Ethical evaluation of informed consent forms used in cardiology clinics and the importance of institutional standardized approach.

OBJECTIVE: This study aimed to evaluate the content of informed consent forms (ICFs) used during cardiology interventions by the university, research and training (R-T), and private hospitals with regard to ethical standards and compare them with the Turkish Society of Cardiology (TSC) templates and among various institutions. METHODS: A total of 185 forms from the university, R-T, and private hospitals and 19 TSC templates were selected and analyzed for 26 criteria. Compliance with TSC templates was also evaluated. Data were presented as the percentage of ICFs satisfying the criteria and compared using the Fisher exact test, and 95% confidence intervals were calculated. RESULTS: TSC templates were more compatible and included more information to comply with ethical standards than ICFs of all 3 types of healthcare institutions. The areas of improvement for these templates were prospects of treatment and alternative treatments, quality of life, explanation for third-party consent, duration of hospitalization, and time to return to normal life. Among the 3 types of hospitals, R-T-ICFs were more compatible with templates. Private hospital ICFs had the poorest compliance with TSC templates. Separate anesthesia ICFs and detailed information about exposure to radioactivity were lacking. CONCLUSION: The current ICFs for cardiology interventions have major ethical deficiencies and need urgent improvement. Professional societies such as TSC are essential institutions to develop and provide guidance and templates for ICFs to meet the ethical standards during the informed consent process and standardization of the process among various institutions.

Readability analysis of informed consent forms for genetic tests in Mexico.

INTRODUCTION: Knowing if the document that supports the informed consent (IC) granted by the patient who undergoes genetic laboratory tests is legible and understandable is important. OBJECTIVE: To analyze the readability of IC documents for laboratory genetic tests (LGT) in Mexico. METHODS: Readability of 10 free IC forms on the internet used for LGT was analyzed using the Legible.es program; the Flesh index, Fernández-Huerta version, and the INFLESZ scale were evaluated. The number of syllables, words, phrases, paragraphs and strange words, time to read the document and minimum years of education required to understand it were counted. RESULTS: 60 % of the analyzed IC documents were found to have poor readability. On average, 3,290 syllables, 1,459 words, 124 sentences, 58 paragraphs and 52 strange words were counted. The time required for reading it was seven minutes and minimum level of education to understand it was six years. CONCLUSIONS: The analyzed IC forms for LGT have low readability rates and exceed the recommended number of words. We propose an IC model for LGT in Mexico that complies with appropriate readability indexes for a correct understanding of the document.

INTRODUCCIÓN: Es importante conocer si el documento que ampara el consentimiento informado (CI) del paciente a quien se le realizan pruebas genéticas de laboratorio (PGL) es legible y comprensible. OBJETIVO: Analizar la legibilidad de documentos de consentimiento informado (CI) para pruebas genéticas de laboratorio (PGL) en México. MÉTODOS: Se analizó la legibilidad de 10 formatos de CI libres en internet utilizados para PGL mediante el programa Legible.es; se evaluó índice de Flesh, versión de Fernández Huerta, y la escala INFLESZ. Se contabilizó el número de sílabas, palabras, frases, párrafos y palabras raras, tiempo para leer el documento y años de escolaridad mínima para entenderlo. RESULTADOS: Se identificó que 60 % de los formatos de CI analizados son poco legibles. En promedio, se contabilizaron 3290 sílabas, 1459 palabras, 124 frases, 58 párrafos y 52 palabras raras. El tiempo requerido para la lectura fue de siete minutos y la escolaridad mínima de seis años. CONCLUSIONES: Los formatos de CI analizados tuvieron bajos índices de legibilidad y exceden el número recomendado de palabras. Proponemos un modelo de CI para PGL en México, que cumple con los índices de legibilidad para la correcta comprensión del documento.

The readability of informed consent forms for research studies conducted in South Africa.

