In view of the present study’s longitudinal design, results are presented under predefined categories according to their sequential order throughout the implementation of the program. Data from semi-structured interviews and prompts was triangulated with data obtained from organizational surveys. Each category describes the successes and challenges encountered in its respective phase and includes (1) course delivery, (2) proposal development, (3) IRB application, (4) data collection, (5) data analysis, (6) manuscript write-up, (7) long-term effects, and (8) mentorship and networking.
1. Course Delivery
All fellows first enrolled in online courses from their home countries and then attended in-person courses in Lebanon during the initial phases of the program. These courses allowed the fellows to prepare and develop their research proposals and ultimately launch their research field work. In general, fellows reported that attending the courses was beneficial for them, mainly due to their multidisciplinary nature which equipped them with the necessary foundational knowledge needed to conduct research on AMR in conflict settings. Responses from organizational surveys also showed that learners’ colleagues believed the educational material and references provided to be useful. Indeed, fellows expressed much satisfaction with the courses because they combined theoretical and practical aspects of research, were clear and easy to understand, and provided credible information by experts in the field.
P.1.Great experience when it comes to courses which were very hmm useful and informative in terms of their scientific background, research background, covering the scientific background to be hmmm as the courses were related to AMR, antimicrobial resistance in conflict settings in addition to research courses that cover qualitative and quantitative research, so it covers both the research and scientific topics that helped to help the researcher to move to go ahead with the research in conflict setting, and it was in addition it was specific or it applies the lenses related to conflict setting, so when it comes to ethical consideration for research, they provided the examples in conflict settings, so it was very helpful, and informative.
That said, fellows also commented that the time allocated for the courses was unevenly distributed; some material was perceived to be basic with more than enough allocated course time, whereas other courses such as Advanced Statistical Analysis was more important yet not given enough time.
Mixed findings were reported regarding the learning modality through which courses were delivered. Online learning was described as a novel experience for all fellows, which was generally perceived as feasible from a technical standpoint, and useful for fellows to store and revert back to course material multiple times should the need arise to better understand them. Importantly, some in-person courses had to be re-delivered online when COVID-19 impacted Lebanon; as such, fellows mentioned that online learning was a key contingency measure for them to be able to resume their courses without significant interruptions.
P.2. The online [modality] had an important benefit which is the ability to record and you can listen again and can heard what have been discussed later and you repeat 1, 2, 3 times to understand, this is also a good advantage for the online [modality]
Despite this advantage, fellows largely preferred in-person learning because they perceived it to be more engaging and interactive, which helped them better understand the material. Additionally, some participants mentioned that online learning was difficult because it required greater organization and discipline, particularly in view of their limited experience with such modalities.
P.3. The face to face [modality] brought us into the very contact with excellent staff, very qualified, and very confident. I felt I could ask any question comfortably, and so this was like a space that I felt was a very positive learning experience and a well-suited space.
2. Proposal Development
Directly after successful completion of the courses and based on shared research interest, fellows were matched with mentors who are experts in their fields. They were expected to negotiate their research topic, to develop a proposal, and to defend it in front of the scientific advisory committee. Although the majority of this phase was originally planned to happen in-person at AUB, including the proposal defence, the COVID-19 outbreak resulted in evacuating fellows to their respective countries and resuming the work remotely.
Overall, fellows mentioned that this phase allowed them to acquire essential knowledge both in terms of the literature on AMR, but also more importantly in terms of understanding how to structure research proposals, the different procedures involved in producing research, how to formulate research objectives and research questions, and how to choose appropriate research designs. Additionally, having the opportunity to present and defend their proposals to a scientific committee was perceived to be especially useful because of the feedback they received, which allowed them to perform major revisions and solidify their proposals.
P.5. If you had asked me what the research steps are before coming to Beirut, I would not have known. I didn’t know that there are different types of research like experimental, quasi-experimental, I didn’t know anything before, and I have no idea. I was surprised to see myself picking up on all this knowledge in a small period of time.
As for the challenges encountered in this phase, they were associated with planning for research in contexts of conflict, and with the ability to apply material learned to develop a research proposal. The first included challenges such as difficulty finding appropriate and relevant literature on AMR in the region, the need to change and adopt a methodological approach that is feasible in the given context of conflict especially following the outbreak of COVID-19, and the limited ability to collaborate with ministries of health to retrieve archival data, and local actors to receive other forms of local support for data collection.
