Keywords
research contributions - publication practices - postgraduate students - Syrian crisis
- residents' attitudes - institutional barriers
Introduction
Health care providers in developing countries need to find innovative solutions to
overcome challenges by performing research projects that are feasible in their circumstances.
The 10-year-long Syrian crisis has deeply affected all aspects of Syrians' lives,
especially health care and education. Over half of their health care facilities became
out of service because of the repeated attacks and bombing.[1] The decline in health care infrastructure, along with the rising numbers of war-related
victims, led to an increased burden on the remaining hospitals and their staff, who
had to increase their efforts and working hours significantly. The global surge in
medical staff burnout (e.g., in the United States)[2] also affects Syrian medical personnel at a staggeringly more severe level. This
erodes their skills and productivity during work and leaves them depleted and with
less work–life satisfaction.[3] In Syria, this problem is more evident among residents during the crisis, and the
percentage of this debilitating syndrome is among the highest worldwide.[4] This is also aggravated by the increase in workplace violence in Syrian hospitals,
which triggered physiological stress and loss of confidence among resident doctors.[5] These serious socioeconomic situations, in addition to the vanishing income and
lack of personal safety, exaggerated the already evident brain drain[6] and caused half of the medical personnel to flee Syria by 2016.[7]
[8]
[9] Those who stayed in Syria are still facing lifestyles that leave them with no time
or enthusiasm to get involved in research activities.[9]
Medical, dental, and pharmacy residents are considered the main possible contributors
to research conduct in Syria for many reasons. First, a research project is a requirement
for their graduation. Second, they are in direct contact with patients as doctors
and dentists or they spend most of their time in university labs as pharmacists. Third,
they have less duties and responsibilities and more time to investigate than the elder
practicing specialists. Finally, they see a wide variety of cases because of working
in central academic health centers with a very high flow of patients. However, the
falling numbers of available medical personnel and the high workload are factors hindering
the increase in research output from Syria, which was already lower before the Syrian
war in comparison to other wealthier Arab countries.[10]
[11]
A recent report about the problems and challenges of medical research in Syria demonstrated
that the most important barriers were the limited financial support and research equipment
and the lack of research-related skills.[12] Another report shed light on comparable results from undergraduate students at Damascus
University.[13] However, there is a lack of comprehensive evidence regarding research productivity
of postgraduate medical personnel.[14]
The aim of this study is to investigate attitudes toward research, perceived barriers,
current needs, and previous research experiences of postgraduates in all medical and
paramedical fields in Syria to lay the groundwork for suggesting evidence-based solutions.
Methods
Setting and Participants
The Syrian Ministry of Higher Education runs seven schools of medicine; only three
of them have higher education programs (i.e., Damascus University, Aleppo University,
and Tishreen University in Latakia). Each of these has higher education programs for
pharmacy and dentistry, in addition to a fourth school for pharmacy in Homs (Al-Baath
University) and a fourth school for dentistry in Hama. There is also a virtual master's
program for medical education from the Syrian Virtual University. All these programs
required the students to conduct and defend an original research study (thesis) to
graduate. However, generally it is not obligatory to publish their work. The target
participants in this cross-sectional study are students of all these programs who
are specifically at the phase of planning for their research studies. This was the
best time point to investigate the attitudes toward conducting a high-quality study
and the barriers for publishing this work later. The year of planning and registering
these master theses differed between specialties and disciplines due to the different
lengths of the programs (2–6 years). However, it is generally the third year for medicine,
the second for dentistry, and the first for pharmacy.
The data were collected via an online questionnaire created using Google Form. First,
chief residents in each department shared an invitation to an online extracurricular
8-hour workshop with all the residents and fellows. The workshop objectives were to
practically provide peer support to residents in preparing their upcoming research
projects. Then the form was sent to those who showed interest in that support individually.
Three days later, a reminder was sent, and all the interested students (n = 429, 100%) completed the questionnaire. Data collection took place over 2 weeks
in July 2020. Participants were informed about the aims of the study and were asked
to provide their consent to participate at the beginning of the questionnaire.
