Harmonising the human biobanking consent process: an Irish experience

Biobanks are repositories of human biological samples and data. They are an important component of clinical research in many disease areas and often represent the first step toward innovative treatments. For biobanks to operate, researchers need human participants to give their samples and associated health data. In Ireland, research participants must provide their freely given informed consent for their samples and data to be taken and used for research purposes. Biobank staff are responsible for communicating the relevant information to participants prior to obtaining their consent, and this communication process is supported by the Participant Information Leaflets and Informed Consent Form (PI/ICFs). PILs/ICFs should be concise, intelligible, and contain relevant information. While not a substitute for layperson and research staff discussions, PILs and ICFs ensure that a layperson has enough information to make an informed choice to participate or not. However, PILs/ICFs are often lengthy, contain technical language and can be complicated and onerous for a layperson to read. The introduction of the General Data Protection Regulation and the related Irish Health Research Regulation presented additional challenges to the Irish biobank community. In May 2019, the National Biobanking Working Group (NBWG) was established in Ireland. It consists of members from diverse research backgrounds located in universities, hospitals and research centres across Ireland and a public/patient partner. The NBWG aimed to develop a suite of resources for health research biobanks via robust and meaningful patient engagement, which are accessible, General Data Protection Regulation/Health Research Regulation-compliant and could be used nationally, including a PIL/ICF template. This open letter describes the process whereby this national biobank PIL/ICF template was produced. The development of this template included review by the Patient Voice in Cancer Research, led by Professor Amanda McCann at University College Dublin and the Health Research Data Protection Network.


Background
In the context of health research, biobanks are managed repositories of human biological samples and associated health data, which are collected, stored and used to facilitate scientific and medical research 1 . Biobanks are an important component of clinical research in many disease areas and often represent the first step toward innovative treatments 2,3 .
For biobanks to operate, researchers need human participants to voluntarily give their biological samples and relevant health data. In line with internationally accepted ethical standards in clinical research such as the Declaration of Helsinki 4 , in Ireland, participants must provide their freely-given informed consent for these samples and data to be taken and used for research purposes 5 . Research staff are responsible for communicating the relevant information to participants and ensuring participants understand the information they have been provided with before participants give their consent. This communication process is supported by Participant Information Leaflets/Informed Consent Forms (PILs/ICFs). PILs/ICFs should be concise 6 , intelligible 5 , and along with the conversation with the research staff, should give the relevant information so that a layperson can determine if they want to take part 4 . (For the purposes of this article, we define laypersons to be members of the public who, due to their background, may not be familiar with aspects of the research process. These individuals may have a wealth of knowledge from their lived experience but are not generally familiar with e.g., research terminology, or the role of the health research biobank. This means that these individuals may find it difficult to understand written or verbal information if it is not simple and free of jargon.) However, clinical research PILs/ICFs are becoming longer 7,8 and in the view of the authors of this letter, are not primarily written to meet the needs of a layperson. Systematic reviews have shown that clinical research participants often have not understood important aspects of a research study they have agreed to take part in 9, 10, particularly those with literacy challenges 11 . While the use of visuals to explain important or complex concepts is strongly recommended 12,13 , they are often under-utilised in clinical research PILs/ICFs 14 . This was identified as a limitation of current biobank PIL/ICFs in use nationally. The Irish Health Research Regulations 5 mandate suitable and specific measures for the processing of personal data for the purposes of health research in addition to the statutory obligations of the European Union General Data Protection Regulation 15-17 . These pieces of legislation have presented additional challenges to research biobankers who aspire to provide clear, concise information which supports the decision-making of potential research participants. For example, this legislation requires that additional information about data protection measures should be provided to research participants. While we welcome research participants being provided with all the pertinent information about their data protection rights, we have found that this additional information is often provided in a format which is not well understood by laypersons. For example, legal jargon is often used and the use of the passive voice, verb nominalisations etc, can make it difficult to understand.
Biobank-based research is frequently investigative in nature, and therefore, the research aims are often broad. Biobank research increasingly yields genetic findings, the relevance of which may be unclear at the time of the analysis. These factors, among others, present additional challenges to ensure that participant consent is informed, while simultaneously ensuring that researchers have the freedom to explore and adapt their research as findings emerge, thus ensuring clinical research continues to advance, achieving the maximum possible information from the samples and data. Research staff are obliged and wish to provide information to participants in a clear and comprehensible way. However, research staff alone may not always be the best judge of what is understandable to the general public. Therefore, it is crucial that members of the general public and patients are involved in co-producing patient-facing documents, including clinical research PILs/ICFs 18-20 . It can also be challenging for research ethics committees and data protection officers to ensure that all of the required information is included in PILs/ICFs due to differing templates produced and wording favoured by individual institutions.
The biobank community in Ireland came together in early 2018, prior to the application of the General Data Protection Regulation legislation and several individuals subsequently volunteered to be part of the National Biobanking Working Group (NBWG). The NBWG was established in May 2019, originally under the auspices of Clinical Research Development Ireland. The group consists of members from diverse research backgrounds who are located in universities, hospitals and research centres across Ireland, and a public/patient partner. Each member has a special interest in making information about health research biobanks accessible and understandable to members of the public. Group members are involved in maternal, infant, paediatric, adult and older adult research areas. The public/ patient member is a patient advocate who doesn't have a scientific, medical or research background and is therefore

