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Akhtar MU, Bhatti ME, Fredericks S. What factors influence patient autonomy in healthcare decision-making? A systematic review of studies from the Global South. Nurs Ethics 2024:9697330241272794. [PMID: 39175161 DOI: 10.1177/09697330241272794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The principle of respect for autonomy (PRA) is a central tenet of bioethics. In the quest for a global bioethics, it is pertinent to ask whether this principle can be applied as it is to cultures and societies that are devoid of the Western sociopolitical historical pressures that led to its emergence. Relational autonomists have argued for a more inclusive approach to patient autonomy which takes into account factors such as interdependency and social relations. However, at the outset of any relational approach, it is necessary to identify underlying factors that influence patient autonomy in non-Western cultures. OBJECTIVE To conduct a review of the literature to uncover the mechanisms through which social, cultural, and religious factors influence and impact the application of the PRA in healthcare decision-making in non-Western cultures and societies. METHODS We conducted a systematic review through a comprehensive search of three major electronic databases of biomedical sciences. Returned citations were imported to Covidence, full texts were assessed for eligibility, included articles were thoroughly reviewed and data was synthesized. PRISMA guidelines were followed. RESULTS Our search retrieved 590 non-duplicate results, 50 of which were included after screening and full-text eligibility checks. The included studies were predominantly qualitative in nature, with few quantitative, mixed-methods, and review studies included. Our synthesis of data identified nine key factors that influenced patients' autonomous decision-making through cultural, social, religious, or intersectional pathways. CONCLUSION Two main conclusions emerge from this review. Firstly, there is a notable dearth of bioethical research examining the influence of diverse factors on patients' inclination towards different conceptions of autonomy. Secondly, the analysis of prevalent collectivist cultures and deference of autonomy adds value to the solution-oriented relational autonomy debate. This raises questions regarding how decision-making can be truly autonomous in the presence of such large-scale factors, warranting further attention.
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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.
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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
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Mogili AR, Mukisa D, Campbell P, Giibwa A, Binoga M, Emoru A, Kalumuna AT, Damoi JO, Melendez C, Waye J, Marin ML, Zhang LP. Do patients actually understand? An evaluation of the informed consent process for endoscopic procedures in rural Uganda. Surg Endosc 2024; 38:4024-4030. [PMID: 38877318 DOI: 10.1007/s00464-024-10971-z] [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: 04/25/2024] [Accepted: 05/28/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION Improving surgical access in low- and middle-income countries is vital for the 5 billion people who lack safe surgical care. Tailoring a culturally sensitive approach to consent is essential for patient comprehension and comfort, thereby alleviating the effects of resource constraints and advancing equitable care. This study examines the consenting process for endoscopy at Kyabirwa Surgical Center in Kyabirwa, Jinja, Uganda, to assess patients' knowledge and attitudes as a potential barrier to participating in endoscopic procedures. METHODS All adult upper endoscopy (EGD) and colonoscopy patients were recruited to participate in a survey of their demographics, knowledge, and attitudes toward their procedure. All patients received a standard consultation explaining the procedure and its risks and benefits. RESULTS 75 patients were included; median age was 54 years and 56% (n = 42) were women. 92% (n = 69) of patients had never had an endoscopy before and 73% (n = 55) of patients were scheduled for an EGD while the remaining 27% (n = 20) were scheduled for a colonoscopy. Most patients 80% (n = 60) had a basic understanding of what an endoscopy is and 87% (n = 65) its diagnostic purpose. Few patients 15% (n = 11) knew of the most common side effects or if they would have a surgical scar 27% (n = 20). Overall, 46.7% (n = 35) of patients were moderately or severely fearful of getting an endoscopy. Additionally, 45.3% (n = 34) of patients were moderately or severely fearful of receiving anesthesia during their endoscopic procedure. Despite this fear, most patients 85.3% (n = 64) stated that they understood the benefits of the procedure either very well or extremely well. CONCLUSIONS Most patients understood the role that an endoscopic procedure plays in their care and its potential benefits. Despite this, many patients continued to have high levels of fear associated with both the endoscopic procedure and with receiving anesthesia during their procedure. Future patient education should focus on addressing patients' fears and the risks of undergoing an endoscopy, which may improve the utilization of surgical services.
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Affiliation(s)
- Abhishek R Mogili
- Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Daniel Mukisa
- Kyabirwa Surgical Center, Uganda Plot 668, Block 4, Kyabirwa, Jinja, Uganda
| | - Peter Campbell
- Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Angellica Giibwa
- Kyabirwa Surgical Center, Uganda Plot 668, Block 4, Kyabirwa, Jinja, Uganda
| | - Moses Binoga
- Kyabirwa Surgical Center, Uganda Plot 668, Block 4, Kyabirwa, Jinja, Uganda
| | - Arthur Emoru
- Kyabirwa Surgical Center, Uganda Plot 668, Block 4, Kyabirwa, Jinja, Uganda
| | - Anna T Kalumuna
- Kyabirwa Surgical Center, Uganda Plot 668, Block 4, Kyabirwa, Jinja, Uganda
| | - Joseph O Damoi
- Kyabirwa Surgical Center, Uganda Plot 668, Block 4, Kyabirwa, Jinja, Uganda
| | - Chelsia Melendez
- Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Jerome Waye
- Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Michael L Marin
- Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Linda P Zhang
- Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
- Department of Surgery, Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA.