Questionnaire and Outcomes Measured
This study used an Arabic questionnaire developed in a previous study to investigate
attitudes, barriers, and practices toward scientific research among undergraduate
medical students in Damascus.[13] However, some of the terms were modified to suit postgraduate students. The questionnaire
was then piloted on 10 participants from different specialties to confirm that all
responders can follow the instructions and answer the questions without concerns regarding
the language, understanding, consistency, and structure.
The first section in the questionnaire included questions about participants̀ demographic
data and self-reported English proficiency. The second section used a 5-point Likert
scale to assess participants' attitudes toward research, as well as their barriers
for conducting it. The third section included multiple-choice questions about participants'
sources of training (intra- or extracurricular), levels of supervisors' encouragement,
and previous research experiences. The last section focused on participants' needs
to plan, conduct, and publish their master theses in peer-reviewed journals.
Analysis of the Outcomes
The data were exported from the online questionnaire to Microsoft Excel 365 version
2011 (year 2020) and then imported into the Statistical Package for the Social Sciences
version 23.0 (SPSS Inc., Chicago, IL).
The year of study was coded according to the usual year of registering the research
proposal in each specialty into three categories (early, normal, and late registration).
The different human medicine specialties were grouped into four categories: (1) internal
medicine and psychiatry; (2) surgical specialties, pediatrics, obstetrics, and gynecology;
(3) otolaryngology, dermatology, and ophthalmology (clinics specialties); and (4)
other medical specialties including radiology, pathology, and laboratory medicine
(translational specialties). Binary logistic regression analysis was used to investigate
the effect of different variables on participation in research and submission of manuscripts
for publication, combined with corresponding odds ratios (ORs) and 95% confidence
intervals (CIs). An alpha value of 0.05 was used to determine the threshold of statistical
significance.
Institution Review Board Statement
The ethical approval was obtained through Damascus University, and it complies with
the Declaration of Helsinki 1975, as revised in 2013. Participation was completely
voluntary, with the assurance of confidentiality.
Results
The sample consisted of 429 postgraduates who showed interest in the suggested extracurricular
support. They represented 21.5% of the targeted population of nearly 2000 students
actively working or studying under the medical, dental, and pharmacy higher education
programs in Syria. Damascus, Latakia, and Aleppo had the largest universities and
they contributed to more than 90% of the sample, and 62.2% of the participants (267/429)
were females. Nearly half of the respondents did not consider the training they had
already received regarding medical research sufficient to rely on, and 77.4% (332/429)
had received encouragement by their mentors to conduct research ([Table 1]).
Table 1
Composition and demographic information of the participants
|
Factors
|
n (%)
|
Response rate (total = 21.5%)
|
|
Gender
|
|
Male
|
162 (37.8)
|
–
|
|
Female
|
267 (62.2)
|
–
|
|
Year of postgraduate study
|
|
1st year
|
48 (11.2)
|
–
|
|
2nd year
|
147 (34.3)
|
–
|
|
3rd year
|
157 (36.6)
|
–
|
|
4th year
|
74 (17.2)
|
–
|
|
5th year
|
3 (0.7)
|
–
|
|
Year of study
|
|
Early registration
|
105 (24.5)
|
–
|
|
Normal registration
|
242 (56.4)
|
–
|
|
Late registration
|
82 (19.1)
|
–
|
|
University
|
|
Damascus University
|
190 (44.3)
|
26.5%
|
|
University of Aleppo
|
89 (20.8)
|
23%
|
|
Tishreen University
|
117 (27.3)
|
20.9%
|
|
University of Hama
|
10 (2.3)
|
35.7%
|
|
Al-Baath University
|
10 (2.3)
|
12.3%
|
|
Syrian Virtual University
|
13 (3)
|
7.6%
|
|
Specialties groups
|
|
Clinics specialties
|
56 (13.1)
|
34.1%
|
|
Surgical specialties
|
60 (13.9)
|
11%
|
|
Internal medicine specialties
|
103 (24)
|
34.5%
|
|
Translational specialties
|
41 (9.6)
|
46.1%
|
|
Pharmacy
|
56 (13.1)
|
22.1%
|
|
Dentistry
|
100 (23.3)
|
23.8%
|
|
Medical education
|
13 (3)
|
7.6%
|
|
Internet connection accessibility
|
|
Low quality
|
281 (65.5)
|
–
|
|
High quality
|
148 (34.5)
|
–
|
|
English language skills: writing
|
|
Poor or intermediate
|
236 (55)
|
–
|
|
Good or excellent
|
193 (45)
|
–
|
|
English language skills: reading and comprehension
|
|
Poor or intermediate
|
151 (35.2)
|
–
|
|
Good or excellent
|
278 (64.8)
|
–
|
|
Sources of education/training about research
|
|
No training
|
188 (43.8)
|
–
|
|
University training
|
108 (25.2)
|
–
|
|
Self-paced training
|
133 (31)
|
–
|
|
Encouraged by mentors to participate in research?