BACKGROUND: Informed consent forms (ICFs) are used to obtain consent from participants. However the complexity and comprehensiveness of these forms may not be appropriate. Readability can be quantified by formulas in Microsoft (MS) Word, such as the Flesch Reading Ease test. The South African (SA) ethics guidelines suggest that the MS Word Flesch-Kincaid Reading Grade score should be used to assess the complexity of ICFs and should be the equivalent of grade 8 level, or lower. OBJECTIVES: To use readability formulas to determine whether current SA ICFs are appropriate for the general population. METHODS: This was a descriptive study of a sample of English ICFs (solicited from our studies, as well as from local researchers) which received approval from local ethical review boards during the past 5 years, for prospective (≥6 months) drug studies that explored treatment and prevention of HIV, tuberculosis, diabetes or cardiovascular disease. ICFs were evaluated in MS Word for Flesch Reading Ease and Flesch-Kincaid Reading Grade, with the Simple Measure of Gobbledygook (SMOG) index calculated using www.readabilityformulas.com. Recommended targets for easy readability are above 60 for the Flesch Reading Ease score, and less than or equal to a grade 8 reading level for the Flesch-Kincaid Reading Grade and SMOG. RESULTS:   A total of 75 consent forms from 35 individual research studies conducted in SA over the last 5 years were included. The consent forms had been approved by six ethics committees across seven of the SA provinces. The median (interquartile range (IQR)) Flesch Reading Ease score was 55.8 (48.7 - 59.7) and 18 (25.0%) of the ICFs had easy or standard readability, while the median (IQR) Flesch-Kincaid Grade was 10.2 (8.8 - 11.4), with 23 (30.6%) at least a grade 8 level or lower. The median (IQR) SMOG index was 9.8 (9.0 - 11.1) and 4 (5.3%) scored below grade 8 level. CONCLUSIONS: Two-thirds of the ICFs from this study fail to meet the SA readability standard, a result matched by using alternative readability formulas. Readability can be improved with simple techniques and by actively monitoring readability metrics.

Assessment of Length and Readability of Informed Consent Documents for COVID-19 Vaccine Trials.

Importance: Informed consent is a fundamental element of research ethics. The COVID-19 vaccine trials are high profile trials that have enrolled more than 100 000 participants. Consent documents must be succinct and understandable to ensure informed voluntary participation. Objective: To assess how well informed consent documents of the COVID-19 vaccine trials achieve the ideal of being succinct and understandable, and to create a shorter, more readable document. Design, Setting, and Participants: This quality improvement study collected and analyzed the informed consent documents used in 4 COVID-19 vaccine phase III randomized clinical trials to quantitatively assess readability and length and, based on this analysis, created a measurably more accessible informed consent document. Analysis was conducted from October 2020 to January 2021. Main Outcomes and Measures: The main outcomes were number of words (measured as word count), time-to-read (measured at reading speeds of 175-300 words per minute), language complexity (measured using Flesch-Kincaid Grade Level assessment), and readability (measured using Flesch Reading Ease Score). Secondary outcomes included clarity of how the placebo group could access the vaccine if it is proven safe and effective. The study also examined the length and readability of an improved consent document. Results: The 4 informed consent documents were a mean (range) of 8333 (7821 to 9340) words long, with a mean (range) 35 (32.6 to 38.9) minutes to read at 240 words per minute. All documents exceeded grade 9 language complexity and scored lower than 60 in the formal reading ease metric, which constitutes difficult. Only 1 document specified that participants in the placebo group might receive vaccine. It was possible to write a document in fewer than 3000 words with a grade 7 to 8 reading level and a formal readability score that was not difficult. Conclusions and Relevance: These findings suggest that existing COVID-19 vaccine informed consent documents were too long, difficult to read, and exceeded grade 9 in language complexity. It was possible to create a shorter, more readable informed consent document for these trials.

Análisis de legibilidad de formatos de consentimiento informado para pruebas genéticas en México / Readability analysis of informed consent forms for genetic tests in Mexico

Resumen Introducción: Es importante conocer si el documento que ampara el consentimiento informado (CI) del paciente a quien se le realizan pruebas genéticas de laboratorio (PGL) es legible y comprensible. Objetivo: Analizar la legibilidad de documentos de CI para pruebas genéticas de laboratorio (PGL) en México. Métodos: Se analizó la legibilidad de 10 formatos de CI libres en internet utilizados para PGL mediante el programa Legible.es; se evaluó índice de Flesh, versión de Fernández Huerta, y la escala INFLESZ. Se contabilizó el número de sílabas, palabras, frases, párrafos y palabras raras, tiempo para leer el documento y años de escolaridad mínima para entenderlo. Resultados: Se identificó que 60 % de los formatos de CI analizados son poco legibles. En promedio, se contabilizaron 3290 sílabas, 1459 palabras, 124 frases, 58 párrafos y 52 palabras raras. El tiempo requerido para la lectura fue de siete minutos y la escolaridad mínima de seis años. Conclusiones: Los formatos de CI analizados tuvieron bajos índices de legibilidad y exceden el número recomendado de palabras. Proponemos un modelo de CI para PGL en México, que cumple con los índices de legibilidad para la correcta comprensión del documento.

