Perspective: The case for research justice: inclusion of patients with limited English proficiency in clinical research

Strategies to promote language inclusion at 17 CTSA hubs

The prioritization of English language in clinical research is a barrier to translational science. We explored promising practices to advance the inclusion of people who speak languages other than English in research conducted within and supported by NIH Clinical Translational Science Award (CTSA) hubs. Key informant interviews were conducted with representatives (n = 24) from CTSA hubs (n = 17). Purposive sampling was used to identify CTSA hubs focused on language inclusion. Hubs electing to participate were interviewed via Zoom. Thematic analysis was performed to analyze interview transcripts. We report on strategies employed by hubs to advance linguistic inclusion and influence institutional change that were identified. Strategies ranged from translations, development of culturally relevant materials and consultations to policies and procedural changes and workforce initiatives. An existing framework was adapted to conceptualize hub strategies. Language justice is paramount to bringing more effective treatments to all people more quickly. Inclusion will require institutional transformation and CTSA hubs are well positioned to catalyze change.

Exclusion of Families Who Speak Languages Other than English from Federally Funded Pediatric Trials

OBJECTIVE

To determine whether individuals in the United States who speak languages other than English (LOE) are excluded from federally funded pediatric clinical trials and whether such trials adhere to the National Institutes of Health policy regarding inclusion of members of minority groups.

STUDY DESIGN

Using ClinicalTrials.gov, we identified all completed, federally funded, US-based trials inclusive of children ≤17 and focused on one of 4 common chronic childhood conditions (asthma, mental health, obesity, and dental caries) as of June 18, 2019. We reviewed ClinicalTrials.gov online content, as well as published manuscripts linked to ClinicalTrials.gov entries, to abstract information about language-related exclusion criteria. Trials were deemed to exclude LOE participants/caregivers if explicit statements regarding exclusion were identified in the study protocol or published manuscript.

RESULTS

Of total, 189 trials met inclusion criteria. Two-thirds (67%) did not address multilingual enrollment. Of the 62 trials that did, 82% excluded LOE individuals. No trials addressed the enrollment of non-English, non-Spanish-speaking individuals. In 93 trials with nonmissing data on ethnicity, Latino individuals comprised 31% of participants in trials that included LOE individuals and 14% of participants in trials that excluded LOE individuals.

CONCLUSIONS

Federally funded pediatric trials in the United States do not adequately address multilingual enrollment, a seeming violation of federal and contractual requirements for accommodation of language barriers by entities receiving federal funding.

Transcending Language Barriers in Obstetrics and Gynecology: A Critical Dimension for Health Equity

There is growing evidence that language discordance between patients and their health care teams negatively affects quality of care, experience of care, and health outcomes, yet there is limited guidance on best practices for advancing equitable care for patients who have language barriers within obstetrics and gynecology. In this commentary, we present two cases of language-discordant care and a framework for addressing language as a critical lens for health inequities in obstetrics and gynecology, which includes a variety of clinical settings such as labor and delivery, perioperative care, outpatient clinics, and inpatient services, as well as sensitivity around reproductive health topics. The proposed framework explores drivers of language-related inequities at the clinician, health system, and societal level. We end with actionable recommendations for enhancing equitable care for patients experiencing language barriers. Because language and communication barriers undergird other structural drivers of inequities in reproductive health outcomes, we urge obstetrician-gynecologists to prioritize improving care for patients experiencing language barriers.

Consent document translation expense hinders inclusive clinical trial enrolment

Patients from historically under-represented racial and ethnic groups are enrolled in cancer clinical trials at disproportionately low rates in the USA1-3. As these patients often have limited English proficiency4-7, we hypothesized that one barrier to their inclusion is the cost to investigators of translating consent documents. To test this hypothesis, we evaluated more than 12,000 consent events at a large cancer centre and assessed whether patients requiring translated consent documents would sign consent documents less frequently in studies lacking industry sponsorship (for which the principal investigator pays the translation costs) than for industry-sponsored studies (for which the translation costs are covered by the sponsor). Here we show that the proportion of consent events for patients with limited English proficiency in studies not sponsored by industry was approximately half of that seen in industry-sponsored studies. We also show that among those signing consent documents, the proportion of consent documents translated into the patient's primary language in studies without industry sponsorship was approximately half of that seen in industry-sponsored studies. The results suggest that the cost of consent document translation in trials not sponsored by industry could be a potentially modifiable barrier to the inclusion of patients with limited English proficiency.