|
|
No
|
97 (22.6)
|
–
|
|
Yes
|
332 (77.4)
|
–
|
Note: n is the number of participants who chose the corresponding answer, and % represents
the percentage of participants who chose the corresponding answer.
Attitudes toward Research and Its Perceived Barriers
Most of the participants showed strong inclination to believe that research plays
an important role in the medical fields, that research methodology should be a part
of their curricula, and that participating in it was important for them as students
and as part of their career plans. However, only 10.9% of the participants (47/429)
agreed with the statement “medical research does not require a lot of money.” Regarding
the barriers for research, over 80% agreed that the inadequate training in research
methodology and in reading and evaluating research articles, as well as the lack of
research facilities, were important obstacles. Similarly, around 70% faced barriers
such as the lack of research opportunities, the absence of reward, and the unavailability
of research mentors. Lack of time and difficulties in accessing medical journals and
in obtaining ethical and scientific approvals for research projects were also important
factors to 60 to 65% of the participants ([Fig. 1]).
Fig. 1 Participants' personal perspectives of the importance and the barriers of research.
Questions were flipped when needed to always make the agreement to the right side
of the figure, and then they were ordered in descending order according to the percentage
of the answers “agree” and “strongly agree” combined. Percentages lower than 5% were
represented but not labelled.
Conducting Research and Publishing Scientific Papers
Seventy-one percent (304/429) had not worked on any research project before the time
of their master theses, and 17.5% (75/429) had only worked on one project. However,
less than 13% (55/429) reached the phase of submitting an article for publication,
and less than 5% (21/429) submitted more than one paper. A third of the reported projects
were single case reports or case series (57/172). “An important skill to learn” and
“to relay scientific information” were the most common reasons for conducting research,
while only 2.5% (11/429) did not find research contribution important at all. The
most common reasons for not conducting any research were the lack of guidance and
supervision (41.3%; 118/286) as well as the lack of opportunities (36.7%; 105/286).
Only 75 of the 172 (43.6%) reported studies were submitted for publication. However,
the rate for basic laboratory-based projects was about 25%. Only 20% (8/40) of the
participants who reached submission reported that all their submissions were eventually
published. Submission of research articles was driven mostly by the necessity for
relaying information (36.2%; 17/47) and career progression (34%; 16/47). On the other
hand, the most important reasons for not submitting scientific papers for publication
were insufficient academic writing experience (30.3%; 20/66) and the lack of guidance
and supervision (27.3% each; 18/66; [Table 2]).
