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Inclusion of Culturally and Linguistically Diverse populations in Clinical Trials:0

 

Nik Zeps
AHRECS Consultant

Clinical trials have enormous value to society as they provide the most robust means of working out whether or not particular treatments used to improve the health of our population work or not. Governments have a stated objective to increase participation in clinical trials based upon a series of assumptions that extend beyond their utility as a means to derive the highest level of reliable evidence about the efficacy and safety of interventions. One of these is that those people who are included derive a tangible benefit from doing so. Whilst this may not be true in all cases, after all up to 50% of people may receive an inferior treatment by definition, there is the potential for people to derive individual benefit, and it is often stated that those involved in a trial receive a higher standard of care than those not included. Certainly, the additional testing and closer scrutiny of people on a trial may equate in some instances to better care, but this should not be seen as a major driver as it could be argued that equitable care should be available as a universal right. A less discussed benefit is the connectedness and satisfaction that people may derive from making a tangible contribution to society through participation in clinical research. Furthermore, there may be indeterminate peer group benefits even if an individual does not benefit.

In an Australian study Smith et al (1) found that CALD people whose preferred language was not-English (PLNE) had the lowest participation rates in clinical trials. Whilst CALD people whose preferred language was English (PLE) had greater levels of enrollment than the PLNE group, they were still underrepresented by population. This has been described across the world and is identified as a pressing concern (2).  Understanding why this is the case is important for a number of reasons. In multiculturally diverse countries like Australia, testing interventions where a significant proportion of the population are not included could result in evidence that is not applicable to those people. This spans across biological differences which may be relevant to drug efficacy or toxicity through to interventions such as screening that may fail to be useful in those populations. Where there is evidence that participation in a clinical trial may present specific advantages there is also the issue of injustice through exclusion of a particular group or groups of persons. Certainly, from an implementation perspective, not including a diverse group of participants and analyzing for cultural and behavioral acceptability may mean that even if an intervention has merit it fails to be taken up.

The reasons for non-inclusion are likely more complex than those of language barriers, although having protocols for clinical trials that specifically exclude people who don’t have higher levels of proficiency in English do not help. It would seem that the language barrier could be soluble through providing greater resources to enable translation services, particular in areas with a clear need for this. Certainly, multi-national trials already have PICFs in multiple languages and these could be readily deployed through use of innovative technologies including eConsent processes.[1] Funders of clinical trials could make it a requirement for such inclusivity and back it up through provision of specific funding for this in any grants they award. Legal means to enforce this, whilst possible, are unlikely to drive systemic change and could have the unintended consequence of making it harder to do any trials at all in an environment already subject to extreme financial pressures.

However, a major reason for low levels of participation in clinical trials may be attributed to equity of access to clinical services in the first place. It is hard to recruit people from the general population into clinical trials, but even harder if specific members of the population don’t come to the health service in the first place. There is relatively little research on this topic and it would seem logical to do this as a priority in parallel with examining why people fail to participate in clinical trials due to language barriers. Perhaps clinical trials are simply the canary alerting us to broader inequities that need greater research and investment. Research into solutions to these inequities is accordingly a priority and may solve clinical trial participation rates as a consequence.

References

  1. Smith A, Agar M, Delaney G, Descallar J, Dobell-Brown K, Grand M, et al. Lower trial participation by culturally and linguistically diverse (CALD) cancer patients is largely due to language barriers. Asia Pac J Clin Oncol. 2018;14(1):52-60.
  2. Clark LT, Watkins L, Pina IL, Elmer M, Akinboboye O, Gorham M, et al. Increasing Diversity in Clinical Trials: Overcoming Critical Barriers. Curr Probl Cardiol. 2019;44(5):148-72.

Nik Zeps participated in the CCV forum at the COSA ASM. A full report of the workshop and research by the CCV and MCCabe centre is forthcoming.

[1] https://ctiq.com.au/wp-content/uploads/eConsent-in-Clinical-Trials-compressed.pdf

This post may be cited as:

Zeps, N. (4 December 2019) Inclusion of Culturally and Linguistically Diverse populations in Clinical Trials. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/inclusion-of-culturally-and-linguistically-diverse-populations-in-clinical-trials

The research use of online data/web 2.0 comments0

 

Does it require research ethics review and specified consent?

