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Ssali A, Namugumya R, Nalubega P, Kyohere M, Seeley J, Doare KL. Exploring the consent process among pregnant and breastfeeding women taking part in a maternal vaccine clinical trial in Kampala, Uganda: a qualitative study. BMC Med Ethics 2024; 25:57. [PMID: 38755578 PMCID: PMC11097482 DOI: 10.1186/s12910-024-01055-7] [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: 02/03/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The involvement of pregnant women in vaccine clinical trials presents unique challenges for the informed consent process. We explored the expectations and experiences of the pregnant women, spouses/partners, health workers and stakeholders of the consent process during a Group B Streptococcus maternal vaccine trial. METHODS We interviewed 56 participants including pregnant women taking part in the trial, women not in the trial, health workers handling the trial procedures, spouses, and community stakeholders. We conducted 13 in-depth interviews and focus group discussions with 23 women in the trial, in-depth interviews with 5 spouses, and 5 women not in the trial, key informant interviews with 5 health workers and 5 other stakeholders were undertaken. RESULTS Decision-making by a pregnant woman to join a trial was done in consultation with spouse, parents, siblings, or trusted health workers. Written study information was appreciated by all but they suggested the use of audio and visual presentation to enhance understanding. Women stressed the need to ensure that their male partners received study information before their pregnant partners joined a clinical trial. Confidentiality in research was emphasised differently by individual participants; while some emphasised it for self, others were keen to protect their family members from being exposed, for allowing them to be involved in research. However, others wanted their community participation to be acknowledged. CONCLUSION We found that pregnant women make decisions to join a clinical trial after consulting with close family. Our findings suggest the need for an information strategy which informs not only the pregnant woman, but also her family about the research she is invited to engage in.
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Affiliation(s)
- Agnes Ssali
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.
| | - Rita Namugumya
- Makerere University -John Hopkins University Research Collaboration, Kampala, Uganda
| | - Phiona Nalubega
- Makerere University -John Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK
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Zemsi A, Nekame LJG, Mohammed N, Batchilly ES, Dabira E, Sillah SO, Sey G, Williams DH, Dondeh BL, Cerami C, Clarke E, D'Alessandro U. Practical Guidelines for Standardised Resolution of Important Protocol Deviations in Clinical Trials Conducted in Sub-Saharan Africa. Ther Innov Regul Sci 2024; 58:395-403. [PMID: 38285370 PMCID: PMC11043146 DOI: 10.1007/s43441-023-00604-3] [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: 07/18/2023] [Accepted: 12/01/2023] [Indexed: 01/30/2024]
Abstract
A clinical trial is any research on human subjects that involves an investigational medicinal product or device. Investigational medicinal products include unlicensed drugs or drugs used outside the product license (e.g. for a new indication) (ICH-GCP). As per the internationally accepted ICH-GCP guidelines, clinical trials should be conducted strictly per the approved protocol. However, during the lifecycle of a trial, protocol deviations may occur. Under ICH efficacy guidelines, protocol deviations are divided into non-important (minor) or important (major), and the latter can jeopardise the participant's rights, safety or the quality of data generated by the study. Existing guidelines on protocol deviation management do not detail or standardise actions to be taken for participants, investigational products, data or samples as part of a holistic management of important protocol deviations. Herein, we propose guidelines to address the current literature gap and promote the standardisation of actions to address important protocol deviations in clinical trials. The advised actions should complement the existing local institutional review board and national regulatory authority requirements.
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Affiliation(s)
- Armel Zemsi
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia.