Table 2
Experience of participants and their motivations and practical limitations regarding
conducting and publishing research
|
Question
|
N (%)
|
Question
|
N (%)
|
|
Number of research projects participated in (total n = 429)
|
Number of scientific papers submitted for publication (total n = 429)
|
|
Never did
|
304 (70.9)
|
Never did
|
374 (87.2)
|
|
One
|
75 (17.5)
|
One
|
34 (7.9)
|
|
Two
|
25 (5.8)
|
Two
|
10 (2.3)
|
|
Three
|
10 (2.3)
|
Three
|
3 (0.7)
|
|
More than three
|
15 (3.5)
|
More than three
|
8 (1.9)
|
|
Types of research projects participated in (total n = 172 running projects)
|
Types of scientific papers submitted for publication (total n = 75 submitted papers)
|
|
Laboratory based
|
19 (11)
|
Laboratory based
|
5 (6.7)
|
|
Case report/case series
|
57 (33.1)
|
Case report/case series
|
28 (37.4)
|
|
Cross-sectional
|
21 (12.2)
|
Cross-sectional
|
9 (12)
|
|
Case–control
|
16 (9.3)
|
Case–control
|
3 (4)
|
|
Cohort
|
8 (4.7)
|
Cohort
|
4 (5.3)
|
|
Randomized control trials
|
8 (4.7)
|
Randomized control trials
|
4 (5.3)
|
|
Systematic review
|
14 (8.1)
|
Systematic review
|
4 (5.3)
|
|
Other
|
29 (16.9)
|
Other
|
18 (24)
|
|
Reasons why it is important to participate in research (total n = 429)
|
Main motivation to consider publication (total n = 47)
|
|
An important skill to learn
|
115 (26.8)
|
Relay information
|
17 (36.2)
|
|
To relay information
|
100 (23.3)
|
Career progression
|
16 (34)
|
|
To improve career
|
68 (15.9)
|
Personal interest
|
11 (23.4)
|
|
To improve the research situation in my country
|
63 (14.7)
|
Reasons for not submitting scientific papers for publication after writing (total
n = 66)
|
|
For personal interest
|
51 (11.9)
|
Lack of experience in academic writing
|
20 (30.3)
|
|
To keep up with peers
|
21 (4.9)
|
Lack of guidance and supervision
|
18 (27.3)
|
|
It is not important
|
11 (2.5)
|
Lack of time
|
18 (27.3)
|
|
Reasons for not participating in research (total n = 286)
|
Research team problems
|
7 (10.6)
|
|
Lack of guidance and supervision
|
118 (41.3)
|
Outcome of paper submissions (total n = 40 submitted papers)
|
|
Did not have the opportunity to take part in research
|
105 (36.7)
|
None were accepted for publication
|
12 (30)
|
|
Lack of time
|
38 (13.3)
|
Only few were accepted for publication
|
11 (27.5)
|
|
Not interested in doing research
|
20 (7)
|
Most were accepted for publication
|
9 (22.5)
|
|
|
All were accepted for publication
|
8 (20)
|
The Impact of Attitudes, Barriers, and Demographic Factors on Research Experiences
Logistic regression analysis of the attitudes was significant regarding participation
(R
2 = 0.06, p = 0.005) and submission of research studies (R
2 = 0.08, p = 0.001). A similar analysis regarding barriers was also significant for both participation
(R
2 = 0.07, p = 0.030) and submission (R
2 = 0.10, p = 0.006). Participants who reported submitting research articles for publication or
even just participating in research projects previously had relatively higher attitudes
toward research. Having research among long-term career goals and believing it is
not always costly were reported significantly higher in participants who had submitted
at least one manuscript for publication (OR [95% CI]: 1.76 [1.12–2.74] and 1.52 [1.13–2.04],
respectively). The perceived barriers did not show a pattern as clear as the attitudes.
However, the lack of training and mentors' support were notably more reported in the
group who had never participated in research. Additionally, language limitations were
significantly lower in participants with submitted manuscripts (OR [95% CI]: 0.69
[0.49–0.94]; [Table 3]).
