Procedure versus process: ethical paradigms and the conduct of qualitative research

Decolonial framework for applying reflexivity and positionality in global health research

Contemporary research practices link to colonial and imperialist knowledge creation and production and may promote harmful perspectives on marginalized and oppressed groups. We present a framework for a decolonial approach to research in global health and health promotion applicable across research settings. This framework is aimed at anticipating and alleviating potentially harmful practices inherent in dominant research methods. The framework focuses from a macro- and micro-level perspective on three critical dyads: 'context' and 'accountability'; 'researcher identity' and 'positionality'; and 'procedural ethics' and 'ethics in practice' considerations. We present guidance for how to consider reflexivity and positionality as they apply in this framework in global health and health promotion research practice.

Research ethics and collaborative research in health and social care: Analysis of UK research ethics policies, scoping review of the literature, and focus group study

Current research ethics frameworks were developed on the footprint of biomedical, experimental research and present several pitfalls when applied to non-experimental social sciences. This work explores how the normative principles underpinning policy and regulatory frameworks of research ethics and the related operational processes work in practice in the context of collaborative health and social care research. The work was organised in three phases. First, UK research ethics policy documents were analysed thematically, with themes further organised under the categories of 'Principles' and 'Processes'. Next, we conducted a scoping review of articles about research ethics in the context of collaborative health and social care research, published in English between 2010 and 2022. We then held an exploratory focus group with ten academic researchers with relevant experience to gather their views on how the research ethics system works in practice in England (UK). The thematic framework developed in the first phase supported the analysis of the articles included in the scoping review and of focus group data. The analysis of policy documents identified twelve themes. All were associated to both a principle and a related operational process. The scoping review identified 31 articles. Across these, some themes were barely acknowledged (e.g., Compliance with legislation). Other themes were extensively covered (e.g., The working of Research Ethics Committees), often to discuss issues and limitations in how, in practice, the research ethics system and its processes deal with collaborative research and to suggest options for improvement. Focus group data were largely consistent with the findings of the scoping review. This work provides evidence of the poor alignment between how the research ethics system is normatively expected to work and how it works in practice and offers options that could make research ethics more fit for purpose when addressing collaborative research in health and social care.

Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives

The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as "procedural ethics" and the identification and handling of ethical issues by researchers during the research process as "ethics in practice." While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

The Lived Experience of Healthcare Workers in Preventing Falls in Community Dwelling Individuals with Dementia

Older adults living with dementia have at least twice the risk of falling compared to their peers living without cognitive impairment. There is evidence for the effectiveness of standard interventions in falls prevention in community dwellings, but they may not translate to individuals with Mild Cognitive Impairment (MCI) or dementia. A qualitative enquiry, adopting an interpretive research design underpinned by a phenomenological approach using semi-structured interviews with four healthcare workers from the field was adopted. Data were analysed using Interpretive Phenomenological Analysis to identify themes. Four major themes were developed: on-going assessment is important in guiding interventions and influencing change, knowledge and experience informs practice, individuals living with dementia have complex physical and cognitive needs, and teamwork is essential in falls prevention strategies, which highlighted falls prevention in this context being multifactorial and complex. The findings found that combining physical and cognitive strategies as part of falls prevention has potential benefits for this population, including reducing falls risks and maintaining function. Targeted training and awareness raising within a supportive multi-disciplinary team structure is required, underpinned by on-going, person-centred assessments.

Participatory Research and the Ethics of Anonymisation

Research in the UK is increasingly regulated by ethics review committees (RECs) which require researchers to seek ethics approval before commencing research. These RECs routinely expect researchers to anonymise data as part of standard ethical research practice. However, the anonymisation of data may sit in tension with participatory approaches to research which prioritise shared ownership of the research. In particular, the need to make decisions relating to ethics prior to the start of research makes it difficult for researchers to meaningfully share decision-making power with their participants—a fundamental principle of participatory approaches. This paper uses a participatory research study as a case study to explore this tension. In the study, the decision to anonymise data was made as part of the ethics approval process. However, over the course of the study, the researcher questioned whether this was the correct decision for this study. In order to afford researchers the flexibility required to involve participants in decision making, this paper argues for a dialogic and situational approach to ethics regulation. Allowing researchers to delay key decisions would mean that researchers could involve participants in the decision-making process rather than purely informing them of the results of decisions made on their behalf.

