Understanding Ethical Issues of Research Participation From the Perspective of Participating Children and Adolescents: A Systematic Review

Research Ethics of Involving Adolescents in Health Research Studies: Perspectives From Australia

PURPOSE

Adolescent participation in health research studies is critical yet complex given the lack of clarity around issues such as consent. This study aimed to understand how those conducting research in Australia navigate research ethics in health research involving adolescents, through qualitative interviews.

METHODS

Purposive sampling was used to recruit 23 researchers involved in adolescent health research using semi-structured in-depth interviews. Interviews were conducted via Zoom and audio-recorded after obtaining informed consent. Thematic analysis was used to construct themes and data were organised using NVivo.

RESULTS

Two contrasting positions emerged from the data: (1) framing of adolescents as inherently vulnerable, their participation in research understood in terms of risk and protection and (2) adolescent engagement in research is understood in terms of empowerment, emphasising their capacity to make decisions about research participation. We traced these positions through three key themes, particularly in relation to the role of ethics committees: (1) competing positions as a result of inferior or superior knowledge about adolescent lives, (2) competing positions resulting in a risk averse or an empowerment approach, and (3) reflections on processes of obtaining consent which involves gatekeeping and tokenism.

DISCUSSION

Our study highlights the contentious topic of navigating ethics committee requirements for the needs of adolescents. Majority of participants felt the current research ethics establishment is not favourable for researchers or adolescents themselves. While it is imperative that perceptions of ethics committees also be studied in the future, our study provides preliminary understanding of how experiences and perceptions shape how researchers interact with the research ethics establishment.

"Taking part in the project has really changed our experience as a family" investigating parents' experience of participation in a study to screen for fetal alcohol spectrum disorder

Background

Screening children for developmental disorders presents unique ethical and methodological challenges, particularly with disorders associated with high levels of shame and stigma. Fetal alcohol spectrum disorder (FASD) is a neurodevelopmental condition resulting from prenatal alcohol exposure. The potential distress caused by informing parents that their child may have FASD has been cited as a significant barrier to conducting such studies. However, limited research has investigated the impact of screening for FASD on parents and children.

Aims

This exploratory study aimed to examine the experiences of a small sample of parents participating in an active case ascertainment prevalence study screening for FASD in Greater Manchester, UK (ADD-GM study).

Methods

Interviews were conducted with six parents, whose children aged 8-10 years, underwent screening (including three cases of FASD). Thematic analysis was performed on the collected data to identify key themes and patterns.

Results

The analysis revealed that parents perceived participation in the study as worthwhile, and their children either enjoyed or were indifferent to the process of data collection. Parents of children identified with FASD reported that although the results were surprising, they did not find the experience overly distressing.

Conclusion

The findings suggest that parents generally view participation positively and perceive limited negative impact. These insights contribute to a better understanding of the challenges and benefits associated with screening children for FASD.

Engaging children, young people, parents and health professionals in interviews: Using an interactive ranking exercise within the co-design of multimedia websites

When planning paediatric trials, it is important to consider how best to communicate with children and young people (CYP) so they understand what they are taking part in. It is also important to consider what information they need. Involving CYP as research participants leads to research that is more relevant although it can be difficult to engage CYP in qualitative research to improve trial materials due to the topic area. This paper describes how a visual ranking exercise within qualitative interviews acted as a helpful conduit to engaging discussions to inform a co-designed website with information for trial participants. 40 people participated in interviews during which the ranking exercise was used (11 CYP aged 9-18 years, 14 parents, 15 professionals). We found the ranking exercise supported participant engagement and prevented them feeling that particular responses were expected. It also enabled participants to discuss their ranking (and decisions behind this) with other participants and the researcher. Co-design interviews with CYP that use interactive exercises such as ranking are likely to elicit richer data than those relying on traditional questioning techniques.

Tailoring Sexual Health Research Practices to Meet the Needs of Adolescent Girls in Low- and Middle-Income Countries: Findings from Mexico

Sexual and reproductive health (SRH) research is essential for the development of population-tailored evidence-based policies and programs that support sexual health among adolescent girls. However, ethical challenges create barriers to girls' participation in low- and middle-income countries (LMICs). From February to September 2019, girls aged 16-20 (n = 30) who participated in the Jovenes Sanos study in Tijuana, Baja California (ClinicalTrials: NCT03660514) responded to in-depth interviews (IDs) on the perceived risks and benefits of participating in studies which address gender-based violence, unintended pregnancy, and STIs. Emergent themes indicated the need to ensure that consent and incentive procedures are tailored to the developmental level of participants, while highlighting the importance of researcher-participant relationships, and demonstrating how research can serve as an opportunity to empower girls to express their sexual health medical needs. Understanding adolescent girls' voices is a critical step in ensuring that consent to participate SRH research is tailored to the developmental needs of participants, is culturally competent, and has a participant-centered approach.

Engaging Adolescents in Contemporary Longitudinal Health Research: Strategies for Promoting Participation and Retention

PURPOSE

High (and nonselective) recruitment and retention rates in longitudinal studies of adolescence are essential for illuminating health trajectories and determinants during this critical period. Knowledge of optimal recruitment and retention strategies must keep pace with emerging challenges and opportunities, such as the shifts towards digitally-based data collection.

METHODS

We used a narrative review approach to synthesize research on promising recruitment and retention strategies for optimizing engagement in the next generation of longitudinal adolescent health studies.

RESULTS

We identified a small number of well-evidenced strategies, emerging challenges and opportunities for recruitment and retention in contemporary studies, and key evidence gaps. Core recommendations include the use of well-evidenced strategies (e.g., incentivizing participation, reducing barriers and burden, and investing in building positive relationships with participants) and coproducing recruitment and retention strategies with adolescents and parents of adolescents.

DISCUSSION

More research is needed into successful recruitment/retention strategies for digital/remote data collection methods, but initial evidence suggests that adopting principles and adapting well-evidenced strategies from traditional longitudinal studies is promising.