P.3. The first challenge had to do with the current context, where we are trying to do this research. The context being the Covid-19 measures that are taken by all the governments and my workplace for example different hospitals which reduced basically my ability to interact with them with partners and to track with my context, and this of course created the issues of logistics when it comes to processing the specimens or to accessing the facilities or who wants to do the research, so this is one issue. The second also, it’s also related to the Covid-19 measure and it is also related to the ongoing let’s say the geopolitical situation of today which is accessing the ministry of health and trying to get the information from it.
Regarding the second category of challenges, some differences were observed among fellows. For example, while some mentioned that they felt ready to apply the knowledge gained on AMR and research methods to develop a research proposal, others reported uncertainty on how to integrate their theoretical understanding into a tangible research proposal. Still others mentioned that they believed their experience was not sufficient to design, implement, and produce a research output from their projects. Another mentioned that their lack of experience affected their ability to properly plan for and communicate the needed lab equipment and subsequently manage their data and perform the required analyses.
P.2. Of course, given the COVID-19 pandemic, country unrest, and restricted mobility which impacted my work on the proposal, I felt that I didn't have the full potential and the required knowledge to conduct a proposal at this level.
These challenges were a priori expected to happen, and this is why fellows were paired with mentors to provide guidance throughout every step of the program. Indeed, mentors were reported to play an important role in the fellowship, as testified by one fellow who faced critical challenges working on a medical topic that did not align well with his background. The fellow reported having to shift multiple times his research project and his proposed methodology because of the latter in addition to the obstacles imposed by the context where he was operating.
P.4. he [the mentor] showed interest and support and transfer all his knowledge and supporting to me and he was changing the subject of the research and I was accepting this because I have difficulty because I have the feeling that we will achieve something, but also for him he was surprised and shocked by the challenge that we faced, but from his side he was available, he was doing the correction, he was always advice to change the article the way of express by his better than me language, his language better than me and he have skill by reporting, he was improve what I produce, but at the end we could not succeed.
3. Irb Application
This phase was generally perceived to be stressful for fellows primarily because their projects depended on securing ethics approval and they had to be ready to collect data in a relatively short period of time. In this regard, fellows expressed concerns about their projects not being approved, not being able to adjust their projects based on IRB’s comments, and not being able to obtain the required permissions for data collection needed by IRB from institutions in their home countries such as hospitals and local NGOs. In addition to these issues, fellows had to consider that they were conducting research in conflict settings during a global pandemic, in countries outside Lebanon, and among sensitive populations, all of which further complicated the process.
P.4. To be honest, it was a challenge at the start to find a university that would offer ethical approval for our research proposal in the midst of Syria's instability and conflicting context.
Despite the presence of major concerns relating to the uncertainty of their local contexts, time constraints imposed by long IRB revision periods, and having to adjust their methodologies to account for COVID-19 restrictions, substantial positive outcomes were reported. During this phase, almost all fellows experienced for the first time the process of applying for ethics clearance, which added significant value to their learning experience in research. This included knowing how and where to apply for IRB approval, communicating with IRB personnel and responding to feedback, and better understanding the role of ethics in conducting research, especially among vulnerable and conflict-affected settings/populations.
P.4. Looking over a handful of IRB application forms was an advantage that I was introduced to. This was particularly useful in terms of learning what are the required documents to include, such as a consent form and what information should be included in this form because, at the end of the day, there may be a harm imposed on the participants, so it is critical to consider the impact that your study will have on the community, whether positively or negatively. The consent allows you to be ethical in your study and considerate of the participants. So, this has a big impact on how you structure your study, what questions you can ask and what information you can get from the interviews. You should be considerate of how your research project will affect your participants.
Overall, fellows reported adequate support from mentors in order to get through this process; however, many encountered significant delays in their research projects primarily because of this time-consuming process. This was one of the reasons why some fellows could not finish their projects on time and required extensions.
