J Sastry, H Pisal, S Sutar, N Kapadia-Kundu, A Joshi, N Suryavanshi, KE Bharucha, A Shrotri, MA Phadke, RC Bollinger and AV Shankar*
Corresponding author: AV Shankar firstname.lastname@example.org
BMC Medicine 2004, 2:28 doi:10.1186/1741-7015-2-28
Bolajoko O. Olusanya
(2004-09-02 20:12) Institute of Child Health, 30 Guilford Street, London WC1N 1EH
This article by Sastry et al  sought to determine practical tools and steps for
facilitating informed consent for public health intervention in communities with low
level of literacy. The use of visual decision aids during group and individual counselling
significantly enhanced the comprehension of the prospective patients on key informed
consent issues. While this outcome was cautiously attributed to the individual counselling
sessions however, the incremental effect on the number of individuals that consented
to undergo the HIV screening test was not clear from the article.
Enhanced comprehension may not necessarily translate to consent to participate in
screening because customs, beliefs or personal values could sometimes influence attitude
towards screening unfavourably. The authors in fact alluded to this possibility among
women in this population who by the local customs are not completely autonomous from
their fathers (if unmarried) and husbands (if married) in making vital health decisions.
And as recently reported, knowledge and attitude on health conditions, the screening
process and treatment are key determinants in consenting to or refusing screening
test . Prior to screening the patients are likely to fall into four main categories
depending on whether their knowledge on HIV/AIDS was good or poor and their attitude
to screening was positive or negative, each requiring unique and culturally appropriate
counselling strategy for informed choice. It is important for the counsellors to appreciate
how this profile ultimately influences the patient’s decision.
It may be argued that the primary goal of communication with patients for ethical
purposes is strictly not to obtain consent but rather to ensure that the patient’s
choice is informed. For instance, the authors reported that of the 17 questions designed
to evaluate the patients’ understanding of the main topics for the group education
and counselling, 8 related to standard ethical issues for informed choice. Presumably,
these would have included full disclosure of the benefits and risks of participating
in the screening test. In effect, informed refusal in this case was to be accepted
theoretically as a legitimate decision, even if this was considered as not being in
the best interest of the patient. However, in voluntary screening for communicable
diseases where overall public interest is at risk this principle is morally difficult
to accept. For instance, there was widespread legitimate concern when some states
in Nigeria boycotted routine polio vaccination . The risk of re-infection within
the country and neighbouring countries far outweighed the right to informed refusal.
The concern would, of course have been minimal if a coverage that assured herd immunity
was achievable without the participation of the boycotting states. Similarly, informed
refusal to participate in HIV/AIDS screening is not risk-free. It is therefore necessary
to ascertain possible reasons for withholding consent in these circumstances with
a view to planning appropriate strategies for securing consent to undergo the screening
test also. The authors’ systematic use of well-structured questionnaires in
the individual counselling sessions would equally prove valuable for this purpose.
1. Sastry J, Pisal H, Sutar S, Kundu N, et al. Optimising the HIV/AIDS informed consent
process in India. BMC Medicine 2004; 2:28
2. Olusanya BO, Luxon LM, Wirz SL. Infant hearing screening: route to informed choice.
Arch Dis Child 2004 (in press)
3. Kapp C. Nigerian states again boycott polio-vaccination drive. Lancet 2004;363:709
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