Difficulties in conducting clinical research among healthcare practitioners in Saudi Arabia: A cross-sectional survey.

BACKGROUND: Research activity represents an important process conducted to address an issue in a precise and systematic manner. Data of this kind regarding the methodological difficulties encountered by healthcare practitioners in conducting clinical research in Saudi Arabia are scarce. This study aims to assess the methodological difficulties encountered by healthcare practitioners in conducting clinical research in Saudi Arabia.
MATERIALS AND METHODS: This cross-sectional survey was conducted among healthcare practitioners who conducted or who were involved in research in Saudi Arabia from June 2018 through August 2018. Data were collected through SurveyMonkey, using a modified version of a questionnaire from a previous similar study.
RESULTS: Overall, 236 respondents participated in the study, more than half, that is, 131 (55.50%) had conducted research as principal investigators, 41 (17.40%) had never attended a research workshop, and 57 (24.20%) were members of research committees. Respondents identified "formulating the research title" and "cooperation between research partners" as the easiest research steps by 58 (24.58%) for each. "Receiving funds and financial resources to complete the research project" ranked the highest difficult step by 124 (52.54%) of the respondents. Attending >2 clinical research workshops was significantly associated with lower methodological difficulty scores. Specifically, those who attended scored 35.28 ± 12.86, while those who did not scored 42.34 ± 12.64, with a highly statistically significant difference (P = 0.001).
CONCLUSION: These findings show that securing funding and finding an available biostatistician contributed greatly to the methodological difficulties of conducting clinical research. The difficulty score decreased significantly with increasing the number of clinical research workshops attended by the researchers.

Background

Research by healthcare practitioners represents an important process in developing new knowledge, skills, attitudes, and values. Further, it can help with the interpretation of existing healthcare resources, abilities, and competencies. Healthcare research is critical for creating healthcare policies to ensure that optimal evidence-based healthcare is delivered to all patients. In the last few years, Saudi Arabia has continuously increased funding for education and research. The education budget was $32.62 billion in 2009, $36.63 billion in 2010, and $45.18 billion in 2011. In addition, a supplement of $21.8 billion was also injected to establish new universities, research labs, and scholarship programmes for higher education. In December 2012, the educational budget slated for 2013 was the highest-ever level: $54.54 billion.[1]

Researchers should be cautious and aware that they may encounter unexpected difficulties and problems while conducting a research project, problems which may even lead to academic failure in conducting and publishing clinical research.[2] Examples of these precautions and difficulties include instances such as when, due to unexpected delays, researchers need more time than the scheduled deadline provided or when they realize that some stages of research are more difficult than the researchers perceived.

Many stages of research can be time-consuming and tedious; however, healthcare practitioners cannot avoid research because it is an academic requirement. Moreover, research requires time and effort, and often projects have target dates of completion. Therefore, appropriate time management of time is essential in conducting research. The demands of research require time management skills similar to those of a successful and busy business executive.[3]

Personal problems, including psychological challenges, such as loss, depression, and anxiety, may interfere with concentration, and they may contribute to feelings of inadequacy or may result in serious academic difficulties. Possible solutions to these challenges include environmental or behavioral changes; however, the environment is less susceptible to change. Hence, solving such problems usually requires behavior modification.[4]

Bocar identified 20 problems that student researchers experience when conducting research. Among these, “cooperation of respondents,” “time management,” “stress management,” “identification of researchable issues,” and “construction of the research title” were the most frequently reported. Additionally, major difficulties included “financial problems;” “construction of interpretations, analysis, findings, conclusions, and recommendations;” “formatting the text content;” and “cooperation between research partners”.[3] Accordingly, Bocar concluded that the cooperation of the chosen respondents outside of the academic institution is a crucial problem. To some extent, students also felt that personal problems like time and poor stress management may disturb their concentration.[3]

There has been little research on this topic in the Kingdom of Saudi Arabia (KSA). One such study aimed to investigate the factors involved in research training, productivity, challenges, and attitudes among trainees in pediatric residency programmes. This study represented a needs assessment phase in the development of a research training curriculum for the Saudi pediatric residency programme, and research productivity and training were found to be low.[5] Further, a study on barriers to improve research productivity in KSA identified problems such as a lack of encouragement from academic staff in conducting and publishing research, a lack of financial support for the research publishing sector, and a lack of research publishing infrastructure.[6]

Data on the difficulties encountered by healthcare practitioners who conduct research in KSA are scarce. Therefore, we aimed to investigate the methodological difficulties encountered by healthcare practitioners who conducted research in KSA and to identify the most difficult problems experienced by healthcare practitioners in conducting clinical research.