The extent and nature of children's involvement in food practice research: a scoping review of qualitative studies

OBJECTIVE

Aligning with the United Nations Convention on the Rights of the Child, amplification of children's voice in food practice research aims to inform initiatives that cater to children's needs and thus improve nutritional outcomes. The aim of this study was to describe children's (aged 6-11 years) involvement across qualitative research investigating their food practice perspectives.

DESIGN

A scoping review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR). Six electronic databases were searched up until March 2023 (Cochrane, CINAHL, Embase, ERIC, Medline and PsychInfo). The Wellcome Framework for young people's involvement in health research guided data extraction. Data were described according to inclusiveness, geography, food-related study topic, research stage and method, and child involvement.

RESULTS

The search identified 120 peer-reviewed studies (134 papers). Active participation was only seen within research implementation stages (i.e. data collection (n 134), analysis (n 31), dissemination (n 9) and re-design (n 7)). More passive forms of participation were identified in research design stages (i.e. agenda setting, resourcing and design). Studies that utilised participatory research methodologies and developmentally appropriate and engaging methods (e.g. PhotoVoice) saw more active participation by children.

CONCLUSION

This review identified a lack of opportunities for children's active participation in all stages of food practice research. Without a radical shift towards providing these opportunities, food and nutrition initiatives, policies or further research that do not meet the needs of children's food-related worlds will continue to be developed. Instead, researchers and their institutions need to advocate for and, where possible, provide voluntary opportunities for children to actively participate in food practice research.

Adolescents' Experiences of Participating in Sensitive Research: A Scoping Review of Qualitative Studies

Despite an increasing emphasis on adolescents' participation rights, there are concerns about their participation in research on sensitive topics, such as trauma and violence. This review reports findings of a scoping review that examined the nature and extent of qualitative studies conducted with adolescents about their experiences of participating in research on sensitive topics. Studies were identified by searching electronic databases and grey literature and reported on qualitative and mixed-methods studies eliciting adolescents' experiences of participating in research on sensitive topics. Seventeen (17) studies were included after screening 4426 records. The scoping review revealed significant adolescent benefits from participation, relating to positive emotions, skill acquisition and enhanced self-efficacy and interpersonal relationships. To a lesser extent, participants also experienced burdens relating to negative emotions, concerns about confidentiality and privacy and inconvenience of participation, which were mitigated by careful attention to research design and researcher engagement and training. Participants shared insights into their motivation to participate, and factors that impacted their experiences of research, such as ethical considerations, including consent procedures, safety and connection in research, study procedures and documentation and researcher characteristics. There were tangible benefits and some burdens involved in adolescents' participation in sensitive research. This review considers implications for research and practice, such as the need to regularly publish findings of consultations, assessing caregiver consent requirements, obtaining adolescent views on study documents and measures and building on existing research, differentiated by age, gender and dis/ability status, especially in diverse and under-represented regions.

Children's assent within clinical care: A concept analysis

Seeking children's assent has been put forward as a way to foster children's involvement in the healthcare decision-making process. However, the functions of the concept of assent within clinical care are manifold, and methods used to recognize children's capacities and promote their involvement in their care remain debated. We performed an instrumentalist concept analysis of assent, with 58 included articles. Final themes were jointly identified through a deliberative process. Two distinct perspectives of assent were predominant: as an affirmative agreement for a specific decision and as part of a continuous, interactive process of care. Differing standards were provided as to how and when to apply the concept of assent. The concept of dissent was largely omitted from conceptions of assent, especially in situations for which children's refusal would lead to severe health consequences. Ethical implications included fostering autonomy, reducing physical/psychological harm to the child, respecting the child as a human being, and fulfilling the universal rights of the child. There remain important gaps in the theory of assent and its desirable and possible practical implications. Practical standards are largely missing, and evidence supporting the claims made in the literature requires further investigation.

Developing a Family Resource: Considerations for Family Member Research Participation

When individuals participate in health care research, the choice often affects the entire family. Researchers are responsible for protecting participants and minimizing any burdens the research may place on them. Resources to educate potential study participants about these issues from a family perspective are lacking. A family-focused, evidence-based resource was created for individuals and families to prompt discussion prior to their consenting to enrollment in research. The resource includes key relevant questions to consider related to their study participation and was revised based on input from family nurse scientists and a hospital-based family advisory group. This resource raises awareness of the importance of employing a family lens when designing research and during the recruitment and enrollment of participants. Adopting a family lens in health care research will support the participant's ability to make an informed choice regarding participation and may ultimately enhance the experience of participants and their families and study outcomes.

Ethical concerns when recruiting children with cancer for research: Swedish healthcare professionals' perceptions and experiences

BACKGROUND

Research is crucial to improve treatment, survival and quality of life for children with cancer. However, recruitment of children for research raises ethical challenges. The aim of this study was to explore and describe ethical values and challenges related to the recruitment of children with cancer for research, from the perspectives and experiences of healthcare professionals in the Swedish context. Another aim was to explore their perceptions of research ethics competence in recruiting children for research.

METHODS

An explorative qualitative study using semi-structured interviews with key informants. Seven physicians and ten nurses were interviewed. Interviews were analysed using inductive qualitative content analysis.

RESULTS

The respondents' ethical challenges and values in recruitment mainly concerned establishing relationships and trust, meeting informational needs, acknowledging vulnerability, and balancing roles and interests. Ensuring ethical competence was raised as important, and interpersonal and communicative skills were highlighted.

CONCLUSION

This study provides empirical insight into recruitment of children with cancer, from the perspectives of healthcare professionals. It also contributes to the understanding of recruitment as a relational process, where aspects of vulnerability, trust and relationship building are important, alongside meeting informational needs. The results provide knowledge on the complexities raised by paediatric research and underpin the importance of building research ethics competence to ensure that the rights and interests of children with cancer are protected in research.

