Addressing the Problems and Challenges of Medical Research During the Syrian Crisis

Introduction : The Syrian crisis started 9 years ago causing substantial damage to the country’s infrastructure, and the consequences of this tragedy have further stunted the underdeveloped research environment in Syria. This paper aims to address the challenges of conducting medical research among Syrian academics during the Syrian crisis. Methods: The data were collected from (471) Syrian researchers (MsC or PhD students, university professors) from 13 universities and hospitals, covering 10 governates. A questionnaire was developed to collect the data and 52 factors were identi�ed as research challenges. Results: The main institutional challenges are: (94%) insu�cient funding, (80.3%) di�culties in acquiring supplies and equipment, (79.6%) lack of neutrality in approving research proposals. In regards to the personal challenges, (70.1%) expressed a high level of motivation to carry out research but only (33.4%) are con�dent that they have enough knowledge, (53.1%) do not have academic writing skills, (73.5%) do not have the basic information about medical statistics. For the crisis related factors, (83.5%) cite collecting data and reaching the sources of data as the main challenge, (80.4%) for losing contact with the patients because of the war situation, (76.3%) for lack of governmental support for the research during the crisis. Conclusion: Syrian medical researchers continue to face a number of challenges and the Syrian crisis has brought more problems and obstacles to the surface. However, despite those numerous challenges, researchers from Syrian institutes are still working on research projects.


Introduction:
The Syrian crisis has been affecting all aspects of life in Syria since it started in 2011.It is considered as the worst humanitarian catastrophe of this century (1).More than 13 out of 23 million Syrians have been displaced [2,3,4] in addition to hundreds of healthcare workers who have been killed and/or tortured which makes Syria one of the most dangerous places for healthcare providers.Several health facilities have been deliberately destroyed (Fouad et al, 2017) [5].As a result, Syria's health care system has been catastrophically impacted, with supply lines shattered and a general degradation of key services [6].
Health sciences research (HSR) is an essential part of improving health care and plays a critical role in the eld of medicine and clinical practice [7].Advances in health care and medicine including disease surveillance, diagnosis, treatment and prevention are all heavily reliant on the quality of research as well as health policy [8].Moreover, the quantity and quality of research papers are considered as the most important indicators of scienti c development in any country [7].Medical students play an important role in the production of knowledge, thus, health-related research training and evidence -based scienti c knowledge are a fundamental part of medical education [7,9,10].
In developing countries, researchers commonly initiate research studies with the best intentions.Unfortunately, researchers' lack of understanding of the social determinants of health and the unique cultural factors of the community inhibit all attempts to attain successful outcomes.Advances in bio-medical research during the last decade have highlighted the necessity of attracting greater numbers of physicians to careers that include a research component.Physicians' participation in research is essential to increase the number of clinical and research studies performed [11].Many developing countries have insu cient resources or a weak infrastructure to support their own research [12].
In view of the above, it is vitally important to study the research environment in Syria, especially during this ongoing crisis, which is considered as a unique environment for researchers and health-providers.

Aim of The Research:
studying the di culties and challenges of conducting medical research during the Syrian crisis.

Study design:
A cross-sectional study was conducted to assess the challenges of medical research among academics in Syria during the Syrian crisis.A special questionnaire was developed and tested on a pilot sample before using the nal version to collect the data.The validity of the questionnaire was approved through a pilot group, and their reliability was examined using Cronbach's Alpha (0.87).The nal questionnaire was divided into 5 sections: 1. Demographic information (8 questions) A paragraphe was added at the beginning of the questionnaire to explain the purpose of the study and ask for the consent of the participants.

Sampling:
The questionnaire was sent to participants via email.Data were collected from 8 different Governates and participants were from 4 different authorities (public hospitals or clinics, private hospitals or clinics, public and private universities), and 14 different a liations.The sample balanced between males and females.other governorates were not reachable during the time of data collection.
All of the participants were MsC or PhD students, university professors.765 academics were contacted and the data were collected between January and June 2019.

Statistical analysis:
Data were analyzed using SPSS V.22, both descriptive and inferential statistics methods were used.Shapiro-Wilk test was used to assess the normal distribution of the data, and afterwards, T-test and ANOVA test were used to test the signi cant difference.