Table 3
The association between the attitudes and barriers and participating in research projects
or submitting papers for publication
|
Conducting research projects
|
Submission of papers for publication
|
|
Factor
|
At least once (n = 125)[a]
|
None (n = 304)[a]
|
OR [95% CI][b]
|
At least once (n = 55)[a]
|
None (n = 374)[a]
|
OR [95% CI][b]
|
|
Importance of research
|
|
The role of research in the medical field is important
|
5 (4–5)
|
5 (4–5)
|
1.13 [0.68–1.85]
|
5 (4–5)
|
5 (4–5)
|
0.97 [0.48–1.98]
|
|
Participating in research or publishing scientific papers during higher education
|
5 (4–5)
|
4 (4–5)
|
1.40 [0.89–2.19]
|
5 (4–5)
|
4 (4–5)
|
1.13 [0.61–2.08]
|
|
Teaching research methodology should be part of the curriculum
|
5 (4–5)
|
4 (4–5)
|
1.13 [0.80–1.58]
|
5 (4–5)
|
4 (4–5)
|
1.27 [0.76–2.09]
|
|
Research will be a part of my long-term career goals
|
4 (4–5)
|
4 (3–4)
|
1.31 [0.96–1.76]
|
4 (4–5)
|
4 (3–4.3)
|
1.76 [1.12–2.74][c]
|
|
Conducting research does not always need a lot of money
|
2 (1–3)
|
2 (1–3)
|
1.05 [0.84–1.31]
|
2 (2–3)
|
2 (1–3)
|
1.52 [1.13–2.04][c]
|
|
Barriers of research
|
|
There is a lack of time during higher education to pursue research
|
4 (3–4)
|
4 (3–4)
|
1.10 [0.85–1.42]
|
4 (3–5)
|
4 (3–4)
|
1.38 [0.96–1.96]
|
|
There is no adequate training in research methodology during higher education
|
4 (4–5)
|
5 (4–5)
|
0.77 [0.50–1.19]
|
4 (4–5)
|
5 (4–5)
|
0.82 [0.47–1.42]
|
|
There is a lack of training in reading and evaluating scientific literature in higher
education
|
4 (4–5)
|
4 (4–5)
|
0.73 [0.51–1.03]
|
4 (3–5)
|
4 (4–5)
|
0.67 [0.42–1.05]
|
|
Research mentors are not easily available
|
4 (3–5)
|
4 (4–5)
|
0.85 [0.64–1.11]
|
4 (3–5)
|
4 (3–5)
|
1.29 [0.88–1.87]
|
|
There is a lack of opportunities to participate in research during higher education
|
4 (3–4)
|
4 (3–5)
|
1.01 [0.74–1.36]
|
4 (3–4)
|
4 (3–5)
|
0.79 [0.53–1.17]
|
|
There is no adequate facility for research
|
4 (4–5)
|
4 (4–5)
|
1.33 [0.92–1.91]
|
4 (4–5)
|
4 (4–5)
|
0.98 [0.61–1.57]
|
|
It is not easy to access medical journals and get all wanted papers during higher
education
|
4 (3–4)
|
4 (3–4)
|
0.93 [0.71–1.20]
|
4 (3–4)
|
4 (3–4)
|
0.81 [0.57–1.14]
|
|
It is not easy to obtain approval for conducting research
|
4 (3–4)
|
4 (3–4)
|
0.98 [0.73–1.31]
|
4 (3–4)
|
4 (3–4)
|
1.11 [0.74–1.65]
|
|
Not enough rewards/motivations to participate in research
|
4 (3–5)
|
4 (3–5)
|
1.15 [0.87–1.49]
|
4 (3–5)
|
4 (3–5)
|
1.03 [0.72–1.47]
|
|
There are language limitations to conduct research
|
3 (2–4)
|
3 (2–4)
|
0.88 [0.69–1.10]
|
3 (2–3)
|
3 (2–4)
|
0.69 [0.49–0.94][c]
|
Abbreviations: CI, confidence interval; OR, odds ratio.
a The ranks are presented as median (1st quartile–3rd quartile), where 1 = strongly
disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree.
b Based on binary logistic regression analysis using Likert scale findings as ordinal
independent covariates, with “strongly disagree” as the lowest value and “strongly
agree” as the highest one.
c Significant independent predictor.
A binary logistic regression analysis of the demographic characteristics revealed
a significant model for research participation (R
2 = 0.25, p < 0.001) and submission (R
2 = 0.28, p < 0.001). Internet connectivity and English writing skills had significant associations
with submitting manuscripts for publication (OR [95% CI]: 1.96 [1.02–3.77] and 4.55
[1.86–11.14], respectively). The results also illustrated a statistically significant
association between research contributions on one side and the source of research
training and the support of mentors on the other side. Students relying on self-training
in research skills were 2.68 (95% CI: 1.48–4.84) times more likely to conduct research
and 3.64 (95% CI: 1.62–8.19) times more likely to submit it in comparison to those
who reported insufficient training. They even had higher odds of participation and
submission than students who reported being properly trained by a formal university
curriculum. On the other hand, students who were encouraged by their mentors were
2.04 (95% CI: 1.02–4.06) times more likely to have conducted research than the rest
of the sample, but that did not induce significant impact on the rate of submitting
manuscripts. Studying at Tishreen University and specializing in pharmacy, dentistry,
or medical education were also positive factors for participation in research projects,
with no effect on submitting manuscripts. Finally, research contributions were homogenous
between genders, study years, and participants with different levels of English reading
skills ([Table 4]).
