The challenges and potential solutions of achieving meaningful consent amongst research participants in northern Thailand: a qualitative study

BACKGROUND

Achieving meaningful consent can be challenging, particularly in contexts of diminished literacy, yet is a vital part of participant protection in global health research.

METHOD

We explored the challenges and potential solutions of achieving meaningful consent through a qualitative study in a predominantly hill tribe ethnic minority population in northern Thailand, a culturally distinctive population with low literacy. Semi-structured interviews were conducted with 37 respondents who had participated in scrub typhus clinical research, their family members, researchers and other key informants. A thematic analysis was conducted.

RESULTS

Our analysis identified four interrelated themes surrounding participants' ability to give consent: varying degrees of research understanding, limitations of using informal translators, issues impacting decisions to join research, and voluntariness of consent. Suggestions for achieving more meaningful consent included the use of formal translators and community engagement with research populations.

CONCLUSIONS

Participant's agency in decision making to join research should be supported, but research information needs to be communicated to potential participants in a way that they can understand. We found that improved understanding about the study and its potential benefits and harms goes beyond literacy or translation and requires attention to social and cultural factors.

Respecting relational agency in the context of vulnerability: What can research ethics learn from the social sciences?

Despite advances in theory, often driven by feminist ethicists, research ethics struggles in practice to adequately account for and respond to the agency and autonomy of people considered vulnerable in the research context. We argue that shifts within feminist research ethics scholarship to better characterise and respond to autonomy and agency can be bolstered by further grounding in discourses from the social sciences, in work that confirms the complex nature of human agency in contexts of structural and other sources of vulnerability. We discuss some of the core concepts and critiques emerging from the literature on women and children's agency in under-resourced settings, highlighting calls to move from individualistic to relational models of agency, and to recognise the ambiguous, value-laden, and heterogeneous nature of the concept. We then draw out what these conceptual shifts might mean for research ethics obligations and guidance, illustrating our analysis using a case vignette based on research ethics work conducted in South Africa. We conclude that if research practices are to be supportive of agency, it will be crucial to scrutinise the moral judgements which underpin accounts of agency, derive more situated definitions of and responses to agency, and enable people and participants to influence these based on their own experiences and self-perceptions.

Vulnerability and agency in research participants' daily lives and the research encounter: A qualitative case study of participants taking part in scrub typhus research in northern Thailand

BACKGROUND

Researchers have a responsibility to protect all participants, especially vulnerable participants, from harm. Vulnerability is increasingly understood to be context specific, yet limited guidance is available regarding the vulnerability and agency of research participants in different cultural settings. This study aims to explore research participants' daily vulnerability and agency, and how these interact with participants' research experiences in their own words. Researchers' views and responses were also explored.

METHODS

A qualitative study was conducted around two scrub typhus research studies in northern Thailand. A thematic analysis was carried out on 42 semi-structured interviews with research participants, their families, researchers and key informants.

RESULTS

The majority of the research participants belonged to a hill tribe ethnic minority group. Common challenges were related to Thai language barriers, travel difficulties, uncertain legal status, unstable employment, lack of education and healthcare. We did not identify new vulnerabilities but we found that the extent of these vulnerabilities might be underestimated or even hidden from researchers in some cases. Despite these challenges people demonstrated agency in their daily lives and were often motivated and supported in this by family members. The majority of perceived research benefits were related to healthcare and gaining knowledge, while attending follow-up visits could be a burden for some.

CONCLUSIONS

Our approach to research in culturally and socioeconomically diverse settings should be more responsive to participants' specific vulnerabilities and abilities evidenced in their daily life, rather than attributing vulnerability on the basis of membership of pre-defined 'vulnerable groups'. Researchers need to be aware and responsive towards the challenges participants face locally in order to minimise the burdens of research participation whilst allowing participants to benefit from research.

Culturally responsive research ethics: How the socio-ethical norms of Arr-nar/Kreng-jai inform research participation at the Thai-Myanmar border

Despite advances, international research ethics guidelines still tend to consist of high-level ethical principles reflecting residual influence from North American and European traditions of ethics. Local ethics committees and community advisory boards can offer more culturally-sensitive approaches to training but most institutions lack substantive practical ethics guidance to engage rich moral understandings in day-to-day research practice in diverse cultural contexts. To address this gap, we conducted an international series of qualitative research ethics case studies, linked prospectively to active research programs in diverse settings. Here, we share findings from two case studies with a research team working on malaria and hepatitis B prevention with pregnant women in clinics serving migrants along the Thai-Myanmar border. In this sociocultural ethical analysis, we consider how core ethical requirements of voluntary participation, provision of fair benefits, and understandings of research risks and burdens are shaped, enriched, and in some instances challenged, by deep-seated and widespread Burmese, Karen and Thai cultural norms known as Arr-nar (in Burmese and Karen) or Kreng-jai (in Thai), encompassing multiple meanings including consideration for others and graciousness. We offer a model illustrating how one might map ethically significant sociocultural influences across the research practice pathway and close with lessons for developing a more culturally responsive research ethics practice in other international settings.

