Challenges in measuring a new construct: perception of voluntariness for research and treatment decision making

Relationship between vaccine hesitancy and vaccination behaviors: Systematic review and meta-analysis of observational studies

BACKGROUND

Vaccination is crucial for prevention of infectious diseases, and identification of the impact of vaccine hesitancy on vaccination programs is crucial for early intervention and formulation of policies to alleviate vaccine hesitancy. The aim of this systematic review was to explore the relationship between vaccine hesitancy and negative vaccination behavior globally.

METHODS

We searched for observational studies in various databases. We conducted a meta-analysis using pooled odds ratios (OR) and 95 % confidence intervals (CI), performed meta regression and subgroup analysis to explore the role factors such as location and individual characteristics on the association between vaccine hesitancy and vaccination behavior.

RESULTS

A total of 46 articles were included in systematic analysis and 34 articles were included in the meta-analysis. The systematic analysis comprised 162,601 samples, whereas the meta-analysis included 147,554 samples. The meta-analysis showed that a higher rate of vaccine hesitancy was associated with an increased likelihood of adverse vaccination behaviors (all adverse behaviors: OR = 1.50, 95 % CI, 1.33-1.70, P < 0.001; unvaccinated: OR = 1.48, 95 % CI, 1.29-1.70, P < 0.001; vaccine delay: OR = 2.61, 95 % CI, 1.97-3.44, P < 0.001). The meta-regression results indicated that the heterogeneity observed was mainly from sample selection methods, age of vaccinees and the health status of participants. The results showed that parents of minor vaccinees or without high-risk health status had a higher association between vaccine hesitancy and vaccine uptake compared with populations exposed to higher health risks or adult vaccinees.

CONCLUSION

The findings provide evidence on the association between vaccine hesitancy and adverse vaccination behaviors. The results showed that these population-specific factors should be considered in future research, and during formulation of interventions and implementation of policies to improve vaccination uptake.

Towards a core-set of mobility measures in ageing research: The need to define mobility and its constructs

BACKGROUND

Mobility is a key determinant and outcome of healthy ageing but its definition, conceptual framework and underlying constructs within the physical domain may need clarification for data comparison and sharing in ageing research. This study aimed to (1) review definitions and conceptual frameworks of mobility, (2) explore agreement on the definition of mobility, conceptual frameworks, constructs and measures of mobility, and (3) define, classify and identify constructs.

METHODS

A three-step approach was adopted: a literature review and two rounds of expert questionnaires (n = 64, n = 31, respectively). Agreement on statements was assessed using a five-point Likert scale; the answer options 'strongly agree' or 'agree' were combined. The percentage of respondents was subsequently used to classify agreements for each statement as: strong (≥ 80%), moderate (≥ 70% and < 80%) and low (< 70%).

RESULTS

A variety of definitions of mobility, conceptual frameworks and constructs were found in the literature and among respondents. Strong agreement was found on defining mobility as the ability to move, including the use of assistive devices. Multiple constructs and measures were identified, but low agreements and variability were found on definitions, classifications and identification of constructs. Strong agreements were found on defining physical capacity (what a person is maximally capable of, 'can do') and performance (what a person actually does in their daily life, 'do') as key constructs of mobility.

CONCLUSION

Agreements on definitions of mobility, physical capacity and performance were found, but constructs of mobility need to be further identified, defined and classified appropriately. Clear terminology and definitions are essential to facilitate communication and interpretation in operationalising the physical domain of mobility as a prerequisite for standardisation of mobility measures.

Development and validation of a food-related analysis-holism scale (F-AHS)

Recent studies have indicated analytic-holistic cognitive style differences of consumers can significantly impact perceptions, opinions, and behaviors toward foods. Interestingly, these studies have also offered evidence that the sole measurement tool to assess analytic-holistic tendencies, the analysis-holism scale (AHS), may not accurately apply to food-experience-related research scenarios. Due to these notions, Studies 1 and 2 employed the use of 465 and 487 participants, respectively, to develop, refine, and finalize a food-related AHS (F-AHS) using exploratory and confirmatory factor analyses and prior research on analytic-holistic differences and scale development. Study 3 was conducted to validate the newly developed F-AHS, based on the results of Studies 1 and 2, by replicating the procedures and analyses from prior research while using the F-AHS instead of the AHS to segment participants (N = 130). The results of Study 3 provided consistent evidence that the F-AHS better separated participants into analytic and holistic groups than the AHS through larger analytic-holistic differences that more closely aligned with prior analytic-holistic research. Our findings showed that the F-AHS is capable of separating consumers into analytic and holistic cognitive style groups and is better suited to sensory and consumer-related applications than the AHS. PRACTICAL APPLICATION: Our findings provide researchers with an optimized tool to separate consumers into analytic and holistic groups in food-experience-related situations. The food-related analysis-holism scale can then be used in both academia and industry to separate consumers based on cognitive style to better understand how and why consumers show variations in perception, acceptance, and behavior in food-related experiences.