Intentions and willingness to engage in risky driving behaviour among high school adolescents: evaluating the bstreetsmart road safety programme

OBJECTIVE

To investigate the impact of a road safety programme on adolescents' willingness to engage in risky behaviour as probationary drivers, adjusted for covariates of interest.

METHOD

The bstreetsmart is a road safety programme delivered to around 25 000 adolescent students annually in New South Wales. Using a smartphone-based app, student and teacher participation incentives, students were surveyed before and after programme attendance. Mixed-methods linear regression analysed pre/post-modified Behaviour of Young Novice Driver (BYNDS_M) scores.

RESULTS

2360 and 1260 students completed pre-event and post-event surveys, respectively. Post-event BYNDS_M scores were around three points lower than pre-event scores (-2.99, 95% CI -3.418 to -2.466), indicating reduced intention to engage in risky driving behaviours. Covariates associated with higher stated intentions of risky driving were exposure to risky driving as a passenger (1.21, 95% CI 0.622 to 2.011) and identifying as non-binary gender (2.48, 95% CI 1.879 to 4.085), adjusting for other predictors.

CONCLUSIONS

Trauma-informed, reality-based injury prevention programmes can be effective in changing short-term stated intentions to engage in risky driving, among a pre-independent driving student population. The adolescent novice driver age group is historically challenging to engage, and injury prevention action must be multipronged to address the many factors influencing their behaviour.

Prioritising Children and Young People with Disability in Research About Domestic and Family Violence: Methodological, Ethical and Pragmatic Reflections

Purpose

The perspectives of children and young people with disability who experience domestic and family violence are under-researched, impeding the development of approaches that meet their needs. Knowledge gaps stem from the layered discursive positioning of disability, childhood/youth, or domestic and family violence in addition to the methodological, ethical and pragmatic complexity of research needed to understand their priorities and be attuned to their lived experience. This article explores methodological, ethical and practical challenges to centring their voices in research about domestic and family violence.

Method

A conceptual framework of feminist disability theory and intersectionality informed our co-designed research, across three phases: (1) quantitative large-scale data linkage and case file analysis; (2) qualitative research with children and young people, their families and service providers and (3) stakeholder engagement workshops.

Results

We reflect on how our research was able to prioritise the contextual agency of children and young people with disability, ways it could not, and other constraints.

Conclusion

Children and young people with disability experiencing domestic and family violence hold an expert and unique vantage point on what happens to them. Amplifying their priorities for directing policy and organisational change requires more of researchers in terms of methods, but also more flexibility in how projects are funded to enable creativity and innovation. We call for collective attention to frameworks for supported decision-making and child ethics to progress inclusive research which recognises the importance of participation for children and young people with disability.

Deeply lonely in the borderland between childhood and adulthood - Experiences of existential loneliness as narrated by adolescents

BACKGROUND

Adolescence is associated with different feelings and experiences that can negatively affect adolescents' health and well-being. In the transition between childhood and adulthood, experiences of loneliness are common. A deep form of loneliness is described as existential loneliness. Studies among adults have shown that existential loneliness often arises in connection with transitions and is related to suffering, but may lead to positive experiences when acknowledged and addressed. Therefore, the aim of this study was to explore adolescents' experiences of existential loneliness.

METHODS

This was an exploratory-descriptive qualitative study based on narrative interviews with 16 adolescents (median age 17.5). The data were analysed inductively using qualitative content analysis.

FINDINGS

Existential loneliness among adolescents was related to experiences of social exclusion and "in-betweenness". To alleviate their suffering, the adolescents tried to avoid burdensome feelings and thoughts, and they chose between sharing or not sharing their inner lives with someone else.

CONCLUSIONS

It is important to support adolescents' sense of belonging, and they may need assistance in dealing with existential loneliness, as well as with finding constructive and healthy ways of recuperating from the suffering. Professionals need knowledge of existential loneliness to promote adolescents' existential health and well-being.

What information and the extent of information to be provided in an informed assent/consent form of pediatric drug trials

Background

This study aimed to determine the elements and the extent of information that child participants and their parents would like to read in an informed assent form (IAF)/informed consent form (ICF) of a pediatric drug trial.

Methods

A descriptive survey was conducted to determine the perceived importance of each element of the ICF content from child participants and their parents who underwent informed assent/consent of a multi-center pediatric drug trial. The respondents were asked to indicate the level of importance of each item in a questionnaire, by giving a rating scale from 1 (not important) to 5 (very important).

Results

A total of 22 families, 17 child participants with the diagnosis of hematology or oncology diseases and 27 parents, were enrolled. Among 30 items, risk–benefit aspects (i.e., direct health benefit [mean: 4.71 for child respondents, 4.89 for parent respondents], indirect/societal benefit [mean: 4.65, 4.85], major foreseeable risk [mean: 4.47, 4.78], post-trial benefit/provision [mean: 4.59, 4.74], and all adverse effects of the drug including uncommon adverse effects [mean: 4.53, 4.74]) were perceived to be of most concerning items from both child participants’ and parents’ viewpoint. None of the items were considered ‘slightly important’ or lower by more than 20% of the respondents.

Conclusions

For pediatric drug trials, risk–benefit information (including direct health benefit, indirect/societal benefit, and post-trial benefit/provision, as well as major foreseeable risk and adverse effects of the drug) should be made a salient feature of an IAF/ICF. This empirical data could help related stakeholders arrange essential information in order of importance and tailor an IAF/ICF to better suit child participants’ and parents’ needs, particularly for pediatric drug trials involving children with the diagnosis of hematology or oncology diseases.

A Critical Review of Clinical Practice Guidelines for Care of Transgender and Gender Diverse Children and Youth for Use by Primary Care Practitioners

Purpose

To examine and critique international clinical practice guidelines (CPGs) related to transgender and gender diverse children and youth and to assess the applicability of the guidelines to ethical and affirming primary care practice.

