Regulation of biomedical research in Africa

South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study

BACKGROUND

The Western-European concept of libertarian rights-based autonomy, which advocates respect for individual rights, may conflict with African cultural values and norms. African communitarian ethics focuses on the interests of the collective whole or community, rather than rugged individualism. Hence collective decision-making processes take precedence over individual autonomy or consent. This apparent conflict may impact informed consent practice during biomedical research in African communities and may hinder ethical principlism in African bioethics. This study explored African biomedical researchers' perspectives regarding informed consent and potential limitations to the principle of respect for autonomy in African communities.

METHODS

We conducted a qualitative study based on in-depth interviews with 12 biomedical researchers, five females and seven males aged 34 to 74 years, currently working at an African university. Interviews lasted 35-40 min each and involved semi-structured open-ended interviews, which allowed participants to offer information about their perceptions and feelings regarding respect for autonomy and informed consent as practised in Africa. Empirical data from the interviews were recorded, transcribed, and analysed using thematic content analysis, together with an interrogation of relevant scientific literature about African communitarian ethics, making evaluations and drawing inferences consistent with the empirical bioethics approach.

RESULTS

Based on these interviews and analysis of relevant literature, we found that informed consent is difficult to apply in an African context because it derives from a Western conception of libertarian rights-based autonomy. Most respondents pointed out that it was challenging to implement informed consent in the African setting. Furthermore, communalism, customary beliefs, spirituality, and relational autonomy are predominant in most African communities, as exemplified by the African moral philosophies of Ubuntu/Botho and Ukama, which emphasize communitarianism over individual rights. We also found that language, education, poverty, and cultural beliefs are barriers to obtaining proper informed consent in African communities.

CONCLUSIONS

We conclude that there are limitations to applying the principle of respect for autonomy and informed consent in African communities, especially in the context of human biomedical research. We recommend using a more relational approach, such as Ross's prima facie duties, to implement informed consent in African communities.

Knowledge and practice of informed consent by physiotherapists and therapy assistants in KwaZulu-Natal Province, South Africa

BACKGROUND

Informed consent is a doctrinal prerequisite in accordance with the National Health Act 2003 and professional ethical guidelines. Current regulations stipulate that healthcare professionals obtain informed consent from patients prior to treatment. Misconduct charges relating to inadequate information disclosure have been recorded against South African physiotherapists.

OBJECTIVES

This study evaluated knowledge and barriers to informed consent practice among physiotherapists and assistants at Ethekwini District public health institutions.

METHODS

This cross-sectional study utilised self-administered questionnaires. Statistical Package for Social Sciences was used to analyse variables. Significance level and attitude correlation was determined using chi-squared tests, Pearson's correlation and Spearman's coefficient.

RESULTS

Forty-nine respondents (43 physiotherapists, 3 technicians, 3 assistants) completed this study. Mean age and professional experience of respondents were 38 and 14 years, respectively. The majority were female (93%); 56% spent 5 to 10 min obtaining informed consent, mostly verbally (89%); while 47% correctly identified age of consent to routine treatment (12 years). Information provided to patients by respondents included treatment benefits (100%), common risks (81%) and 'all material risks' (31%). Fifty per cent of respondents showed positive attitudes to informed consent.

CONCLUSIONS

Some practising physiotherapists and assistants in KwaZulu-Natal public healthcare institutions had only partial knowledge of informed consent regulations and local laws. Barriers to informed consent included language and excessive workload.

CLINICAL IMPLICATIONS

Patient-centred care is quality healthcare, and adequate informed consent knowledge improves clinical outcomes, respects patients' dignity and autonomy. Continued professional education on healthcare law and ethics should be provided to practising physiotherapists and assistants.

Biomedical research ethics in Cameroon: a survey to assess training needs of medical residents and students

BACKGROUND

Training curricula in research ethics for potential and future researchers should be implemented and constantly updated. This requires data regarding training needs.

METHODS

We conducted a cross-sectional survey on residents, fifth and sixth-year medical students registered in the 2006-2007 academic year at the Faculty of Medicine and Biomedical Sciences (FMBS) of the University of Yaounde 1, Cameroon.