IRBs and the Protection-Inclusion Dilemma: Finding a Balance

Institutional review boards, tasked with facilitating ethical research, are often pulled in competing directions. In what we call the protection-inclusion dilemma, we acknowledge the tensions IRBs face in aiming to both protect potential research participants from harm and include under-represented populations in research. In this manuscript, we examine the history of protectionism that has dominated research ethics oversight in the United States, as well as two responses to such protectionism: inclusion initiatives and critiques of the term vulnerability. We look at what we know about IRB decision-making in relation to protecting and including "vulnerable" groups in research and examine the lack of regulatory guidance related to this dilemma, which encourages protection over inclusion within IRB practice. Finally, we offer recommendations related to how IRBs might strike a better balance between inclusion and protection in research ethics oversight.

Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research

AIMS

Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S.

METHODS

A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language.

RESULTS

A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable.

CONCLUSIONS

As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.

Inclusion of Non-English-Speaking Participants in Pediatric Health Research: A Review

Importance

The inclusion of non-English-speaking (NES) participants in pediatric research is an essential step to improving health equity for these populations. Although some studies have shown lack of progress in NES research participation in the past decade, few have examined NES inclusivity in pediatric research or details about the practices that researchers have used to communicate with NES participants.

Objective

To assess how frequently NES families were included in pediatric research, how rates of inclusion changed over time, what languages were included, and methodological details about oral and written communication with NES participants.

Evidence Review

In this review, all original investigation articles published in JAMA Pediatrics, Pediatrics, and The Journal of Pediatrics between January 2012 and November 2021 were screened. Eligible articles, which included those based in the US and with human participants, were reviewed to determine whether they included or excluded NES participants or whether or not there was specific mention of language. A second-round review was conducted on the subset of articles that included NES participants to determine methodological details (eg, languages included, type of study, region where the study was located, and oral and written communication practices with NES participants).

Findings

Of the 8142 articles screened, 5008 (62%) met inclusion criteria; of these, 469 (9%) included NES participants. The most common language was Spanish (350 [75%]); 145 articles (31%) reported non-English or other language without specification. A total of 230 articles (49%) reported the number of NES participants, and 61 (13%) specified the methods used to determine whether participants preferred a language other than English. In all, 101 (22%) and 136 (29%) articles specified how oral and written communication occurred with NES participants, respectively.

Conclusions and Relevance

This review of 3 pediatric journals provides preliminary evidence suggesting exclusion of NES communities from pediatric research from 2012 to 2021 and highlights an opportunity to provide more methodological detail about communication with NES participants. Best practices for improving inclusivity of NES participants are needed to guide researchers toward improved methods and more relevant results.

Diversity, Equity, and Inclusion in Clinical Trials

Minority groups are vastly underrepresented in clinical trial participants and leadership. Because these studies provide innovative and revolutionary treatment options to patients with cancer and have the potential to extend survival, it is imperative that public and private stakeholders, as well as hospital and clinical trial leadership, prioritize equity and inclusion of diverse populations in clinical trial development and recruitment strategies. Achieving equity in clinical trials could be an important step in reducing the overall cancer burden and mortality disparities in vulnerable populations.

Development and psychometric evaluation of the Spanish version of the lung cancer screening health belief scale

OBJECTIVE

The aim of this study was to describe the translation and psychometric testing of the Lung Cancer Screening Health Belief Scale (LCSHBS) into Spanish.

METHODS

The English version of the LCSHBS was professionally translated in accordance with best practices in the translation of patient-reported outcome tools. The independent certified professional translator completed a forward translation of the LCSHBS from English to Spanish, followed by a review of the translated questionnaire by a certified Memorial Sloan Kettering Cancer Center Spanish-English bicultural expert, who reviewed the scale for accuracy.

RESULTS

Initial testing of the scales is valid and reliable, and supports the Spanish version of the LCSHBS (LCSHBS-S). Internal consistency reliability of the scales was supported with Cronbach's ranging from 0.81 to 0.96. Construct validity was established with confirmatory factor analysis and testing for differences between individuals who have and have not screened in theoretically proposed directions. These newly translated scales can help investigators expand this research into the large Spanish-speaking lung screening-eligible population as they develop and test critical behavioural interventions to increase lung cancer screening in the at-risk population.