Qualitative Data Sharing: Participant Understanding, Motivation, and Consent

Expectations to share data underlying studies are increasing, but research on how participants, particularly those in qualitative research, respond to requests for data sharing is limited. We studied research participants' willingness to, understanding of, and motivations for data sharing. As part of a larger qualitative study on abortion reporting, we conducted interviews with 64 cisgender women in two states in early 2020 and asked for consent to share de-identified data. At the end of interviews, we asked participants to reflect on their motivations for agreeing or declining to share their data. The vast majority of respondents consented to data sharing and reported that helping others was a primary motivation for agreeing to share their data. However, a substantial number of participants showed a limited understanding of the concept of "data sharing." Additional research is needed on how to improve participants' understanding of data sharing and thus ensure fully informed consent.

Reflections of methodological and ethical challenges in conducting research during COVID-19 involving resettled refugee youth in Canada

Research involving migrant youth involves navigating and negotiating complex challenges in order to uphold their rights and dignity, but also all while maintaining scientific rigour. COVID-19 has changed the global landscape within many domains and has increasingly highlighted inequities that exist. With restrictions focusing on maintaining physical distancing set in place to curb the spread of the virus, conducting in-person research becomes complicated. This article reflects on the ethical and methodological challenges encountered when conducting qualitative research during the pandemic with Syrian migrant youth who are resettled in Canada. The three areas discussed from the study are recruitment, informed consent and managing the interviews. Special attention to culture as being part of the study's methodology as an active reflexive process is also highlighted. The goal of this article is to contribute to the growing understanding of complexities of conducting research during COVID-19 with populations which have layered vulnerabilities, such as migrant youth. This article hopes that the reflections may help future researchers in conducting their research during this pandemic by being cognizant of both the ethical and methodological challenges discussed.

Huge variation in obtaining ethical permission for a non-interventional observational study in Europe

Background

Ethical approval (EA) must be obtained before medical research can start. We describe the differences in EA for an pseudonymous, non-interventional, observational European study.

Methods

Sixteen European national coordinators (NCs) of the international study on very old intensive care patients answered an online questionnaire concerning their experience getting EA.

Results

N = 8/16 of the NCs could apply at one single national ethical committee (EC), while the others had to apply to various regional ECs and/or individual hospital institutional research boards (IRBs). The time between applying for EA and the first decision varied between 7 days and 300 days. In 9/16 informed consent from the patient was not deemed necessary; in 7/16 informed consent was required from the patient or relatives. The upload of coded data to a central database required additional information in 14/16. In 4/16 the NCs had to ask separate approval to keep a subject identification code list to de-pseudonymize the patients if questions would occur. Only 2/16 of the NCs agreed that informed consent was necessary for this observational study. Overall, 6/16 of the NCs were satisfied with the entire process and 8/16 were (very) unsatisfied. 11/16 would welcome a European central EC that would judge observational studies for all European countries.

Discussion

Variations in the process and prolonged time needed to get EA for observational studies hampers inclusion of patients in some European countries. This might have a negative influence on the external validity. Further harmonization of ethical approval process across Europe is welcomed for low-risk observational studies.

Conclusion

Getting ethical approval for low-risk, non-interventional, observational studies varies enormously across European countries.

How to get ethics committee approval for clinical trials in Turkey?

The “ethics committee approval” required to conduct clinical trials can be difficult to obtain for researchers due to problems with their time management, evaluating clinical investigations as a routine process as a part of their work; confusions regarding the concepts of treatment, interference, research and intervention, and sometimes due to lack of knowledge. Ethics committee approval process in our country is discussed by informing the investigators who want to conduct clinical research, about the issues that should be considered in accordance with the current legal regulations related to the clinical trials involving human volunteers.

How is the audit of therapy intensity influencing rehabilitation in inpatient stroke units in the UK? An ethnographic study

OBJECTIVES

Occupational therapy, physiotherapy and speech and language therapy are central to rehabilitation after a stroke. The UK has introduced an audited performance target: that 45 min of each therapy should be provided to patients deemed appropriate. We sought to understand how this has influenced delivery of stroke unit therapy.

DESIGN

Ethnographic study, including observation and interviews. The theoretical framework drew on the work of Lipsky and Power, framing therapists as 'street level bureaucrats' in an 'audit society'.

SETTING

Stroke units in three English hospitals.

PARTICIPANTS

Forty-three participants were interviewed, including patients, therapists and other staff.

RESULTS

There was wide variation in how therapy time was recorded and in decision-making regarding which patients were 'appropriate for therapy' or auditable. Therapists interpreted their roles differently in each stroke unit. Therapists doubted the validity of the audit results and did not believe their results reflected the quality of services they provided. Some assumed their audit results would inform commissioning decisions. Senior therapy leaders shaped priorities and practices in each therapy team. Patients were inactive outside therapy sessions. Patients differed regarding the quantity of therapy they felt they needed but consistently wanted to be more involved in decisions and treated as individuals.