Amendments from Version 2
Protocol V3 includes amendments and clarifications which were suggested by the reviewers. These included citing some relevant literature to support the rationale for this project, clarifying the nature of the patient/public involvement in the development of the participant information leaflet/informed consent form template and providing more information abut the background of these patients/members of the public.
Any further responses from the reviewers can be found at the end of the article REVISED ideally placed to represent the perspectives of laypersons. The NBWG was established at a crucial juncture in the Irish health research landscape just after the implementation of new European Union data protection legislation (General Data Protection Regulation) 17 , Irish health research legislation (Health Research Regulations) 5 and also the publication of the first international biobanking standard International Organization for Standardization (ISO) 20387: 2018 21 . The main aim of the NBWG was to address foreseen challenges for compliance brought about by the new legislation and to jointly work towards an improved understanding of the reshaping of the biobank landscape in Ireland.
The NBWG has developed a suite of tools and resources, including infographics, a general biobanking awareness leaflet and single PIL/ICF template specifically designed for health research biobanks, via robust and meaningful public and patient engagement, which could be adopted nationally. The group also developed a video which describes some of the research at St James' Hospital, Dublin and Trinity College Dublin: https://www.stjames.ie/cancer/research/biobanknetwork/ This video aims to increase awareness of the importance of health research biobanks, and has been shared widely on social media and is played in multiple waiting rooms in St James' Hospital, Dublin. The NBWG also seeks to engage with members of the public and patients to increase awareness about the value of taking part in research biobanks. The inclusive and unified approach taken by the NBWG removes the need for multiple biobanks within Ireland to develop their own resources separately, a process which can be time-consuming and costly.
The aim of this open letter is to describe the process whereby a national template for a biobank PIL/ICF was co-produced by the NBWG, with public-patient partners from the Patient Voice in Cancer Research. While we recognise that regulatory and research governance requirements, and cultural perspectives will vary between countries, the process may be of interest to other countries seeking to develop a national template.

Development of the PIL/ICF template
The NBWG initially convened via teleconference in May 2019. One significant challenge raised during this inaugural meeting was the lack of a standardized PIL/ICF template that could be used by all biobanks throughout Ireland. As informed consent is the cornerstone of all research, including biobanking, the group decided to prioritize this development.
To undertake this task, it was determined that the NBWG would meet on a bimonthly or monthly basis, initially in person, and subsequently via videoconference due to COVID-19 pandemic restrictions. As a starting point, the group collated and reviewed more than eight research ethics committee-approved biobank PIL/ICF templates in use at that time across Irish universities and hospitals. A PIL/ICF developed by Cancer Trials Ireland, the leading cancer research organisation in Ireland was also reviewed 22. Based on the review process, it was agreed to divide the template PIL into three sections deemed most important (explained below). The group then reviewed and amended each section, using an iterative process, ensuring that the resulting template was applicable to a broad range of biobank research, disease areas and research environments (hospitals, academic institutions, not for profit organisations etc) within Ireland. The NBWG's public-patient member was involved in every stage of the development and review process and in particular advised on whether language was understandable and relevant to research participants. The three sections were as follows:

