Among focus group participants, adherence with safe sleep practices was poor despite awareness of the American Academy of Pediatrics recommendations. Many mothers expressed beliefs and instincts that infants were safe in various unsafe sleep environments. Future study should investigate the efficacy of alternative educational strategies, including education of grandmothers, who have significant influence over adolescent mothers.

frican human genome research is advancing rapidly, owing to falling sequencing costs and international interest in African genomic data: the diversity of African genomes can provide novel insights into biological and etiological mechanisms, thereby promoting diagnostic, prognostic and therapeutic advances for populations in Africa and the rest of the world 1,2. Conducting genomic research in Africa can be logistically challenging 3,4 , but equally challenging is recruiting African participants-many of whom have knowledge-and/or poverty-related vulnerabilities 5,6-while ensuring that they are properly informed and truly consenting, and that they retain their autonomy and agency (examples in refs. 5,7-12). Dynamic consent models, such as those using ongoing engagement through online media 13,14 , ensure autonomy and choice for participants. However, these models cannot be implemented in many African environments, owing to suboptimal internet and smartphone access, and poor digital literacy. In broad-consent models, participants consent to all future use of their samples under the oversight of an access committee, but this consent comes at the cost of the autonomy and individual preferences of participants 10,15. Tiered informed consent addresses these challenges by providing detailed information about the intended specimen/data use and storage, thus enabling participants to individually select a level of specimen and/or data sharing through responses to specific questions 10,16-18. The launch of the H3Africa genotyping chip, with 2.7 million African-specific genomic variants 19 , has increased opportunities for meta-analyses combining multiple cohorts of African participants. To undertake such studies with an ethical mandate, research participants must be properly informed, and their data/ sample-use preferences must be accurately understood, faithfully recorded and implemented with integrity. We propose a framework for undertaking ethically sound, tiered-informed-consent processes in Africa, which provides a comprehensive guide on compiling participant information and an informed-consent template for capturing each participant's consent information and mapping it to data-use ontologies.

This pilot represents the first known examination of diagnostic pauses in the outpatient setting, and this work potentially paves the way for more broad-based systems and/or electronic interventions to address diagnostic error.