| | | | - Nuredin Mohammed
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | | | - Edgard Dabira
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Sheikh Omar Sillah
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Gibbi Sey
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Daisy H Williams
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Bai-Lamin Dondeh
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Carla Cerami
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Ed Clarke
- MRCG at LSHTM, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
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Luseno WK, Iritani BJ, Hartman S, Odongo FS, Otieno FA, Ongili BO, Rennie S. Assessment of Consent Comprehension Among Kenyan Adolescents, Young Adults, and Parents: Comparison of Enhanced and Standard Consenting Procedures. J Adolesc Health 2024; 74:605-612. [PMID: 38069940 PMCID: PMC10873115 DOI: 10.1016/j.jadohealth.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE Youth aged 15-19 years and parents of minors aged 15-17 years in sub-Saharan Africa are under-represented in empirical consent research. Thus, knowledge is limited concerning the adequacy of consent procedures and need for strategies to improve consent comprehension among these groups. We assessed comprehension following standard consent procedures and evaluated an enhanced procedure among Kenyan youth and parents. METHODS Participants were adolescents aged 15-17 years (n = 273), their parents (n = 196), and young adults aged 18-19 years (n = 196). We used a quasi-experimental cohort design to implement standard and enhanced (single condition: extended discussion, test/feedback) consent procedures. Participants completed a 21-item informed consent comprehension assessment instrument. RESULTS After standard consent procedures, mean comprehension scores were 11.36, 13.64, and 13.43 (score range: 0-21) among adolescents, young adults, and parents, respectively. About 6.2% of adolescents, 19.6% of young adults, and 21.4% of parents answered ≥ 80% of the questions correctly. After the enhanced procedures, comprehension scores (15.87 adolescents, 17.81 young adults, and 16.77 parents) and proportions answering ≥ 80% of the questions correctly (44.9% adolescents, 76.8% young adults, and 64.3% parents) increased significantly. Regression analysis indicated statistically significant differences (p < .001) in comprehension scores between the enhanced and standard groups (β = 3.87 adolescents, β = 4.03 young adults, and β = 3.60 parents) after controlling for sociodemographic factors. DISCUSSION Enhancing consent procedures with extended discussions, quizzes, and additional explanation where understanding is inadequate is a promising approach for improving comprehension. However, poorer comprehension among adolescents compared to young adults and parents underscores the need for research to identify additional approaches to improve understanding.
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Affiliation(s)
| | - Bonita J Iritani
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina
| | - Shane Hartman
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina
| | - Fredrick S Odongo
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | | | - Barrack Otieno Ongili
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Mazzochi AT, Dennis M, Chun HYY. Electronic informed consent: effects on enrolment, practical and economic benefits, challenges, and drawbacks-a systematic review of studies within randomized controlled trials. Trials 2023; 24:127. [PMID: 36810093 PMCID: PMC9942032 DOI: 10.1186/s13063-022-06959-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 11/24/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Enrolment is one of the most challenging aspects of conducting clinical trials, preceded by the process of informed consent (IC). Different strategies to improve recruitment in clinical trials have been used, including electronic IC. During COVID-19 pandemic, barriers to enrolment have been evident. Although digital technologies were acknowledged as the future of clinical research and potential advantages were shown for recruitment, electronic informed consent (e-IC) has not yet been globally adopted. The purpose of this review is to investigate the effect of using e-IC on enrolment, practical and economic benefits, challenges, and drawbacks when compared to traditional informed consent, through a systematic review. METHODS Embase, Global Health Library, Medline, and The Cochrane Library databases were searched. No limit was set for publication date, age, sex, or study design. We included all studies within a randomized controlled trial (RCT), published in English, Chinese or Spanish, evaluating the electronic consent process used in the parent RCT. Studies were included if any of the three components ((i) information provision, (ii) participant's comprehension, (iii) signature) of the IC process was designed as electronic, whether administered remotely or face-to-face. The primary outcome was the rate of enrolment to the parent trial. Secondary outcomes were summarized according to the various findings reported on the use of electronic consent. RESULTS From a total of 9069 titles, 12 studies were included in the final analysis with a total of 8864 participants. Five studies of high heterogeneity and risk of bias showed mixed results on the efficacy of e-IC on enrolment. Data of included studies suggested e-IC could improve comprehension and recall of study-related information. Meta-analysis could not be conducted due to different study designs and outcome measures and the predominantly qualitative findings. CONCLUSION Few published studies have investigated the impact of e-IC on enrolment and findings were mixed. e-IC may improve participant's comprehension and recall of information. High-quality studies are needed to evaluate the potential benefit of e-IC to increase clinical trial enrolment. TRIAL REGISTRATION PROSPERO CRD42021231035 . Registration date: 19-Feb-2021.