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Sánchez MC, Hernández Clemente JC, García López FJ. Public and Patients' Perspectives Towards Data and Sample Sharing for Research: An Overview of Empirical Findings. J Empir Res Hum Res Ethics 2023; 18:319-345. [PMID: 37936410 DOI: 10.1177/15562646231212644] [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] [Indexed: 11/09/2023]
Abstract
We aimed to review the attitudes and perspectives of the public and patients towards the sharing of data and biospecimens for research and to identify common dimensions, regardless of setting. Our review included systematic, scoping or thematic reviews of empirical studies retrieved from Medline (PubMed interface), Web of Science, Scopus, ProQuest and Cochrane Reviews. The main themes identified and synthesised across the 14 reviews were readiness and motivations; potential risks and safeguards; trust, transparency and accountability; autonomy and preferred type of consent; and factors influencing data and biospecimen sharing and consent. Sociodemographic factors and research and individual context remain relevant influencing factors in all settings, while preferences for types of consent are highly heterogeneous. Trusted environments and adapted consent options with participant engagement are relevant to improve research participation.
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Moodley Y, van Wyk J, Ning Y, Wexner S, Gounden C, Naidoo V, Kader S, Neugut AI, Kiran RP. Self-adherence to post-colonoscopy consults in patients undergoing diagnostic colonoscopy: Findings from a cross-sectional, quantitative survey at a South African quaternary hospital. PLoS One 2023; 18:e0288752. [PMID: 37463177 PMCID: PMC10353782 DOI: 10.1371/journal.pone.0288752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
Post-colonoscopy consults empower patients to make informed decisions around their subsequent treatment, and non-compliance with these consults ("no-shows") hinders disease management. There is a paucity in the literature regarding self-adherence to post-colonoscopy consults in resource-limited settings such as South Africa. An understanding of self-adherence to post-colonoscopy consults in this setting is required to establish whether improved interventions are needed, and what specific elements of self-adherence should be addressed with these interventions. The objective of this hypothesis-generating, cross-sectional, quantitative survey was to conduct a baseline assessment of cognitive, motivational, social, and behavioural variables related to self-adherence to post-colonoscopy consults in patients who underwent diagnostic colonoscopy at a South African quaternary hospital. The Adherence Determinants Questionnaire (ADQ) was administered in 47 patients to establish a baseline assessment of elements related to self-adherence to post-colonoscopy consults, including interpersonal aspects of care, perceived utility, severity, susceptibility, subjective norms, intentions, and supports/barriers. ADQ scores were transformed to a percentage of the maximum score for each element (100.0%). The overall mean transformed ADQ score was 57.8%. The mean transformed scores for specific ADQ components were as follows: subjective norms (40.8%), perceived severity (55.4%), perceived utility (56.6%), intentions (59.4%), supports/barriers (59.9%), interpersonal aspects (62.2%), and perceived susceptibility (65.9%). There were no statistically significant differences in overall mean transformed ADQ scores and individual ADQ elements across categories of participant age (p-values ranging between 0.180 and 0.949 when compared between participants ≤40 years and >40 years old), gender (p-values ranging between 0.071 and 0.946 when compared between males and females), and race (p-values ranging between 0.119 and 0.774 when compared between Black Africans and non-Black Africans). Our findings suggest a general need for appropriate interventions to improve self-adherence to post-colonoscopy consults in our setting.
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Affiliation(s)
- Yoshan Moodley
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jacqueline van Wyk
- Department of Health Sciences Education, University of Cape Town, Cape Town, South Africa
- School of Clinical Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Yuming Ning
- Department of Surgery, Columbia University, New York, NY, United States of America
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, United States of America
| | - Cathrine Gounden
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Vasudevan Naidoo
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shakeel Kader
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Alfred I. Neugut
- Department of Medicine and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, United States of America
| | - Ravi P. Kiran
- Department of Surgery, Columbia University, New York, NY, United States of America
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Kaawa-Mafigiri D, Ekusai Sebatta D, Munabi I, Mwaka ES. Genetic and Genomic Researchers' Perspectives on Biological Sample Sharing in Collaborative Research in Uganda: A Qualitative Study. J Empir Res Hum Res Ethics 2023:15562646231171289. [PMID: 37151037 DOI: 10.1177/15562646231171289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Numerous ethical, legal, and social issues arise with biological sample sharing. The study explored the perspectives of genetic and genomic researchers on the sharing of biological samples in international collaborative research. Qualitative in-depth interviews were conducted with 15 researchers. Participants expressed positive attitudes towards biobanking and appreciated the benefits of cross-border sharing of biological samples but noted that this practice had adversely affected local capacity building efforts. There was limited understanding of the ethical and regulatory frameworks governing sample sharing. Researchers emphasized the importance of respecting cultural values in biobanking research. Issues concerning poor governance and inequitable benefit sharing were also raised. There is a need for fair and equitable international collaborations where all researchers are treated with respect and as equal partners.