Dr Gary Allen
AHRECS Senior Consultant

The internet is a rich source of information for researchers. On the Web 2.0 we see extensive commentary on numerous life matters, which may be of interest to researchers in a wide range of (sub)disciplines. Research interest in these matters frequently prompts the following questions –Can I use that in my project? Hasn’t that already been published? Is research ethics review required? Is it necessary to obtain express consent for the research use?

It’s important to recognise that these questions aren’t posed in isolation. Cases like the OkCupid data scraping scandal, the Ashley Madison hack, Emotional Contagion, Cambridge Analytica and others provide a disturbing context.  At a time when the use of the internet and social media is startingly high (Nielsen 2019, Australian Bureau of Statistics 2018, commentaries such as the WebAlive blog 2019), there is also significant distrust of the platforms people are using. Consequently, there are good reasons for researchers and research ethics reviewers to be cautious about use of existing material for research, even if the terms and conditions of a site/platform specifically discuss research.

Like many ethics questions, there isn’t a single simple answer that is correct all the time.  The use of some kinds of data for research may not meet the National Statement’s definition of human research. Use of other kinds of data may meet that definition but will be exempt from review and so not require explicit consent. Use of other kinds of data or other uses of data that involves no more than low risk can be reviewed outside an HREC meeting and others will actually have to be considered at an HREC meeting.

AHRECS proposes a three-part test, which can be applied to individual projects to test whether a proposed use of internet data is human research and needs ethics review and this will also guide whether explicit and project-specific consent is required. If this test is formally adopted by an institution and by its research ethics committees, it would provide a transparent, consistent, and predictable way to judge these matters.

You can find a word copy of the questions, as well as a png and pdf copy of the flow diagram in our subscribers’ area.
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For any questions email enquiry@ahrecs.com

Part One of this test is whether the content of a site or platform is publicly available. One component of this test is whether the researcher will be using scraping, spoofing or hacking of the site/platform to obtain information.
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Part Two of the test relates to whether individuals have consented and will be reasonably identifiable from the data and its proposed research use and whether there are risks to those individuals.  A component of this test is exploring whether an exemption from the consent requirement is necessary (i.e. as provided for by paragraphs 2.3.9 -12 of the National Statement and are lawful under any privacy regulation that applies).

Part Three of the test relates to how the proposed project relates to the national human research ethics guidelines – the National Statement – and whether there are any matters that must be considered by a human research ethics committee.  For example, Section 3 of the National Statement (2007 updated 2018) discusses some methodological matters and Section 4 some potential participant issues that must be considered by an HREC.

Individually, any one of these parts could determine that review and consent is required. But meeting all three parts of the test is necessary to indicate that the work is exempt before a project can be exempted from review.

Even if the tests indicate review/consent is required, that doesn’t mean the research is ethically problematic, just a project requires for more due consideration.

The implication of this is that not all research based upon online comments or social media posts can be exempted from review but, conversely, not all such work must be ethically reviewed.  The approach that should be taken depends upon project-specific design matters.  A strong and justifiable institutional process will have nuanced criteria on these matters.  Failing to establish transparent and predictable policies would be a serious lapse in an important area of research.

Booklet 37 of the Griffith University Research Ethics Manual now incorporates this three-part test.

In the subscribers’ area you will find a suggested question set for the three-part test, as well as a graphic overview of the work flow for the questions.

It is recommended institutions adopt their own version of the test, including policy positions with regard to the use of hacked or scraped data, or the research use of material in a manner at odds with a site/platform’s rules.