Research ethics in context: understanding the vulnerabilities, agency and resourcefulness of research participants living along the Thai-Myanmar border

BACKGROUND

Research ethics guidelines set a high bar for conducting research with vulnerable populations, often resulting in their exclusion from beneficial research. Our study aims to better characterise participants' vulnerabilities, agency, resourcefulness and sources of support.

METHODS

We undertook qualitative research around two clinical studies involving migrant women living along the Thai-Myanmar border. We conducted 32 in-depth interviews and 10 focus group discussions with research participants, families, researchers and key informants.

RESULTS

We found that being 'undocumented' is at the core of many structural vulnerabilities, reflecting political, economic, social and health needs. Although migrant women lead challenging lives, they have a support network that includes family, employers, community leaders, non-governmental organisations and research networks. Migrant women choose to participate in research to access quality healthcare, gain knowledge and obtain extra money. However, research has the potential to exacerbate existing vulnerabilities, such as the burdens of cross-border travel, foregoing work and being more visible as migrants.

CONCLUSIONS

Our study confirms that research is important to provide evidence-based care and was viewed by participants as offering many benefits, but it also has hidden burdens. Migrant women exercised agency and resourcefulness when navigating challenges in their lives and research participation.

Use of a GnRH agonist implant as alternative for surgical neutering in pet ferrets

In the current study, the duration of effectiveness, owner satisfaction and side effects of a gonadotrophin releasing hormone-agonist (deslorelin) implant were investigated during a two-year follow-up study in which 61 male and 69 female entire pet ferrets were given a 4.7 mg deslorelin implant as alternative to surgical neutering. In 27 participating non-oestrous jills, a double-blind placebo controlled study was performed to investigate whether a single low dose of medroxyprogesterone (2 mg orally) four days preceding placement of the implant could prevent oestrus induction. The duration of effectiveness of the implant ranged from 301 days to over 1339 days (mean 1012±38 days), with no sex difference present. Over 90 per cent of owners were pleased with the effects of the implant. Minor local side effects were noted in less than 20 per cent of ferrets, which all resolved within a week without treatment. Oestrus was induced in 77 per cent of jills receiving medroxyprogesterone and 50 per cent of jills receiving the placebo, indicating that administration of a low-dose progestogen cannot prevent postimplant oestrus. Based on the minimum duration of effectiveness, it is advised to place a new implant on a yearly basis to guarantee continuous gonadal suppression, although biannual replacement may be sufficient in the majority of ferrets.

Cumulative pregnancy rates and selective drop-out of patients in in-vitro fertilization treatment

The validity of the cumulative pregnancy rate (CPR) calculated by life-table approach, obtained in a transport in-vitro fertilization (IVF) programme, was tested by the determination of possible influence of selective drop-out of patients with a poor treatment prognosis. A cohort of 1211 patients who had a first IVF cycle was followed, and the CPR after three IVF cycles was assessed. First cycles of patients who discontinued treatment after failed IVF, and of those who did not achieve a pregnancy but proceeded to a subsequent cycle, were compared for fertilization rate and for occurrence of prognosticators of poor treatment outcome: oocyte yield < or =2, and replacement of <2 embryos. The CPR after three cycles was 54.9%. No differences were found in the first and second cycles of patients who continued treatment and those who dropped out. Selective drop-out of patients with a poor treatment prognosis was not found. Therefore, although calculations of CPR using life-table analysis generally overestimate the real probability of pregnancy after successive IVF cycles, the calculated CPR after three IVF cycles gives a reliable indication of the chance of occurrence of a pregnancy for the population studied.

Treatment policy after poor fertilization in the first IVF cycle

PURPOSE

The chance of recurrence of poor fertilization in a second in vitro fertilization (IVF) cycle was assessed.

METHODS

Total fertilization failure was defined, and the relationship between the fertilization rate and the number of motile sperm cells per milliliter of semen was assessed. Patients with a total fertilization failure or poor fertilization (20% or less of the oocytes fertilized) were divided into three subgroups with different chances of fertilization and were followed in a subsequent IVF cycle.

RESULTS

The recurrence rate of total fertilization failure was high in all three groups (45-70%), and poor fertilization frequently occurred in the second cycle (50-75%).