CONCLUSIONS

Development of effective interventions to enhance shared decision-making about lung cancer screening between patients and providers must first identify factors influencing the individual's screening participation. Future efforts facilitating patient-provider conversations are better informed by understanding the perspective of the individual making the decision.

Impact of ethnicity on parental health outcomes and experiences after paediatric intensive care unit discharge: a mixed-methods systematic review

The impact of ethnicity on parental health outcome after paediatric intensive care unit (PICU) discharge remains unclear. Thirteen medical and healthcare databases, unpublished studies and grey literature were searched up to November 5, 2021. We performed a mixed-method systematic review to understand the impact of ethnicity on parental outcomes after PICU discharge, including eight quantitative and eight qualitative studies. Among 1529 parents included, 1064 (72%) were White. Higher prevalence of post-traumatic stress disorder was seen in Black parents (17% White vs 36% Black, p = .03). Latino ethnicity was found to have protective effect against anxiety as compared to White parents (coefficient - 4.27, p < .001). A total of 91 findings were aggregated into 14 categories, and the five synthesized themes from the eight qualitative studies were long-term psychological impact after PICU, use of coping strategies, challenges of re-integration, changes in relationships and the utilization of formal support services and resources. Mixed-method synthesis found that parents of ethnic minority group were underrepresented (18%) and had higher attrition rates in a longitudinal study as compared to White parents following childhood critical illness.   Conclusion: There are significant gaps in evidence related to the impact of ethnicity on long-term parental health outcomes after PICU discharge. Ethnic diversity and inclusiveness in long-term PICU research may aid understanding of the parental experiences and outcomes to close the gap in health disparity.

Linguistic validation of the Spanish version of the Anal Cancer High-Grade squamous intraepithelial lesions outcomes Research Health-Related Symptom Index (A-HRSI): AMC-A04

OBJECTIVES

The Anal Cancer High-grade squamous intraepithelial lesions (HSIL) Outcomes Research (ANCHOR) Health-Related Symptom Index (A-HRSI) is a 25-item measure that assesses physical symptoms and impacts, and psychological symptoms. To promote generalizability and equity in the capture of these concepts in Spanish-speaking participants, we linguistically validated a Spanish version of A-HRSI.

METHODS

Following independent forward translation and reconciliation of A-HRSI from English to Spanish, two rounds of cognitive interviews were completed with ANCHOR participants who had been diagnosed with anal HSIL in the prior nine months and preferred delivery of their healthcare in Spanish. Interviews were coded to highlight any items and concepts that were reported as being difficult for any reason by ≥ 3 participants, with such items revised during a research team panel discussion and tested in a second round of interviews if applicable.

RESULTS

Seventeen participants representing 8 nationalities were enrolled (Round 1 n=10, Round 2 n=7); 7 participants reported not completing high school (41.2%). No difficulties were reported with respect to the theoretical concepts measured by A-HRSI. We made modifications to the Spanish translation of eight items and two response option terms in cases where participants had difficulty understanding a term, experienced problems in discriminating between terms, or preferred the use of an alternative term to represent the concept(s).

CONCLUSION

The Spanish version of A-HRSI is a linguistically valid tool that can be used to assess physical symptoms, impacts, and psychological symptoms related to anal HSIL. Language is a tremendous barrier to enrolling patients to clinical trials. The anal cancer high-grade squamous intraepithelial lesions (HSIL) outcomes research [ANCHOR] trial is a randomized clinical trial that recently established that the treatment of anal HSIL, versus active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV (PLWH). The ANCHOR Health-Related Symptom Index (A-HRSI) is a 25-item patient-reported outcomes measure that was developed to assess physical symptoms, physical impacts, and psychological symptoms related to anal HSIL. As approximately 10% of ANCHOR participants preferred the delivery of their healthcare in Spanish, the purpose of the present study was to linguistically validate a Spanish version of A-HRSI. Based on feedback from interviews with 17 participants from the ANCHOR trial who had been diagnosed with anal HSIL in the prior nine months and preferred delivery of their healthcare in Spanish, we made modifications to the Spanish translation of eight items and two response option terms in cases where participants had difficulty understanding a term, experienced problems in discriminating between terms, or preferred the use of an alternative term to represent the concept(s). The Spanish version of A-HRSI is a linguistically valid tool that can be used to assess physical symptoms, impacts, and psychological symptoms related to anal HSIL as part of clinical trials or routine care.