Methods

A review was conducted to obtain English language clinical guidelines. Guidelines were obtained from electronic databases, medical associations, government agencies, and community organizations. Guidelines were critiqued by all authors using the AGREE II instrument.

Results

Nine documents were reviewed. Overall, there was agreement among reviewers that the scope, purpose, and clarity of presentation of the guidelines was carried out well. Areas identified for improvement in all guidelines included clarity/rigor of methodologic development, inclusion of community stakeholders, and transparency of editorial independence. The Endocrine Society Clinical Practice Guideline scored highest overall. Despite lower overall scores, other guidelines were identified as having strengths of practical utility within primary care and/or in the discussion of specific social, ethical, and cultural considerations of transgender care in differing contexts worldwide.

Conclusion

The use of specific, high-quality CPGs can support primary care practitioners to provide gender-affirming care to children and youth. Methodologic improvement in the development of these CPGs is needed to ensure the best possible quality of care is being outlined.

Understanding Bullying and Cyberbullying Through an Ecological Systems Framework: the Value of Qualitative Interviewing in a Mixed Methods Approach

Recognized as complex and relational, researchers endorse a systems/social-ecological framework in examining bullying and cyberbullying. According to this framework, bullying and cyberbullying are examined across the nested social contexts in which youth live—encompassing individual features; relationships including family, peers, and educators; and ecological conditions such as digital technology. Qualitative inquiry of bullying and cyberbullying provides a research methodology capable of bringing to the fore salient discourses such as dominant social norms and otherwise invisible nuances such as motivations and dilemmas, which might not be accessed through quantitative studies. Through use of a longitudinal and multi-perspective mixed methods study, the purpose of the current paper is to demonstrate the ways qualitative interviews contextualize quantitative findings and to present novel discussion of how qualitative interviews explain and enrich the quantitative findings. The following thematic areas emerged and are discussed: augmenting quantitative findings through qualitative interviews, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning.

Does digital, multimedia information increase recruitment and retention in a children's wrist fracture treatment trial, and what do people think of it? A randomised controlled Study Within A Trial (SWAT)

OBJECTIVES

To evaluate digital, multimedia information (MMI) for its effects on trial recruitment, retention, decisions about participation and acceptability by patients, compared with printed information.

DESIGN

Study Within A Trial using random cluster allocation within the Forearm Fracture Recovery in Children Evaluation (FORCE) study.

SETTING

Emergency departments in 23 UK hospitals.

PARTICIPANTS

1409 children aged 4-16 years attending with a torus (buckle) fracture, and their parents/guardian. Children's mean age was 9.2 years, 41.0% were female, 77.4% were ethnically White and 90.0% spoke English as a first language.

INTERVENTIONS

Participants and their parents/guardian received trial information either via multimedia, including animated videos, talking head videos and text (revised for readability and age appropriateness when needed) on tablet computer (MMI group; n=681), or printed participant information sheet (PIS group; n=728).

OUTCOME MEASURES

Primary outcome was recruitment rate to FORCE. Secondary outcomes were Decision-Making Questionnaire (nine Likert items, analysed summatively and individually), three 'free text' questions (deriving subjective evaluations) and trial retention.

RESULTS

MMI produced a small, not statistically significant increase in recruitment: 475 (69.8%) participants were recruited from the MMI group; 484 (66.5%) from the PIS group (OR=1.35; 95% CI 0.76 to 2.40, p=0.31). A total of 324 (23.0%) questionnaires were returned and analysed. There was no difference in total Decision-Making Questionnaire scores: adjusted mean difference 0.05 (95% CI -1.23 to 1.32, p=0.94). The MMI group was more likely to report the information 'very easy' to understand (89; 57.8% vs 67; 39.4%; Z=2.60, p=0.01) and identify information that was explained well (96; 62.3% vs 71; 41.8%). Almost all FORCE recruits were retained at the 6 weeks' timepoint and there was no difference in retention rate between the information groups: MMI (473; 99.6%); PIS (481; 99.4%).

CONCLUSIONS

MMI did not increase recruitment or retention in the FORCE trial, but participants rated multimedia as easier to understand and were more likely to evaluate it positively.

TRIAL REGISTRATION NUMBER

ISRCTN73136092 and ISRCTN13955395.

Examining the impact of social stressor stimuli in eliciting physiological reactivity in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis protocol

INTRODUCTION

Stress is not experienced the same by everyone. Some individuals, such as individuals with autism spectrum disorder (ASD), are at risk of heightened sensitivity to stress responses. ASD is a neurodevelopmental disorder commonly characterised by deficits in social communication and social interaction. Among different stressor stimuli, social stressors are particularly worth our attention due to the social and communication challenges inherent in ASD. This study aims to systematically evaluate different social stressor stimuli in eliciting physiological reactivity in ASD, focusing on the children and adolescent population.

METHODS AND ANALYSIS

We designed a study protocol for this study and submitted it to PROSPERO for systematic review registration. Any studies with children and adolescents with ASD between the ages of 0 and 18 in clinical and community settings will be included. All types of social stressor interventions will be included. The outcome of interest will include studies with physiological activity of the participants being measured, for example, measures related to autonomic functioning, electrodermal functioning and cortisol level. The primary literature sources will be across four electronic databases: MEDLINE, Embase, PsycInfo and CINAHL in August 2021. The second source of literature will be across grey literature, including ProQuest Dissertations & Theses Global and across clinical trial registries in August 2021. Hand searching of references will be performed on the reference lists of all included studies. Two volunteers pursuing postgraduate-level studies will independently search and screen potential studies for eligibility. Finally, all references considered by hand searching will be reviewed by two researchers. The methodological quality of the research will be assessed by adopting the quality assessment used by a previous study. The assessment consists of four primary categories: descriptive validity, internal validity, external validity and statistical conclusion validity.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. Results will be disseminated through conferences and publications in relevant peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021244039.