Methods

Study design and setting

This a cross-sectional survey that included healthcare practitioners who were engaged in clinical research in KSA. Healthcare practitioners who have conducted or have been involved in any kind of clinical research were eligible to participate in the study. Ethical approval for the study was sought from the Research Ethics Committee at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. Participants consented to participate within the email through which the SurveyMonkey Questionnaire was provided.

Data collection

Data were collected via SurveyMonkey from the beginning of June 2018 until the end of August 2018 using a similar questionnaire developed by Bocar to identify the difficulties in conducting research in political fields,[3] after securing permission to use the questionnaire from the author and making a few modifications to involve more methodological steps in conducting clinical research in healthcare fields. The modified questionnaire consisted of 2 sections. The first pertained to the demographic characteristics of the study participants, including age, gender, nationality, profession, experience, history of conducting or participating in research, attending research workshops, or being a member of a research committee. The second section comprises 22 items that represent the main methodological steps in research, which were assessed on a 4-point Likert scale according to the degree of difficulty (not difficult, somewhat difficult, moderately difficult, and extremely difficult).

Statistical analysis

Data were analyzed using SPSS V.22. Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as percentages. The t-test and one-way analysis of variance were used for continuous variables, and the χ2 test was used for categorical variables. Cronbach's alpha was used to assess the reliability and internal consistency of the items in the questionnaire. A P value <0.05 was considered statistically significant.

Results

Using SurveyMonkey, a cross-sectional survey was distributed among healthcare practitioners and researchers in Riyadh City. In total, 330 participants responded, and 94 participants with no experience in the research were excluded from the analysis. The baseline characteristics of the respondents have been presented in Table 1. The majority (89.8%) of the participants were citizens of KSA; 61.90% were males, and the highest percentage (44.10%) were aged 31–40 years. More than three quarters (76.30%) of the participants were physicians, 36.9% had experience of >10 years, and more than half (55.50%) of them had conducted research as a principal investigator. While 58.50% of the respondents had attended 1 or 2 research workshops, 17.40% reported that they had never attended a research workshop. Further, 24.20% of the respondents were members of research committees.

Table 1

Characteristics of the participants

		Number	Percentage
Nationality	Saudi	212	89.8
	Non-Saudi	24	10.2
Age (years)	20-30	79	33.5
	31-40	104	44.1
	41-50	36	15.3
	≥51	17	7.2
Gender	Male	146	61.9
	Female	90	38.1
Health care profession	Physician	180	76.3
	Pharmacist	41	17.4
	Nurse	13	5.5
	Physiotherapist	1	0.4
	Other	1	0.4
Experience (years)	1- 5	81	34.3
	6- 10	68	28.8
	>10	87	36.9
Conducted or participated in research in the past	Yes (as a co-investigator)	79	33.5
	Yes (as a principal investigator)	131	55.5
	Yes (as a volunteer)	26	11.0
Attended research workshops	Yes (>2 workshops)	57	24.2
	Yes (1 to 2 workshops)	138	58.5
	No (none)	41	17.4
A member of a research committee	Yes	57	24.2
	No	179	75.8

The Cronbach's alpha was 0.914 for the entire questionnaire, which reflects excellent reliability and internal consistency of the items in Table 2.

Table 2

Reliability analysis of the overall questionnaire

Item	Scale mean if item deleted	Scale variance if item deleted	Corrected item-total correlation	Cronbach’s alpha if item deleted
Identification of researchable issue and idea	37.62	150.65	0.46	0.91
Formulating the research title	37.84	151.26	0.44	0.91
Collecting and reviewing related studies in the literature to support your research	37.66	150.03	0.50	0.91
Building your research methodology	37.43	147.87	0.59	0.91
Making research questionnaires	37.68	147.48	0.59	0.91
Writing the research proposal	37.56	147.24	0.62	0.91
Getting research ethics board approval	37.51	149.99	0.42	0.91
Cooperation between research partners	37.74	149.42	0.46	0.91
The patience to complete your research	37.69	148.11	0.56	0.91
Research supervisor patience when completing research supervision	37.70	148.50	0.55	0.91
Research inexperience	37.41	148.04	0.58	0.91
Cooperation of respondents with your research procedures	37.47	151.50	0.49	0.91
Counting the responses and data entry	37.59	147.66	0.54	0.91
Using the appropriate statistical tools to analyze data	37.25	148.04	0.55	0.91
Interpreting the results and data analysis	37.26	147.01	0.62	0.91
Finding an available statistician to help you in your data analysis	36.95	152.54	0.42	0.91
Writing and editing the manuscript	37.19	148.73	0.63	0.91
Reporting the study discussions and recommendations	37.41	147.46	0.65	0.91
Choosing the appropriate journal for publishing research findings	37.11	148.96	0.55	0.91
Manuscript submission	37.38	148.22	0.60	0.91
Managing time	37.08	148.43	0.58	0.91
Managing stress	37.23	148.88	0.53	0.91
Receiving funds and financial resources to complete your research project	36.86	151.47	0.45	0.91