Breaking through barriers: the need for effective research to promote language-concordant communication as a facilitator of equitable emergency care

Individuals with limited English proficiency (LEP) are at high risk for adverse outcomes in the US health care system. This is particularly true for patients with LEP seeking care in the emergency department (ED). Although professional language interpretation improves the quality of care for these patients, it remains underused. The dynamic, discontinuous nature of an ED visit poses distinct challenges and opportunities for providing equitable, high-quality care for patients with LEP. Evidence-based best practices for identifying patients with LEP and using professional interpretation are well described but inadequately implemented. There are few examples in the literature of rigorous interventions to improve quality of care and outcomes for patients with LEP. There is an urgent need for high-quality research to improve communication with patients with LEP along the continuum of emergency care in order to achieve equity in outcomes.

Evaluating the frequency of English language requirements in clinical trial eligibility criteria: A systematic analysis using ClinicalTrials.gov

BACKGROUND

A number of prior studies have demonstrated that research participants with limited English proficiency in the United States are routinely excluded from clinical trial participation. Systematic exclusion through study eligibility criteria that require trial participants to be able to speak, read, and/or understand English affects access to clinical trials and scientific generalizability. We sought to establish the frequency with which English language proficiency is required and, conversely, when non-English languages are affirmatively accommodated in US interventional clinical trials for adult populations.

METHODS AND FINDINGS

We used the advanced search function on ClinicalTrials.gov specifying interventional studies for adults with at least 1 site in the US. In addition, we used these search criteria to find studies with an available posted protocol. A computer program was written to search for evidence of English or Spanish language requirements, or the posted protocol, when available, was manually read for these language requirements. Of the 14,367 clinical trials registered on ClinicalTrials.gov between 1 January 2019 and 1 December 2020 that met baseline search criteria, 18.98% (95% CI 18.34%-19.62%; n = 2,727) required the ability to read, speak, and/or understand English, and 2.71% (95% CI 2.45%-2.98%; n = 390) specifically mentioned accommodation of translation to another language. The remaining trials in this analysis and the following sub-analyses did not mention English language requirements or accommodation of languages other than English. Of 2,585 federally funded clinical trials, 28.86% (95% CI 27.11%-30.61%; n = 746) required English language proficiency and 4.68% (95% CI 3.87%-5.50%; n = 121) specified accommodation of other languages; of the 5,286 industry-funded trials, 5.30% (95% CI 4.69%-5.90%; n = 280) required English and 0.49% (95% CI 0.30%-0.69%; n = 26) accommodated other languages. Trials related to infectious disease were less likely to specify an English requirement than all registered trials (10.07% versus 18.98%; relative risk [RR] = 0.53; 95% CI 0.44-0.64; p < 0.001). Trials related to COVID-19 were also less likely to specify an English requirement than all registered trials (8.18% versus 18.98%; RR = 0.43; 95% CI 0.33-0.56; p < 0.001). Trials with a posted protocol (n = 366) were more likely than all registered clinical trials to specify an English requirement (36.89% versus 18.98%; RR = 1.94, 95% CI 1.69-2.23; p < 0.001). A separate analysis of studies with posted protocols in 4 therapeutic areas (depression, diabetes, breast cancer, and prostate cancer) demonstrated that clinical trials related to depression were the most likely to require English (52.24%; 95% CI 40.28%-64.20%). One limitation of this study is that the computer program only searched for the terms "English" and "Spanish" and may have missed evidence of other language accommodations. Another limitation is that we did not differentiate between requirements to read English, speak English, understand English, and be a native English speaker; we grouped these requirements together in the category of English language requirements.

CONCLUSIONS

A meaningful percentage of US interventional clinical trials for adults exclude individuals who cannot read, speak, and/or understand English, or are not native English speakers. To advance more inclusive and generalizable research, funders, sponsors, institutions, investigators, institutional review boards, and others should prioritize translating study materials and eliminate language requirements unless justified either scientifically or ethically.