The Reactions of Adolescents, Parents and Clinicians to Participating in Qualitative Research Interviews Regarding Adolescents Bereaved by Suicide and Other Traumatic Death

There are concerns that involving adolescents bereaved by suicide and other traumatic death in research may cause distress and harm. However, no study has investigated such bereaved adolescents’ research experiences. In addition, no study has looked at the experiences of parents and clinicians as participants in adolescent suicide and traumatic death bereavement research. This study aimed to explore the short-term impact of research participation experienced by adolescents, parents, and clinicians. A total of 61 participants (adolescents, n = 17; parents, n = 12; clinicians, n = 32) filled out a short survey within two weeks of having taken part in a qualitative interview study. Data were analyzed descriptively. Most participants had experienced no distress while participating and no negative effects of participating; rather, participation was experienced as helpful for them and they would highly recommend participating in a study like this to others. A few adolescents and parents reported some distress, related to anxiety about participation and the unpleasantness of grief memories. The study clearly indicates that bereaved adolescents, parents and clinicians can safely participate in research interviews regarding their experiences of grief and help after suicide, generally valuing the opportunity to share their experience. To prevent and mitigate potential distress, training of research staff and implementation of appropriate participant distress protocols are imperative. Future studies could include longitudinal follow-up of participants to assess any longer-term consequences.

What I Wish You Knew: Insights on Burnout, Inertia, Meltdown, and Shutdown From Autistic Youth

Introduction: Burnout, inertia, meltdown, and shutdown (BIMS) have been identified as important parts of some autistic people's lives. This study builds on our previous work that offered early academic descriptions of these phenomena, based on the perspectives of autistic adults. Objectives: This study aimed to explore the unique knowledge and insights of eight autistic children and youth to extend and refine our earlier description of burnout, inertia, and meltdown, with additional exploration of shutdown. We also aimed to explore how these youth cope with these phenomena and what others around them do that make things better or worse, with a hope to glean knowledge to design better supports. Methods: One-to-one interviews were conducted with eight children and youth, who shared their experience with BIMS. To match individual communication strengths of children and youth, we took a flexible approach to interviews, allowing for augmentative communication systems and use of visual images to support verbal interviews, as needed. We conducted a reflexive, inductive thematic analysis, using an iterative process of coding, collating, reviewing, and mapping themes. Findings: Our analysis has identified that these youth describe BIMS as a multi-faceted experience involving emotional, cognitive and physical components. Moreover, these multifaceted experiences are often misunderstood by neurotypical adults, which contributes to inadequate support in managing BIMS. Of the four experiences, these youth identified meltdowns as most common. Conclusion: By gaining first-hand perspectives, we have identified novel insights into BIMS and developed a more holistic understanding of these phenomena. These youths' descriptions of supportive strategies for BIMS stress the importance of compassion and collaboration from trusted adults. This new knowledge will provide a foundation for how to better support autistic children and youth. Further research is required to develop an understanding of BIMS, especially with respect to how it is experienced by children and youth. Future research should leverage the insights and experiential knowledge of autistic children and youth to co-design support tool(s) for BIMS.

Trends and gaps in precision health research: a scoping review

OBJECTIVE

To determine progress and gaps in global precision health research, examining whether precision health studies integrate multiple types of information for health promotion or restoration.

DESIGN

Scoping review.

DATA SOURCES

Searches in Medline (OVID), PsycINFO (OVID), Embase, Scopus, Web of Science and grey literature (Google Scholar) were carried out in June 2020.

ELIGIBILITY CRITERIA

Studies should describe original precision health research; involve human participants, datasets or samples; and collect health-related information. Reviews, editorial articles, conference abstracts or posters, dissertations and articles not published in English were excluded.

DATA EXTRACTION AND SYNTHESIS

The following data were extracted in independent duplicate: author details, study objectives, technology developed, study design, health conditions addressed, precision health focus, data collected for personalisation, participant characteristics and sentence defining 'precision health'. Quantitative and qualitative data were summarised narratively in text and presented in tables and graphs.

RESULTS

After screening 8053 articles, 225 studies were reviewed. Almost half (105/225, 46.7%) of the studies focused on developing an intervention, primarily digital health promotion tools (80/225, 35.6%). Only 28.9% (65/225) of the studies used at least four types of participant data for tailoring, with personalisation usually based on behavioural (108/225, 48%), sociodemographic (100/225, 44.4%) and/or clinical (98/225, 43.6%) information. Participant median age was 48 years old (IQR 28-61), and the top three health conditions addressed were metabolic disorders (35/225, 15.6%), cardiovascular disease (29/225, 12.9%) and cancer (26/225, 11.6%). Only 68% of the studies (153/225) reported participants' gender, 38.7% (87/225) provided participants' race/ethnicity, and 20.4% (46/225) included people from socioeconomically disadvantaged backgrounds. More than 57% of the articles (130/225) have authors from only one discipline.

CONCLUSIONS

Although there is a growing number of precision health studies that test or develop interventions, there is a significant gap in the integration of multiple data types, systematic intervention assessment using randomised controlled trials and reporting of participant gender and ethnicity. Greater interdisciplinary collaboration is needed to gather multiple data types; collectively analyse big and complex data; and provide interventions that restore, maintain and/or promote good health for all, from birth to old age.

Trust and consent: a prospective study on parents' perspective during a neonatal trial

OBJECTIVE

This study aimed to describe how parents and physicians experienced the informed consent interview and to investigate the aspects of the relationship that influenced parents' decision during the consent process for a randomised clinical trial in a tertiary neonatal intensive care unit (NICU). The secondary objective was to describe the perspectives of parents and physicians in the specific situation of prenatal informed consent.

SETTING

Single centre study in NICU of the Centre Hospitalier Intercommunal de Créteil, France, using a convenience period from February to May 2016.

DESIGN

Ancillary study to a randomised clinical trial: Prettineo. Records of interviews for consent.