Kinesiophobia and Fear Avoidance in Older Adults: A Systematic Review on Constructs and Related Measures

BACKGROUND AND PURPOSE

In light of the fear avoidance model, kinesiophobia and fear avoidance (FA) can lead to physical inactivity and disability. Previous studies regarding kinesiophobia and FA in older adults have reported conflicting results. The purpose of this review was to identify the reported constructs and assessment instruments used in published studies on kinesiophobia and FA in older adults and to verify the alignment between the instruments used and the constructs under study.

METHODS

Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 statement (PRISMA-2020), 4 databases were searched from January 2005 to March 2020. All study types, except qualitative, were eligible for inclusion. The participants were 65 years and older. Studies were excluded in the absence of sufficient data on participant age. Study characteristics, constructs related to kinesiophobia, fear and/or avoidance, and instruments used were extracted independently by 2 reviewers.

RESULTS

Fourteen articles were selected for inclusion in the study, in which 7 constructs were identified. The most reported constructs were "fear avoidance beliefs" (FAB) (50%; n = 7), "kinesiophobia" (35.7%; n = 5), and "fear of falling" (14.3%; n = 2). The remaining constructs were only approached, each in 7.1% (n = 1) of the included studies. Seven instruments were used to assess the constructs. The Fear Avoidance Beliefs Questionnaire (FABQ) was the most used instrument (n = 3) to evaluate "FAB," and the Tampa Scale for Kinesiophobia-11 (TSK-11) was the most reported (n = 3) to assess "kinesiophobia."

CONCLUSION

This review identified a large diversity in the constructs and instruments used to study kinesiophobia and FA among older adults. Some constructs are used interchangeably although they do not share the same conceptual definition. There is poor standardization in the use of assessment tools in accordance with the construct under study. Clinical evaluation and study results can be biased owing to this ambiguity.

Examining the language demands of informed consent documents in patient recruitment to cancer trials using tools from corpus and computational linguistics

Obtaining informed consent (IC) is an ethical imperative, signifying participants' understanding of the conditions and implications of research participation. One setting where the stakes for understanding are high is randomized controlled trials (RCTs), which test the effectiveness and safety of medical interventions. However, the use of legalese and medicalese in ethical forms coupled with the need to explain RCT-related concepts (e.g. randomization) can increase patients' cognitive load when reading text. There is a need to systematically examine the language demands of IC documents, including whether the processes intended to safeguard patients by providing clear information might do the opposite through complex, inaccessible language. Therefore, the goal of this study is to build an open-access corpus of patient information sheets (PIS) and consent forms (CF) and analyze each genre using an interdisciplinary approach to capture multidimensional measures of language quality beyond traditional readability measures. A search of publicly-available online IC documents for UK-based cancer RCTs (2000-17) yielded corpora of 27 PIS and 23 CF. Textual analysis using the computational tool, Coh-Metrix, revealed different linguistic dimensions relating to the complexity of IC documents, particularly low word concreteness for PIS and low referential and deep cohesion for CF, although both had high narrativity. Key part-of-speech analyses using Wmatrix corpus software revealed a contrast between the overrepresentation of the pronoun 'you' plus modal verbs in PIS and 'I' in CF, exposing the contradiction inherent in conveying uncertainty to patients using tentative language in PIS while making them affirm certainty in their understanding in CF.

Understanding voluntariness of consent in first-in-human cell therapy trials

Consensus about contents of voluntariness in informed consent is lacking. Core criteria for voluntary consent are needed to ensure voluntariness. This article outlines the multidimensionality of voluntariness and identifies what could reduce voluntariness, especially in first-in-human clinical trials involving cell therapies. In such trials, truly voluntary consent is especially important because: such trials may involve risk of serious harm, while in case of some diseases, eligible patients often have potentially effective therapeutic alternatives; patients considering participation in high-risk first-in-human trials may feel more desperate and some may be dependent on their caregivers, including those in the family; implanted cells cannot be taken out of the patient's body if the patient wants to withdraw.

