1
|
Appiah R, Raviola G, Weobong B. Balancing Ethics and Culture: A Scoping Review of Ethico-Cultural and Implementation Challenges of the Individual-Based Consent Model in African Research. J Empir Res Hum Res Ethics 2024; 19:143-172. [PMID: 38497301 PMCID: PMC11298123 DOI: 10.1177/15562646241237669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/19/2024]
Abstract
Objective: This review explores the ethico-cultural and implementation challenges associated with the individual-based informed consent (IC) model in the relatively collectivistic African context and examines suggested approaches to manage them. Methods: We searched four databases for peer-reviewed studies published in English between 2000 to 2023 that examined the ethico-cultural and implementation challenges associated with the IC model in Africa. Results: Findings suggest that the individual-based IC model largely misaligns with certain African social values and ethos and subverts the authority and functions of community gatekeepers. Three recommendations were proffered to manage these challenges, that researchers should: adopt a multi-step approach to IC, conduct a rapid ethical assessment, and generate an African-centered IC model. Conclusions: A pluriversal, context-specific, multi-step IC model that critically harmonizes the cultural values of the local population and the general principles of IC can minimize ethics dumping, safeguard the integrity of the research process, and promote respectful engagement.
Collapse
Affiliation(s)
- Richard Appiah
- Department of Psychology, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
- Center for African Studies, Harvard University, Cambridge, MA, USA
- College of Health Sciences, University of Ghana, Accra, Ghana
- Department of Psychology, University of Johannesburg, Johannesburg, South Africa
| | - Giuseppe Raviola
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Benedict Weobong
- College of Health Sciences, University of Ghana, Accra, Ghana
- School of Global Health, Faculty of Health, York University, Toronto, ON, Canada
| |
Collapse
|
2
|
Bolado GN, Ataro BA, Feleke MG, Gadabo CK, Kebamo TE, Minuta WM. Informed consent practice and associated factors among healthcare professionals in public hospitals of Southern Ethiopia, 2023: a mixed-method study. BMC Nurs 2024; 23:77. [PMID: 38287367 PMCID: PMC10826175 DOI: 10.1186/s12912-024-01748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/19/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Patients may sign a consent form before the specific treatment is offered for a variety of reasons, including during an outpatient appointment. Healthcare professionals must obtain consent from patients or other legal persons before providing any treatment or performing any procedures. But, little attention has been given to the informed consent process in Ethiopia. OBJECTIVE To assess informed consent practice and associated factors among healthcare professionals in Wolaita Zone, Southern Ethiopia public hospitals from January, 2023. METHODS An institutional-based cross-sectional mixed-method study was conducted among 399 healthcare professionals. Simple random sampling and purposive sampling techniques were used to select healthcare professionals for quantitative and qualitative studies respectively. Data for both studies were collected using self-administered questionnaire and key informant interview respectively. EpiDataV4.6 and the Statistical Package for the Social Science was used for entry and analysis of quantitative data. OpenCode software was used for thematic analysis for qualitative data. RESULTS 339 respondents were included in the study, with a response rate of 94.3%. The good practice of informed consent among the healthcare professionals is 53.1%. There was a significant association between the good practice of informed consent and being male [AOR: 0.003 (95% CI: 0.000-0.017)], working in a comprehensive specialized hospital [AOR: 4.775 (95% CI: 1.45-15.74)] and in-service training [AOR: 0.038 (95% CI: 0.013-0.114)]. CONCLUSION AND RECOMMENDATIONS More than half of healthcare professionals had good practices for informed consent. However, it is critical to plan and intervene various strategies with the goal of improving knowledge and attitude toward informed consent.