Can an ethics officer role reduce delays in research ethics approval? A mixed-method evaluation of an improvement project

OBJECTIVE

Frustration continues to be directed at delays in gaining approvals for undertaking health research in the UK. We aimed to evaluate the impact of an ethics officer intervention on rates of favourable opinions (approval) and provisional opinions (requiring revision and resubmission) and on the time taken to reach a final opinion by research ethics committees (RECs), to characterise how the role operated in practice, and to investigate applicants' views.

DESIGN

Mixed-method study involving (i) a 2-group, non-randomised before-and-after intervention study of RECs assigned an ethics officer and a matched comparator group; (ii) a process evaluation involving a survey of applicants and documentary analysis.

PARTICIPANTS

6 RECs and 3 associated ethics officers; 18 comparator RECs; REC applicants.

RESULTS

Rates of provisional and favourable opinions between ethics officer and comparator RECs did not show a statistically significant effect of the intervention (logistic regression, p=0.26 for favourable opinions and p=0.31 for provisional opinions). Mean time to reach a decision showed a non-significant reduction (ANOVA, p=0.22) from 33.3 to 32.0 days in the ethics officer RECs compared with the comparator RECs (32.6 to 32.9 days). The survey (30% response rate) indicated applicant satisfaction and also suggested that ethics officer support might be more useful before submission. Ethics officers were successful in identifying many issues with applications, but the intervention did not function exactly as designed: in 31% of applicants, no contact between the applicants and the ethics officer took place before REC review.

LIMITATIONS

This study was a non-randomised comparison cohort study. Some data were missing.

CONCLUSIONS

An ethics officer intervention, as designed and implemented in this study, did not increase the proportion of applications to RECs that were approved on first review and did not reduce the time to a committee decision.

Why take part in personalised cancer research? Patients' genetic misconception, genetic responsibility and incomprehension of stratification-an empirical-ethical examination

Therapeutic misconception is a well-known challenge for informed decision-making for cancer research participants. What is still missing, is a detailed understanding of the impact of "personalised" treatment research (e.g. biomarkers for stratification) on research participants. For this, we conducted the first longitudinal empirical-ethical study based on semi-structured interviews with colorectal cancer patients (n = 40) enrolled in a biomarker trial for (neo)adjuvant treatment, analysing the patients' understanding of and perspectives on research and treatment with qualitative methods. In addition to therapeutic misconception based on patients' confusion of research and treatment, and here triggered by misled motivation, information paternalism or incomprehension, we identified genetic misconception and genetic responsibility as new problematic issues. Patients mainly were not aware of the major research aim of future stratification into responders and non-responders nor did they fully acknowledge this as the aim for personalised cancer research. Thus, ethical and practical reflection on informed decision-making in cancer treatment and research should take into account the complexity of lay interpretations of modern personalised medicine. Instead of very formalistic, liability-oriented informed consent procedures, we suggest a more personalised communication approach to inform and motivate patients for cancer research.

Development and oversight of ethical health promotion quality assurance and evaluation activities involving human participants

ISSUE ADDRESSED

This paper considers the role of ethics and ethics review processes in the development of health promotion quality assurance and evaluation activities involving human participants.

CONTENT

The Australian National Health and Medical Research Council (NHMRC) National Statement on Ethical Conduct in Human Research and associated documents provide the framework for the ethical conduct and independent review of research (including quality assurance and evaluation) involving humans in Australia. Identifying the level of risk to which participants may be exposed by participation in quality assurance and evaluation activities is essential for health promotion workers undertaking such activities. Organisations can establish processes other than review by a Human Research Ethics Committee for negligible and low risk research activities. Health promotion quality assurance and evaluation activities often involve negligible and low risk to participants. Seven triggers that indicate the need for ethics review of quality assurance and evaluation activities and a procedural checklist for developing ethical quality assurance and evaluation activities are provided.

CONCLUSION

Health promotion workers should be familiar with the NHMRC's National Statement on Ethical Conduct in Human Research. When ethical considerations underpin the planning and conduct of all quality assurance and evaluation from the very beginning, the activity is the better for it, independent 'ethics approval' can mostly be secured without much trouble and workers' frustration levels are reduced. So what? Health promotion quality assurance and evaluation activities must be ethically justified. Health promotion workers should be familiar with the NHMRC's National Statement on Ethical Conduct in Human Research and should use it when developing health promotion quality assurance and evaluation activities.