POPULATION

parents and physicians. Mixed study including qualitative and quantitative interview data about participants' recall and feelings about the consent process. Interviews were reviewed using thematic discourse analysis.

RESULTS

Parents' recall and understanding of the study's main goal and design was good. Parents and physicians had a positive experience, and trust was one of the main reasons for parents to consent. Misunderstanding (bad comprehension) was the main reason for refusal.Before birth, three situations can compromise parents' consent: the mother already consented to participate in other studies, the absence of the father during the interview and the feeling that the baby's birth is not an imminent possibility.

CONCLUSIONS

Confronting parents and physicians' perspectives in research can help us reach answers to sensitive issues such as content and timing of information. Each different types of study raises different ethical dilemmas for consent that might be discussed in a more individual way.

Consent to research participation: understanding and motivation among German pupils

Background

The EU’s 2006 Paediatric Regulation aims to support authorisation of medicine for children, thus effectively increasing paediatric research. It is ethically imperative to simultaneously establish procedures that protect children’s rights.

Method

This study endeavours (a) to evaluate whether a template consent form designed by the Standing Working Group of the German-Research-Ethics-Committees (AKEK) adequately informs adolescents about research participation, and (b) to investigate associated phenomena like therapeutic misconception and motives for research participation. In March 2016 a questionnaire study was conducted among 279 pupils (mean age 13.1 years) of a secondary school in northern Germany.

Results

A majority of participants showed a general good understanding of foundational research ethics concepts as understood from the AKEK consent form. Nevertheless, our data also suggests possible susceptibility to therapeutic misconception. Own health concerns and pro-social considerations were found to be significant motivational factors for participating in research, while anticipation of pain lessens likelihood of participation. Advice from trusted others is an important decisional influence, too. Furthermore, data security was found to be a relevant aspect of adolescents’ decision-making process.

Conclusion

Bearing in mind adolescents’ generally good understanding, we infer the lack of knowledge about medical research in general to be one source of therapeutic misconception. To further improve the quality of consent we propose a multi-staged approach whereby general research education is completed before an individual becomes a patient or potential participant. To the best of our knowledge this is the first German questionnaire-study addressing issues of informed consent in a large under-age sample.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00661-z.

Evaluating the use of multimedia information when recruiting adolescents to orthodontics research: A randomised controlled trial

Objective:

To compare two methods of providing information about the Bone Anchored Maxillary Protraction (BAMP) trial: standard printed information and multimedia websites, for their quality and ease of understanding, and impact on decision-making.

Design:

Randomised controlled trial.

Setting:

Orthodontic outpatient clinic in the UK.

Methods:

Participants were 109 adolescents (aged 11–14 years) attending for orthodontic treatment. While awaiting treatment they were asked to imagine being recruited to the BAMP clinical trial. They were individually randomised to receive the printed or the multimedia website information (comprising text, animations and ‘talking head’ videos). After reading or viewing the information, they completed a 9-item Likert scale Decision-Making Questionnaire (DMQ) (score range 0–36) plus three free-text questions on their evaluation of the information.

Results:

A total of 104 participants completed the questionnaire. Mean total DMQ scores were higher (more positive) in the website group (28.1 vs. 27.0), although the difference was small and not statistically significant (P = 0.20). Analysis of individual questionnaire items showed two statistically significant differences: the website information had higher ratings on ‘easy to understand’ (Z = 3.03; P = 0.003) and ‘confidence in decision-making’ (Z = 2.00; P = 0.044). On the three free-text questions, more positive and fewer negative comments were made about the websites than the printed information.

Conclusion:

In this hypothetical trial setting, adolescent patients found that trial information conveyed on a multimedia website was easier to understand and made them more confident in their decision about trial participation. Their subjective evaluations of the website were also more positive and less negative than about the printed information. Multimedia information has the potential to increase the quality of engagement and information exchange when seeking consent for research.

A Critical Review of Standards to Examine the Parameters of Child-Friendly Environment (CFE) in Parks and Open Space of Planned Neighborhoods: A Case of Lucknow City, India

The creation of cities has been one of the most phenomenal achievements of human endeavor. Adults are the major stakeholders for such achievements but the children are helpless and representationless. The current research paper aims at understanding the issues faced by the children in the rapidly urbanized world where the lack of child-friendly environments/open spaces for their outdoor activities is cause for concern. The research paper looked at various national and international norms, standards, and practices of parks and open spaces to identify various child-friendly environmental parameters. The research adopted the Delphi method as a tool for the validation of child-friendly environment parameters. It also used children’s drawings and essays to understand children’s perceptions about the child-friendly environment. It is observed that present government norms and policies do not adhere to those parameters. The research found that Lucknow city does not meet the defined quantitative norms and standards as laid out by the national norms and standards for open spaces and parks. The quality dimensions for planning a child-friendly environment are weakly addressed by cities and neighborhoods. The city neighborhoods lack the physical, cognitive, perceptional, emotional, and social dimensions of a child-friendly environment. There is a need to adopt suitable norms and standards with measurable parameters as part of various dimensions and implement these in creating a child-friendly environment in planned neighborhoods.

Children and young people's experiences of completing mental health and wellbeing measures for research: learning from two school-based pilot projects

BACKGROUND

In recent years there has been growing interest in child and adolescent mental health and wellbeing, alongside increasing emphasis on schools as a crucial site for research and intervention. This has coincided with an increased use of self-report mental health and wellbeing measures in research with this population, including in school-based research projects. We set out to explore the way that children and young people perceive and experience completing mental health and wellbeing measures, with a specific focus on completion in a school context, in order to inform future measure and research design.

METHODS

We conducted semi-structured interviews and focus groups with 133 participants aged 8-16 years following their completion of mental health and wellbeing measures as part of school-based research programmes, using thematic analysis to identify patterns of experience.