The difficulty rating of each of the questionnaire items by number and percentage of respondents has been presented in Table 3. The highest proportion of respondents (24.58% for each) rated formulating the research title and cooperation between research partners as “not difficult.” Similarly, the highest proportion of respondents (34.32%) rated “cooperation of respondents with research procedures” as “somewhat difficult.” The percentage of respondents who ranked items as “moderately difficult” ranged between 25.42% and 47.46%, with the highest being the item “writing and editing the manuscript.” Finally, the highest proportion of respondents (52.54%) rated “receiving funds and financial resources to complete the research project” as “extremely difficult,” followed by “finding an available statistician to help with data analysis” (43.64%).

Table 3

Answers to the questions

Item	Not difficult		Somewhat difficult		Moderately difficult		Strongly difficult
	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
Identification of researchable issue and idea	43	18.22	63	26.69	99	41.95	31	13.14
Formulating the research title	58	24.58	73	30.93	86	36.44	19	8.05
Collecting and reviewing related studies in the literature to support your research	42	17.80	74	31.36	89	37.71	31	13.14
Building your research methodology	25	10.59	78	33.05	78	33.05	55	23.31
Making research questionnaires	45	19.07	76	32.20	81	34.32	34	14.41
Writing the research proposal	37	15.68	66	27.97	97	41.10	36	15.25
Getting research ethics board approval	46	19.49	61	25.85	68	28.81	61	25.85
Cooperation between research partners	58	24.58	72	30.51	65	27.54	41	17.37
The patience to complete your research	46	19.49	77	32.63	78	33.05	35	14.83
Research supervisor patience when completing research supervision	46	19.49	79	33.47	77	32.63	34	14.41
Research inexperience	24	10.17	78	33.05	77	32.63	57	24.15
Cooperation of respondents with your research procedures	19	8.05	81	34.32	99	41.95	37	15.68
Counting the responses and data entry	48	20.34	64	27.12	75	31.78	49	20.76
Using the appropriate statistical tools to analyze data	26	11.02	53	22.46	83	35.17	74	31.36
Interpreting the results and data analysis	24	10.17	54	22.88	90	38.14	68	28.81
Finding an available statistician to help you in your data analysis	9	3.81	46	19.49	78	33.05	103	43.64
Writing and editing the manuscript	13	5.51	51	21.61	112	47.46	60	25.42
Reporting the study discussions and recommendations	25	10.59	63	26.69	104	44.07	44	18.64
Choosing the appropriate journal for publishing research findings	17	7.20	49	20.76	86	36.44	84	35.59
Manuscript submission	25	10.59	59	25.00	104	44.07	48	20.34
Managing time	14	5.93	53	22.46	78	33.05	91	38.50
Managing stress	22	9.32	56	23.73	85	36.02	73	30.93
Receiving funds and financial resources to complete your research project	11	4.66	41	17.37	60	25.42	124	52.54

The mean ± SD score for each item on the questionnaire was examined with reference to the number of research workshops attended. These findings have been presented in Table 4. The mean scores on the whole questionnaire and its individual items fell between “somewhat difficult” and “moderately difficult.” Further, the overall mean score decreased with an increase in the number of research workshops attended. Specifically, it was 42.34 ± 12.64, 39.75 ± 12.43, and 35.28 ± 12.86 for those who had never attended workshops, who had attended 1 or 2 workshops, and who had attended >2 workshops, respectively. However, when compared with those who had not attended any workshops, the mean score for those who had attended 1 or 2 workshops was not significantly lower (P = 0.244), while that of those who had attended >2 workshops was significantly lower (P < 0.001). Accordingly, for the majority of the assessed items, the difficulty score was found to decrease with an increase in the number of workshops attended, especially for the following items (all significant at P < 0.05): “collecting and reviewing related studies in the literature”, “developing the research methodology,” “writing the research proposal,” “securing approval from the research ethics board,” “the patience to complete the study,” “counting the responses and data entry,” and “using appropriate statistical tools to analyze the data” [Figure 1].