A step-by-step approach to developing scales for survey research

BACKGROUND

While questionnaires and scales are some of the simplest methods of collecting data, their development requires a rigorous process. In recent years, several new questionnaires and scales have been developed. Although various papers have outlined how to develop questionnaires, their use in survey research, as well as how to ensure their validity and reliability, the actual development of scales - including the generation of items, scaling, the testing of validity and reliability, and refinement of the scale - is missing in the literature.

AIM

To outline a systematic and rigorous process for developing scales for survey research and to differentiate between three interchangeably used terms: scale, questionnaire and inventory.

DISCUSSION

Developing a valid and reliable scale is daunting because of the challenges associated with the conceptualisation, contextualisation and operationalisation of the phenomenon of interest. Researchers should use multiple approaches at each step of development to tackle these challenges.

CONCLUSION

This paper provides a step-by-step approach to developing scales by providing explicit instructions and practical examples. This six-step process can enable nurse researchers to develop a scale applicable to their study's intended population, which is also valid and reliable for measuring the phenomenon of interest.

IMPLICATIONS FOR PRACTICE

Rigorous nursing research demands that instruments be valid and reliable measures. Systematic development of scales is key to ensuring that nurse researchers accurately measure abstract concepts when conducting surveys with a given population. This paper is a first step in addressing the gap in the methodological literature and will contribute to greater rigour in research.

Evaluation of methods used for estimating content validity

The assessment of content validity is a critical and complex step in the development process of instruments which are frequently used to measure complex constructs in social and administrative pharmacy research. The aims of this study were to investigate the elements of content validity; to describe a practical approach for assessing content validity; and to discuss existing content validity indices. This is a narrative review of the assessment and quantification of content validity. It describes the key stages of conducting the content validation study and discusses the quantification and evaluation of the content validity estimates. Content validity provides evidence about the degree to which elements of an assessment instrument are relevant to and representative of the targeted construct for a particular assessment purpose. The assessment of content validity relies on using a panel of experts to evaluate instrument elements and rate them based on their relevance and representativeness to the content domain. It is a three-stage process that includes; the development stage, judgment and quantifying stage, and revising and reconstruction stage. To quantify the expert judgments, several indices have been discussed in this paper such as the content validity ratio (CVR), content validity index (CVI), modified-Kappa, and some agreement indices. A practical guide describes the process of content validity evaluation is provided. In summary, content validation processes and content validity indices are essential factors in the instrument development process, should be treated and reported as important as other types of construct validation. Determining item CVI and reporting an overall CVI are important components necessary to instruments especially when the instrument is used to measure health outcomes or to guide a clinical decision making. Content validity deserves a rigorous assessment process as the obtained information from this process are invaluable for the quality of the newly developed instrument.

Consent for Anesthesia Clinical Trials on the Day of Surgery

Background

Opportunities for anesthesia research investigators to obtain consent for clinical trials are often restricted to the day of surgery, which may limit the ability of subjects to freely decide about research participation. The aim of this study was to determine whether subjects providing same-day informed consent for anesthesia research are comfortable doing so.

Methods

A 25-question survey was distributed to 200 subjects providing informed consent for one of two low-risk clinical trials. While consent on the day of surgery was permitted for both studies, a preadmission telephone call was required for one. The questionnaire was provided to each subject at the time of discharge from the hospital. The questions were structured to assess six domains relating to the consent process, and each question was graded on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Overall satisfaction with same-day consent was assessed using an 11-point scale with 0 = extremely dissatisfied and 10 = extremely satisfied.

Results

Completed questionnaires were received from 129 subjects. Median scores for satisfaction with the consent process were 9.5 to 10. Most respondents reported that the protocol was well explained and comprehended and that the setting in which consent was obtained was appropriate (median score of 5). Most patients strongly disagreed that they were anxious at the time of consent, felt obligated to participate, or had regrets about participation (median score of 1). Ten percent or less of subjects reported negative responses to any of the questions, and no differences were observed between the study groups.

Conclusion

More than 96% of subjects who provided same-day informed consent for low-risk research were satisfied with the consent process.

Enduring and emerging challenges of informed consent

The author summarizes emerging standards for informed consent as the underpinning of ethical research in humans.

