With the aforementioned findings and the large representative sample, this study could successfully uncover postgraduate students’ attitudes towards 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 towards previous research experiences in order to identify the main gaps and to suggest fact-based solutions to improve medical research productivity in Syria.
Participants in this survey study reported high positive attitudes towards medical research similarly to what was reported in Saudi Arabia , which is one of the leading Arab countries in medical research conduct [15, 16]. These attitudes were also higher in comparison to the attitudes of medical students at Damascus University, which were captured in 2018 using the same tool of measurement . However, this contrasted with two studies from Iran and Pakistan that reported lower attitudes towards research for postgraduates in comparison to undergraduates [17, 18]. The reasons for that in the Syrian sample might have been 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 . The main motivations for the participants’ willingness to contribute to research while suffering from the devastating consequences of this war were to relay evidence-based knowledge and to develop a flourishing academic career (Table 2).
These attitudes were faced with a wide variety of barriers, the most important of which was the absence of adequate training of research methodology. This reason had also been singled out as the main barrier in a sample of nearly 200 medical residents in Saudi Arabia . 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 by our studied group of students. This finding was in line with several other studies even in the most productive countries in medical research in the area such as Saudi Arabia and Iran [14, 18]. However, that did not clearly 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 [14, 18, 20]. On the contrary, the surveyed Syrian students put the need for mentors’ support prior to these other barriers. This can be explained by the findings of Khan et al. who reported that 65.2% of Pakistani postgraduate medical trainees thought they could plan and conduct research without supervision, and only 11% of their participants considered the unavailability of mentors as a hindrance . Therefore, students’ knowledge, experience, and confidence in this sample seemed much higher than the ones reported by our participants.
Although lack of time remained an important limitation to medical research in Syria, especially during the current war , it was more significant to resident physicians worldwide [22-24]. This might explain why participants seemed to focus more on quick short studies that require less methodological knowledge, less support by mentors, and less or no funding, such as case reports and cross-sectional studies. Nevertheless, the number of published case reports remained modest [25, 26], and these studies were less likely to fulfill the unmet research needs of the Syrian healthcare 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 gab 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 and boost the positive attitudes allowing for the publication of at least the projects being conducted as a requirement for graduation.
Syrian institutions should implement more practical in-house workshops to supplement the current research curriculum, which was rated insufficient by our participants. For instance, a remote-site for the Introduction to the Principles and Practice of Clinical Research (IPPCR) course, presented by the U.S. National Institutes of Health (NIH) , was established in Syria since 2015 and more than four annual workshops based on this course have been delivered so far [13, 28]. Online workshops, on the other hand, can provide a more affordable, widely accessible, and flexible option that still leads to comparable results [13, 29-32]. These educational events should be recorded and published afterwards for self-paced learning, and should cover all aspects of research methodology, academic writing, and biomedical statistics since training was lacking overall (Figure 2). These trainings will also add the possibility for conducting more methodologically challenging projects. However, relaxing the restrictions and requirements for master theses would still be necessary, such as allowing students to conduct bibliographical studies such as systematic reviews and meta-epidemiological studies which can be done even in hospitals with low flow of patients and still produce high-quality evidence.
Another institutional suggestion is to build an online platform that archives all Master and PhD research projects, making them available for all national and international researchers. This platform can allow national collaboration between post-graduate students in different universities and different specialties, as well as between them and other healthcare researchers nationally and internationally. In addition, organizing a national 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 attitude that research is feasible even with limited or no funding (i.e. the attitude item of least ranks in this study (Figure 1) . For better applicability, this can be supplemented by publishing an Arabic concise guide targeting mentors and post-graduate students summarizing the basics of research methodology, academic writing, and medical statistics. These training and partnership attempts in addition to leadership skills lied at the heart of the recently published framework, which aimed at strengthening health research capacities in the Middle East and North Africa region .
The numbers of mentors in Syria dropped significantly during the years of the conflict [6, 7, 35]. However, they still hold a crucial responsibility in the process of improving research conduct among their mentees. Their expertise that accumulated over the years of war might have uncovered to them many crisis-related possible research lines that are of high priority and need to be investigated and reported. Mentors’ active encouragement is also one of the most established associations with higher research output in this study and in others [14, 18]. However, this encouragement needs to be as practical as possible, at least by frequent meetings with students and critical revisions of each phase of the projects. Another suggestion to overcome this lack of supervisors in Syria is to allow long-distance mentoring by experts in other countries , especially that more than half of the papers published by Syrians are done in collaboration with external institution . This can additionally address the barriers of internet connectivity and language limitations as well as the lack of access to medical journals.
Residents also have their share of the responsibility, the first step of which may be to collaborate with colleagues to provide scientific support, conduct nation-wide studies, and reduce efforts duplication. These collaborations can take place between colleagues from the same specialty in two different institutions or across disciplines to provide a more translational and multifaceted analysis of health problems. Another advice isto get involved in other research studies before their master theses, because it was shown that medical students who were involved in research projects had superior research productivity after graduation [23, 38]. Furthermore, cooperating between post-graduate students and medical undergraduate students who are interested in the same specialty may reduce the time burden for postgraduates and create additional opportunities for undergraduates to participate in the master thesis publication. The suggested platform for studies’ registration above can play a pivotal role in creating these collaborations.
As a limitation, we can argue that the data in this survey study were collected using a self-reported online questionnaire. However, the individualized communication of the survey by chief residents with their respective residents’ groups should have maximized recruitment and improved the quality of reporting. Therefore, the current analysis that captured the opinions of nearly a quarter of the whole targeted population in all of Syria, fulfilled the goal to assess postgraduate students’ attitudes, barriers and practices in research, and to suggest fact-based solutions that could save a lot of the currently wasted efforts by pushing master theses projects towards publication.