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Australasian Human Research Ethics Consultancy Services Pty Ltd (AHRECS)

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

Clergy service to HRECs: the useful paradox within secular governance of research involving human participants0

 

Aviva Kipen, Union for Progressive Judaism and Progressive Judaism Victoria.

In 2015, I earned a Doctor of Ministry Studies degree from the University of Divinity in Melbourne. The thesis, investigating how 13 Christian and Jewish clergy experienced HREC service in their pastoral care roles, arose from my own human research ethics committee and Victorian Biotechnologies Ethics Advisory Committee service and extensive interfaith work. I had been mentored into my service to the Monash University HREC by the Rev’d Dr Judy Redman, the then Victorian Uniting Church Outreach Ministries Coordinator. I found myself in the company of Anglican clergy and had succeeded Catholics – nuns and priests – Buddhist monks and also male rabbis who had served before me. Joining Judy, the serving female minister, made the gender issue less remarkable than it might otherwise have been, even in the late 1990s. The faith interchanges on succession raised my immediate curiosity that would later lead to the research question and the project on which this piece draws.

The then National Guidelines were clear: we clergy appointees were not there to push our own denominational barrows. Still, I became curious about what was really going on in the minds of others who served HRECs interchangeably from a range of faiths and traditions regardless of often-irreconcilable theologies in the ‘pastoral chairs’. My interfaith work meant I was confident that, in the event of content matters being beyond my own repertoire, I would have an extensive network from which to seek expert guidance if asked to do so. But HREC appointment provides an opportunity to serve far beyond the specifics of faith content occasionally referenced in research applications.

I became aware that the recruitment of ‘the pastor’ in other committees was not always simple. I had been spotted at a meeting about chaplaincy in women’s prisons! How had others been identified and invited to join committees? What constituted their self-understanding of the ministry service being gifted to the committees they served? Would my interviews disclose any kind of ‘evangelism by stealth’?  Did faiths or denominations target access to committees assessing large amounts politically/theologically/ethically sensitive, kinds of research?

I discovered no documents showing the means by which the Catholic Church became an early adopter of the opportunity to be represented, but clearly there were Catholic clergy leading the discussion in the early years. My research showed great diversity within the voices of the Christian ministers. Even within denominations, including between current serving Catholics, there was diversity of expression on ground-breaking issues. It became clear that the one participant who asserted his role as being to represent the Catholic position, was the exceptional Catholic voice. Other Catholics applied the provisions of the current National Statement informed by their own faith understanding, but with broad appreciation for other communities’ concerns.

Many clergy enjoyed the intellectual effort of meeting preparation and assessing applications, perhaps indicating a somewhat obsessive character trait. The rigor of disciplined meetings, the collegiality with co-assessors and committee colleagues was experienced by many as a valued counterweight to congregational demands. When appointed, some experienced a bit of resistance and some took a gentle ribbing. But as they became known and trusted on their merits and performance, tenures were frequently extended. There was some inference that if individuals had theologies unable to embrace the content or methodologies required in assessing projects, it would be unlikely that they would find their way onto committees. A few references to short tenures alluded to non-renewal of clergy who were not a good fit.

The diversity of appointments reflects the neighbourhoods/communities served by HRECs and is appropriately representative of our national diversity. One participant was from a highly conservative evangelical denomination. The interview triggered deeply thoughtful reaction about personal identity relative to the HREC work. I would later find out that the reflection resulted in some major theological grappling as a consequence of the conversation. Regardless of denomination, interviewees found themselves intrigued by the attention my investigation was bringing to HREC clergy/pastoral work, which had almost invariably been out of the faiths’ hierarchical spotlights. Most remained entirely grateful for the freedom to do the HREC work without such attention.

One pastor described choosing not to participate in a committee discussion because he was aware his personal knowledge was not sufficient. It was a frank admission. The example begs the question of how applications need to enable comprehension and how lay and other non-disciplinary experts are enabled in their roles. Others found solutions to specific matters of dogma by offering wordings that would provide enough cues to the faith’s adherents to ensure they were going to be able to make informed choices without imperilling projects. What emerged was that clergy were clear about their denominational obligations and the tension between them and the needs of others in the general community.

Given that the task of assessing applications and contributing to meetings is identical for all HREC members, how do clergy understand themselves alongside their colleagues (who may be harbouring strong religious views but are not required to disclose them and which need not be presumed) as contributors to the wellbeing of the research landscape? Several clergy described pastoral care for committee colleagues and secretariat staff, by virtue of regular contact with them. This was implicit and automatic pastoral work. Care for researchers and participants whom the HREC members will never meet, is also natural pastoral work and a clear driver for clergy in their appointments.

Serving HRECs also provides clergy with a window to unfolding knowledge, a forward-looking perspective, regular use of critical faculties not always appreciated in congregational work, intelligent company, confidential settings in which they can be full participants without any oversight from their hierarchies resulting in contributions that don’t need to follow predictable, dogmatic lines, and a chance to serve beyond the faith or denomination. Australia has encoded high standards for itself in the research domain. Participants in my research were clear that high ethical research standards fit congruently into their understanding of their ministry work and several specialise in HREC work as their ministry interest. Many of these have high-level academic qualifications and years of expertise, which are offered repeatedly to the Australian community through HREC service.

Rabbi Dr Aviva Kipen has held Monash University HREC appointments and served on the Victorian Bio-Ethics Advisory Committee. She returned to serve a second term on the Australian Health Ethics Committee of NHMRC in 2019 and has begun the current triennium for the Victorian DHHS HREC. All comments reflect material in the thesis Kipen, A. (2015) Serving God and The Commonwealth of Australia: The Ministry Experiences of Clergy in Victorian Human Research Ethics Committees. Melbourne: University of Divinity.

This post may be cited as:
Kipen, A. (3 November 2019) Clergy service to HRECs: the useful paradox within secular governance of research involving human participants. Retrieved from: https://ahrecs.com/human-research-ethics/clergy-service-to-hrecs-the-useful-paradox-within-secular-governance-of-research-involving-human-participants

Keywords
Clergy, religion, denomination, ministry, faith

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

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