References

Australian agency to probe Facebook after shocking revelation – The New Daily. Accessed 16/11/19 from https://thenewdaily.com.au/news/world/2018/04/05/facebook-data-leak-australia/

Australian Bureau of Statistics (2018) 8153.0 – Internet Activity, Australia, June 2018. Retrieved from https://www.abs.gov.au/ausstats/abs@.nsf/mf/8153.0/ (accessed 27 September 2019)

Chamber, C. (2014 01 July) Facebook fiasco: was Cornell’s study of ‘emotional contagion’ an ethics breach? The Guardian. Accessed 16/11/19 from http://www.theguardian.com/science/head-quarters/2014/jul/01/facebook-cornell-study-emotional-contagion-ethics-breach

Griffith University (Updated 2019) Griffith University Research Ethics Manual (GUREM). Accessed 16/11/19 from https://www.griffith.edu.au/research/research-services/research-ethics-integrity/human/gurem

McCook, A. (2016 16 May) Publicly available data on thousands of OKCupid users pulled over copyright claim.  Retraction Watch. Accessed 16/11/19 from http://retractionwatch.com/2016/05/16/publicly-available-data-on-thousands-of-okcupid-users-pulled-over-copyright-claim/

Nielsen (2019, 26 July) TOTAL CONSUMER REPORT 2019: Navigating the trust economy in CPG. Retrieved from https://www.nielsen.com/us/en/insights/report/2019/total-consumer-report-2019/ (accessed 27 September 2019)

NHMRC (2007 updated 2018) National Statement on Ethical Conduct in Human Research. Accessed 17/11/19 from https://www.nhmrc.gov.au/about-us/publications/national-statement-ethical-conduct-human-research-2007-updated-2018

Satran, J. (2015 02 September) Ashley Madison Hack Creates Ethical Conundrum For Researchers. Huffington Post. Accessed 16/11/19 from http://www.huffingtonpost.com.au/entry/ashley-madison-hack-creates-ethical-conundrum-for-researchers_55e4ac43e4b0b7a96339dfe9?section=australia&adsSiteOverride=au

WebAlive (2019 24 June) The State of Australia’s Ecommerce in 2019 Retrieved from https://www.webalive.com.au/ecommerce-statistics-australia/ (accessed 27 September 2019).

Recommendations for further reading

Editorial (2018 12 March) Cambridge Analytica controversy must spur researchers to update data ethics. Nature. Accessed 16/11/19 from https://www.nature.com/articles/d41586-018-03856-4?utm_source=briefing-dy&utm_medium=email&utm_campaign=briefing&utm_content=20180329

Neuroskeptic (2018 14 July) The Ethics of Research on Leaked Data: Ashley Madison. Discover. Accessed 16/11/19 from http://blogs.discovermagazine.com/neuroskeptic/2018/07/14/ethics-research-leaked-ashley-madison/#.Xc97NC1L0RU

Newman, L. (2017 3 July) WikiLeaks Just Dumped a Mega-Trove of CIA Hacking Secrets. Wired Magazine. Accessed 16/11/19 from https://www.wired.com/2017/03/wikileaks-cia-hacks-dump/

Weaver, M (2018 25 April) Cambridge University rejected Facebook study over ‘deceptive’ privacy standards. TheGuardian. Accessed 16/11/19 from https://www.theguardian.com/technology/2018/apr/24/cambridge-university-rejected-facebook-study-over-deceptive-privacy-standards

Woodfield, K (ed.) (2017) The Ethics of Online Research. Emerald Publishing. https://doi.org/10.1108/S2398-601820180000002004

Zhang, S. (2016 20 May ) Scientists are just as confused about the ethics of big-data research as you. Wired Magazine. Accessed 16/011/19 from http://www.wired.com/2016/05/scientists-just-confused-ethics-big-data-research/

Competing interests

Gary is the principal author of the Griffith University Research Ethics Manual (GUREM) and receives a proportion of license sales.

This post may be cited as:
Allen, G. (23 November 2019) The research use of online data/web 2.0 comments. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/the-research-use-of-online-data-web-2-0-comments

Empowering and enabling participation in human research: Reflections from two Queenslanders living with Multiple Sclerosis0

 

Dr Gary Allen
MS Qld Ambassador | AHRECS Senior Consultant | Member NS s4 review committee


Natalie Walsh
MS Qld Community Engagement Manager

Participation in ethical human research often provides four positive opportunities for persons living with MS:

(i) A welcome distraction from the sometimes-cruel realities of living with this progressive neurological condition.