Table 4
Associations between conducting research projects/submitting scientific papers and
participants' characteristics (n = 429)
|
Factor
|
Conducting research projects
|
Submission of papers for publication
|
|
n (%)
|
OR [95% CI][a]
|
n (%)
|
OR [95% CI][a]
|
|
By gender
|
|
Female (n = 267)
|
75 (28.1)
|
Reference
|
36 (13.5)
|
Reference
|
|
Male (n = 162)
|
50 (30.9)
|
1.08 [0.66–1.77]
|
19 (11.7)
|
0.89 [0.45–1.78]
|
|
By year of study
|
|
Early registration (n = 105)
|
23 (21.9)
|
Reference
|
15 (14.3)
|
Reference
|
|
Normal registration (n = 242)
|
58 (24)
|
0.55 [0.26–1.18]
|
20 (8.3)
|
0.55 [0.22–1.38]
|
|
Late registration (n = 82)
|
44 (53.7)
|
2.24 [0.94–5.31]
|
20 (24.4)
|
1.87 [0.66–5.32]
|
|
By university[b]
|
|
Damascus University (n = 190)
|
48 (25.3)
|
Reference
|
18 (9.5)
|
Reference
|
|
University of Aleppo (n = 89)
|
24 (27)
|
1.43 [0.74–2.76]
|
13 (14.6)
|
2.06 [0.87–4.83]
|
|
Tishreen University (n = 117)
|
40 (34.2)
|
2 [1.08–3.68][c]
|
18 (15.4)
|
2.04 [0.89–4.68]
|
|
By specialties groups
|
|
Clinics specialties (n = 56)
|
12 (21.4)
|
Reference
|
9 (16.1)
|
Reference
|
|
Surgical specialties (n = 60)
|
16 (26.7)
|
1.13 [0.42–3.07]
|
9 (15)
|
0.68 [0.21–2.20]
|
|
Internal medicine specialties (n = 103)
|
20 (19.4)
|
1.50 [0.55–4.11]
|
13 (12.6)
|
1.08 [0.33–3.53]
|
|
Translational specialties (n = 41)
|
11 (26.8)
|
1.88 [0.66–5.33]
|
7 (17.1)
|
1.49 [0.44–5.05]
|
|
Pharmacy (n = 56)
|
23 (41.1)
|
2.86 [1.07–7.70][c]
|
6 (10.7)
|
0.58 [0.16–2.07]
|
|
Dentistry (n = 100)
|
36 (36)
|
3 [1.21–7.47][c]
|
5 (5)
|
0.34 [0.09–1.21]
|
|
Medical education (n = 13)
|
7 (53.8)
|
5.09 [1.18–22.09][c]
|
6 (46.2)
|
4.79 [1–22.96]
|
|
By Internet connection accessibility
|
|
Low quality (n = 281)
|
70 (24.9)
|
Reference
|
26 (9.3)
|
Reference
|
|
High quality (n = 148)
|
55 (37.2)
|
1.45 [0.89–2.38]
|
29 (19.6)
|
1.96 [1.02–3.77][c]
|
|
English language skills (writing)
|
|
Poor or intermediate (n = 236)
|
52 (22)
|
Reference
|
17 (7.2)
|
Reference
|
|
Good or excellent (n = 193)
|
73 (37.8)
|
2.04 [1.15–3.61][c]
|
38 (19.7)
|
4.55 [1.86–11.14][c]
|
|
English language skills (reading and comprehension)
|
|
Poor or intermediate (n = 151)
|
32 (21.2)
|
Reference
|
16 (10.6)
|
Reference
|
|
Good or excellent (n = 278)
|
93 (33.5)
|
1.01 [0.54–1.90]
|
39 (14)
|
0.44 [0.17–1.13]
|
|
Sources of education/training about research
|
|
No sufficient training (n = 188)
|
31 (16.5)
|
Reference
|
12 (6.4)
|
Reference
|
|
University training (n = 108)
|
39 (36.1)
|
2.17 [1.14–4.15][c]
|
14 (13)
|
3.24 [1.24–8.43][c]
|
|
Self-paced training (n = 133)
|
55 (41.4)
|
2.68 [1.48–4.84][c]
|
29 (21.8)
|
3.64 [1.62–8.19][c]
|
|
Encouraged by mentors to participate in research
|
|
No (n = 97)
|
14 (14.4)
|
Reference
|
7 (7.2)
|
Reference
|
|
Yes (n = 332)
|
111 (33.4)
|
2.04 [1.02–4.06][c]
|
48 (14.5)
|
1.47 [0.58–3.75]
|
Abbreviations: CI, confidence interval; OR, odds ratio.