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Affiliation(s)
- Ana Teresita Mazzochi
- Usher Institute, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ho-Yan Yvonne Chun
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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O'Sullivan Greene E, Shiely F. Recording and reporting of recruitment strategies in trial protocols, registries, and publications was nonexistent. J Clin Epidemiol 2022; 152:248-256. [PMID: 36273772 DOI: 10.1016/j.jclinepi.2022.10.014] [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: 07/20/2022] [Revised: 09/27/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To investigate how trialists record and report their recruitment strategies and the recruiter details in trial protocols, registries, and publications. STUDY DESIGN AND SETTING A retrospective study of ovarian cancer (OC) trials between 2010 and 2021. We reviewed 154 trial publications, 30 protocols, 105 registry entries, and 26 trial websites associated with 88 phase III OC trials. RESULTS None of the 88 trials reviewed published a recruitment strategy or made reference to an available recruitment strategy for the trial. Only 31% (n = 28) made reference to the recruiter but this was reported only in the protocol so we have no evidence these named recruiters performed the task. None of the trials reviewed which closed early or extended recruitment timelines due to slow accrual, reported measures taken to improve recruitment rates before stoppages or changes took place. There were disparities in the reported target recruitment numbers between the protocol, the publication, and the registry. CONCLUSION Recruitment strategies exist, and we are sure most trial centers use recruitment strategies, but they need to be recorded and reported, as part of the supplementary material if not the main publication, so we can evaluate their effectiveness.
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Affiliation(s)
| | - Frances Shiely
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, Cork, Ireland; School of Public Health, University College Cork, Cork, Ireland.
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Sacco G, Noublanche F, Blazek F, Hue C, Carballido L, Asfar M, Allain P, Annweiler C. How to deal with the consent of adults with cognitive impairment involved in European geriatric living labs? Philos Ethics Humanit Med 2021; 16:3. [PMID: 34130730 PMCID: PMC8207703 DOI: 10.1186/s13010-021-00101-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 05/25/2021] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Living labs are realistic environments designed to create links between technology developers and end-users (i.e. mostly older adults). Research in LLH (Living labs in health) covers a wide range of studies from non-interventional studies to CT (clinical trials) and should involve patients with neurocognitive disorders. However, the ethical issues raised by the design, development, and implementation of research and development projects in LLH have been the subject of only little interest thus far. OBJECTIVE Our aim was to determine a pragmatic, ethical and regulatory correct approach to seek the informed consent of patients with neurocognitive disorders according to the different types of studies carried out in European LLH, with a focus on the French context. METHODS A narrative review of regulatory texts and clinical articles was conducted, and a pragmatic procedure to determine the decision-making capacity of older adults in LLH was proposed. RESULTS Individuals must be adequately informed and freely agree to participate in CT. The capacity to consent should be assessed in CT including cognitively impaired older adults. We propose the following steps: first to assess for delirium using the 4 'A's Test (4AT) or the 3-min Diagnostic interview for Confusion Assessment Method (3D-CAM), second to search for medical history of major neurocognitive disorder, and third to assess the decision capacity using the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC). CONCLUSIONS Including individuals with neurocognitive disorders in research implies using an efficient and pragmatic strategy to inform participants and obtain their consent. The tool we offer here may be useful in the routine operation of LLH but can also be extended to all CT with this population.
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Affiliation(s)
- Guillaume Sacco
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, Angers, France.
- Univ Angers, Université de Nantes, LPPL, SFR CONFLUENCES, F-49000, Angers, France.
- Université Côte d'Azur, CoBTek, Nice, France.
| | - Frédéric Noublanche
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, Angers, France
- Univ Angers, Université de Nantes, LPPL, SFR CONFLUENCES, F-49000, Angers, France
| | | | | | | | - Marine Asfar
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, Angers, France
| | - Philippe Allain
- Univ Angers, Université de Nantes, LPPL, SFR CONFLUENCES, F-49000, Angers, France
| | - Cédric Annweiler
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, Angers, France.
- Univ Angers, Université de Nantes, LPPL, SFR CONFLUENCES, F-49000, Angers, France.
- Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, Canada.
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Abstract
OBJECTIVES To describe legal guardians' understanding of key concepts in a research consent form presented within 24 hours of their child's admission to the PICU and to explore legal guardians' opinions of the format (language, length) of the consent form and the overall consent process. DESIGN Single-center, exploratory pilot study. SETTING PICU at a tertiary-care hospital in Canada. SUBJECTS Forty-one English- and French-speaking legal guardians of children less than 18 years old, who had been admitted to the PICU within the past 24 hours and were expected to stay at least 48 hours, between October 2018 and February 2019. INTERVENTIONS The consent form from a previous PICU trial was given and explained to legal guardians within 24 hours of their child's admission to the PICU. MEASUREMENTS AND MAIN RESULTS Legal guardians' understanding of key concepts in the consent form was evaluated using a questionnaire the day after the form was explained, and opinions were collected verbally and using an additional survey. The median number of questions answered incorrectly was three of seven (interquartile range = 2-4). Participants best understood the topic of the study (5% incorrect), but 80% of participants were unable to recall a single risk. The median rating of the language in the form was five of five (very easy to understand; interquartile range = 4-5), and 88% of participants said it was a reasonable length. CONCLUSIONS Despite positive opinions of the consent form, most legal guardians did not understand all key components of the consent information provided to them orally and in writing within 24 hours of their child's PICU admission. Future studies are required to determine barriers to understanding and explore alternative approaches to obtaining consent in this setting.