4. Data Collection
Multiple successes related to data collection were highlighted by fellows. For instance, one described how he was able to successfully reach the target sample size of participants in his study. He also noted that he gained skills in selecting his sample of participants based on the required characteristics with the capability to diversify it and ensure equal gender representation, allowing him to then stratify data by gender in a context where data from women is underrepresented in research. The fellow further indicated that he gained knowledge in conducting and managing interviews with increased understanding of how to steer interviews to obtain the necessary information. He also mentioned learning how to transcribe interviews despite time restraints.
P.4. As I started to conduct more and more interviews, I began to experience an improvement in my ability to ask suitable questions to bypass any unnecessary answers from the participants. I attained experience in how to conduct and manage interviews…. The most significant success that I believe to have achieved is that after initially planning to recruit 10–15 participants in order to reach data saturation, I was able to successfully recruit and interview 14 participants with the required characteristics. I was able to accomplish this specifically during times of country unrest and instability.
During this phase, fellows mentioned experiencing various challenges during recruitment, sampling, and conducting interviews. One fellow highlighted learning how to build working relationships with the lab experts during data collection when needing to secure materials for lab sample testing. By building these relationships, the fellow was able to obtain a second sample that was more representative than the one they initially utilized. Another fellow noted challenges in effectively testing for samples in hospitals due to unreliable test results obtained from hospital labs that showed very little expertise and cooperation; this also affected the communication and relationship between the lab members and the mentors.
One fellow highlighted having trouble in recruiting participants who met his inclusion criteria given that their contact information was missing from the hospitals, forcing him to travel across town to access the participants’ contact information and execute proper recruitment. Additionally, he indicated being forced to engage in further rounds of recruitment due to a high dropout rate among participants who initially provided their consent to participate. Additional challenges encountered during the interviews involved the need to conduct interviews for an extended period of time in order to reach saturation and to ensure appropriate quality of data from participants’ narratives was obtained. Importantly, internet connectivity issues impeded the scheduling and conducting of online interviews. Finally, the fellow also reported experiencing emotional distress when interviewing participants given that their stories revolved around living in war and conflict settings.
Almost all fellows reported that contextual challenges relating to COVID-19 restrictions, along with civil unrest within their countries, contributed to limiting the fellows’ mobility which was needed for data collection. One of them reported facing difficulties in collecting and storing data given the country’s political unrest and its impact on the health system. Others indicated that COVID-19 restrictions posed difficulty on their ability to visit hospitals to collect lab samples, or their ability to cross country borders to visit hospitals where they can collect samples.
P.1. I felt like something was wrong. We discovered that the collected sample did not contain phyto chlorophyll or enterococcus, so we had to change it and perform another round of sampling; we also doubted that there was a mistake in the testing technique or a problem in how the samples were stored. So, sample testing and quality assurance had certain difficulties, which I had to overcome by doing a re-sampling.
P.4. To be honest, we were in a conflicted country that was constantly exposed to breakdowns, notably in its healthcare system and when dealing with data management and storage. So we faced difficulty in recruiting the target sample that had to be interviewed, especially that the participants’ data found in the hospitals was highly disorganized. At the same time, because our target sample was limited to individuals with antimicrobial resistance, it was difficult to trace who had antimicrobial resistance and who did not based on the available disorganized data.
5. Data Analysis
Fellows also provided feedback on the data analysis phase, perceiving it to be successful overall. Fellows particularly mentioned refining their skills in quantitative data analysis, such as via using statistical analysis software, as well as improving their skills in conducting, transcribing, and thematically coding qualitative data.
P.5. The most important achievement was that I was able to learn something new, such as how to use SPSS and how to deal with Excel sheets and perform certain functions that I had never done before. I gained skills in conducting analyses and reading bar and graph analysis outputs, which I consider to be personal achievements.
P.4. What I accomplished during this analysis phase is the ability to extract codes, themes, and categories from all the 14 interviews that I conducted. So what I accomplished is the formulation of a large document including 7,000 words incorporating the most important codes related to the infected participants in addition to the themes and categories that facilitated my upcoming tasks.
One learner mentioned improving her capability to prepare data for analysis by categorizing the data into subfolders and inserting them into multiple SPSS sheets, which facilitated the production of significant and interpretable results. The fellow also expressed a newfound ability to interpret and draw conclusions from the obtained results while emphasizing the importance of interpreting insignificant results. Others reported difficulty in treating data sets that included missing and unclear data, extracting meaningful themes from qualitative interviews because of poor participant reports, and importing and exporting data on statistical software.