Evidence for Health I: Producing evidence for improving health and reducing inequities

In an ideal world, researchers and decision-makers would be involved from the outset in co-producing evidence, with local health needs assessments informing the research agenda and research evidence informing the actions taken to improve health. The first step in improving the health of individuals and populations is therefore gaining a better understanding of what the main health problems are, and of these, which are the most urgent priorities by using both quantitative data to develop a health portrait and qualitative data to better understand why the local population thinks that addressing certain health challenges should be prioritized in their context. Understanding the causes of these health problems often involves analytical research, such as case-control and cohort studies, or qualitative studies to better understand how more complex exposures lead to specific health problems (e.g. by interviewing local teenagers discovering that watching teachers smoke in the school yard, peer pressure, and media influence smoking initiation among youth). Such research helps to develop a logic model to better map out the proximal and distal causes of poor health and to determine potential pathways for intervening and impacting health outcomes. Rarely is there a single 'cure' or stand-alone intervention, but rather, a continuum of strategies are needed from diagnosis and treatment of patients already affected, to disease prevention, health promotion and addressing the upstream social determinants of health. Research for developing and testing more upstream interventions must often go beyond randomized controlled trials, which are expensive, less amenable to more complex interventions, and can be associated with certain ethical challenges. Indeed, a much neglected area of the research cycle is implementation and evaluation research, which often involves quasi-experimental research study designs as well as qualitative research, to better understand how to derive the greatest benefit from existing interventions and ways of maximizing health improvements in specific local contexts. There is therefore a need to alter current incentive structures within the research enterprise to place greater emphasis on implementation and evaluation research conducted in collaboration with knowledge users who are in a position to use the findings in practice to improve health.

Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study

STUDY OBJECTIVE

We explored physicians' perceptions of and attitudes toward triage and end-of-life decisions for elderly critically ill patients at the emergency department (ED)-ICU interface.

METHODS

This was a qualitative study with thematic analysis of data collected through semistructured interviews (15 emergency physicians and 9 ICU physicians) and nonparticipant observations (324 hours, 8 units, in 2 hospitals in France).

RESULTS

Six themes emerged: (1) Physicians revealed a representation of elderly patients that comprised both negative and positive stereotypes, and expressed the concept of physiologic age. (2) These age-related factors influenced physicians' decisionmaking in resuscitate/not resuscitate situations. (3) Three main communication patterns framed the decisions: interdisciplinary decisions, decisions by 2 physicians on their own, and unilateral decisions by 1 physician; however, some physicians avoided decisions, facing uncertainty and conflicts. (4) Conflicts and communication gaps occurred at the ED-ICU interface and upstream of the ED-ICU interface. (5) End-of-life decisions were perceived as more complex in the ED, in the absence of family or of information about elderly patients' end-of-life preferences, and when there was conflict with relatives, time pressure, and a lack of training in end-of-life decisionmaking. (6) During decisionmaking, patients' safety and quality of care were potentially compromised by delayed or denied intensive care and lack of palliative care.

CONCLUSION

These qualitative findings highlight the cognitive heuristics and biases, interphysician conflicts, and communication gaps influencing physicians' triage and end-of-life decisions for elderly critically ill patients at the ED-ICU interface and suggest strategies to improve these decisions.

Emerging issues in paediatric health research consent forms in Canada: working towards best practices

Background

Obtaining a research participant’s voluntary and informed consent is the bedrock of sound ethics practice. Greater inclusion of children in research has led to questions about how paediatric consent operates in practice to accord with current and emerging legal and socio-ethical issues, norms, and requirements.

Methods

Employing a qualitative thematic content analysis, we examined paediatric consent forms from major academic centres and public organisations across Canada dated from 2008–2011, which were purposively selected to reflect different types of research ethics boards, participants, and studies. The studies included biobanking, longitudinal studies, and gene-environment studies. Our purpose was to explore the following six emerging issues: (1) whether the scope of parental consent allows for a child’s assent, dissent, or future consent; (2) whether the concepts of risk and benefit incorporate the child’s psychological and social perspective; (3) whether a child’s ability to withdraw is respected and to what extent withdrawal is permitted; (4) whether the return of research results includes individual results and/or incidental findings and the processes involved therein; (5) whether privacy and confidentiality concerns adequately address the child’s perspective and whether standard data and/or sample identifiability nomenclature is used; and (6) whether retention of and access to paediatric biological samples and associated medical data are addressed.

Results

The review suggests gaps and variability in the consent forms with respect to addressing each of the six issues. Many forms did not discuss the possibility of returning research results, be they individual or general/aggregate results. Forms were also divided in terms of the scope of parental consent (specific versus broad), and none discussed a process for resolving disputes that can arise when either the parents or the child wishes to withdraw from the study.

Conclusions

The analysis provides valuable insight and evidence into how consent forms address current ethical issues. While we do not thoroughly explore the contexts and reasons behind consent form gaps and variability, we do advocate and formulate the development of best practices for drafting paediatric health research consent forms. This can greatly ameliorate current gaps and facilitate harmonised and yet contextualised approaches to paediatric health research ethics.