:
Sample analysis: (Table N.1) represents the sample characteristics.The total number of questionnaires accepted in the study was 465, the response rate was 60.8%.All participants signed an electronic consent form to participate in the study.
Males were (58.9%) of the sample and females were (41.1%).Most of the sample consisted of Syrian researchers (98.1%) in addition to a small number of participants had different citizenship (1.9%).
Data were collected from 8 Syrian Governates which were reachable to collect data.Damascus had the highest percentage followed by Hamah (41.7%, 24.3%) respectively.

General Attitude Of Syrian Academics Toward Medical Research:
Most of the Syrian academics are interested in medical research (91.6%), and they think it is very important (99.6%), and would like to develop a career in medical research (53.1%).However, only (10.3%) of the Syrian academics have published an article in peer-reviewed journal and only (35.9%) have attended research-related workshops (Table N.2).
Academics from public hospitals or universities had a signi cantly higher rate of publishing articles (P = 0.013), and there is a signi cant difference between public and private authorities to develop a career in research (P = 0.034).

Institutional Factors Affecting Medical Research:
Twenty-three factors have been identi ed as institutional factors affecting the process of medical research in the Syrian institutes.Lack of nancial support (94%), low number of supervisors (89.2%), and the decreased governmental support for medical equipment and its maintenance (91.6%) were the main institutional factors (Table N.3).
Moreover, participants reported a high level of impartiality in approving the research protocols (79.6%), and there is no freedom to choose the research topic (68.2%).
Additionally, the low collaboration between different specialties (83.4%), or different governates (82.6%), and the lack of awareness for the importance of medical research (83.7%) had a high percentage among the participants' responses.The other factors are presented in (Table N.3).

Personal Factors Affecting Medical Research:
Thirteen personal factors medical research were investigated in this study.Participants reported a high level of motivation to start a medical research (70.1%), and expressed interest to work with a team on a medical research project (90.8%).However, the lack of essential research skills were a major obstacle to most of the sample, for instance, lack of protocol writing skills (56.1%), low literature review skills (46.5%), academic English skills (62.2%) and academic writing skills (53.1%).
The fear of being solely responsible for a medical research project was common (73.3%), which was the same gure for nding the right supervisor for the research (73.3%).
Finally, the participants of the sample think that the community were not interested in medical research, and the results of research were not applicable in real life (73.38%,50.6%) respectively (Table N.4).
Participants from public authorities had signi cantly better research skills in writing the research protocol, literature reviews, and academic writing compared to the private sector (p = 0.002, 0.024, 0.032) respectively.

Syrian Crisis Factors Affecting Medical Research:
The Syrian crisis has directly or indirectly affected different aspects of life.8 speci c factors were identi ed relating to the Syrian crisis and affecting the medical research process.Most of the sample participants found it di cult to conduct a medical research during the crisis (78.3%).Internet and electricity rationing directly affected the medical research process (74.4%), and data sources were quite di cult to access during the crisis (73.5%), and there was a high rate of sample drop out during the crisis (80.4%).
There has been a signi cant loss of documents and governmental databases because of the war which directly affected the medical research (72.5%), and it has been more di cult to obtain approval for research during the crisis (56.4%).Surprisingly, participants from public authorities didn't nd that the crisis had an impact on the data collection process compared to the private sector (P = 0.007).