Measuring Voluntariness of Consent to Research

The conceptual complexity of the term voluntariness has resulted in relatively few empirical studies of the voluntariness component of consent to research. As the call for a formal assessment of voluntariness to be incorporated into the consent process intensifies, more researchers are responding to the challenge of developing a valid and reliable measure of voluntariness. The purpose of this article was to summarize and describe the empirical literature on voluntariness of consent. As part of a broader study on the voluntariness of consent to research, existing empirical studies of voluntariness of consent to research were reviewed to establish how voluntariness of consent to research has been assessed to date. Fifteen studies using different voluntariness assessment instruments were identified and included in the review. The review found that little attempt has been made to systematically collect data on the reliability and validity of voluntariness assessment instruments. No two instruments reviewed were found to be based on a shared conceptualization of voluntary consent to research.

Developing an index to measure the voluntariness of consent to research

The goals of the current study were to expand the content domain and further validate the Coercion Assessment Scale (CAS), a measure of perceived coercion for criminally involved substance abusers being recruited into research. Unlike the few existing measures of this construct, the CAS identifies specific external sources of pressure that may influence one's decision to participate. In Phase 1, we conducted focus groups with criminal justice clients and stakeholders to expand the instrument by identifying additional sources of pressure. In Phase 2, we evaluated the expanded measure (i.e., endorsement rates, reliability, validity) in an ongoing research trial. Results identified new sources of pressure and provided evidence supporting the CAS's utility and reliability over time as well as convergent and discriminative validity.

Review of measurement instruments in research ethics in the biomedical sciences, 2008−2012

There is an urgent need in biomedical science to understand whether regulations are being met, prerequisite to goals of subject protection and integrity in research practice. This article presents an update of a 2006 summary of measurement instruments in research ethics with psychometric information in the years 2008−2012. A review of 25 instruments identified seven used in the time period 2008−2012 and which had accumulated at least one study of its psychometric qualities beyond its developmental phase. Many of these instruments had been accumulating psychometric information over more than a decade. Two additional but still underdeveloped instruments addressing important bioethical issues − coercion and therapeutic misconception − are included because they address important issues in research ethics. Bioethicists use a wide range of methods for knowledge development and verification; each method should meet stringent standards of quality. Measurement instruments that meet these standards have the potential to greatly ease the work of institutional review boards and other regulatory bodies as well as to enhance empirical work on human research ethics.

Informed consent for anesthesia: a review of practice and strategies for optimizing the consent process

PURPOSE

Patients must receive information in a manner that promotes understanding so they can make informed decisions about anesthesia and other medical interventions. Unfortunately, history is replete with examples of the negative consequences of inadequate disclosure of information and lack of patient understanding. While obtaining consent for anesthesia poses unique challenges, the ability of the anesthesiologist to engage the patient in meaningful discussion is critical as a means to ensure that the patient is truly informed. This narrative review aims to: 1) discuss the process of informed consent as it applies to anesthesia practice; 2) describe the salient issues related to patient capacity, disclosure, understanding, decision-making, and documentation of the informed consent process; and 3) discuss current strategies to improve the presentation and understanding of consent information.

SOURCE

Review of the extant literature, including the authors' own research.

PRINCIPAL FINDINGS

Despite the ethical imperative of informed consent, many decision-makers have limited understanding of medical information. The reasons for this are multifactorial but often result from incomplete disclosure and presentation of generic information that does not take into account differences in information needs, values, and preferences of individual patients. Several simple strategies are available, however, that can enhance decision-makers' understanding of both written and verbal information.

CONCLUSIONS

Despite the unique challenges of obtaining consent for anesthesia on the day of surgery, attention to the manner in which information for anesthesia care is provided and adoption of simple strategies to enhance understanding can go a long way to ensure that decision-makers are appropriately informed.

Perceptions of academic health science research center personnel regarding informed consent processes and therapeutic misconception

INTRODUCTION

Instrumentation exists to measure voluntariness and misunderstanding in informed consent processes. However, research personnel's perspectives about using instrumentation to measure therapeutic misconceptions in research participants has not been reported. We designed a workshop to promote research personnel knowledge of emerging instrumentation and to study the perceptions of research personnel regarding such instruments.

METHODS AND FINDINGS

Two nationally recognized experts who have developed psychometric instruments to measure aspects of informed consent presented their recent findings to research personnel of the Medical University of South Carolina at a one-day workshop. Following the presentations, workshop attendees divided into two focus groups and shared their perceptions regarding the presentation content. Inductive thematic analysis detected themes related to informed consent processes including: investigator/provider role clarity; investigator transparency; therapeutic misconception; and screening subjects for understanding.