Section A: Taking part -This section explains what
a health research biobank is and invites individuals to take part. It outlines that participation is voluntary, that consent can be withdrawn, the benefits and risks of taking part, the procedure for biobanking and what will happen to participants' health data should they choose to take part. The NBWG public-patient member was particularly passionate about giving the most practical information at the start of the document, with further detail relevant to data protection to follow.

Section B: Biobank Management -This section
describes the security and compliance measures in place for participants' data, details of the biobank funding, and ethics committee approval.

Section C: What does the biobank do with my healthcare data?
-This section outlines what kind of data will be collected and stored, the rationale for this and the participants' rights.
These three sections of the PIL are followed by the ICF, which is divided into two sections.
Best practice guidelines for communicating clearly with laypersons, including the National Adult Literacy Agency (NALA) guidelines 23 were incorporated. For example, sentences were written in the active voice; plain, commonly used words were included whenever possible, and the section headings were posed as conversational-style questions to prompt pre-processing of information. Guidelines for optimal layout were also incorporated, such as using adequate line spacing and font size. Bold font was used for section headings as it is more accessible for dyslexic readers and those with literacy challenges, rather than underlining and all-capitals 24-26 . The group valued input from all members, but particularly from our public-patient member to ensure that the language and content was understandable and relevant to research participants. The group informally shared the PIL/ICF with a selection of friends and family members who are neither medical professionals nor currently attending a hospital. It is important that personnel without regular medical contact or a previous diagnosis can understand the PIL/ICF, as individuals are often presented with the option of joining a biobank prior to confirmation of disease diagnosis.
The group decided to include a glossary of key terms at the beginning of the PIL/ICF template to which readers could refer. Terms which laypersons may not be familiar with, such as 'coded data' and 'identifiable data' were included. To assess how well the template worked, the group decided to apply it to a well-established biobank at St James's Hospital, Dublin; biobank-specific and site-specific information was added. Once the provisional content was decided, the group invited a professional graphic designer to design an infographic (see Figure 1)  • Is the PIL/ICF easy to understand? (two groups were assigned this topic as this was the main purpose of the review) • Would patients be happy to consent to all parts of the consent form?
• Is it understood why samples and data are stored for a long time period?
• Does the document explain why data/samples may be shared with researchers around the world?
• Is it clear why samples and data may be shared with commercial companies?
• Are patients interested in updates on projects supported by the Biobank?
•  attendees also provided informative feedback on content highlighting where it could be improved, including: • clarifying the meaning of some of the key terms.
• emphasising the benefits to society in the future.
• clearly stating security measures in place for participant data.
• keeping General Data Protection Regulation information clear and concise.
There were mixed views on whether potential participants should be offered the option to consent to some aspects but not others and whether ongoing updates should be provided to participants. The feedback was incorporated into the draft template.

Review by the Health Research Data Protection Network and the Data Protection Commission
The

Limitations
There are some limitations to this project. The PIL/ICF template developed by this group is intended for adult readers with the capacity to consent. Therefore, additional and/or different considerations will be needed for PIL/ICFs for children or adults lacking the capacity to give their consent. However, the process for the design and evaluation of a PIL/ICF could easily be adapted to facilitate stakeholder engagement for children and vulnerable research participants. While this PIL/ICF template was designed with the health research biobank in mind, the overall structure and much of the content could be applied to other forms of health research.