Discussion:
There is no doubt that the Syrian crisis has been widely affecting Syrians' lives [1].Lack of health facilities and the spread of new diseases, as well as the systematic targeting of the Syrian researchers and the brain drain outside Syria during the crisis period have intensi ed the need for medical research during this time of current con ict.
Before the war, the production of scienti c research in Syria has been reported in a quantitative and qualitative analysis in 2011 (13).The author of the previous study found that the Syrian institutions producing research had a gap that need to be bridged.
However, there was a spectrum of research originating from Syrian universities except for clinical research which was of a limited number and quality (13).
The overall research productivity from the Arab world has been gradually increasing but there was unbalanced distribution of research production between the Arab countries (14)(15).Saudi Arabia and Egypt produced almost 60% of research from the Arab speaking world (13).
The result of this study has found that postgraduate students did not have enough knowledge of research methodology which was one of the most important factors affecting their medical research productivity.Studies have shown that the early involvement of medical students in research promotes a tendency to continue researching in later stages of the medical profession [16,17].Additionally, early research education enables the students to develop critical appraisal skills [18] along with encouraging them to pursue their career in basic medical sciences or clinical research [19].Furthermore, the ability of evaluating the literature provides lessons in teamwork and brings about experience in writing and practice in communicating data with the scienti c eld [20].Literature shows that medical students' involvement in research projects has declined in recent years [21,22].
Silcox showed that 75% of postgraduate students prefer to engage in other scholarly activities compared to the research [23].Studies have veri ed that medical students' involvement in research is clearly associated with postgraduate research [17,24].The role of undergraduate research assistants becomes thus even more important [17,25].Another study from Calgary University depicted that introducing a formal research workshop resulted in a signi cant increase in submission of medical research by students from (11%) to (59%) [26,27].
Research should be conducted using an appropriate method for the unique community and the culture of the proposed research site.Challenges have been encountered when conducting research in developing countries where cultural perspectives often vary signi cantly from those of developed countries.These challenges include protecting the rights of the most vulnerable and disadvantaged populations while balancing the needs of the many (28).The same results have been found in this study, the Syrian community is not interested in medical research and have not found it useful, and the Syrian researchers were not working on research that have an application in real life.Some of the problems of scienti c research in developing countries include lack of educated human resources that are capable of conducting scienti c research.Developing countries' governments research priorities, funding and nancial support are insu cient to conduct scienti c research.Existence of requirements to carry out a scienti c research, such as expensive equipment, the need of various specializations to carry out a research, and the length of time to complete research Some researches require a continuous communication between the researcher and the members of the sample, which may be di cult in developing countries due to the limited means of communication.Import di culties in developing countries are also among the most important factors limiting scienti c research, but governments rarely admit this as a causative element.For example, the required time for the arrival of imported scienti c equipment and spare parts, different foreign currency exchange and the approval of governments in developing countries to commence a research [29].
Research ndings have shown that the majority of undergraduate medical students are interested in doing research, but that some o cial and educational factors turn out to be a barrier and challenge in doing it.These factors include previous training and skills in research [7], faculty staff who lack experience [30], motivationally worthwhile environment at the institution [27], o cial procedures, lack of time, arduousness, intense workload, poor guidance and inadequate nancial renumeration [26,27,31,32].
In the primary care eld, most studies found that time, nancial constraints, (Khan et al, 2006) [7] di cult clinical practices [33], and lack of interest (Jowett et al, 2000) [34], as well as nancial inducements and infrastructure support are the key factors in promoting research (Shewan et al, 2005) [35].According to a recent study in Iran, 70% of medical science students are not willing to undertake research due to barriers and challenges in the research [36].In addition, the increasing cost of education, higher nancial returns from clinical careers, reduction of research budgets with increased competition for research funding may have contributed to this decline (37).Poor training in research skills in the medical curriculum is thought to be responsible for this (38).
Finally, the Syrian crisis has presented new challenges and factors which made the process of medical research more di cult for all the Syrian researchers.Scholars in Syria are facing unusual situations because they can not access patients in speci c areas, can not get governmental approval for the research proposals and can not use some of the highly technical equipment.However, all of these challenges have not inhibited their motivation, and during the current Syrian situation there has been a noticeable increase in the quantity and the quality of the published research.

Conclusion:
Syrian medical researchers are facing a bewildering array of challenges.Despite the many di culties, scholars in Syrian institutes are still working on research projects, and the experience of Syrian researchers can be very inspiring for academics working in areas of con ict or in settings of limited resources.

2 .
General attitude to medical research (7 questions) 3. Institutional factors affecting medical research (23 questions) 4. Personal factors affecting medical research (13 questions) 5. Factors related to the Syrian crisis affecting medical research (8 questions) AbbreviationsEBM Evidence-Based Medicine.MSc master of science (master degree student)