FINDINGS

We identified six themes: Reflecting on emotions during completion; the importance of anonymity; understanding what is going to happen; ease of responding to items; level of demand; and interacting with the measure format.

CONCLUSIONS

Our findings offer greater insight into children and young people's perceptions and experiences in reporting on their mental health and wellbeing. Such understanding can be used to support more ethical and robust data collection procedures in child and adolescent mental health research, both for data quality and ethical purposes. We offer several practical recommendations for researchers, including facilitating this in a school context.

Parental consent: A potential barrier for underage teens' participation in an mHealth mental health intervention

PURPOSE

We sought to examine whether underage adolescents displaying symptoms for a mental illness (i.e., an eating disorder) would be willing to obtain parental consent to participate in a study to test the efficacy of an evidence-based mobile mental health intervention targeting teens with eating disorders.

METHODS

The participants (n = 366) were 15 to 17 year-old English-speakers who post or follow social media accounts on Instagram that emphasize being thin as important or attractive. The participants were administered a survey through Qualtrics to assess eating disorder pathology, interest in trying an evidence-based mobile mental-health intervention, and comfort level with obtaining parental consent to partake in a research study about such an intervention.

RESULTS

About 85% of participants met clinical or subclinical criteria for an eating disorder; however, only 12% had received a treatment within the past six months. While 83% of participants were interested in trying a mobile health interventions app, only 35% indicated willingness to obtain parental consent to participate in a research study. The primary reasons presented for unwillingness to obtain consent included importance of retaining privacy and feeling that parents lack awareness or understanding about mental health issues.

CONCLUSIONS

While barriers exist to obtaining treatment for eating disorders, a mobile intervention app may close some of these gaps. Many underage participants indicated interest in obtaining such treatment, yet only a third were willing to obtain parental consent. Future studies should investigate how to reduce these barriers to obtaining parental consent to facilitate teen access to research and mobile mental health treatment.

Factors affecting adolescents' participation in randomized controlled trials evaluating the effectiveness of healthcare interventions: the case of the STEPSTONES project

Background

Recruitment of adolescents to intervention studies is a known challenge. For randomized controlled trials (RCT) to be generalizable, reach must be assessed, which means ascertaining how many of the intended population actually participated in the trial. The aim of this study was to evaluate the reach and representativeness of an RCT evaluating the effectiveness of a complex intervention for adolescents with chronic conditions.

Methods

A mixed methods sequential explanatory design was employed. Firstly, quantitative cross-sectional data from the RCT, patient registries and medical records were collected and analysed regarding baseline differences between participants and non-participants in the trial. Secondly, qualitative data on their reasons for participating or not were collected and analysed with content analysis to explain the quantitative findings.

Results

Participants showed larger differences in effect sizes and a significantly more complex chronic condition than non-participants. No other statistically significant differences were reported, and effect sizes were negligible. Reasons for declining or accepting participation were categorized into three main categories: altruistic reasons, personal reasons and external reasons and factors.

Conclusions

Integration of quantitative and qualitative findings showed that participation in the RCT was affected by disease complexity, the perceived need to give back to healthcare and research and the adolescents’ willingness to engage in their illness. To empower adolescents with chronic conditions and motivate them to participate in research, future intervention studies should consider developing tailored recruitment strategies and communications with sub-groups that are harder to reach.

Why do patients take part in research? An overview of systematic reviews of psychosocial barriers and facilitators

BACKGROUND

Understanding why people take part in health research is critical to improve research efficiency and generalisability. The aim of this overview of systematic reviews was to identify psychosocial determinants of research participation and map them to psychological theory and empirical recruitment research, to identify effective strategies to increase research participation.

METHODS

Qualitative and quantitative systematic reviews were systematically identified. No date or language limits were applied. Two reviewers independently selected reviews. Methodological quality was rated using AMSTAR, and poor-quality reviews (scoring 0-3) were excluded. Barriers and facilitators were coded to psychological theory (Theoretical Domains Framework) and empirical recruitment research (recruitment interventions that had been subjected to randomised controlled trial evaluation).

RESULTS

We included 26 systematic reviews (429 unique primary studies), covering a wide range of patient populations and health settings. We identified five groups of facilitators, of which three were dominant (potential for personal benefit, altruism, trust) and appear to be relevant across research setting and design. We identified nine groups of barriers, which were more dependent on the particular study (context, population, design). Two determinants (participant information, social influences) were found to be both barriers and facilitators. Barriers and facilitators could be coded to the Motivation and Opportunity components of the Theoretical Domains Framework; only one was coded to a Capability component. There was some overlap between psychosocial determinants and empirical recruitment research, but some barriers and facilitators had not been tested at all.

CONCLUSIONS

Identifying effective recruitment strategies could increase the efficiency and generalisability of primary research. We identified a number of barriers and facilitators that could be addressed by researchers. There is a need for more research to identify effective recruitment strategies that draw on the psychosocial facilitators and barriers identified in this overview.

Researching the Experiences of Children with Cancer: Considerations for Practice

Children and adolescents with cancer often participate in medical and psychosocial research throughout their diagnosis and treatment. Furthermore, this involvement frequently extends into the survivorship period. Sometimes referred to as "doubly vulnerable" research participants, children and adolescents with cancer are not only minors, but also minors facing significant medical, developmental, and psychosocial stressors associated with chronic illness. Thus, it is important to exercise care in designing and conducting research with this population; however, these considerations have not been adequately addressed in pediatric healthcare literature. Therefore, the purpose of this review is to describe the research preferences and experiences of children and adolescents with cancer to identify techniques for supporting this population as research participants. By incorporating developmentally appropriate, context-specific, and child-centered adjustments, researchers can help children and adolescents with cancer effectively and meaningfully describe their illness experiences while also developing a positive outlook on future research participation.