Enhancing Recruitment and Retention of Minority Populations for Clinical Research in Pulmonary, Critical Care, and Sleep Medicine: An Official American Thoracic Society Research Statement

Background: Well-designed clinical research needs to obtain information that is applicable to the general population. However, most current studies fail to include substantial cohorts of racial/ethnic minority populations. Such underrepresentation may lead to delayed diagnosis or misdiagnosis of disease, wide application of approved interventions without appropriate knowledge of their usefulness in certain populations, and development of recommendations that are not broadly applicable.Goals: To develop best practices for recruitment and retention of racial/ethnic minorities for clinical research in pulmonary, critical care, and sleep medicine.Methods: The American Thoracic Society convened a workshop in May of 2019. This included an international interprofessional group from academia, industry, the NIH, and the U.S. Food and Drug Administration, with expertise ranging from clinical and biomedical research to community-based participatory research methods and patient advocacy. Workshop participants addressed historical and current mistrust of scientific research, systemic bias, and social and structural barriers to minority participation in clinical research. A literature search of PubMed and Google Scholar was performed to support conclusions. The search was not a systematic review of the literature.Results: Barriers at the individual, interpersonal, institutional, and federal/policy levels were identified as limiting to minority participation in clinical research. Through the use of a multilevel framework, workshop participants proposed evidence-based solutions to the identified barriers.Conclusions: To date, minority participation in clinical research is not representative of the U.S. and global populations. This American Thoracic Society research statement identifies potential evidence-based solutions by applying a multilevel framework that is anchored in community engagement methods and patient advocacy.

IRB Policies for Obtaining Informed Consent from Non-English-Speaking People

United States regulations for the protection of human research subjects prescribe parameters for documentation of valid informed consent, which include the stipulation that the process be in a "language understandable to the subject." While significant energy has been devoted to improving the readability of consent documents, supplemental educational tools, and nuanced measurements of individual decisional capacity, there is little guidance about how to best meet the informational needs of adults with decisional capacity who do not speak English. This article reviews the institutional review board policies from the twenty-one research centers that received the most funding from the National Institutes of Health in 2018 and compares their guidelines for obtaining informed consent from non-English speakers. Inconsistent practices suggest the need for more assertive federal direction on what parameters constitute valid consent for this population. These practices also indicate a reluctance to directly engage the ethical underpinnings of consent policies for non-English speakers.

Tool for the Meaningful Consideration of Language Barriers in Qualitative Health Research

Individuals who experience language barriers are largely excluded as participants from health research, resulting in gaps in knowledge that have implications for the development of equitable policies, tools, and strategies. Drawing on the existing literature and on their collective experience conducting occupational health research in contexts of language barriers, the authors propose a tool to assist qualitative researchers and representatives from funding agencies and ethics review boards with the meaningful consideration of language barriers in research. There remain gaps and debates with respect to the relevant ethical and methodological guidance set forth by funding agencies and institutions and proposed in the scientific literature. This article adds to knowledge in this area by contributing our experiences, observations, and recommendations, including around the issue of conducting research in contexts of more or less linguistic diversity.

Successful Healthcare Provider Strategies to Overcome Psychological Insulin Resistance in Japanese Patients with Type 2 Diabetes

INTRODUCTION

EMOTION was a multinational, noninterventional study surveying current insulin-using adults with type 2 diabetes mellitus (T2D) who were initially reluctant to begin insulin treatment. In this Japanese population subanalysis of EMOTION, we identify the frequency and level of helpfulness of healthcare provider (HCP) actions, and we analyze life events ('actions/events') that assist T2D patients with psychological insulin resistance in the decision to initiate insulin.

METHODS

Participants were selected from Survey Sampling International and their local partners' market research panels in Japan. Quantitative surveys were administered between December 2016 and August 2017 to patients who met the study criteria. Participants were asked whether 45 actions/events occurred, and to rate the level of helpfulness of the actions/events in contributing to their decision to initiate insulin.

RESULTS

Among the 594 eligible participating adults in the EMOTION study, 99 were from Japan. Despite initial reluctance to begin insulin treatment, 80.8% of the Japanese participants immediately commenced insulin. Practical demonstrations by HCPs on how to use insulin were rated by participants as most helpful. Examples of such practical demonstrations, reported as helping moderately or a lot, were 'HCP walked patient through the process of exactly how to take insulin' (82.8%), 'HCP showed an insulin pen' (79.7%), and 'HCP helped patient to see how simple it was to inject insulin' (79.1%).

