Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies
Abstract Background Cluster randomized trials are common in health research in low- and middle-income countries raising issues that challenge interpretation of standard ethical guidelines. While the Ottawa Statement on the ethical design and conduct of cluster randomized trials provides guidance for...
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doaj-50cc92996c78436a847339ae6d39aeba2020-11-25T02:23:36ZengBMCTrials1745-62152020-04-0121S11910.1186/s13063-020-04269-3Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studiesAugustine T. Choko0Gholamreza Roshandel1Donaldson F. Conserve2Elizabeth L. Corbett3Katherine Fielding4Karla Hemming5Reza Malekzadeh6Charles Weijer7Malawi-Liverpool Wellcome Trust Clinical Research ProgrammeGolestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical SciencesDepartment of Health Promotion, Education and Behaviour, University of South CarolinaMalawi-Liverpool Wellcome Trust Clinical Research ProgrammeDepartment of Infectious Disease Epidemiology, London School of Hygiene and Tropical MedicineInstitute of Applied Health Research, University of BirminghamDigestive Disease Research Center, Digestive Diseases Research Institute, Tehran University of Medical SciencesRotman Institute of Philosophy, Western UniversityAbstract Background Cluster randomized trials are common in health research in low- and middle-income countries raising issues that challenge interpretation of standard ethical guidelines. While the Ottawa Statement on the ethical design and conduct of cluster randomized trials provides guidance for researchers and research ethics committees, it does not explicitly focus on low- and middle-income settings. Main body In this paper, we use the lens of the Ottawa Statement to analyze two cluster randomized trials conducted in low- and middle-income settings in order to identify gaps or ethical issues requiring further analysis and guidance. The PolyIran trial was a parallel-arm, cluster trial examining the effectiveness of a polypill for prevention of cardiovascular disease in Golestan province, Iran. The PASTAL trial was an adaptive, multistage, parallel-arm, cluster trial evaluating the effect of incentives for human immunodeficiency virus self-testing and follow-up on male partners of pregnant women in Malawi. Through an in-depth case analysis of these two studies we highlight several issues in need of further exploration. First, standards for verbal consent and waivers of consent require methods for operationalization if they are to be employed consistently. Second, the appropriate choice of a control arm remains contentious. Particularly in the case of implementation interventions, locally available care is required as the comparator to address questions of comparative effectiveness. However, locally available care might be lower than standards set out in national guidelines. Third, while the need for access to effective interventions post-trial is widely recognized, it is often not possible to guarantee this upfront. Clarity on what is required of researchers and sponsors is needed. Fourth, there is a pressing need for ethics education and capacity building regarding cluster randomized trials in these settings. Conclusion We identify four issues in cluster randomized trials conducted in low- and middle-income countries for which further ethical analysis and guidance is required.http://link.springer.com/article/10.1186/s13063-020-04269-3Cluster randomized trialResearch ethicsEthicsLow- and middle-income countriesInformed consentEquipoise |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Augustine T. Choko Gholamreza Roshandel Donaldson F. Conserve Elizabeth L. Corbett Katherine Fielding Karla Hemming Reza Malekzadeh Charles Weijer |
spellingShingle |
Augustine T. Choko Gholamreza Roshandel Donaldson F. Conserve Elizabeth L. Corbett Katherine Fielding Karla Hemming Reza Malekzadeh Charles Weijer Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies Trials Cluster randomized trial Research ethics Ethics Low- and middle-income countries Informed consent Equipoise |
author_facet |
Augustine T. Choko Gholamreza Roshandel Donaldson F. Conserve Elizabeth L. Corbett Katherine Fielding Karla Hemming Reza Malekzadeh Charles Weijer |
author_sort |
Augustine T. Choko |
title |
Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies |
title_short |
Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies |
title_full |
Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies |
title_fullStr |
Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies |
title_full_unstemmed |
Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies |
title_sort |
ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies |
publisher |
BMC |
series |
Trials |
issn |
1745-6215 |
publishDate |
2020-04-01 |
description |
Abstract Background Cluster randomized trials are common in health research in low- and middle-income countries raising issues that challenge interpretation of standard ethical guidelines. While the Ottawa Statement on the ethical design and conduct of cluster randomized trials provides guidance for researchers and research ethics committees, it does not explicitly focus on low- and middle-income settings. Main body In this paper, we use the lens of the Ottawa Statement to analyze two cluster randomized trials conducted in low- and middle-income settings in order to identify gaps or ethical issues requiring further analysis and guidance. The PolyIran trial was a parallel-arm, cluster trial examining the effectiveness of a polypill for prevention of cardiovascular disease in Golestan province, Iran. The PASTAL trial was an adaptive, multistage, parallel-arm, cluster trial evaluating the effect of incentives for human immunodeficiency virus self-testing and follow-up on male partners of pregnant women in Malawi. Through an in-depth case analysis of these two studies we highlight several issues in need of further exploration. First, standards for verbal consent and waivers of consent require methods for operationalization if they are to be employed consistently. Second, the appropriate choice of a control arm remains contentious. Particularly in the case of implementation interventions, locally available care is required as the comparator to address questions of comparative effectiveness. However, locally available care might be lower than standards set out in national guidelines. Third, while the need for access to effective interventions post-trial is widely recognized, it is often not possible to guarantee this upfront. Clarity on what is required of researchers and sponsors is needed. Fourth, there is a pressing need for ethics education and capacity building regarding cluster randomized trials in these settings. Conclusion We identify four issues in cluster randomized trials conducted in low- and middle-income countries for which further ethical analysis and guidance is required. |
topic |
Cluster randomized trial Research ethics Ethics Low- and middle-income countries Informed consent Equipoise |
url |
http://link.springer.com/article/10.1186/s13063-020-04269-3 |
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