When evaluating risk, different considerations may apply to research conducted outside the US Specifically:
- research methods that have virtually no risk in the US might have risk when conducted in other countries;
- questions that may be innocuous in the US could be offensive in other countries;
- breach of confidentiality could have much more dangerous consequences than in the U.S.; and/or
- assuring and maintaining confidentiality in foreign countries may be difficult.
If not already knowledgeable, researchers must become knowledgeable in local context issues that are relevant to the specific research. Specifically, researchers may need to:
- consult with community leaders and stake holders who may be able to provide important insights about the local research context, including information about local customs, norms, and laws
- communicate and coordinate with local IRBs or ethics groups as well as work with their U.S. IRB
- provide approval documentation for the research received by the PI from the local IRB or ethics group, as applicably defined by the specific community in which the research will be taking place. Examples of acceptable documentation include: local IRB or ethics group approval documents, letters from community leaders and stakeholders, etc.
- develop local collaborative relationships to assist in the approval, design, and conduct of the research
- identify and communicate with a local contact who is fluent in the local language.
Consideration should be given to the most appropriate method of obtaining informed consent, including literacy levels, confidentiality concerns, and cultural norms. Different cultures have different authority structures for approval and consent. Researchers should be aware of and honor different cultural attitudes regarding consent. These attitudes may include differences with regard to autonomy and coercion (e.g., what we might consider to be coercive in the US may not be so in a different culture and vice versa).
In some cases, verbal consent (combined with a waiver of documentation of written consent) may be more appropriate because signing a consent document would put participants at greater risk. In some cases, even when a consent document is appropriate, it may not be appropriate to include some of the required information in the document. For example, email addresses or phone numbers in consent documents may not be realistic or feasible in a foreign country.
Consent is best obtained using the language that is most familiar to the prospective subject. Ideally the researcher or research team is fluent in the local language. If not, the investigator might seek collaborators or hire assistants who are fluent in the local language. A third option is to hire interpreters.
When hiring interpreters, the following elements should be considered:
- In a small population, the relationship between the interpreter and the subjects must be considered.
- The interpreter might exert influence or undue pressure that could lead to selection bias.
- The interpreter may not relay information in a clear and unbiased manner (e.g., he/she may leave out information they believe is unpleasant or culturally inappropriate).
- In addition to the initial consent process, fluent researchers or interpreters should be available to answer questions, address complaints, or relay instructions throughout the conduct of the study.
- Some languages are not written and sometimes people speak a language but may not be able to read or write it.
- There may not be any translations of important words like ‘placebo’ or ‘randomization’.
- It may be culturally inappropriate to ask for a signature and may indicate a lack of trust.
- It may be appropriate to use alternative consent procedures, such as the use of a short form and witness, photos or videos, or other alternate forms of documentation.
Children may have different statuses in foreign countries than in the US. Questions that may need to be considered are:
- What is the age of majority?
- What is the relationship between parents and their children in that country?
- What is an acceptable and effective parental permission process?
- What is an acceptable and effective child assent process and are there laws pertaining to orphans in that country?
Through consultation with experts, the IRB must ensure that the risk assessment holds true at the foreign site. Thus, knowledge of local context is important even in research that may be exempt. Even in exempt research, informed consent, parental permission, or child assent may still be ethically appropriate and/or required under local law. The researcher should include information in the research submission to address the local community ethical standards where the study will be conducted. This information should include details regarding local review (as applicable) and the investigator's experience with the locality. This information will be considered when approving exempt research conducted at a performance site outside of the U.S.
To assist researchers who are conducting expedited or full board research in a foreign country, the IRB requires that the KC IRB questionnaire regarding Transnational Research (Questionnaire G5) be completed. This allows the researcher to consider and detail relevant political, social, cultural, and economic norms or issues and gives the IRB a sense of how knowledgeable the researcher is about the region where the research will take place.