CONCLUSION

This study identifies actions that HCPs can use to assist Japanese patients in deciding whether to initiate insulin. These findings may aid the development of clinical interventions addressing reluctance to begin insulin treatment among Japanese patients with T2D.

FUNDING

Eli Lilly and Company and Boehringer Ingelheim. Plain language summary available for this article.

A paradigm for understanding trust and mistrust in medical research: The Community VOICES study

BACKGROUND

To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple variables have been identified as factors associated with research participant trust/mistrust. A conceptual model that provides meaningful insight into the interplay of factors impacting trust may promote more ethical research practice and provide an enhanced, actionable understanding of participant mistrust.

METHODS

A structured survey was developed to capture attitudes toward research conducted in emergency situations; this article focuses on items designed to assess respondents' level of trust or mistrust in medical research in general. Community-based interviews were conducted in English or Spanish with 355 New York City residents (white 42%, African American 29%, Latino 22%).

RESULTS

Generally favorable attitudes toward research were expressed by a majority (85.3%), but many respondents expressed mistrust. Factor analysis yielded four specific domains of trust/mistrust, each of which was associated with different demographic variables: general trustworthiness (older age, not disabled); perceptions of discrimination (African American, Latino, Spanish language preference); perceptions of deception (prior research experience, African American); and perceptions of exploitation (less education).

CONCLUSIONS

The four domains identified in the analysis provide a framework for understanding specific areas of research trust/mistrust among disparate study populations. This model offers a conceptual basis for the design of tailored interventions that target specific groups to promote trust of individual researchers and research institutions as well as to facilitate broader research participation.

The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity

Health disparities persist despite ongoing efforts. Given the United States' rapidly changing demography and socio-cultural diversity, a paradigm shift in behavioral medicine is needed to advance research and interventions focused on health equity. This paper introduces the ConNECT Framework as a model to link the sciences of behavioral medicine and health equity with the goal of achieving equitable health and outcomes in the twenty-first century. We first evaluate the state of health equity efforts in behavioral medicine science and identify key opportunities to advance the field. We then discuss and present actionable recommendations related to ConNECT's five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training. The framework holds significant promise for furthering health equity and ushering in a new and refreshing era of behavioral medicine science and practice.

Exclusion of Non-English Speakers in Published Emergency Medicine Research - A Comparison of 2004 and 2014

BACKGROUND

Non-English speakers (NES) as a proportion of the United States population have steadily increased in recent years. There remains substantial risk of excluding NES from research.

OBJECTIVE

To assess whether the percentage of emergency medicine (EM) studies that exclude Non-English speakers from participation has changed with time.

METHODS

In a structured fashion, the lead investigator analyzed all original research articles in Academic Emergency Medicine and Annals of Emergency Medicine retrospectively for 2004 and prospectively for 2014. An independent investigator conducted a blind review of a sample of articles to assess for interobserver agreement. Demographic data were analyzed using descriptive statistics. Chi-square, t-tests, and linear regression models were utilized; alpha set at 0.05. Cohen's kappa calculated to assess interrater reliability.

RESULTS

We included a total of 236 original research articles. Overall, 11% excluded NES from research (10% AEM, 12% Annals). Cohen's kappa (nonweighted) was 0.73. Comparing all articles in 2004 vs. 2014, research excluded NES 6% vs. 16% of the time respectively (P=0.02). This was not statistically significant when comparing year to year for AEM (7.3% vs. 14.5%; P=0.12) and Annals (6.7% vs. 19%; P=0.06) separately. Factors affecting NES exclusion included type of study design (P<0.001), geographic area (P=0.009) and hospital type (P=0.035). Interestingly, 42% of articles failed to mention language as an exclusion or inclusion criteria.

CONCLUSION

We found that the percentage of articles excluding NES from EM research increased between 2004 and 20014. Further, many investigators do not report whether NES are excluded/included in their studies.