P.5. When dealing with missing data or biased data I had to travel back and forth, which was challenging at that time due to mobility issues in the country which were exacerbated by country upheaval and war. This was one challenge. Another challenge was related to my limited experience in using SPSS. I faced technical problems regarding how to work on SPSS and how to import and export data, but I managed at the end, Thank God.
6. Manuscript Write-up
While most fellows managed to finish their data collection and analysis as well as collate their findings into a manuscript for publication, some key challenges were reported. Some fellows found difficulty in situating study findings within the larger literature because of limited existing knowledge in their topic of interest. Others mentioned challenges in translating qualitative findings into tangible scientific recommendations. Another found it difficult to adjust the format of the paper to fit the journal requirements in terms of structure, content, and word count without compromising the quality of their writing.
P.1.The journal's format, which we chose to publish in, led me to make changes to my paper's writing. For example, one of the requirements dictated that the reference list should not exceed 25 references, which forced me to delete multiple references because I had between 30 and 40 references in my paper initially. So yes, adapting my paper to the standard format required by the journal, in which I planned to publish, was a challenge.
P.4. To be honest, reporting what the participants said and interpreting it into scientific words was a challenge for me. I had to translate the participants' spoken language into scientific words without compromising their thoughts. This was considered a little difficult for me.
During the final phase of the manuscript write-up, numerous successes were reported by the learners. One fellow highlighted their capability to finalize research findings, successfully compile a draft, find an appropriate journal, and begin the publication process, all while amidst a global pandemic and period of political/civil unrest.
Another fellow mentioned that during the final stages of the manuscript write-up, he realized that his findings can be used on a larger scale to aid health organizations operating in conflict settings, as well as decision makers, in better understanding and considering the needs and concerns of AMR patients. He also realized that his research has the potential to form the base findings for a follow-up study that can include a larger and more diversified sample, and which can be applied within a broader context. Other fellows mentioned gaining vast knowledge of AMR which was exemplified by their ability to conduct a study within a conflict setting and write a manuscript on the topic.
P.3. another thing of course I studied ten times the amount of information that I had on AMR during this period of time. So of course, there are the benefits of you know learning more about your topic hmmm and if at the end you know you have a paper now in your hand so this is the positive thing.
P.4. I believe that my research findings, even if they will not have a large significant impact, will nevertheless be useful to health organizations working in conflict zones such as north-western Syria, as they will gain a wealth of information that they can consider. This information might be able to encourage them to think about how to better serve patients, as some of my study's findings revealed a variety of issues that patients face.
7. Long-term Effects
All learners noted that long-term changes took place in relation to their research capacity, performance and behaviour, and personal development following their completion of the CREEW fellowship.
In terms of research capacity, learners noticed a significant enhancement of knowledge and skills in conducting research, specifically within the context of fragile and conflict settings and on the topic of AMR. One fellow noted that he can now conduct research in a more structured and systematic manner. Another learner reported that the research skills he developed, in terms of looking up scientific articles, allowed him to convey and share evidence-based information with government officials that is backed up by credible references. The data received from fellows was supported by information gathered from learners’ colleagues who pinpointed that the CREEW training did indeed contribute to updating the research knowledge and skills of the learners and provided them useful information on AMR in conflict settings. In addition, this fellowship allowed learners to become familiar with the possible challenges they might face when conducting research in fragile settings and conflict-affected areas.
P.5. It was great phase okay, as an induction okay, and then impact of doing the proposal, the mentoring, having a lot of experience on using different tools of analysing the data and entering the data; different tools for citation, and how to do citation and how to use PubMed for looking into literatures. Therefore, I learned a lot of things. I never knew about how to do citations, how to do research, how to look for the proper literature, where to look for the literature. And during my looking for the literature have a great impact on my knowledge, on the researches, so yeah, I can see that the three phases have a great impact on me
P.4. Of course, I attained the capability to plan for research projects specifically in the process related to receiving ethical approval from IRB or from the health authorities in the region where I worked, as well as the hospital from which the samples were taken. I also learned how to sample and how to select my samples based on the criteria and characteristics specified. Of course, I have applied the knowledge that I gained from the fellowship program that I was attending at the time.