(ii) An opportunity to provide insight into the practical challenges of symptoms that may be invisible to observers other than family, close friends and carers, and to give voice to the experiences of persons who are disenfranchised.

(iii) Access to whatever benefits are anticipated as a result of a project.

(iv) An opportunity to make a positive contribution to the body of knowledge and/or other public good.

The exclusion of people living with MS from research is a concern with regard to the ethical values of Justice (e.g. NS 4.5.3) and Beneficence because it denies access to the benefits described above, on the grounds of a disability. It is also a merit and integrity concern because, if a section of the community is excluded from a research project, there is at least the possibility the results might be different for people living with MS.

Prevalence in society
In Australia 1 in 5 people live with a disability. The average age of people diagnosed with MS is just 30 and 3 out of 4 are female.

On average, more than 10 Australians are diagnosed with MS every week. There are over 25,600 people in Australia living with MS, including 4,970 Queenslanders and the condition affects each person differently. The progress, severity and specific symptoms of MS cannot be predicted. MS is a lifelong condition for which a cure is yet to be found. However, doctors and scientists are making discoveries about the treatment and management of MS every day.

MS is one of the most common chronic neurological conditions of the Central Nervous System and may affect the brain, spinal cord and optic nerve and impacts more young people in Australia than any other chronic progressive neurological disease.

Symptoms and research
It is important to note that the symptoms associated with MS can be different differ in both presentation and severity for each individual.

Symptoms of MS will vary and are unpredictable.  No two people will experience the same symptoms to the same degree. Symptoms can come and go, and can also be affected temporarily by other factors such as hot weather or an infection.

Although MS can cause a wide variety of symptoms, most people only experience a small number of these.  For most of the common MS symptoms, there are now many effective forms of symptom management. It is also important to note that the symptoms listed here are not exclusive to MS and can appear in many different neurological conditions.

The symptoms of MS can be both visible and invisible to others and include:

  • Changes in memory, concentration or reasoning
  • Slurring or slowing of speech
  • Extreme tiredness (unusual fatigue): a debilitating kind of general exhaustion and weariness which is unpredictable disproportionate to the activity
  • Visual disturbance, including blurring of vision, double vision (diplopia), inflammation of the optic nerve (optic neuritis), pain and (rarely) loss of vision
  • Dizziness and vertigo
  • Emotional and mood changes
  • Pain
  • Altered sensation, such as tingling, numbness or pins and needles
  • Altered muscle tone, such as muscle weakness, tremor, stiffness or spasms
  • Difficulties with walking, balance or coordination: – these include loss of balance, tremors, unstable walking (ataxia), dizziness (vertigo), clumsiness of a limb, lack of coordination, and weakness (affecting in particular the legs)
  • Sexual changes
  • Bladder and bowel changes
  • Sensitivity to heat and/or cold

Exclusion
The exclusion of persons living with MS can typically occur in one of two ways:

(i) Intentionally because of the perceived vulnerability of the population, especially if an individual’s symptoms include impact on executive function, such as cognition and memory.

(ii) Unintentionally
……..a. because the research activities don’t accommodate the limitations imposed by an individual’s symptoms.
……..b. because communication is not extended to the networks outside of the research community.

Empowering and enabling participation
The exclusion of persons living with MS from research should be limited to circumstances where an individual’s symptoms would confound the collected data (e.g. a person with a severe intention tremor in their lead hand is unlikely to be able to quickly draw a shape they saw) or where they are especially vulnerable to harm (e.g. high-intensity exercise when their symptoms include autonomic impact on their cardiovascular system).

Rather than excluding potential participants who live with MS, researchers and review bodies are encouraged to consider:

(i) Whether the complexity of the research and nature of the risks are such that the competence of potential participants should be established. This might be explored in a simple conversation, as is recommended by paragraph 4.5.10 of the National Statement, e.g.

…….a. in the case of low risk anonymous data collection, accepting consent without establishing competence.