Collapse
Affiliation(s)
- Getachew Nigussie Bolado
- Adult Health Nursing, School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia.
| | - Bizuayehu Atnafu Ataro
- Adult Health Nursing, School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | - Mulualem Gete Feleke
- Adult Health Nursing, School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | - Christian Kebede Gadabo
- Pediatrics and Child Health Nursing, School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | - Tamirat Ersino Kebamo
- Department of Medical Laboratory, School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | | |
Collapse
|
3
|
Bitter CC, Ngabirano AA, Simon EL, Taylor DM. Principles of research ethics: A research primer for low- and middle-income countries. Afr J Emerg Med 2020; 10:S125-S129. [PMID: 32837877 PMCID: PMC7423570 DOI: 10.1016/j.afjem.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/17/2020] [Accepted: 07/11/2020] [Indexed: 12/15/2022] Open
Abstract
Ethical oversight in the form of review boards and research ethics committees provide protection for research subjects as well as guidance for safe conduct of studies. As the number of collaborative emergency care research studies carried out in low- and middle-income countries increases, it is crucial to have a shared understanding of how ethics should inform choice of study topic, study design, methods of obtaining consent, data management, and access to treatment after closure of the study. This paper describes the basic principles of Western research ethics - respect for persons, beneficence, and justice - and how the principles may be contextualized in different settings, by researchers of various backgrounds with different funding streams. Examples of lapses in ethical practice of research are used to highlight best practices.
Collapse
Affiliation(s)
- Cindy C. Bitter
- Saint Louis University School of Medicine, Division of Emergency Medicine, St. Louis MO, USA
| | - Annet Alenyo Ngabirano
- Aga Khan University, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Erin L. Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - David McD. Taylor
- University of Melbourne, Department of Medicine, Parkville, Victoria, Australia
- Austin Health, Heidelburg, Victoria, Australia
| |
Collapse
|
4
|
Čebron U, Honeyman C, Berhane M, Patel V, Martin D, McGurk M. Barriers to Obtaining Informed Consent on Shortterm Surgical Missions. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2823. [PMID: 33133898 PMCID: PMC7571941 DOI: 10.1097/gox.0000000000002823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
Short-term surgical missions (STSMs) enable visiting surgeons to help address inequalities in the provision of surgical care in resource-limited settings. One criticism of STSMs is a failure to obtain informed consent from patients before major surgical interventions. We aim to use collective evidence to establish the barriers to obtaining informed consent on STSMs and in resource-limited settings and suggest practical solutions to overcome them. METHODS A systematic review was performed using PubMed and Web of Science databases and following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. In addition to the data synthesized from the systematic review, we also include pertinent data from a recent long-term follow-up study in Ethiopia. RESULTS Of the 72 records screened, 11 studies were included in our review. The most common barrier to obtaining informed consent was a paternalistic approach to medicine and patient education. Other common barriers were a lack of ethics education among surgeons in low-income and middle-income countries, cultural beliefs toward healthcare, and language barriers between the surgeons and patients. Our experience of a decade of reconstructive surgery missions in Ethiopia corroborates this. In a long-term follow-up study of our head-and-neck patients, informed consent was obtained for 85% (n = 68) of patients over a 14-year period. CONCLUSIONS This study highlights the main barriers to obtaining informed consent on STSMs and in the resource-limited setting. We propose a checklist that incorporates practical solutions to the most common barriers surgeons will experience, aimed to improve the process of informed consent on STSMs.
Collapse
Affiliation(s)
- Urška Čebron
- From the Department of Hand, Plastic, Reconstructive and Burn Surgery, University of Tübingen, Tübingen, Germany
| | - Calum Honeyman
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Meklit Berhane
- Department of Plastic and Reconstructive Surgery, ALERT Hospital, Addis Ababa, Ethiopia
| | - Vinod Patel
- Department of Oral Surgery, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Dominique Martin
- Department of Plastic & Reconstructive Surgery, University of Bordeaux, Bordeaux, France
| | - Mark McGurk
- Department of Oral & Maxillofacial Surgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
5
|
Grant CL, Robinson T, Al Hinai A, Mack C, Guilfoyle R, Saleh A. Ethical considerations in global surgery: a scoping review. BMJ Glob Health 2020; 5:e002319. [PMID: 32399258 PMCID: PMC7204923 DOI: 10.1136/bmjgh-2020-002319] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge. Methods A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature. Results Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies. Conclusion The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.