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Affiliation(s)
| | | | - Ian Munabi
- College of Health Sciences, Makerere University, Kampala, Uganda
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Russell AM, Shepherd V, Woolfall K, Young B, Gillies K, Volkmer A, Jayes M, Huxtable R, Perkins A, Noor NM, Nickolls B, Wade J. Complex and alternate consent pathways in clinical trials: methodological and ethical challenges encountered by underserved groups and a call to action. Trials 2023; 24:151. [PMID: 36855178 PMCID: PMC9973248 DOI: 10.1186/s13063-023-07159-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Informed consent is considered a fundamental requirement for participation in trials, yet obtaining consent is challenging in a number of populations and settings. This may be due to participants having communication or other disabilities, their capacity to consent fluctuates or they lack capacity, or in emergency situations where their medical condition or the urgent nature of the treatment precludes seeking consent from either the participant or a representative. These challenges, and the subsequent complexity of designing and conducting trials where alternative consent pathways are required, contribute to these populations being underserved in research. Recognising and addressing these challenges is essential to support trials involving these populations and ensure that they have an equitable opportunity to participate in, and benefit from, research. Given the complex nature of these challenges, which are encountered by both adults and children, a cross-disciplinary approach is required. DISCUSSION A UK-wide collaboration, a sub-group of the Trial Conduct Working Group in the MRC-NIHR Trial Methodology Research Partnership, was formed to collectively address these challenges. Members are drawn from disciplines including bioethics, qualitative research, trials methodology, healthcare professions, and social sciences. This commentary draws on our collective expertise to identify key populations where particular methodological and ethical challenges around consent are encountered, articulate the specific issues arising in each population, summarise ongoing and completed research, and identify targets for future research. Key populations include people with communication or other disabilities, people whose capacity to consent fluctuates, adults who lack the capacity to consent, and adults and children in emergency and urgent care settings. Work is ongoing by the sub-group to create a database of resources, to update NIHR guidance, and to develop proposals to address identified research gaps. CONCLUSION Collaboration across disciplines, sectors, organisations, and countries is essential if the ethical and methodological challenges surrounding trials involving complex and alternate consent pathways are to be addressed. Explicating these challenges, sharing resources, and identifying gaps for future research is an essential first step. We hope that doing so will serve as a call to action for others seeking ways to address the current consent-based exclusion of underserved populations from trials.
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Affiliation(s)
- Amy M Russell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Anna Volkmer
- Department of Psychology and Language Sciences, University College London, London, UK
| | - Mark Jayes
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alexander Perkins
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nurulamin M Noor
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Beverley Nickolls
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Julia Wade
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
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Patients’ Experience on Practice and Applicability of Informed Consent in Traditional Medical Practice in KwaZulu-Natal Province, South Africa. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:3674467. [PMID: 35096108 PMCID: PMC8794665 DOI: 10.1155/2022/3674467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/21/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
Abstract
Background Informed consent (IC) is constitutionally protected in South Africa based on individual rights to bodily integrity and well-being. In terms of the law, patients cannot be involved in medical treatment or research without IC. This study explored patients' experience on practice and applicability of IC in African traditional medicine (ATM) in Msunduzi and eThekwini municipalities, KwaZulu-Natal province, South Africa, to evaluate whether important elements of IC such as full information disclosure, capacity, understanding, and volition are considered or being applied during ATM. Methods This cross-sectional quantitative study was conducted using semistructured questionnaires administered to patients attending traditional health practitioners' (THPs') treatment centres. Stata V15.1 was used to analyse variables including descriptive and inferential data analysis. Results One hundred and twenty-nine (129) participants completed this study, of which 62% were females. Most participants were in the age range of 26–35 (38.8%). All respondents were IsiZulu home-language speakers, single (62.8%), employed (48%), and with some tertiary education (48.8%). Most patients were informed about their diagnosis (58.9%), treatment benefits (79.8%), and recommended treatment (79.8%). Fewer were informed about risks of treatment (36.4%), right of refusal (3.1%), and risks of refusing recommended treatment (0.8%). All participants reported satisfaction with information disclosed by the THPs and did not feel coerced to accept treatment. Consent was obtained verbally in all cases. The majority of participants (76.7%) sought surrogate assistance when consulting THPS, and 81.4% preferred being informed about all treatment risks. Most respondents also preferred involvement in healthcare decision-making during ATM. Conclusion This study reveals that most patients consulting THPs in the KwaZulu-Natal province for treatment are aware of their right to information disclosure and the need to reach agreement before involvement in ATM treatment procedures. The study also showed that some key elements of IC are currently being applied during ATM practice in South Africa.
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Chima SC. Evaluating Knowledge, Practice, and Barriers to Informed Consent Among Professional and Staff Nurses in South Africa: An Empirical Study. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1089785ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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