RESULTS

Two-fifths (40.4%) of respondents (response rate 70.9%) reported training in research ethics. Less than half were aware of specific regulatory texts relevant to research ethics. Among those who reported conducting a research project 66.7% declared having obtained informed consent from participants and 32.9% having submitted their protocol to an Ethics Review Committee. Participants identified training priorities in research ethics and responsibilities of key actors in the protection of research participants.

CONCLUSION

There is a need to improve the training and attitude of medical students and residents in order to prepare them to respect and protect research participants.

Network of Ethical Relationships model for global North-South population health research

Although a substantial body of literature exists that details how to address ethical issues and provide oversight for traditional research study designs, there currently is very little guidance available to researchers on how to deal with the unique and novel challenges that arise when conducting research that goes outside of these well-defined boundaries. One such example is North-South (N-S) team-based global population health (GPH) research. This paper presents a Network of Ethical Relationships (NER) model which can allow GPH researchers better understand and resolve ethical issues that arise in N-S collaborative research efforts. The NER model elucidates some of the core relationships involved in GPH research and sheds light on the complex milieu of moral, institutional, societal and legal processes in which it is embedded. The utility of the NER model is examined by reviewing 14 GPH research teams, looking at two relationships in more detail - Researcher-Ethics Board, and Researcher-Funder relationships. The paper argues that improved dialogue and flexibility in the application of formal ethical rules and procedures can lead to research being conducted in a more ethical manner since it better accounts for the multitude of voices and perspectives influencing researchers' choices and actions.

Appropriateness of no-fault compensation for research-related injuries from an African perspective: an appeal for action by African countries

Compensation for research-related injuries (RRIs) remains a challenge in the current environment of global collaborative biomedical research as exemplified by the continued reluctance of the US government, a major player in international biomedical research, to enact regulation for mandatory compensation for RRIs. This stance is in stark contrast to the mandatory compensation policies adopted by other democracies like the European Union (EU) countries. These positions taken by the USA and the EU create a nexus of confusion when research is exported to low-income and middle-income countries which have no laws guiding compensation for RRIs. In this paper, we begin by exploring the background to policies concerning RRIs, how they reflect on the traditional dispute resolution mechanisms in African societies, and how this compares with the no-fault compensation model. We then explore the underlying African ethical framework of Ubuntu in the sub-Saharan region, guiding traditional practices of dispute resolution and compensation, and how this framework can help to form the moral justification for no-fault compensation as the preferred compensation model for RRIs for African countries. Finally, we call upon countries in the African Union (AU), to adopt a no-fault policy for compensation of RRIs, and enact it into a regulatory requirement for insurance-based no-fault compensation for biomedical research, which will then be enforced by member states of the AU.

Readiness of ethics review systems for a changing public health landscape in the WHO African Region

BACKGROUND

The increasing emphasis on research, development and innovation for health in providing solutions to the high burden of diseases in the African Region has warranted a proliferation of studies including clinical trials. This changing public health landscape requires that countries develop adequate ethics review capacities to protect and minimize risks to study participants. Therefore, this study assessed the readiness of national ethics committees to respond to challenges posed by a globalized biomedical research system which is constantly challenged by new public health threats, rapid scientific and technological advancements affecting biomedical research and development, delivery and manufacture of vaccines and therapies, and health technology transfer.

METHODS

This is a descriptive study, which used a questionnaire structured to elicit information on the existence of relevant national legal frameworks, mechanisms for ethical review; as well as capacity requirements for national ethics committees. The questionnaire was available in English and French and was sent to 41 of the then 46 Member States of the WHO African Region, excluding the five Lusophone Member States. Information was gathered from senior officials in ministries of health, who by virtue of their offices were considered to have expert knowledge of research ethics review systems in their respective countries.

RESULTS

Thirty three of the 41 countries (80.5 %) responded. Thirty (90.9 %) of respondent countries had a national ethics review committee (NEC); 79 % of which were established by law. Twenty-five (83.3 %) NECs had secretarial and administrative support. Over 50 % of countries with NECs indicated a need for capacity strengthening through periodic training on international guidelines for health research (including clinical trials) ethics; and allocation of funds for administrative and secretariat support.