Abstract Introduction: Knowing if the document that supports the informed consent (IC) granted by the patient who undergoes genetic laboratory tests is legible and understandable is important. Objective: To analyze the readability of IC documents for laboratory genetic tests (LGT) in Mexico. Methods: Readability of 10 free IC forms on the internet used for LGT was analyzed using the Legible.es program; the Flesh index, Fernández-Huerta version, and the INFLESZ scale were evaluated. The number of syllables, words, phrases, paragraphs and strange words, time to read the document and minimum years of education required to understand it were counted. Results: 60 % of the analyzed IC documents were found to have poor readability. On average, 3,290 syllables, 1,459 words, 124 sentences, 58 paragraphs and 52 strange words were counted. The time required for reading it was seven minutes and minimum level of education to understand it was six years. Conclusions: The analyzed IC forms for LGT have low readability rates and exceed the recommended number of words. We propose an IC model for LGT in Mexico that complies with appropriate readability indexes for a correct understanding of the document.

Some researchers wear yellow pants, but even fewer participants read consent forms: Exploring and improving consent form reading in human subjects research.

Though consent forms include important information, those experienced with behavioral research often observe that participants do not carefully read consent forms. Three studies examined participants' reading of consent forms for in-person experiments. In each study, we inserted the phrase "some researchers wear yellow pants" into sections of the consent form and measured participants' reading of the form by testing their recall of the color yellow. In Study 1, we found that the majority of participants did not read consent forms thoroughly. This suggests that overall, participants sign consent forms that they have not read, confirming what has been observed anecdotally and documented in other research domains. Study 2 examined which sections of consent forms participants read and found that participants were more likely to read the first 2 sections of a consent form (procedure and risks) than later sections (benefits and anonymity and confidentiality). Given that rates of recall of the target phrase were under 70% even when the sentence was inserted into earlier sections of the form, we explored ways to improve participant reading in Study 3. Theorizing that the presence of a researcher may influence participants' retention of the form, we assigned participants to read the form with or without a researcher present. Results indicated that removing the researcher from the room while participants read the consent form decreased recall of the target phrase. Implications of these results and suggestions for future researchers are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessing Parent Decisions About Child Participation in a Behavioral Health Intervention Study and Utility of Informed Consent Forms.

Importance: Obtaining informed consent is an important ethical obligation for clinical research participation that is imperfectly implemented. Research on improving consent processes often focuses on consent forms, but little is known about consent forms' influence on decision-making compared with other types of engagement. Objective: To evaluate whether parents decide whether to enroll their children in research before or after they receive the consent form. Design, Setting, and Participants: An online survey of 88 parents who enrolled or declined to enroll their child in a weight management intervention study between January 2, 2018, and June 24, 2019, was conducted; surveys were completed between February 2, 2018, and July 9, 2019. A 31-item survey asked about impressions of the study throughout the enrollment process, timing of enrollment decisions, and decision-making factors. Responses were summarized descriptively and subgroups were compared using the Fisher exact test or χ2 test. Main Outcomes and Measures: Self-reported timing of enrollment decision. Results: A total of 106 parents were approached and gave permission for their contact information to be shared with the study team; 22 additional parents declined to allow their information to be shared, and 24 lost contact with the partner study before they could be asked for permission. A total of 88 parents (67 enrollees, 21 decliners) completed the survey (83% participation rate); 79 of 88 reporting gender (instead of sex, as biological sex was not relevant to survey) information were women (91%), 66 participants (75%) were non-Hispanic White, and 63 participants (72%) had annual household incomes greater than or equal to $70 000. No significant differences in respondent characteristics between enrollees and decliners were identified. Fifty-nine parents (67%) responded that they decided whether to enroll in the weight management study before receiving the consent form. Only 17 of 69 parents (25%) who remembered receiving the consent form responded that it taught them new information. Conclusions and Relevance: The findings of this study suggest that interventions to improve informed consent forms may have limited influence on decision-making because many research decisions occur before review of the consent form. It appears that regulatory review and interventions to improve decision-making should focus more on early engagement (eg, recruitment materials). Future studies should test timing of decisions in other types of research with different populations and clinical settings.