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Ditai J, Abeso J, Odeke NM, Mobbs N, Dusabe-Richards J, Mudoola M, Carrol ED, Olupot-Olupot P, Storr J, Medina-Lara A, Gladstone M, Faragher EB, Weeks AD. BabyGel pilot: a pilot cluster randomised trial of the provision of alcohol handgel to postpartum mothers to prevent neonatal and young infant infection-related morbidity in the community. Pilot Feasibility Stud 2019; 5:49. [PMID: 30962946 PMCID: PMC6436217 DOI: 10.1186/s40814-019-0432-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/12/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Alcohol-based hand rub (ABHR) is widely used in both health and social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in African rural homes. Our study piloted a cluster randomised trial of providing ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the communities. METHODS We conducted a pilot parallel cluster randomised controlled trial across ten villages (clusters) in rural Eastern Uganda. Pregnant women of over 34 weeks' gestation were recruited over a period of 3 months. Both clusters received the standard of care of antenatal health education, Maama Kit, and clinic appointments. In addition, women in the intervention villages received ABHR, instructions on ABHR use, a poster on the 'three moments of hand hygiene', and training. We followed up each mother-baby pair for 3 months after birth and measured rates of consent, recruitment, and follow-up (our target rate was more than 80%). Other measures included ABHR use (the acceptable use was more than four times a day) and its mode of distribution (village health workers (VHWs) or pharmacy), acceptability of study protocol and electronic data capture, and the use of WHO Integrated Management of Childhood Illness (IMCI) tool to screen for newborn infection. RESULTS We selected 36% (10/28) of villages for randomisation to either intervention or control. Over 12 weeks, 176 pregnant women were screened and 58.5% (103/176) were eligible. All, 100% (103/103), eligible women gave consent and were enrolled into the trial (55 intervention and 48 control). After birth, 94.5% (52/55) of mothers in the intervention and 100% (48/48) of mothers in the control villages were followed up within 72 h. Most, 90.9% (50/55), of the mothers in the intervention villages (96.2% of live births) and 95.8% (46/48) of mothers in the control villages (95.9% of live births) were followed up at 3 months. In intervention villages, the average hand rub use was 6.6 times per day. VHWs accounted for all ABHR stock, compared to the pharmacy that could not account for 5 l of ABHR. The screening tool was positive for infection among a third of babies, i.e. 29.2% (14/48) in the intervention villages versus 31.4% (16/51) in the control villages.VHWs completed the first four questions of IMCI screening tool with ease and accuracy. There were no adverse reactions with the ABHR. CONCLUSION It is feasible to conduct a cluster-randomised controlled trial (cRCT) of the provision of ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the community in resource-poor settings. Our results indicate that home recruitment promotes excellent follow-up and retention of participants in community trials. The intervention was safe. This pilot study informed the substantial changes necessary in the larger cRCT, including a change in the primary outcome to a composite outcome considering multiple methods of infection detection. A large BabyGel cluster randomised controlled trial is now required. TRIAL REGISTRATION ISRCTN67852437, registered March 02, 2015. TRIAL FUNDING Medical Research Council/WellcomeTrust/DfID (Global Health Trials Scheme).
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Affiliation(s)
- J. Ditai
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.O Box 2190, Mbale, Uganda
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
- Busitema University Faculty of Health Sciences, P.O Box 1460, Mbale, Uganda
| | - J. Abeso
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
- Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda
| | - N. M. Odeke
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.O Box 2190, Mbale, Uganda
| | - N. Mobbs
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
| | - J. Dusabe-Richards
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - M. Mudoola
- Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.O Box 2190, Mbale, Uganda
| | - E. D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool, L69 7BE UK
| | - P. Olupot-Olupot
- Busitema University Faculty of Health Sciences, P.O Box 1460, Mbale, Uganda
| | | | - A. Medina-Lara
- Health Economics Group, University of Exeter, Exeter, UK
| | - M. Gladstone
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
| | - E. B. Faragher
- Busitema University Faculty of Health Sciences, P.O Box 1460, Mbale, Uganda
| | - A. D. Weeks
- Sanyu Research Unit, Department of Women’s and Children’s Health, Liverpool Women’s Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS UK
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