CONCLUSIONS

Despite the existing training initiatives, the Region still experiences a shortage of professionals trained in health research ethics/ethicists. Committees continue to face various capacity needs especially for evaluating clinical trials, for monitoring ongoing research, database management and for accrediting institutional ethics committees. Given the growing number of clinical trials involving human participants in the African Region, there is urgent need for supporting countries without NECs to establish them; capacity strengthening where they exist; and creation of a regional network and joint ethical review mechanisms, whose membership would be open to all NECs of the Region.

Research ethics policies and practices in health research institutions in sub-Saharan African countries: results of a questionnaire-based survey

OBJECTIVE

To describe the state of research ethics policies and practices in health research institutions in sub-Saharan African countries.

DESIGN

A structured questionnaire was used to solicit information on research ethics from health research institutions.

SETTING

Forty-two sub-Saharan African countries.

PARTICIPANTS

Key informants from the health research institutions.

MAIN OUTCOME MEASURES

Existence of institutional ethics review policies and mechanisms.

RESULTS

About half (51%) of respondent institutions reported having policies on research ethics and 58% had written policies requiring that researchers obtain informed consent of research participants. About one-third of respondent institutions (34%) had established ethics review committees, 42% required that studies went through ethics review committees and 46% had linkages with national or regional ethics organisations. Regarding operating procedures for ethics review committees, 53% had adopted standard operating procedures. Less than one-quarter of respondent institutions reported having policies in place to monitor ongoing research. Of the institutions that monitored ongoing research, 34% did an annual ethical review and 74% required a periodic written report. Only 36% provided any type of ethics training for staff, including those conducting health research and those who were not members of the ethics review committee.

CONCLUSIONS

There are substantial gaps in the capacity of health research institutions in the WHO African Region to undertake ethical review of studies before, during and after studies conducted. There is a need to strengthen such capacity in order to ensure the wellbeing of individuals enrolled in studies and that of communities that host these studies.

Viewpoint discrimination and contestation of ideas on its merits, leadership and organizational ethics: expanding the African bioethics agenda

The 3rd Pan-African Ethics Human Rights and Medical Law (3rd EHRML) conference was held in Johannesburg on July 7, 2013, as part of the Africa Health Congress. The conference brought together bioethicists, researchers and scholars from South Africa, Zimbabwe, Kenya and Nigeria working in the field of bioethics as well as students and healthcare workers interested in learning about ethical issues confronting the African continent. The conference which ran with a theme of "Bioethical and legal perspectives in biomedical research and medical practice in Africa with a focus on: Informed consent, HIV-AIDS & Tuberculosis, leadership & organizational ethics, patients and healthcare workers rights," was designed to expand the dialogue on African bioethics beyond the traditional focus on research ethics and the ethical dilemmas surrounding the conduct of biomedical research in developing countries. This introductory article highlights some of areas of focus at the conference including issues of leadership, organizational ethics and patients and healthcare workers rights in Africa. We analyze the importance of free speech, public debate of issues, argumentation and the need to introduce the teaching and learning of ethics to students in Africa in accordance with UNESCO guidelines. This article also focuses on other challenges confronting Africa today from an ethical standpoint, including the issues of poor leadership and organizational ethics which are main contributors to the problems prevalent in African countries, such as poverty, poor education and healthcare delivery systems, terrorism, social inequities, infrastructural deficits and other forms of 'structural violence' confronting vulnerable African communities. We believe that each of the eight articles included in this supplement, which have been rigorously peer-reviewed are a good example of current research on bioethics in Africa, and explore some new directions towards broadening the African bioethics agenda as we move forward to a new dawn for Africa in the 21st century.

Ethical and legal implications of whole genome and whole exome sequencing in African populations

BACKGROUND

Rapid advances in high throughput genomic technologies and next generation sequencing are making medical genomic research more readily accessible and affordable, including the sequencing of patient and control whole genomes and exomes in order to elucidate genetic factors underlying disease. Over the next five years, the Human Heredity and Health in Africa (H3Africa) Initiative, funded by the Wellcome Trust (United Kingdom) and the National Institutes of Health (United States of America), will contribute greatly towards sequencing of numerous African samples for biomedical research.