…….b. considering strategies to scaffold consent and respecting the wishes of individuals, even if substitute consent is required.

…….c. including a support person to provide individual assistance to participants

(ii) Conducting testing in a cool and bright location and at preferred times, such as mornings.

(iii) Allowing participants to request rest breaks with refreshments available

(iv) Supporting screen readers and closed captioning.

(v) Supporting suitable interface controls other than a mouse.

(vi) Reimbursing transport, parking or companion costs if travel is required.

Reference groups
The establishment of a reference group can be a valuable way to explore whether the anticipated benefits of a project are perceived as justifying the risks (as recommended by paragraph 2.1.5 of the National Statement), whether the support strategies are sufficient, and whether the language of the recruitment and consent materials are appropriate.

References:
National Statement on Ethical Conduct in Human Research (2007 updated 2018)

This post may be cited as:
Allen, G. & Walsh N. (1 October 2019) Empowering and enabling participation in human research: Reflections from two Queenslanders living with Multiple Sclerosis. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/empowering-and-enabling-participation-in-human-research-reflections-from-two-queenslanders-living-with-multiple-sclerosis

We respect you… we just don’t need to hear from you any more: Should the consumer and their community participate in research as partners instead of just being subjects?1

 

By
Dr Gary Allen| Senior Policy Officer, Office for Research Griffith University | Ambassador Council the Hopkins Centre|
Ambassador MS Qld | Member Labor Enabled| Senior Consultant AHRECS

Associate Professor Carolyn Ehrlich| the Hopkins Centre| Research fellow at Griffith University

On behalf of the consumer inclusion in ethics research project, The Hopkins Centre, Griffith University

Much has already been said about the significance of the 2018 update to the Australian Code for the Responsible Conduct of Research. The Australian Code describes the national framework for the responsible conception, design, conduct, governance and reporting of research. Collectively this is referred to as research integrity. The Australian Code has changed from a 37-page book of detailed and prescriptive rules to a six-page book of high-level principles and responsibilities.

This is not another piece arguing the pros and cons of the flexibility of principles or the certainty of a single national standard.

Instead, this is a discussion about an important idea, which was present in the 2007 version of the Australian Code, but that was discarded without explanation or acknowledgement in the 2018 update. This important idea relates to consumer and community participation and its extension to consumer and community involvement in research.

At provision 1.13 of the 2007 version of the Australian Code there was a simple statement that Australian research institutions and researchers should encourage and facilitate consumer and community participation in research. The provision was included in the 2007 version as one part of the implementation of the Statement on Consumer and Community Participation in Health and Medical Research (NHMRC and Consumers’ Health Forum of Australia Inc, 2002) and went on to underpin the updated version of that statement, which was released in September 2016.  The absence from the 2018 version of the Australian Code of even a brief reference to consumer/community participation in research is (or SHOULD be) a significant cause for concern.

That brief encouragement provided support for consumer-guided designs, research participants as co-researchers and action research across most disciplines. With a few sentences, it mainstreamed the Statement on Consumer and Community Participation in Health and Medical Research and reinforced the importance of consumers and communities beyond ‘just’ research subjects in medical research.

Examples of that participation include the role of consumers and community members:

  1. On a reference/advisory group (including providing lived-experience with regard to the focus, objectives and deliverables of a project)
  2. As co-researchers
  3. In providing lived-experience into the significance of risks, harms and burdens, and the degree to which the risks are justified by the anticipated benefits (see Pär Segerdah 2019).
  4. In providing valuable insights for service/clinical decisions (see Carlini 2019 for an example).

A real example of this working well is of Cancer Australia which mandates the inclusion of consumers in their funding scheme, both in terms of applicants articulating how consumers are engaged (in the ways outlined above and also as reviewers and members of the review panels that evaluate grants). The inclusion of consumers improves projects immeasurably.  Cooperative cancer trials groups have a consumer advisory panel or committee. It would be unimaginable to do cancer trials without consumer involvement in their design. Such community participation is also evident in the recently approved research strategy at Epworth Health.