CONCLUSIONS

Poor fertilization frequently recurs in the second IVF cycle. The use of intracytoplasmic sperm injection could be considered after fertilization of 20% or less of oocytes in the first cycle, irrespective of the number of motile sperm cells per milliliter of semen.

Transport-in-vitro fertilization/intracellular sperm injection: a prospective randomized study

We performed a prospective randomized clinical trial to investigate whether long distance oocyte transport prior to an intracytoplasmic sperm injection (ICSI) procedure influences fertilization rates, embryo quality and/or embryo implantation rates. After informed consent, 100 infertile couples booked for ICSI treatment were randomized into two groups. In group 1 (n = 50), patients were stimulated and monitored in Rotterdam (The Netherlands), and oocyte retrieval, ICSI procedure and embryo transfer took place in Gent (Belgium). In group 2 (n = 50), patients were stimulated, monitored and punctured in Rotterdam and the oocytes were transported in their follicular fluid in an isothermic transport box to Gent, where the ICSI procedure and the embryo transfer took place. In both groups the stimulation and monitoring regimen, puncture technique, laboratory conditions and transfer policy were identical. In both groups, the number of fertilized oocytes (7.13 +/- 0.65 versus 5.53 +/- 0.60, P = 0.08), the number of transferred embryos (2.36 +/- 0.09 versus 2.40 +/- 0.11, P = 0.87) and the embryo implantation rate [20/113 (17.7%) versus 19/103 (18.4%), P = 0.89] was similar. In group 1, the number of retrieved oocytes was higher (10.83 +/- 0.95 versus 8.44 +/- 0.93, P = 0.05). The total score of the embryos obtained (18.90 +/- 1.73 versus 12.64 +/- 1.26, P = 0.01), the number of good quality embryos (4.63 +/- 0.49 versus 2.98 +/- 0.38, P = 0.02), the mean score of the transferred embryos (3.32 +/- 0.11 versus 2.94 +/- 0.13, P = 0.05) and the number of embryos available for cryopreservation (2.70 +/- 0.45 versus 1.48 +/- 0.38, P = 0.03) were significantly higher in group 1. Therefore, long distance transport of oocytes prior to ICSI does not affect oocyte fertilization and embryo implantation rates, although a negative effect on embryo quality cannot be excluded.

A triplet pregnancy after in vitro fertilization is a procedure-related complication that should be prevented by replacement of two embryos only

OBJECTIVE

To investigate whether the incidence and obstetric outcome of triplet pregnancies after IVF treatment justify strict limitation of the number of embryos to be replaced to two.

DESIGN

Retrospective analysis.

SETTING

A transport IVF program.

PATIENT(S)

All patients who had more than one embryo replaced.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Obstetric outcome, pregnancy.

RESULT(S)

High-order pregnancies occurred in 24 cases (23 triplets and 1 quadruplet). Three patients opted for selective embryo reduction (12.5%). Three triplet pregnancies spontaneously reduced to twins. Comparison of 18 triplets, reaching at least 20 weeks' gestation, with 54 twin pregnancies shows a higher perinatal mortality in the triplet group, causing 6 out of 18 patients to be confronted with at least one perinatal death. Triplets were born at a lower gestational age, had a lower birth weight, and a higher hospital admission rate of longer duration. Replacement of two, three, or four embryos did not lead to differences in pregnancy rates in the population studied. When a pregnancy occurred after replacement of three embryos, the risk of having a triplet pregnancy was 7.5%.

CONCLUSION(S)

The obstetric outcome of triplet pregnancies in our population indicates that triplet pregnancies after IVF treatment have to be prevented. Selective embryo reduction is acceptable for few patients only and can therefore not be seen as a solution. Replacement of three embryos results in triplet pregnancy in an unacceptably high percentage. Replacement of two embryos only gives acceptable IVF results and is the method chosen in the IVF program in Rotterdam to prevent triplet pregnancies.

The ovarian response as a predictor for successful in vitro fertilization treatment after the age of 40 years

OBJECTIVE

To determine whether age or response to controlled ovarian hyperstimulation (COH) is a better predictor of IVF outcome in women > or = 40 years.

DESIGN

Retrospective analysis.

SETTING

A transport IVF program.

PATIENT(S)

For patients undergoing IVF treatment the correlation between treatment outcome and age and response to COH was analyzed using the data of 2,588 consecutive cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy.

RESULT(S)

The incidence of poor ovarian response rises significantly with increasing age. Analysis of all cycles showed a significant decrease in clinical and ongoing pregnancy rate for women > or = 40 years. Analysis of cycles with a good ovarian response showed no statistically significant differences for these parameters between women > or = 40 years and those younger. A logistic regression analysis on pregnancy showed that ovarian response contributes more to the prediction of pregnancy than age.