a Binary logistic regression results.
b The three smallest universities were excluded from the analysis and the total is
n = 396.
c Significant independent predictor according to the regression analysis.
Research Needs for Preparing Master Theses
Most of the participants (93.5%) reported their need to attend trainings to plan,
conduct, and publish their studies. With regard to the components of this training,
academic writing was the most commonly reported need (91.2%), followed by peer review
processes (86.8%) and preparing research proposal (85.8%; [Fig. 2]).
Fig. 2 The training needs for preparing master theses among medical higher studies trainees.
Percentages lower than 5% were represented but not labelled.
Discussion
With our findings and the large representative sample, this study could successfully
uncover postgraduate students' attitudes toward research and their perceived barriers
hindering the publication of the conducted projects. It could also investigate the
contributions of these factors and the demographic characteristics toward previous
research experiences in order to identify the main gaps and to suggest evidence-based
solutions to improve medical research productivity in Syria.
Participants reported positive attitudes toward research similarly to what was reported
in Saudi Arabia,[15] one of the leading Arab countries in medical research.[16]
[17] These attitudes were also higher compared with those of Damascus University's medical
students in 2018 using the same questionnaire.[13] However, this contrasted with two studies from Iran and Pakistan that reported lower
attitudes toward research for postgraduates in comparison to undergraduates.[18]
[19] The reasons for this in the Syrian sample might be that participants were in daily
contact with the uncertainties in disease management and the limitations of relevant
guidelines, along with the limited resources during the crisis.[20] The sensed limited resources might have also caused more postgraduates to believe
that all medical research is costly, in comparison to undergraduates.[13]
These attitudes were faced with a wide variety of barriers, the most important of
which was the absence of adequate training. This reason had also been singled out
as the main barrier for residents in Saudi Arabia.[15] It is worth noting that all the included programs had at least one module for research
methodology during the first, second, or third year of higher medical education. However,
these modules were deemed ineffective in equipping students with the necessary tools
to conduct research independently. The unavailability of research mentors was another
important obstacle reported from our participants, which was in line with results
even in the most productive countries in medical research in the area such as Saudi
Arabia and Iran.[15]
[19] However, that did not reflect the true importance of this limitation because lack
of time, funding, and reward as well as stress were factors of more importance than
mentors' unavailability to the Saudi, Pakistani, and Iranian participants.[15]
[19]
[21] On the contrary, our sample put the need for mentors' support prior to these barriers,
possibly because of the exaggerated drain of Syrian mentors during the war.[6]
[7]
[8]
[9] Another reason might be that 65.2% of Pakistani postgraduates thought they could
conduct research without supervision,[21] which again reflects higher students' knowledge, experience, and confidence.
Although lack of time remained an important limitation to medical research in Syria,
especially during the current war,[22] it was more significant to resident physicians worldwide.[23]
[24]
[25] Nevertheless, together with the previous barriers, this might explain why participants
seemed to focus more on quick short studies that require less methodological knowledge,
support by mentors, and funding, such as case reports and cross-sectional studies.
Yet the number of published case reports remained modest,[26]
[27] and these studies were less likely to fulfill the unmet research needs of the Syrian
health care system.