Most notably, learners reported a change in their behaviour following the completion of the fellowship by which they were able to translate the information they learned into performance. For instance, some learners mentioned that the knowledge acquired on the methods of conducting research was applicable to their work, and for some this information was used to advance and develop the quality of their work. One learner noted that the experience gained from the fellowship allowed him to launch new scientific projects, and revise and modify those that were already implemented. One learner also mentioned that he was able to provide support and guidance for his colleagues in their research projects as a result of the experience he gained during this fellowship. Indeed, one of the learner’s colleagues did mention that the learner was “committed to the topic of AMR” and was “promoting AMR activities within the rest of the team”. At a national scale, the fellowship reportedly equipped one fellow with the knowledge and evidence that can allow him to contribute to the proposition of solutions to the healthcare system in his conflict-affected country.
P.1 My current job, yes when it comes to study and research design because one of my responsibilities is to manage research studies and to follow on that issue. It was very helpful for me during my current job and for my academic study even because I am currently a PhD student. It was very helpful hmm in terms of research topic and knowledge and practice and in terms also of the scientific topic which is antimicrobial resistance, so it was really a great experience and helpful in my current duties and responsibilities.
P.5: I am practicing it every day, as I told you we used all the researches on the antibiotic all the data, all the... to launch another antibiotic stewardship in another project, and also restart all the data, committee and all the program of the rational prescriptions in Abs hospital one of the biggest hospitals covered by MSF in Yemen, so I was having direct relation to the job to work and also improve the quality of care of the patients directly. So, as I told you we have antibiotic stewardship in Abs and now we started another antibiotic stewardship in Kanawa and now I am applying the same tools of collecting the data, data analysis based on the results of the research that I did with the CREEW.
All learners reported that development took place on a personal level as well. For example, some learners mentioned that the fellowship positively affected their career path and their credentials as researchers. Others noted that they gained the knowledge, skills, and confidence to work towards becoming established researchers capable of conducting further research in the future. Two learners mentioned that they were able to benefit from the fellowship in their postgraduate studies where they applied the principles learned to carry out their own research. Some learners also managed to disseminate their research findings at health conferences and in the form of publications; and while not all learners were able to share their work in the given timeframe, they all expressed their enthusiasm to do so and to become involved in future research activities.
P.4. Today, as I began working on the write-up of my thesis, CREEW training served as a reference for my work which also allowed me to support my peers when it comes to working on their research studies. I was able to do this because I learned the research principles from CREEW; those principles also served a basis for my research studies at the university level specifically for my Master’s thesis in political science and international relations.
P.1. For the journal publication, I am working on that for the publication of the paper, for the dissemination workshops yes, we have presented in at least two or three webinars, one was locally and the second was through GHI webinar and the third one was, the third one was related to a network or a forum supported by the GHI and university in East Anglia, the UK, so yes, we did the dissemination and working on the publication
8. Mentorship And Networking
The significance of this program was clearly expressed by fellows. Regarding their learning experience, fellows considered it a worthwhile and beneficial experience, noting that contextualization of the fellowship to conflict settings added value to the program. The fact that this program was completed by AUB, a reputable university in the MENA region, added to the significance of the learning experience as well. In addition, learners expressed their appreciation for the continuous support provided by the CREEW team and the follow-up process, which allowed fellows to provide feedback regarding the program.
P.1. The program's overall strength and distinctiveness, as well as the courses' and mentorship guidance's uniqueness, are built on their focus and specialized customization to the conflict setting. I've worked with a variety of fellowship and mentorship programs, but what sets this one apart from the rest is that it's specifically designed for conflict settings. This is the program's most major strength.
P.5. Even when I am telling you the nature of my work and even the context of Yemen as you know we are working in a conflict area, and working with MSF, you know what MSF is, we work in the frontline, so it was not easy for me. However, the CREEW team was continuously following up and this is something that I really admire, even at the time that I feel low because maybe I cannot continue so no they were continuously supporting me; they were even offering help for me. So the thing is that the continuous support that I got and that I am still getting is amazing, so they keep pushing you, not push you, support you and to do the things. It was a great experience to be honest.