DISCUSSION

Funding agencies and journals often require submission of genomic data from research participants to databases that allow open or controlled data access for all investigators. Access to such genotype-phenotype and pedigree data, however, needs careful control in order to prevent identification of individuals or families. This is particularly the case in Africa, where many researchers and their patients are inexperienced in the ethical issues accompanying whole genome and exome research; and where an historical unidirectional flow of samples and data out of Africa has created a sense of exploitation and distrust. In the current study, we analysed the implications of the anticipated surge of next generation sequencing data in Africa and the subsequent data sharing concepts on the protection of privacy of research subjects. We performed a retrospective analysis of the informed consent process for the continent and the rest-of-the-world and examined relevant legislation, both current and proposed. We investigated the following issues: (i) informed consent, including guidelines for performing culturally-sensitive next generation sequencing research in Africa and availability of suitable informed consent documents; (ii) data security and subject privacy whilst practicing data sharing; (iii) conveying the implications of such concepts to research participants in resource limited settings.

SUMMARY

We conclude that, in order to meet the unique requirements of performing next generation sequencing-related research in African populations, novel approaches to the informed consent process are required. This will help to avoid infringement of privacy of individual subjects as well as to ensure that informed consent adheres to acceptable data protection levels with regard to use and transfer of such information.

Impact of three years training on operations capacities of research ethics committees in Nigeria

This paper describes a three-year project designed to build the capacity of members of research ethics committes to perform their roles and responsibilities efficiently and effectively. The project participants were made up of a cross-section of the membership of 13 Research Ethics Committees (RECs) functioning in Nigeria. They received training to develop their capacity to evaluate research protocols, monitor trial implementation, provide constructive input to trial staff, and assess the trial's success in promoting community engagement in the research. Following the training, technical assistance was provided to participants on an ongoing basis and the project's impacts were assessed quantitatively and qualitatively. Results indicate that sustained investment in capacity building efforts (including training, ongoing technical assistance, and the provision of multiple tools) improved the participants' knowledge of both the ethical principles relevant to biomedical research and how effective REC should function. Such investment was also shown to have a positive impact on the knowledge levels of other RECs members (those who did not receive training) and the overall operations of the RECs to which the participants belonged. Building the capacity of REC members to fulfill their roles effectively requires sustained effort and investment and pays off by enabling RECs to fulfill their essential mission of ensuring that trials are conducted safely and ethically.

Assessing the quality of informed consent in a resource-limited setting: a cross-sectional study

Background

The process of obtaining informed consent continues to be a contentious issue in clinical and public health research carried out in resource-limited settings. We sought to evaluate this process among human research participants in randomly selected active research studies approved by the School of Medicine Research and Ethics Committee at the College of Health Sciences, Makerere University.

Methods

Data were collected using semi-structured interviewer-administered questionnaires on clinic days after initial or repeat informed consent procedures for the respective clinical studies had been administered to each study participant.

Results

Of the 600 participants interviewed, two thirds (64.2%, 385/600) were female. Overall mean age of study participants was 37.6 (SD = 7.7) years. Amongst all participants, less than a tenth (5.9%, 35/598) reported that they were not given enough information before making a decision to participate. A similar proportion (5.7%, 34/597) reported that they had not signed a consent form prior to making a decision to participate in the study. A third (33.7%, 201/596) of the participants were not aware that they could, at any time, voluntarily withdraw participation from these studies. Participants in clinical trials were 50% less likely than those in observational studies [clinical trial vs. observational; (odds ratio, OR = 0.5; 95% CI: 0.35-0.78)] to perceive that refusal to participate in the parent research project would affect their regular medical care.

Conclusions

Most of the participants signed informed consent forms and a vast majority felt that they received enough information before deciding to participate. On the contrary, several were not aware that they could voluntarily withdraw their participation. Participants in observational studies were more likely than those in clinical trials to perceive that refusal to participate in the parent study would affect their regular medical care.