The variability of participation in medical research in our sample could be better
explained by the demographic characteristics than the self-reported attitudes and
perceived barriers. This might be due to students' inadequate awareness of the factors
that carry the most impact on hindering or boosting research productivity, as well
as the lack of comprehensive advice on how to fill in the gap and help postgraduate
students to publish (i.e., the aim of our survey). The extensive and overall analysis
achieved in this study could reveal specific institutional and individual recommendations
that should be able to mitigate these barriers, allowing for the publication of at
least the projects being conducted as a requirement for graduation.
To ameliorate the lack of training, Syrian institutions should implement more practical
workshops to supplement the current research curricula, which was rated insufficient
by our participants. An example of successful affordable alternatives was the peer-liaised
four workshops based on the Introduction to the Principles and Practice of Clinical
Research (IPPCR) course,[14]
[28] presented by the U.S. National Institutes of Health.[29] Online workshops can also provide a more affordable, accessible, and flexible option
that still leads to comparable outcomes.[14]
[30]
[31]
[32]
[33] These educational events should be recorded and published afterward for self-paced
learning, which was deemed highly effective, and should cover all aspects of research
methodology, academic writing, and biomedical statistics, as training was lacking
overall.
Other institutional suggestions include providing stable internet connectivity at
faculties and hospitals and building a national online platform that archives students'
research proposals, in order to facilitate collaboration between students in different
universities and specialties, as well as between them and other researchers nationally
and internationally. In addition, organizing an annual conference for published master
theses in peer-reviewed journals to be presented to younger students would spark excitement,
encourage scholarly activity, and boost the belief in research feasibility even with
limited funding.[34] These training and partnership attempts lied at the heart of the recently published
framework aimed at strengthening health research capacities in the Middle East and
North Africa region.[35]
Although the numbers of mentors in Syria dropped during the conflict,[7]
[8]
[36] they still hold crucial responsibility in the process of improving research conduct
among their mentees. Their expertise that accumulated over the years of war could
uncover many possible crisis-related research fields that are of high priority to
be investigated. This could mitigate the barrier of rare research opportunities. Mentors'
active encouragement is also one of the most established associations with higher
research output in this study and others.[15]
[19] Therefore, allowing long-distance mentoring by experts worldwide might overcome
the lack of supervisors in Syria,[37] especially that more than half of the papers published by Syrians were in collaboration
with external institution[38] and that a large bulk of the Syrian professionals are practicing abroad.[6] This can additionally address language barriers and the lack of access to medical
journals.
Residents also have their share of the responsibility. The first step may be to collaborate
with peers in order to reduce efforts duplication, conduct multicenter studies, and
provide scientific support across disciplines, especially with the evident lack of
mentors' support. Another advice is to get involved in research studies prior to the
master theses because it was shown that medical students who were involved in research
projects had superior research productivity after graduation.[24]
[39] Furthermore, cooperation between postgraduate and undergraduate students may reduce
the time burden for postgraduates and create additional opportunities for undergraduates
to participate in publications.
Limitations and Strengths
Limitations and Strengths
Our findings resulted from a self-reported online questionnaire without objective
assessment of the research-related knowledge and confidence. However, the individualized
communication of the survey should have maximized recruitment (i.e., nearly a quarter
of the target population in all of Syria) and improved the quality of reporting. Therefore,
the suggested evidence-based solutions may save a lot of the currently wasted efforts
by pushing master thesis projects toward publication. On the other hand, due to the
limited number of authors in Syria, a case–control study focusing on them would represent
a further step toward a more detailed understanding of the facilitating factors of
medical research in Syria (e.g., dissecting the sources used for self-training on
medical research skills). Lastly, the important factor of lack of research funding
was marginalized in our report, including the suggested solutions, as it might be
far from the current reality in Syria where crucial equipment and medications are
unaffordable and where international and national funding are extremely difficult
due to the sanctions and the collapsing economy, respectively.
Conclusion
Several common barriers of medical research, including the lack of training and mentorship,
prevent postgraduate students from conducting and publishing research regardless of
their positive attitudes toward it. However, the intrasample contrasts regarding prior
research contributions unveiled a possibility of improvement with coordinated low-cost
institutional and individual efforts such as peer-run self-paced training opportunities
and long-distance mentorship.
