title: Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials.
abstract: BACKGROUND
  Obtaining informed consent is a cornerstone of biomedical research, yet participants comprehension of presented information is often low. The most effective interventions to improve understanding rates have not been identified.
  
  
  OBJECTIVE
  To systematically analyze the random controlled trials testing interventions to research informed consent process. The primary outcome of interest was quantitative rates of participant understanding; secondary outcomes were rates of information retention, satisfaction, and accrual. Interventional categories included multimedia, enhanced consent documents, extended discussions, test/feedback quizzes, and miscellaneous methods.
  
  
  METHODS
  The search spanned from database inception through September 2010. It was run on Ovid MEDLINE, Ovid EMBASE, Ovid CINAHL, Ovid PsycInfo and Cochrane CENTRAL, ISI Web of Science and Scopus. Five reviewers working independently and in duplicate screened full abstract text to determine eligibility. We included only RCTs. 39 out of 1523 articles fulfilled review criteria (2.6%), with a total of 54 interventions. A data extraction form was created in Distiller, an online reference management system, through an iterative process. One author collected data on study design, population, demographics, intervention, and analytical technique.
  
  
  RESULTS
  Meta-analysis was possible on 22 interventions: multimedia, enhanced form, and extended discussion categories; all 54 interventions were assessed by review. Meta-analysis of multimedia approaches was associated with a non-significant increase in understanding scores (SMD 0.30, 95% CI, -0.23 to 0.84); enhanced consent form, with significant increase (SMD 1.73, 95% CI, 0.99 to 2.47); and extended discussion, with significant increase (SMD 0.53, 95% CI, 0.21 to 0.84). By review, 31% of multimedia interventions showed significant improvement in understanding; 41% for enhanced consent form; 50% for extended discussion; 33% for test/feedback; and 29% for miscellaneous.Multiple sources of variation existed between included studies: control processes, the presence of a human proctor, real vs. simulated protocol, and assessment formats.
  
  
  CONCLUSIONS
  Enhanced consent forms and extended discussions were most effective in improving participant understanding. Interventions of all categories had no negative impact on participant satisfaction or study accrual. Identification of best practices for studies of informed consent interventions would aid future systematic comparisons.
authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Nishimura
authors.forename: Jantey
authors.initials: J
authors.lastname: Carey
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Erwin
authors.forename: Jon C
authors.initials: JC
authors.lastname: Tilburt
authors.forename: M Hassan
authors.initials: MH
authors.lastname: Murad
authors.forename: Jennifer B
authors.initials: JB
authors.lastname: McCormick
mesh_terms: D003142:Communication; D032882:Comprehension; D015986:Confounding Factors, Epidemiologic; D032962:Consent Forms / Q000592:standards*; D006801:Humans; D007258:Informed Consent / Q000941:ethics / Q000523:psychology / Q000592:standards; D020407:Internet; D019212:Multimedia; D016032:Randomized Controlled Trials as Topic; D012107:Research Design