Implementing National System of Health Research Ethics Regulations: The Nigerian Experience

Efforts by Nigerian authorities to institutionalize health research dates back to the early 70's with the establishment of the Medical Research Council. Subsequently efforts to strengthen a national health research system in line with the concept of Essential National Health Research (ENHR) were made but albeit un-successfully. This may have been as a result of poor political support, and lack of regulations to promote health research in the country. However little is known about health research regulations and their implementation in Nigeria. Health and health research in Nigeria is not regulated via a set of clearly defined legislation. While the country has developed a regulation document for health research ethics, compliance to this document is likely to be affected by the lack of legislation in for the health system as an entity. In this paper we narrate the developments in health, health research, and health regulations; we describe process for, and extent of implementation of the National Code of Health Research Ethics. We conclude that several factors affect the extent of implementation of the ethics code amongst which legislation is an important one.

Sprinting Research and Spot Jogging Regulation: The State of Bioethics in Cameroon

Cameroon is a Central African country lying at latitude 6°N and longitude 12°E. The country has a surface area of circa 475,442 square kilometers, and is bordered by several other African countries: Nigeria, Chad, the Central African Republic, the Republic of Congo, Equatorial Guinea, and Gabon. With a population of nearly 20 million inhabitants, Cameroon is a very diverse country, geographically, culturally, and linguistically.

Informed Consent in Human Subject Research: A Comparison of Current International and Nigerian Guidelines

Informed consent is a basic requirement for the conduct of ethical research involving human subjects. Currently, the Helsinki Declaration of the World Medical Association and the International Ethical Guidelines for Biomedical Research of the Council for International Organizations of Medical Sciences (CIOMS) are widely accepted as international codes regulating human subject research and the informed consent sections of these documents are quite important. Debates on the applicability of these guidelines in different socio-cultural settings are ongoing and many workers have advocated the need for national or regional guidelines. Nigeria, a developing country, has recently adopted its national guideline regulating human subject research: The National Health Research Ethics Committee (NHREC) code. A content analysis of the three guidelines was done to see if the Nigerian guidelines confer any additional protection for research subjects. The concept of a Community Advisory Committee in the Nigerian guideline is a novel one that emphasizes research as a community burden and should promote a form of “research friendship” to foster the welfare of research participants. There is also the need for a regular update of the NHREC code so as to address some issues that were not considered in its current version.

Efficacy trials of biomedical strategies to prevent HIV infection

PURPOSE OF REVIEW

The aim of this article is to outline key challenges facing the conduct of efficacy trials for biomedical strategies to prevent HIV infection.

RECENT FINDINGS

The past 2-3 years have seen tumultuous development in this field. There have been disappointing findings in efficacy trials of vaginal microbicides, vaccines, the diaphragm and suppressive therapy for herpes, but a major breakthrough with the evidence that male circumcision prevents acquisition of infection. Meanwhile, clarity has started to emerge on a number of issues regarding trial conduct, including provision of standard of care, involvement of communities, and preparation for implementing effective interventions.

SUMMARY

HIV prevention practice must continue to rely on condom promotion and other established strategies while biomedical approaches continue to be assessed and their implementation strategies evolve.

Health research oversight in Africa

Increased research involving human participants in developing countries has resulted in commensurate rise in needs for functional research oversight activities. The importance of developing countries regulatory and ethical review authorities to demonstrate capability in reviewing clinical trials, quality of the products as well as clinical data obtained through well-coordinated oversight systems cannot be over-emphasized. According to the recent international changes in regulatory frameworks and evolving manufacture's strategies, African countries are now responsible to review applications and license new products without necessarily having them licensed in the north so long as they are not intended to be used there. This paper reviews the status of health research oversight in Africa and gives an overview of some mechanisms that are being put in place in an effort to strengthen oversight of health research. Practical challenges that are prevailing in the field will be highlighted.

Race, science and a novel: an interdisciplinary dialogue

In the novel Racists by Kunal Basu (2006), two competing scientists initiate an experiment that they believe will prove which race is superior. The research subjects, one white and one black infant, are sequestered on an isolated island in the care of a mute nurse. The contest must be waged in a 'natural laboratory' with no artificial interventions and with the prospect that one will die at the hands of the other. The politics of empire, the slave trade and the advent of a new scientific way of viewing life, Darwinism, set the stage for the fictional experiment, but the ramifications of such thinking extend into the present. Coming from the disciplines of nursing, philosophy and science, we discuss how a novel can illuminate the moral dimensions of science and healthcare. The critical distance afforded by the novel provides a rich terrain for the examination of issues such as race, care and the purity of science. Despite the recent dominance of social explanations of race, science requires the examination of the differences between human beings at the biological level. The view that biology is destiny is a powerful one with dangerous consequences, especially since the belief that certain human beings' destinies are far worthier than others is a corollary of such a view. In this paper, we present the cross-disciplinary conversation, which has been facilitated by this novel. We hope this will inform ethics educators of the rich potential of using fiction as a pedagogical tool.

