the decision to participate in clinical research. Rather, patients' decisions to participate (or not) in clinical research appear to be primarily determined by their capacity to deal with the current health event that has disrupted their life, and by their available mental and physical resources.

DISCUSSION AND CONCLUSION

Older patients display varying levels of engagement in their own health, ranging from low engagement with high trust in the medical profession, to high engagement mirrored by distrust of the medical profession. Structural conditions, such as personal benefit from trial participation, or logistic barriers to participation, seem to affect both accepters and refusers in the same manner.

Animations about Clinical Trial Participation for Cancer Patients and Survivors

Communicating about clinical trials and medical research is challenging. An appropriate communication is essential to reduce some of the barriers associated with poor patients' enrollment in clinical trials and with patients' uninformed consent or uninformed refusal. An experiment was conducted to assess the effects of educational animations compared to brochures with and without visuals, and with the materials currently used by the NIH. These materials focused on explaining placebos, randomization, the steps necessary to enroll in a clinical trial, and how and by who patients' protection is ensured. A total of 1194 cancer patients and survivors completed this 4 by 4 experiment through a Qualtrics panel. The findings showed that animations improved participants knowledge about and attitudes toward clinical trials and were more effective than brochures presenting information from the NIH, especially for those individuals with low motivation and low ability to comprehend health-related information. Several evidence-based theoretical explanations of the functioning of animations are provided.

The Influence of Patient Identification and Narrative Transportation on Intentions to Participate in Cancer Research

Cancer decision-making interventions commonly utilize narratives as a persuasive strategy to increase identification with the message source, promote involvement with the topic, and elicit greater willingness to adopt recommended behaviors. However, there is little empirical research examining the mechanisms underlying the effectiveness of this strategy in the context of cancer research participation. Data for the current manuscript were collected as part of a larger study conducted with cancer patients (N = 413) from the USA, UK, and the Republic of Ireland. Participants viewed and evaluated video-recorded vignettes, illustrating different strategies for discussing clinical trials participation with family members. Results showed nationality was a significant predictor of identification with the main character (i.e., patient) in the vignette. Unexpectedly, these cross-national differences in identification disappeared when patients currently undergoing treatment had higher perceived susceptibility of their cancer. Identification with the main character in the vignettes was a significant predictor of intentions to participate in cancer research, but only when the mediating role of narrative transportation was considered. The findings demonstrate the importance of considering how individual and social identities influence identification with characters in cancer narratives and yield practical guidance for developing arts-based interventions to increase cancer research participation.

Factors associated with clinical trials that fail and opportunities for improving the likelihood of success: A review

Clinical trials are time consuming, expensive, and often burdensome on patients. Clinical trials can fail for many reasons. This survey reviews many of these reasons and offers insights on opportunities for improving the likelihood of creating and executing successful clinical trials. Literature from the past 30 years was reviewed for relevant data. Common patterns in reported successful trials are identified, including factors regarding the study site, study coordinator/investigator, and the effects on participating patients. Specific instances where artificial intelligence can help improve clinical trials are identified.

A content analysis of Clinical and Translational Science Award (CTSA) strategies for communicating about clinical research participation online

Introduction

There is a dearth of literature providing guidance on how to effectively communicate about clinical research (CR).

Methods

Using the transactional model of communication, a content analysis of the investigator (n=62) and participant (n=18) Web sites of institutions funded through the National Institutes of Health Clinical and Translational Science Award (CTSA) was conducted to identify their strategies (e.g., messages) for communicating about CR participation.

Results

CTSAs targeted investigators with CR participation content across the main Web sites, although most CTSAs (n=55; 88.7%) also included CR participation content for participants. In total, 18 CTSAs (29%) hosted participant Web sites. Participant sites included 13 message types about CR participation (e.g., registry enrollment) and 5 additional channels (e.g., email, phone number) to communicate about CR. However, many CTSA participant Web sites excluded information explaining the CR process and offered CR content exclusively in English.

Conclusion

CTSAs should identify their target audience and design strategies (e.g., messages, channels) accordingly.

A Research Agenda for Communication Scholars in the Precision Medicine Era

The 2015 announcement of the Precision Medicine Initiative (PMI) galvanized and energized efforts to reconsider medical practice through tailoring of prevention and treatment recommendations based on genetics, environment, and lifestyle. Numerous disciplines contributed white papers identifying challenges associated with PMI and calling for discipline-specific research that might provide solutions to such challenges. Throughout these white papers, the prominence of communication in achieving the PMI's goals is obviously apparent. In this article, we highlight opportunities for communication scholars' contributions to the PMI based on challenges identified in white papers from other disciplines and work already conducted by research teams in the field of communication.