CONCLUSION(S)

Patients aged > or = 40 years with a good response to COH have a good prognosis for IVF treatment. The age limit for acceptance of patients should not be set at 40 years. Instead, the response to COH can be used to predict candidates likely to have a successful IVF outcome.

The incidence of major clinical complications in a Dutch transport IVF programme

Four different major clinical complications were identified in a retrospective analysis of 2495 in-vitro fertilization (IVF) cycles resulting in oocyte retrieval. The severe form of ovarian hyperstimulation syndrome (OHSS) occurred in 18 patients, giving a prevalence for this complication of 0.7%. Seven (39%) of these 18 patients had previously been diagnosed as having polycystic ovaries. Eleven patients were admitted with moderate OHSS. Adnexal torsion was diagnosed in two patients. Ovariectomy was considered necessary in both cases. Complications of the transvaginal procedure occurred in seven cases (0.3%): one patient had an acute appendicitis with puncture holes in the appendix, six patients were admitted shortly after oocyte retrieval with a pelvic inflammatory disease. Of the 624 pregnancies obtained, 13 were ectopic, giving an ectopic pregnancy rate of 2.1%. It is concluded that serious clinical complications of IVF treatment are rare. However, patients should be counselled for the occurrence of serious procedure-related complications before entering an IVF programme.

Minimal monitoring of ovarian hyperstimulation: a useful simplification of the clinical phase of in vitro fertilization treatment

OBJECTIVE

To investigate the feasibility of IVF treatment with minimal monitoring during ovarian hyperstimulation.

DESIGN

Retrospective analysis and prospective study with real-time control group.

SETTING

Transport IVF program with transport clinic and satellite clinics.

PATIENTS

One hundred consecutive IVF cycles monitored at a transport clinic and 100 concurrent consecutive cycles monitored at satellite clinics, using the same stimulation-monitoring protocol and resulting in oocyte aspiration, are compared retrospectively for the number of ultrasound (US) measurements carried out during monitoring and for results of IVF treatment. No patient selection took place. After introduction of a minimal monitoring protocol at a transport clinic, a prospective study was started comparing 100 minimal monitoring cycles at a transport clinic with 100 concurrent conventional monitoring cycles at satellite clinics, all resulting in oocyte aspiration. Patients entered the retrospective or prospective study only once. In all cases the same laboratory facility was used. Monitoring of ovarian hyperstimulation was done with US measurements only. Cycles were canceled for impending ovarian hyperstimulation syndrome (OHSS) when > 35 follicles were seen to develop during hyperstimulation.

RESULTS

Retrospective analysis shows no difference for the average number of US measurements at transport and satellite clinics (2.8 +/- 0.9 and 3.0 +/- 1.0; mean +/- SD). No differences were found in the number of ongoing pregnancies obtained in the two groups: 22 and 18, respectively. One case of severe OHSS occurred in the satellite clinic group. Introduction of minimal monitoring at the transport clinic gives a significant reduction of the average number of US measurements at the transport clinic compared with satellite clinics, where conventional monitoring continued to be used (1.5 +/- 0.8 versus 2.8 +/- 0.9). Ongoing pregnancies at transport and satellite clinics numbered 33 and 26, respectively. In both groups one patient developed severe OHSS. Sixty-two percent of cycles at the transport clinic were monitored with one US measurement only. No cancellations for impending OHSS occurred during the study period.

CONCLUSION

A large group of patients need only one US measurement during monitoring of ovarian hyperstimulation. Minimal monitoring gives a useful further simplification of the clinical phase of IVF treatment, without adverse effects on treatment outcome and incidence of OHSS.

Results of decentralized in-vitro fertilization treatment with transport and satellite clinics

The results of in-vitro fertilization (IVF) treatments carried out in a university IVF centre are compared with those obtained following 15-40 min transportation of oocytes from a transport IVF clinic to the central IVF laboratory of the university centre. Moreover, treatment results following monitoring of ovarian stimulation in satellite clinics, combined with ovum retrieval at the transport clinic and transport of oocytes to the central IVF laboratory, are described. In a total of 5540 IVF treatment cycles, 24-26% of viable pregnancies per embryo transfer were found in the three groups. Comparison of results, obtained with the three different treatment modalities, showed no negative influences of transporting oocytes from transport clinic to IVF laboratory and of monitoring ovarian stimulation in satellite clinics. It is concluded that decentralization of the clinical phase of IVF treatment is possible. This leads to a more optimal use of existing laboratory facilities in large urban areas. It is stressed that good communication between satellite clinic, transport clinic and IVF laboratory is necessary for a decentralized IVF programme. To obtain good quality assurance, both the satellite clinic and the transport clinic must adhere to the same protocol.