Improving recruitment and retention of adolescents and young adults with cancer in randomized controlled clinical trials

Participation of adolescents and young adults (AYAs) with cancer in randomized clinical trials (RCTs) is necessary to advance treatments and psychosocial programs. Exploring AYAs experiences in an RCT will inform strategies to support recruitment and retention. A qualitative design was used to study the experiences of 13 AYAs in the Stories and Music for Adolescent and Young Adult Resilience during Transplant I (SMART I) trial. Key themes included: Weighing the Pros and Cons; Randomization Preferences; Completing Measures; and Worthwhile Experience. The experiences of AYAs during RCTs can bring insights that inform the design and management of AYA trials. Strategies include improving assent/consent processes, design of electronic interfaces and encouraging researcher flexibility.

Improving the informed consent process among HIV-infected undisclosed minors participating in a biomedical research: insights from the multicentre nutritional SNACS study in Senegal

OBJECTIVES

Providing research information in a manner accessible to minors participating in biomedical research is a major challenge. Guidance is dramatically lacking regarding best practices for seeking informed consent among undisclosed minors enrolled in HIV-related research. We implemented an improved informed consent process (IICP) and identified factors associated with understanding of the information presented to HIV-infected minors prior to their enrolment in a study.

METHODS

We enrolled study participants attending 12 paediatric HIV clinics in Senegal. Children ≥7 years were provided with standardised research information using the IICP, which involves viewing a video and taking part in extended group discussions. Understanding was assessed by seven basic questions scored 1 or 2 points, with a maximum score of 11 points. A score of 9 or more points was defined as satisfactory understanding. Factors associated with understanding were identified using a stepwise logistic regression model.

RESULTS

Overall, 112 children, with a median age of 12.9 years (IQR: 10.2-15.0), participated in the IICP, of whom 37% were HIV disclosed. 71% achieved a satisfactory understanding score and all gave consent to participate in the research. HIV-disclosed children were more likely to demonstrate satisfactory understanding than undisclosed children (aOR = 3.2, 95% CI: 1.1-9.6). Age, study setting and education level were not associated with satisfactory understanding.

CONCLUSION

These findings provide practical guidance for the development of improved and friendly informed consent processes in research involving minors. The implementation of the paediatric HIV research agenda will require a standardised and operational definition of informed consent, integrating the issue of HIV disclosure.

Supporting children and young people when making decisions about joining clinical trials: qualitative study to inform multimedia website development

OBJECTIVES

To understand stakeholders' views regarding the content and design of paediatric clinical trial multimedia websites. To describe how this knowledge informed the development of the multimedia websites.

DESIGN

Qualitative study comprising two rounds of interviews or focus groups, with thematic analysis of interview transcripts.

PARTICIPANTS

Sixty-two people (21 children and young people with long-term health conditions, 24 parents and 17 professionals).

SETTING

One UK children's hospital and one UK Young Persons' Advisory Group.

RESULTS

When asked what was important in deciding whether to join a trial, children, young people and parents prioritised information about what participation would involve, what the trial was testing, potential benefits and risks of participation and knowing they could leave the trial if they later changed their minds. Young people and parents trusted trial teams to follow regulatory and quality requirements and therefore did not think such information was a priority for the websites, although logos of trusted organisations could lend credibility. Professionals largely concurred with these views. Children and young people advised on the importance of designing the multimedia website to ensure its appearance, tone and wording suited the intended audience and on using animated characters to facilitate children's engagement.

CONCLUSIONS

Our study provides insights into the information that families value when deciding about healthcare trial participation. It provides guidance on the design of information resources to appeal to children and young people, while also being acceptable to parents and professionals who are often gatekeepers of children's access to information. Our findings will be of use to others developing similar multimedia websites. We report specific information needs and new visual preferences that are not usually addressed in printed trial information. Our work illustrates what qualitative research and participatory design practices can contribute to the development of information resources more generally.

TRIAL REGISTRATION NUMBER

ISRCTN73136092; Pre-results.

Clinical research with adolescents: barriers and how to overcome them

PURPOSE OF REVIEW

This review aims to emphasize the importance of including adolescents in research, outline current standards and evaluate barriers that prevent adolescent research. We also hope to provide some guidance and call for much needed additional direction in the field.

RECENT FINDINGS

The absolute necessity for including adolescents in research has been an area of focus within the community of adolescent providers and care takers. Recent policy and support from major organizations has emphasized the importance of including this population in research but also pointed out many of the complexities.

SUMMARY

Adolescent research is imperative to guiding policy and promoting evidence-based care. Current standards provide both guidance and barriers, yet more research is needed to further guide conduct of ethical research in this population.

Does the Risk Outweigh the Benefits? Adolescent Responses to Completing Health Surveys

The aim of this study is to describe the self-reported experiences of adolescents in population-based samples when completing health-related surveys on topics with varying potential for evoking distress. Survey data were collected in three school-based studies of bullying behaviors (N = 1,771, 12-14 years), alcohol use (N = 823, 12, 15, and 17 years), and electronic image sharing (N = 274, 13 years). Between 5% and 15% of respondents reported being upset at survey completion, but at most 1.4% were entirely negative in their evaluation. Age was not associated with being upset, but younger adolescents were more likely to see benefit in participation. Although concurrent mental health symptoms increased the risk of being upset, this was mostly mitigated by perceived benefits from participation.

Youth and Parent Appraisals of Participation in a Study of Spontaneous and Induced Pediatric Clinical Pain

The current study examined youths' and their parents' perceptions concerning participation in an investigation of spontaneous and induced pain during recovery from laparoscopic appendectomy. Youth (age range 5-17 years) and their parents independently completed surveys about their study participation. On a 0 (very negative) -to-10 (very positive) scale, both parents 9.4(1.3) [mean(SD)] and youth 7.9(2.4) rated their experience as positive. Among youth, experience ratings did not differ by pain severity and survey responses did not differ by age. Most youth (83%) reported they would tell another youth to participate. Ethical issues regarding instigation of pain in youth for research purposes are examined.