Genome Editing 2020: Ethics and Human Rights in Germline Editing in Humans and Gene Drives in Mosquitoes.

The moon landing, now more than a half century in the past, has turned out to be the culmination of human space travel, rather than its beginning. Genetic engineering, especially applications of CRISPR, now presents the most publicly-discussed engineering challenges-and not just technical, but ethical as well. In this article, I will use the two most controversial genomic engineering applications to help identify the ethics and human rights implications of these research projects. Each of these techniques directly modifies the mechanisms of evolution, threatens to alter our views of ourselves as humans and our planet as our home, and presents novel informed consent and dual use challenges: human genome editing and gene drives in insects.I begin with a discussion of so far disastrously unsuccessful attempts to regulate germline editing in humans, including a summary of the first application of germline genome editing in humans and its aftermath. I then turn to a discussion of setting ethical standards for a genomic technology that has not yet been deployed in nature-gene drives. Finally, I end by suggesting that human rights can and should be directly applicable to defining the ethics of genomic research.

IRB Policies for Obtaining Informed Consent from Non-English-Speaking People.

United States regulations for the protection of human research subjects prescribe parameters for documentation of valid informed consent, which include the stipulation that the process be in a "language understandable to the subject." While significant energy has been devoted to improving the readability of consent documents, supplemental educational tools, and nuanced measurements of individual decisional capacity, there is little guidance about how to best meet the informational needs of adults with decisional capacity who do not speak English. This article reviews the institutional review board policies from the twenty-one research centers that received the most funding from the National Institutes of Health in 2018 and compares their guidelines for obtaining informed consent from non-English speakers. Inconsistent practices suggest the need for more assertive federal direction on what parameters constitute valid consent for this population. These practices also indicate a reluctance to directly engage the ethical underpinnings of consent policies for non-English speakers.

Consensus on Language for Advance Informed Consent in Health Care-Associated Pneumonia Clinical Trials Using a Delphi Process.

Importance: Information to be included in advance informed consent forms for health care-associated pneumonia treatment trials remains to be determined. Objective: To identify and determine how to describe information to be included in an advance informed consent form for an early-enrollment noninferiority hospital-acquired and/or ventilator-associated bacterial pneumonia (HABP/VABP) clinical trial. Design, Setting, and Participants: A Delphi consensus process with stakeholders in HABP/VABP clinical trials was conducted using qualitative semistructured telephone interviews from June to August 2016, followed by 2 online surveys, the first from April to May 2017, and the second from September to October 2017. All stakeholders who participated in the interview were invited to participate in the first survey. Stakeholders who participated in the first survey were invited to participate in the second survey. Stakeholders were patients at risk of pneumonia, caregivers, representatives of institutional review boards, investigators, and study coordinators. Main Outcomes and Measures: Description and consensus of information to be included in advance informed consent forms for early enrollment in noninferiority HABP/VABP clinical trials. Results: Suggestions from 52 stakeholders about what key informed consent concepts to include and how to explain them were used to create 3 categories to be included in an advance consent form: (1) reassurances on patient health and treatment, (2) rationale for advance consent and early enrollment, and (3) an explanation of noninferiority. At the end of the Delphi process, at least 80% consensus was reached among the 40 stakeholders who participated in the second online survey on each of the statements to include in the proposed consent text. Throughout the process, however, describing and reaching consensus on statements about noninferiority was more problematic than the other categories. Conclusions and Relevance: The stakeholders endorsed consent language to be used in combination with a strategy for enrolling patients at highest risk for pneumonia before infection onset. Data-driven consent language may help potential participants make informed decisions about their involvement in clinical research and improve enrollment rates, which are necessary to evaluate new treatments and improve patient care. The proposed consent language may be adapted for other trials using an early enrollment strategy and for noninferiority trials.

Communicating genetic information to family members: analysis of consent forms for diagnostic genomic sequencing.