As reported by the fellows, the networks and connections fellows formed were important aspects that contributed to the significance of the program. Participants noted that being in contact with fellows from diverse backgrounds and countries enriched their learning experience and enhanced the exchange of information. It also allowed them to expand their network as researchers in conflict settings. Learners also mentioned that they became better acquainted with health professionals through their research projects and were put in contact with qualified and competent instructors.
P.1. In addition to the presentation of multiple disciplines, another significant feature of this program is that it combines multiple fellows who are either interested in conducting research across the different MENA countries with a similar conflict setting context, or who themselves reside in conflict settings. For instance, I am from Palestine, someone was from Yemen, another from Syria and there was also someone from Iraq. This combination was regarded as a unique and strong point given that it facilitated learning by the ability to share ideas and being exposed to ideas coming from others.
P.3. I think the one thing that I did do is I immediately took the program forward with people who were interested in medicine, health and public health. I introduced them to the program. I really wanted to replicate it, to find a way to replicate it here with people who are on the field. You see, from my experience I came into contact with people who were really interested in what’s going on, and I found out if you want to do research in areas that are still witnessing conflict, these are the really really tough zones, you need to have people partners in those areas. Hmm, whenever I would talk to them about what I was doing with my research, they got very interested, and they really wanted to find a way to even themselves get involved in the program.
The mentorship component of the fellowship was considered a unique and excellent experience by all learners. Participants reported that beyond the theoretical aspect of the fellowship, the mentorship phase provided them with practical experience of conducting research; fellows also noted that the rigorous guidance and support provided by the mentors allowed them to overcome challenges that arose during project implementation. Learners showed great appreciation for their mentors, whom they described as experienced, knowledgeable, capable of conveying information clearly, and who reportedly demonstrated flexibility when needing to conduct meetings with learners. The mentorship experience was also considered valuable by learners’ colleagues, with one of them mentioning that the direct learning received from mentors contributed to the acquisition of knowledge and skills in the field of research. This colleague also added that this experience wouldn’t have been “optimal” had it not been followed by this phase.
P.1. The mentorship as I understood it mainly helped to guide the research project, so regular meeting with the mentor was very helpful to speak about the challenges to overcome the obstacles and to discuss any possible alternatives for any obstacle that hindered the process. So hmm I think it was very helpful having a mentor that can guide the process rather than doing or replicating the role of teaching or providing scientific information. It was about how to move with the research.
P.3. And after the mentorship, I think I am a lot more. Well, I learned how mentors, how a professional mentor really handles topics. And also I got to know a good writer, you know my mentor is a researcher and I got to read a lot of research that he does, and so I think that is important also, I think if you have a good mentor and you can read what they’ve written, and you have access to their papers, they’re a mentor with you for, they’ll stay with you, you know the experience is more prolonged because you can always go back and study what they told and you can study what was written.
Despite the positive overall experience reported by learners, some fellows faced certain challenges that were related to logistical and external factors. One learner in particular reported issues with accommodation during the didactic phase which was completed in Beirut, noting that they didn’t receive their stipend on time, which further impeded their ability to continue their research project. Another learner mentioned that the limited funding received was not enough to support their research project. Additionally, some learners reported that the time allocated for project implementation was insufficient, especially among those with other work obligations.
Furthermore, it was challenging for fellows to cope with the emergencies that occurred within their conflict settings while completing their fellowships, particularly with the advent of the COVID-19 pandemic which further imposed limitations on learners’ mobility. Indeed, one of the learner’s colleagues did mention that the COVID-19 situation imposed barriers on the learners and limited their ability to collect data and their access to research laboratories. Lastly, one learner was not able to complete the research project after needing to change the topic due to contextual restrictions set by the pandemic; this fellow believed that their educational background was incompatible with the newly assigned project and therefore opted to terminate the research project.
P.1. A general shortcoming is the restricted resources available during the fellowship process; the financial resources that were available do not allow you to perform a large-scale project. If you want to conduct a high-quality experimental project, you'll need a large budget, but the budget we had was considered small.
P.4. As a humanitarian worker, I found out that I didn't have enough time to work on my research project. Now that CREEW has been in operation for almost two years, I believe the time allocated to complete the research study was insufficient. For instance, I could not find the free time to conduct interviews, analyse the data and perform transcription.