The UNESCO Universal Declaration on Bioethics and Human Rights: perspectives from Kenya and South Africa

In October 2005, UNESCO (the United Nations Educational, Scientific and Cultural Organization) adopted the Universal Declaration on Bioethics and Human Rights. This was the culmination of nearly 2 years of deliberations and negotiations. As a non-binding instrument, the declaration must be incorporated by UNESCO's member states into their national laws, regulations or policies in order to take effect. Based on documentary evidence and data from interviews, this paper compares the declaration's universal principles with national bioethics guidelines and practice in Kenya and South Africa. It concentrates on areas of particular relevance to developing countries, such as protection of vulnerable persons and social responsibility. The comparison demonstrates the need for universal principles to be contextualised before they can be applied in a meaningful sense at national level. The paper also assesses the 'added value' of the declaration in terms of biomedical research ethics, given that there are already well-established international instruments on bioethics, namely the World Medical Association Declaration of Helsinki and the CIOMS (Council for International Organizations of Medical Sciences) guidelines on biomedical research. It may be that the added value lies as much in the follow-up capacity building activities being initiated by UNESCO as in the document itself.

Outcome of a research ethics training workshop among clinicians and scientists in a Nigerian university

Background

In Nigeria, as in other developing countries, access to training in research ethics is limited, due to weak social, economic, and health infrastructure. The project described in this article was designed to develop the capacity of academic staff of the College of Medicine, University of Ibadan, Nigeria to conduct ethically acceptable research involving human participants.

Methods

Three in-depth interviews and one focus group discussion were conducted to assess the training needs of participants. A research ethics training workshop was then conducted with College of Medicine faculty. A 23-item questionnaire that assessed knowledge of research ethics, application of principles of ethics, operations of the Institutional Review Board (IRB) and ethics reasoning was developed to be a pre-post test evaluation of the training workshop. Ninety-seven workshop participants completed the questionnaire before and after the workshop; 59 of them completed a second post-test questionnaire one month after the workshop.

Results

The trainees came from a multi-disciplinary background including medicine, nursing, pharmacy, social science and laboratory science. The mean scores for knowledge of the principles of research ethics rose from 0.67 out of 3 points at pre-test to 2.25 at post-test (p < 0.05). Also, 42% correctly mentioned one international guideline or regulation at pretest, with most of those knowing of the Declaration of Helsinki. Trainees' knowledge of the operations of an IRB increased from 6.05 at pre-test to 6.29 at post test out of 7 points. Overall, participants retained much of the knowledge acquired from the workshop one month after its completion.

Conclusion

The training improved participants' knowledge of principles of research ethics, international guidelines and regulations and operations of IRBs. It thus provided an opportunity for research ethics capacity development among academic staff in a developing country institution.

Applying research ethics guidelines: the view from a sub-saharan research ethics committee

CONSIDERABLE VARIATION HAS BEEN demonstrated in applying regulations across research ethics committees (RECs) in the U.S., U.K., and European nations. With the rise of international research collaborations, RECs in developing countries apply a variety of international regulations. We conducted a qualitative descriptive pilot study with members of the national REC in Malawi to determine criteria they use to review research, and their views on international collaborations. Qualitative content analysis demonstrated that international guidelines are interpreted in light of local African conditions such that emphasis is placed on examining benefit to the community and ensuring the informed consent process translates concepts in locally-meaningful ways. Members suggest that RECs often must comply with regulations that do not fit local conditions. Recommendations are provided for improving such international collaborations.

The structure and function of research ethics committees in Africa: a case study

Kass and colleagues explore the strengths and weaknesses of research ethics committees in Africa.