Communicating results from genomic sequencing to family members can play an essential role allowing access to surveillance, prevention, treatment or prophylactic measures. Yet, many patients struggle with communication of these results and it is unclear to what extent this is discussed during the consent process. We conducted an online systematic search and used content analysis to explore how consent forms for genomic sequencing address communication of genetic information to family members. Our search yielded 68 consent forms from 11 countries. Although 57 forms alluded to the familial nature of results, forms varied in their discussion of the potential familial implications of results. Only 11 addressed communication of genetic information with family members, with differences in who would be responsible for this process. Several forms offered patients options regarding communication, even in countries where national guidelines and legislation allow for the disclosure of results in the absence of patient consent. These findings are concerning because they show how forms may potentially mislead patients and health care professionals about whether communication is permissible in cases where the patient does not consent. We suggest that providers and health care professionals reconsider how consent forms address communicating genetic information to family members.

Electronic Informed Consent in Mobile Applications Research.

The article covers electronic informed consent (eIC) from different dimensions so that practitioners might understand the history, regulation, and current status of eIC. It covers the transition of informed consent to electronic screens and the implications of that transition in terms of design, costs, and data analysis. The article explores the limits of regulation mandating eIC for mobile application research, and addresses some of the broader social context around eIC.

Evaluation of length and complexity of written consent forms in English and Hebrew for participation in clinical trials authorized in one medical institution in Israel: A descriptive study.

Informed consent forms (ICFs) in clinical trials are the only objective testimony whether the information provided to participants is comprehensive and presented in an accessible language. We evaluated the length of Hebrew ICFs and their English translations and evaluated the readability of the latter. In fifteen clinical trials (5 with pharmacogentic sub-study), the median number (IQR) of pages and words were: English clinical ICFs - 16 pages (13,18) and 7360 words (6959,8289); Hebrew clinical ICFs - 12 pages (10,14), 5807 words (5258,6403); English pharmacogenetics ICFs - 7 pages (4,11), 2930 words (2234,5100); Hebrew pharmacogenetics ICFs - 5 pages (4,8.5), 2273 words (1663,3889); the two English ICFs combined - 23 pages (18;29.5), 10,820 words (9515,15,600); and the two Hebrew ICFs combined - 19 pages (16,23), 8258 words (7340,10,515). Differences between the Hebrew clinical trial ICFs and their English translations were significant (p < 0.001). Median (IQR) Flesch Reading Ease scores for the clinical and the pharmacogenetics ICFs were 48.4 (42.7, 49.9) and 42.2 (41.7,42.65), respectively. Thirteen studies were multinational. Twelve were conducted simultaneously in the United States, where an assessment of readability scores is customary. In conclusion, the consent forms evaluated in this study were long, and readability scores were low.

The Consent Form in the Chinese CRISPR Study: In Search of Ethical Gene Editing.

This editorial provides an ethical analysis of the consent materials and other documents relating to the recent creation and birth of twin girls who had their genes edited using CRISPR-cas9 in a controversial Chinese research study. It also examines the "draft ethical principles" published by the leader of the research study. The results of the analysis further intensify serious ethical concerns about the conduct of this study.

Too Dense and Too Detailed: Evaluation of the Health Literacy Attributes of an Informed Consent Document.

The US government recently updated the Common Rule, a set of federal regulations to ensure the ethical conduct of human subjects research. The new regulations require that consent documents provide information that is clear and concise enough to enable truly informed consent. This study explores potential American Indian research participants' understanding and perceptions of an example consent document, focusing on possible improvements to better serve the requirements of the revised Common Rule. Participants completed a survey that collected demographic data and measured health literacy, numeracy, and comprehension of the example document. Next, they participated in focus groups to answer open-ended questions regarding their views on the example document. We calculated mean scores and frequencies of response to analyze quantitative survey data and performed a qualitative thematic analysis of focus group transcripts. Results demonstrated that American Indian participants with relatively strong health literacy skills clearly understood key elements of the consent document, including the purpose of signing it, confidentiality, compensation, and whom to contact for questions. However, they were overwhelmed by details on research procedures and were concerned about the document's layout. To make consent documents more readily comprehensible, participants recommended the addition of headings, bullets, graphics, and relevant pictures. They also recommended a two-step consent process, comprising a short introduction to the research project followed by a longer explanation of procedures. These results illustrate the potential advantages of community engagement in drafting consent materials. Health researchers would likely benefit from community recommendations like the ones we elicited as they design consent documents adherent to the revised Common Rule.