The above matters (such as whether a project is addressing a genuine community need and whether the risks of the project are justified by its benefits) can be especially significant for vulnerable individuals, especially persons living with ‘invisible conditions’, whereby people may have symptoms or disabilities that might not be immediately obvious to others, and/or when the ‘subjects’ of research are vulnerable, over-researched, or historically disenfranchised. Rather than protecting them from harm, and without a clear mandate for involving them more fully in the co-design and co-production of research that directly impacts their lives, there is a real risk of unintended consequences whereby these people may become even more disenfranchised, over-researched and vulnerable research ‘subjects’.

It is important to acknowledge that the 2016 Statement remains in place, the National Statement on Ethical Conduct in Human Research (2007 updated 2018) continues to articulate the core values of justice and respect, and the new Chapter 3.1 of the 2018 update of the National Statement on Ethical Conductmentions co-researcher designs. More specifically, paragraphs 1.1(a) and 2.1.5 identify community engagement as an important element in research design and planning. The omission from the Australian Code (2018) is out of step with the National Safety and Quality Health Service Standard which calls (2012 p15) for consumer and community involvement in deliberations about risk.

What is a concern now is that the overarching Australian Code for the Responsible Conduct of Research no longer urges publicly-funded research institutions to encourage consumer and community participation in research beyond them being the subjects of research.  On balance, this appears to be inconsistent with other relevant national research standards issued by the same agencies as the Code.

Those voices and perspectives were around before the 2007 version of the Australian Code and hopefully, they will continue to be into the future. That is true because it is becoming more widely accepted that consumers, such as people living with a chronic disease or disability and their carers, have a valuable perspective and a voice that should be listened to. One way a research project can have impact is by heeding those voices and meeting the needs of those Australians. However, in the 2018 update of the Australian Code, there is no longer an obligation on Australian institutions and researchers to encourage and facilitate consumer and community participation in research.

But will the same amount and scope of consumer and community-engaged research be conducted without that encouragement in the Australian Code?

It seems we are about to find out. We just wished there had been a national discussion about that change first – including targeted engagement with the populations who are now no longer encouraged to collaboratively participate in research, and who will potentially be relegated back to a position of being a subject within researcher designed projects and studies.

One way the current situation could be addressed would be in a good practice guide. The Australian Code (2018) is complemented with good practice guides, which suggest how institutions and researchers should interpret and apply the Australian Code’s principles and responsibilities to their practice. A good practice guide for collaborative research could reinforce the importance of consumer and community participation in research.

REFERENCES

Carlini, J. (18 January 2018) Consumer Co-design for End of Life Care Discharge Project. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/consumer-co-design-for-end-of-life-care-discharge-project

NHMRC(2007) Australian Code for the Responsible Conduct of Research

NHMRC(2007 updated 2018) National Statement on Ethical Conduct in Human Research

NHMRC (2016) Statement on Consumer and Community Involvement in Health and Medical Research

NHMRC (2018) Australian Code for the Responsible Conduct of Research

NSQHS (2012) National Safety and Quality Health Service Standards

Pär Segerdah (2019) Ask the patients about the benefits and the risks. The Ethics Blog. Retrieved from: https://ethicsblog.crb.uu.se/2019/01/16/ask-the-patients-about-the-benefits-and-the-risks/

ACKNOWLEDGEMENTS

With grateful thanks to the following people for their contributions:

Delena Amsters, QHealth
Mark Israel, AHRECS
Mandy Nielsen, QHealth
Michael Norwood, Griffith University
Maddy Slattery, Griffith University
Colin Thomson AM, AHRECS
Nik Zeps, AHRECS, Epworth Healthcare

This post may be cited as:
Allen, G. & Ehrlich, C. (21 June 2019) We respect you… we just don’t need to hear from you any more: Should the consumer and their community participate in research as partners instead of just being subjects? Research Ethics Monthly. Retrieved from: https://ahrecs.com/research-integrity/we-respect-you-we-just-dont-need-to-hear-from-you-any-more-should-the-consumer-and-their-community-participate-in-research-as-partners-instead-of-just-being-subjects

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