Collapse
Affiliation(s)
| | - Tessa Robinson
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Alreem Al Hinai
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Cheryl Mack
- Department of Pediatrics, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Regan Guilfoyle
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Office of Global Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Abdullah Saleh
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Office of Global Surgery, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
6
|
Glaser J, Nouri S, Fernandez A, Sudore RL, Schillinger D, Klein-Fedyshin M, Schenker Y. Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures: An Updated Systematic Review. Med Decis Making 2020; 40:119-143. [PMID: 31948345 DOI: 10.1177/0272989x19896348] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background. Patient comprehension is fundamental to valid informed consent. Current practices often result in inadequate patient comprehension. Purpose. An updated review to evaluate the characteristics and outcomes of interventions to improve patient comprehension in clinical informed consent. Data Sources. Systematic searches of MEDLINE and EMBASE (2008-2018). Study Selection. We included randomized and nonrandomized controlled trials evaluating interventions to improve patient comprehension in clinical informed consent. Data Extraction. Reviewers independently abstracted data using a standardized form, comparing all results and resolving disagreements by consensus. Data Synthesis. Fifty-two studies of 60 interventions met inclusion criteria. Compared with standard informed consent, a statistically significant improvement in patient comprehension was seen with 43% (6/14) of written interventions, 56% (15/27) of audiovisual interventions, 67% (2/3) of multicomponent interventions, 85% (11/13) of interactive digital interventions, and 100% (3/3) of verbal discussion with test/feedback or teach-back interventions. Eighty-five percent of studies (44/52) evaluated patients' understanding of risks, 69% (41/52) general knowledge about the procedure, 35% (18/52) understanding of benefits, and 31% (16/52) understanding of alternatives. Participants' education level was reported heterogeneously, and only 8% (4/52) of studies examined effects according to health literacy. Most studies (79%, 41/52) did not specify participants' race/ethnicity. Limitations. Variation in interventions and outcome measures precluded conduct of a meta-analysis or calculation of mean effect size. Control group processes were variable and inconsistently characterized. Nearly half of studies (44%, 23/52) had a high risk of bias for the patient comprehension outcome. Conclusions. Interventions to improve patient comprehension in informed consent are heterogeneous. Interactive interventions, particularly with test/feedback or teach-back components, appear superior. Future research should emphasize all key elements of informed consent and explore effects among vulnerable populations.
Collapse
Affiliation(s)
- Johanna Glaser
- School of Medicine, University of California, San Francisco, CA, USA
| | - Sarah Nouri
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Alicia Fernandez
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Dean Schillinger
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | | | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
7
|
Tarpley MJ, Costas-Chavarri A, Akinyi B, Tarpley JL. Ethics as a Non-technical Skill for Surgical Education in Sub-Saharan Africa. World J Surg 2020; 44:1349-1360. [PMID: 31897693 PMCID: PMC7224139 DOI: 10.1007/s00268-019-05351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background In recent years, surgical education has increased its focus on the non-technical skills such as communication and interpersonal relationships while continuing to strive for technical excellence of procedures and patient care. An awareness of the ethical aspects of surgical practice that involve non-technical skills and judgment is of vital concern to surgical educators and encompasses disparate issues ranging from adequate supervision of trainees to surgical care access. Methods This bibliographical research effort seeks to report on ethical challenges from a sub-Saharan Africa (SSA) perspective as found in the peer-reviewed literature employing African Journals Online, Bioline, and other sources with African information as well as PubMed and PubMed Central. The principles of autonomy, non-maleficence, beneficence, and justice offer a framework for a study of issues including: access to care (socioeconomic issues and distance from health facilities); resource utilization and decision making based on availability and cost of resources, including ICU and terminal extubation; informed consent (both communication about reasonable expectations post-procedure and research participation); research ethics, including local projects and international collaboration; quality and safety including supervision of less experienced professionals; and those religious and cultural issues that may affect any ethical decision making. The religious and cultural environment receives attention because beliefs and traditions affect medical choices ranging from acceptance of procedures, amputations, to end-of-life decisions. Results and Conclusions Ethics awareness and ethics education should be a vital component of non-technical skills training in surgical education and medical practice in SSA for trainees. Continuing professional development of faculty should include an awareness of ethical issues.
Collapse
Affiliation(s)
- Margaret J. Tarpley
- University of Botswana, PMB 00713, Gaborone, Botswana
- Vanderbilt University, 1611 21st Avenue South, Nashville, TN 37232 USA
| | | | | | - John L. Tarpley
- University of Botswana, PMB 00713, Gaborone, Botswana
- Vanderbilt University, 1611 21st Avenue South, Nashville, TN 37232 USA
| |
Collapse
|