Future directions
The experience of the NBWG members is that the standard data protection information included in biobank PILs is often too complicated, lengthy and poorly understood by research participants. For this reason, the group attempted to use easy-to-understand language and to explain terminology, which is not in common use. To receive feedback on this aspect, the group intends to submit the PIL/ICF to the National Adult Literacy Agency for a full review. In addition, the group hopes to receive feedback from the Data Protection Commission on the accuracy of the explanations of the data protection terminologies. Ongoing work, using insights gained from the patient-public partners as part of this project, is focused on the production of a video version of the PIL/ICF specifically aimed at making the information more accessible to individuals with literacy challenges. The NBWG welcomes feedback from users of the PIL/ICF template and informal or formal evaluations of the template's effectiveness. Finally, the group hopes that the newly-developed biobank PIL/ICF template will eventually be adopted nationally as a standardised template, with the option to accordingly adapt it for specific patient groups. Ideally the group would favour a national standardised suite of documents and are willing to engage with other public-patient groups, including those representing minorities such as those with disabilities and members of the travelling community, to achieve this goal.

Data availability Underlying data
No data are associated with this article. • To each individual who generously shared their input, thoughts and opinions on this initiative at many stages along the process.

Department of Pharmacology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
This open letter describes the developmental process of the national biobank informed consent template in Ireland. Overall, the manuscript is sufficient in general, however, there are some issues that need to be addressed.
The title of the two sections is not representative of the content provided therein. For example, "Joining a health research biobank" does not represent "the benefits and risks of taking part". For another example, "details of the biobank funding" is not related to anything about "what does the biobank do with your healthcare data?" In addition, the content in the manuscript seems to be inconsistent with the template (in Supplementary  File 3). In Supplementary File 3, there are 3 sections: Section A (Taking Part), Section B (Biobank Management), Section C (What does the biobank do with my healthcare data?) 1.
In Figure 1, what is the meaning of the arrow from "7" to "1"? I do not understand the link between "For future patients better tests, treatments, drugs or medical devices" and "Participant".

Is the Open Letter written in accessible language? Yes
Where applicable, are recommendations and next steps explained clearly for others to follow? Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Human research ethics; Informed consent; Biobank research.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Author Response 07 Jan 2022

Lydia O'Sullivan, University College Dublin, Ireland
Thank you Prof Koonrungsesomboon for your time in reviewing our paper. We appreciate all of your comments and suggested changes. We have addressed each of the points you have raised and amended the paper accordingly.
We have now amended the manuscript so that it matches the content in Supplementary File 3.
The meaning of the arrow from "7" to "1" in Figure 1 relates to the fact that if a participant donates a biobank sample(s) and healthcare data, these can be used to develop new tests, treatments etc. These innovations will ultimately benefit research participants in the future. We explain this in the PIL (Supplementary File 3) within Section A/Point 3/What are the benefits to me? We also outline in this section that developing new tests, treatments etc often take a long time, so the benefits may not accrue to the participant themselves, but to others in the future. We recognise that no infographic/diagram will be able to explain the biobank process perfectly, but this version has been reviewed and approved by our wider public-patient partners. Our public-patient input highlighted how important it was to show a biobank as a circular process, rather then linear, which starts and ends with the participant. This is what we have tried to convey in this diagram.
Supplementary File 3/Part 1/Point 1 allows for participants who cannot read -"I have read, or had explained to me….", but we do acknowledge the value of having a line for a witness to allow for participants who cannot write and we will consider adding this to a future version of the PIL/ICF template.
We recognise that biobank PIL/ICFs templates exist in many other parts of the world. However, since the regulatory and research governance requirements, as well as cultural perspectives, vary in different countries and jurisdictions, we feel it is important that PIL/ICF templates are developed nationally or locally in conjunction with public-patient partners. The aim of this paper was to describe the experience we had in Ireland and we feel that researchers in other countries may be interested in this experience. We have produced a PIL/ICF template which aims to be compliant with the ethical and governance guidelines which are applicable in Ireland. We have now clarified this point at the end of the Background section, after stating the aim of the paper.
Third paragraph -you have established some relevant links here e.g. importance of involving patient/public in developing patient-facing documents. This can be supported by references to academic literature.