CONCLUSION

Our findings suggest future directions in applied, proactive empirical research to better understand investigator perceptions and practices related to transparency in research, and to develop instrumentation to detect risks to the integrity of informed consent in order to promote voluntariness and autonomy and minimize therapeutic misconception in research practices.

Factors related to voluntary parental decision-making in pediatric oncology

OBJECTIVE

The aim of the current study was to examine demographic and contextual correlates of voluntariness in parents making research or treatment decisions for their children with cancer.

METHODS

Participants included 184 parents of children with cancer who made a decision about enrolling the child in a research or treatment protocol within the previous 10 days. Parents completed questionnaires that assessed voluntariness, external influence by others, concern that the child's care would be negatively affected if the parent did not agree, time pressure, information adequacy, and demographics.

RESULTS

Lower perceived voluntariness was associated with lower education, male gender, minority status, and not having previous experience with a similar decision. Parents who reported lower voluntariness also perceived more external influence and time pressure, had more concern about the child's care being negatively affected if they declined, and perceived that they had either too much or not enough information about the decision. In a multivariate regression, education, minority status, gender, external influence, and too little information remained significantly associated with voluntariness.

CONCLUSIONS

Several groups of parents appear to be at risk for decreased voluntariness when making research or treatment decisions for their seriously ill children, including fathers, nonwhite parents, and those with less education. Parental voluntariness may be enhanced by helping parents to mitigate the effects of unhelpful or unwanted influences by others and ensuring that their information needs are met.

The use of students as participants in a study of eating disorders in a developing country: case study in the ethics of mental health research

This article describes the ethical analysis of an eating disorder study in which a university-based researcher in South Africa set out to establish the cross-cultural validity of the Eating Disorders Inventory. The following ethical issues are considered in the analysis: study design, social value, study population, risks and benefits, oversight, informed consent, and posttrial obligations. The ethics analysis is based on an adaptation of the structured framework proposed by Emanuel et al. (The Oxford textbook of clinical research ethics; pp. 123-133, 2008) for ethical research in developing countries. The analysis reveals that research that, on superficial analysis, seems to be low risk and noninterventional can result in adverse psychosocial effects and complexities for research participants and researchers alike. The study underlines the need for special ethics scrutiny of mental health-related research proposals involving students as research participants, especially when conducted by their own teachers.

The decision making control instrument to assess voluntary consent

BACKGROUND

The decision to participate in a research intervention or to undergo medical treatment should be both informed and voluntary.

OBJECTIVE

The aim of the present study was to develop an instrument to measure the perceived voluntariness of parents making decisions for their seriously ill children.

METHODS

A total of 219 parents completed questionnaires within 10 days of making such a decision at a large, urban tertiary care hospital for children. Parents were presented with an experimental form of the Decision Making Control Instrument (DMCI), a measure of the perception of voluntariness. Data obtained from the 28-item form were analyzed using a combination of both exploratory and confirmatory factor analytic techniques.

RESULTS

The 28 items were reduced to 9 items representing 3 oblique dimensions: Self-Control, Absence of Control, and Others' Control. The hypothesis that the 3-factor covariance structure of our model was consistent with that of the data was supported. Internal consistency for the scale as a whole was high (0.83); internal consistency for the subscales ranged from 0.68 to 0.87. DMCI scores were associated with measures of affect, trust, and decision self-efficacy, supporting the construct validity of the new instrument.

CONCLUSION

The DMCI is an important new tool that can be used to inform our understanding of the voluntariness of treatment and research decisions in medical settings.

Relationship of external influence to parental distress in decision making regarding children with a life-threatening illness

OBJECTIVE

To examine the relationship of external influence to parental distress when making a decision about research or treatment for a child with a life-threatening illness and to test potential moderators of this relationship.

METHODS

Parents (n = 219) who made a decision about research or treatment for a child completed measures of external influence, distress, decision-making preference, and coping.

RESULTS

More external influence was associated with more hostility, uncertainty, and confusion. Decision-making preference and coping style moderated the relationship between external influence and distress: More external influence was associated with more distress when decision-making preference was low and task-focused coping was high.

CONCLUSIONS

External influence appears to be related to distress in parents making research and treatment decisions for children with life-threatening illnesses. However, it is important to consider parent characteristics, such as decision-making preference and coping style, when examining the effects of contextual factors on distress during decision making.