A review of approaches to improve participation of culturally and linguistically diverse populations in clinical trials

The under-representation of culturally and linguistically diverse participants in clinical trials is an ongoing concern for medical researchers and the community. The aim of this review is to examine the complex issue of recruiting culturally and linguistically diverse (CALD) older people to medical research and to examine responses to these issues. The review focuses on (1) trends in the existing literature on barriers to and strategies for recruiting CALD and older people to clinical research, (2) issues with informed consent for CALD populations, and (3) the efficacy of innovative approaches, including approaches incorporating multimedia in research and consent processes. The literature indicates that predominant barriers to greater involvement of CALD patients in clinical trials are communication, including literacy and health literacy considerations; English language competence; and cultural factors in the research setting such as mistrust of consent processes, as well as considerable practical and logistical barriers, including mobility considerations. Some evidence exists that incorporating multimedia resources into the informed consent process can improve patient understanding and is preferred by patients, yet these findings are inconclusive. A multi-methodological approach, including the use of culturally and linguistically sensitive multimedia tools, may help address the issue of low inclusion of CALD groups in clinical research. Researcher education needs to be taken into account to address preconceptions about CALD resistance to research participation and to raise awareness of cultural concerns in regard to research participation.

A review of approaches to improve participation of culturally and linguistically diverse populations in clinical trials

The under-representation of culturally and linguistically diverse participants in clinical trials is an ongoing concern for medical researchers and the community. The aim of this review is to examine the complex issue of recruiting culturally and linguistically diverse (CALD) older people to medical research and to examine responses to these issues. The review focuses on (1) trends in the existing literature on barriers to and strategies for recruiting CALD and older people to clinical research, (2) issues with informed consent for CALD populations, and (3) the efficacy of innovative approaches, including approaches incorporating multimedia in research and consent processes. The literature indicates that predominant barriers to greater involvement of CALD patients in clinical trials are communication, including literacy and health literacy considerations; English language competence; and cultural factors in the research setting such as mistrust of consent processes, as well as considerable practical and logistical barriers, including mobility considerations. Some evidence exists that incorporating multimedia resources into the informed consent process can improve patient understanding and is preferred by patients, yet these findings are inconclusive. A multi-methodological approach, including the use of culturally and linguistically sensitive multimedia tools, may help address the issue of low inclusion of CALD groups in clinical research. Researcher education needs to be taken into account to address preconceptions about CALD resistance to research participation and to raise awareness of cultural concerns in regard to research participation.

Culturally and Linguistically Diverse Populations in Medical Research: Perceptions and Experiences of Older Italians, Their Families, Ethics Administrators and Researchers

BACKGROUND

Low-participation of culturally and linguistically diverse (CALD) patients in medical research remains a problem in migrant and refugee destination countries such as Australia. The aims of this study were to explore i) CALD persons' perceptions and experiences of the medical system and medical research, in this case, older Italian Australians; and ii) the views of research professionals on CALD patient participation in medical research.

DESIGN AND METHODS

A qualitative study was conducted in Melbourne, Australia, in 2015 utilising in-depth interviews and focus groups with four stakeholder groups: older Italian Australians (n=21); adult children of older Italian Australians (n=10); hospital Human Research Ethics Committee administrators (n=4); and clinical researchers (n=4). The data were analysed for content and thematic analysis.

RESULTS

Themes for the CALD and family group were getting by in medical interactions; receptivity to medical research: testing the waters; and, receptivity to technology for support: passive versus active. Themes for the researcher and HREC groups about CALD patient participation in research were: exclusion; cultural factors; and e-consent.

CONCLUSIONS

Our findings from four stakeholder perspectives and experiences confirm that there were considerable cultural, linguistic, and resourcing barriers hindering the participation of older Italian-Australians in medical research. Furthermore, our findings showed that in this study setting there were few enabling strategies in place to address these barriers despite the national ethics guidelines for equitable participation in research. The findings informed the creation of a multimedia tool whose purpose is to address and improve representation of CALD groups in clinical research. Significance for public healthMany people from culturally and linguistically diverse (CALD) backgrounds remain excluded from medical research such as clinical trials due to a range of language and cultural factors that can be amplified when this population is ageing. This exclusion has implications for the ability of CALD populations to benefit from participating in medical research and for applying research findings to CALD populations. It is essential to develop and implement strategies to include CALD communities in medical research and to uphold the ethical obligation of obtaining informed consent to research. The findings of this study have guided the development of a tablet-based resource which can be used in clinical and community contexts to raise awareness about the purpose of medical research. The resource has been carefully designed to be appropriate for participants' cultural background as well as their preferred language and literacy level. Such a resource has potential to address some of the cultural and linguistic barriers to clinical trial participation of CALD populations.