4.
While the effort taken by the authors to ensure the format of the information sheets met literacy guidelines is acknowledged, the NBWG membership has multiple representatives from various research fields, however, there is only a single public-patient partner, was this an individual person or a group of people? Please consider limitations that may be posed by lack of diverse patient/public representation in the working group as you have mentioned that only one member of the group was a patient/public. You could include some detail to highlight if they belonged to mainstream population group, or how they were representative of biobank participants, what level of experience they had and how this may have affected their contribution, and what level of actual contribution they made to the process and outcome.

5.
The aim statement alludes that more than one patient/public partner was involved in the process while the above paragraph mentions one member of patient/public group as a member of the working group. Please clarify.

6.
Thank you for describing the process in good detail. Were the patient/public partner also involved in drafting and generating ideas for the PIL/ICF draft and subsequent versions along with ensuring that the language was understandable and relevant to research participants. The workshop conducted to collect feedback on the draft is a great approach 7.
and authors may wish to consider commenting on the diversity of patient/public participants who provided feedback on the draft.
In draft PILs (Section C, point 6), authors may consider adding a line that that staff can assist patient/participant to know their rights by providing them with a copy of the document if needed.

8.
Is there a plan for evaluating the effectiveness of these revised forms? It would be prudent to see how they are working in practice, given the limited public-patient representation in the development. They could be tested with people from minority groups, such as those from ethnically diverse backgrounds, children and young people, and children and adults with intellectual disability. As there is limited detail on the involvement of diverse laypeople, the evaluation could include how useful the revised forms are for minority groups, and what adaptions may be necessary.

9.
Infographic and use of multimedia are good but the letter lacks detail on whether they are being used by or helpful for the general public; what has been the feedback on these resources from biobank participants? 10.
For question 4 our response is partly because there are many acronyms used. It is difficult to read a document with multiple acronyms, even where they are explained. We found we had to regularly go back and check some of the acronyms that are used only a few times in the letter. For example, GDPR, HRDPN, RECs. We would suggest acronyms are not used in these situations.

Does the article adequately reference differing views and opinions? Partly
Are all factual statements correct, and are statements and arguments made adequately supported by citations? Partly

Is the Open Letter written in accessible language? Partly
Where applicable, are recommendations and next steps explained clearly for others to follow? Yes We have now included a reference to a paper that they have published (Reference 30), describing how they formed and how they operate. The NBWG is currently seeking more public-patient representatives to ensure a more balanced representation.
The patient/public partner was involved at every stage of drafting and generating ideas for the PIL/ICF draft and ensuring the language was understandable and relevant to research participants. We have now added a sentence in paragraph two of the 'Development of the PIL/ICF template' section to clarify this. As noted in point 5 above, we have now also added a reference (Reference 30) regarding the formation and composition of the patient/public participants at the workshop.
We will certainly consider adding a sentence about staff providing a written copy of participant data protection rights in a future version the PIL/ICF template. We do also note, in several places in the template, that prospective participants can request further information from the investigator or study coordinator.
This paper describes the first step in the process -co-developing a PIL/ICF template for biobanks with patient/public representatives. We acknowledge that it is important to evaluate the effectiveness of these form in practice and have now noted in the 'Future Directions' section that we welcome such evaluations of effectiveness. We hope that this paper will increase awareness of this PIL/ICF template and lead to these kind of evaluations; however, an assessment of the effectiveness of the PIL/ICF template is outside the scope of this paper. We disagree that the template development process involved 'limited' publicpatient representation -as noted in point 5 above and as described in the paper, the template was reviewed and adapted following feedback from ~ 90 public-patient representatives, in addition to our NBWG patient representative who has been part of this work since its inception. This amounts to over 200 public-patient hours involvement in total.
Many thanks again.
Competing Interests: No competing interests were disclosed.