Cultural aspects related to informed consent in health research: A systematic review

BACKGROUND

In order to protect the autonomy of human subjects, we need to take their culture into account when we are obtaining informed consent.

OBJECTIVE AND RESEARCH DESIGN

This study describes the cultural aspects related to informed consent in health research and is based on electronic searches that were conducted using the Scopus, PubMed, CINAHL, and Cochrane databases published between 2000 and 2013. A total of 25 articles were selected.

FINDINGS

Our findings indicate that cultural perspectives relating to the informed consent process are essential during the whole research process and particularly crucial in the planning phase of a study. Our study indicates that appropriate communication between different stakeholders plays a vital role in cultural understanding.

DISCUSSION AND CONCLUSION

The researchers' awareness of cultural differences and their ability to work in a culturally sensitive way are key factors in improving study participation and retention in a multicultural context. Taking cultural aspects into account during the whole research process improves the quality of research.

Unequal treatment of human research subjects

Unequal treatment of human research subjects is a significant ethical concern, because justice in research involving human subjects requires equal protection of rights and equal protection from harm and exploitation. Disputes sometimes arise concerning the issue of unequal treatment of research subjects. Allegedly unequal treatment occurs when subjects are treated differently and there is a genuine dispute concerning the appropriateness of equal treatment. Patently unequal treatment occurs when subjects are treated differently and there is not a genuine dispute about the appropriateness of equal treatment. Allegedly unequal treatment will probably always occur in research with human subjects due to disagreements about fundamental questions of justice. The best way to deal with allegedly unequal treatment is to promote honest and open discussions of the issues at stake. Research regulations can help to minimize patently unequal treatment by providing rules for investigators, ethical review boards, institutions, and sponsors to follow. However, patently unequal treatment may still occur because the regulations are subject to interpretation. Federal agencies have provided interpretive guidance that can help promote consistent review and oversight of human subjects research. Additional direction may be needed on topics that are not adequately covered by current guidance or regulations. International guidelines can help promote equal treatment of human subjects around the globe. While minor variations in the treatment of research subjects should be tolerated and even welcomed, major ones (i.e. those that significantly impact human rights or welfare) should be avoided or minimized.

Patient- and trial-specific barriers to participation in cardiovascular randomized clinical trials

OBJECTIVES

The purpose of this study was to quantitatively examine the association of patient- and trial-specific factors with participation in cardiovascular randomized clinical trials.

BACKGROUND

Randomized clinical trials are central to evidenced-based medicine, but low patient participation rates and potentially modifiable barriers are not well understood.

METHODS

At a large U.S. academic health system, we examined screening logs from December 1, 2005, to February 28, 2011, from 15 cardiovascular randomized clinical trials. We identified 655 patients who were screened and potentially eligible for participation in at least 1 trial. We used multivariable Poisson regression to quantify the risk of not participating in a trial associated with patient- and trial-specific factors.

RESULTS

The median age was 63 years (interquartile range: 54 to 72), 35% were women, and the median Charlson Index was 2 (interquartile range: 1 to 5). Forty-two percent of patients did not participate in a trial. In multivariable regression (C-Index 0.85), trial-specific factors strongly associated with not participating included intensive trial-related testing (relative risk [RR]: 1.89; 95% confidence interval [CI]: 1.63 to 2.20) and anticipated trial participation >6 months (RR: 4.10; 95% CI: 2.30 to 7.29). Patient-specific factors associated with not participating included older age (RR: 1.23; 95% CI: 1.11 to 1.36, per 10-year increase if age ≥65 years), out-of-state residence (RR: 1.26; 95% CI: 1.04 to 1.54), and female sex (RR: 1.17; 95% CI: 1.01 to 1.35). Race was not associated with participation.

CONCLUSIONS

While patient-specific factors were associated with not participating in cardiovascular trials, longer trial duration and intensive trial-related testing were most strongly associated with risk for patients not participating. Innovative trial designs fostering convenience may most enhance trial participation.