Table 4

Mean score of the questionnaire regarding the difficulties of conducting research by research workshop attendance (out of 3)

Item	Attending research workshops
	No (none)		Yes (1 to 2 workshops)		P†	Yes (>2 workshops)		P‡
	Mean	SD	Mean	SD		Mean	SD
Identification of researchable issue and idea	1.56	0.95	1.59	0.92	0.875	1.25	0.95	0.108
Formulating the research title	1.39	0.92	1.30	0.92	0.602	1.14	0.93	0.192
Collecting and reviewing related studies in the literature to support your research	1.80	0.90	1.48	0.90	0.042*	1.18	0.97	0.001*
Building your research methodology	1.90	1.02	1.73	0.91	0.306	1.44	0.95	0.023*
Making research questionnaires	1.49	1.08	1.53	0.94	0.812	1.19	0.90	0.143
Writing the research proposal	1.76	0.89	1.67	0.89	0.604	1.14	0.95	0.001*
Getting research ethics board approval	1.88	1.03	1.65	1.05	0.226	1.32	1.10	0.012*
Cooperation between research partners	1.56	1.05	1.39	1.05	0.365	1.21	1.00	0.096
The patience to complete your research	1.71	0.98	1.44	0.97	0.128	1.21	0.90	0.011*
Research supervisor patience when completing research supervision	1.59	1.05	1.43	0.94	0.383	1.26	0.94	0.113
Research inexperience	1.85	0.91	1.73	0.93	0.461	1.54	1.00	0.120
Cooperation of respondents with your research procedures	1.78	0.82	1.64	0.79	0.316	1.60	0.96	0.324
Counting the responses and data entry	1.85	0.96	1.49	1.08	0.051	1.40	0.96	0.025*
Using the appropriate statistical tools to analyze data	2.10	1.02	1.91	0.97	0.272	1.61	0.96	0.018*
Interpreting the results and data analysis	2.02	0.94	1.88	0.94	0.378	1.68	0.98	0.088
Finding an available statistician to help you in your data analysis	2.15	0.91	2.12	0.88	0.884	2.28	0.82	0.446
Writing and editing the manuscript	1.88	0.75	2.04	0.84	0.280	1.70	0.82	0.280
Reporting the study discussions and recommendations	1.76	0.89	1.80	0.84	0.751	1.44	0.96	0.100
Choosing the appropriate journal for publishing research findings	2.24	0.86	1.98	0.93	0.105	1.89	0.94	0.063
Manuscript submission	1.88	0.95	1.78	0.90	0.529	1.56	0.85	0.086
Managing time	1.95	1.02	2.07	0.91	0.496	2.05	0.87	0.599
Managing stress	1.95	0.95	1.88	0.95	0.692	1.84	0.98	0.582
Receiving funds and financial resources to complete your research project	2.29	1.01	2.22	0.89	0.646	2.33	0.87	0.832
Overall score (out of 69)	42.34	12.64	39.75	12.43	0.244	35.28	12.86	0.008*

Not difficult=0, somewhat difficult=1, moderately difficult=2, strongly difficult=3.*Significant P value (P value < 0.05).†P value between no at all and yes (1 to 2 workshops).‡ P value between no at all and yes (>2 workshops).

Figure 1

The most difficult steps in clinical research methodology encountered by the healthcare researchers

Further, male participants showed significantly (P < 0.05) lower overall scores (37.83 ± 12.87) compared with females (41.21 ± 12.30). There was a statistically significant difference (P < 0.05) between the age groups in terms of the overall score on difficulties in conducting research, which was lowest for elderly participants (aged ≥50 years), with a mean score of 31.76 ± 16.40. Types of healthcare professionals showed a significant difference in difficulties in conducting research, with the highest scores observed among physicians, followed by nurses and pharmacists (40.26 ± 12.19, 36.85 ± 14.08, and 34.98 ± 14.26, respectively). Moreover, those with more experience (>10 years) and members of research committees showed significantly (P < 0.001) lower overall scores (35.22 ± 13.38 and 35.00 ± 13.51, respectively). These data have been presented in Table 5.

Table 5

Mean of the total score for the difficulties of conducting research by characteristics of the participants

		Mean	SD	P
Nationality	Saudi	39.65	12.42	0.058
	Non-Saudi	34.46	14.71
Age (years)	20-30	39.85	12.07	0.033*
	31-40	40.62	11.97
	41-50	36.67	13.42
	≥51	31.76	16.40
Gender	Male	37.83	12.87	0.047*
	Female	41.21	12.30
Healthcare profession	Physician	40.26	12.19	0.046*
	Pharmacist	34.98	14.26
	Nurse	36.85	14.08
Experience (years)	1-5	40.98	12.49	0.001*
	6-10	41.90	11.02
	>10	35.22	13.38
Conducted or participated in research in the past	Yes (as co-investigator)	39.39	11.91	0.868
	Yes (as principal investigator)	39.20	13.15
	Yes (as a volunteer)	37.88	13.46
A member of a research committee	Yes	35.00	13.51	0.005*
	No	40.43	12.23

* Significant P value (P value<0.05)

Discussion

The current study is a “Methodological Difficulties Assessment” supporting research productivity in KSA. Thus, we observed that the financial support and availability of biostatisticians were the most common methodological difficulties in conducting clinical research among healthcare practitioners in Saudi Arabia, a finding that is in line with those reported in a similar study conducted among student researchers in Ozamiz.[3] Alshayea highlighted that for KSA to achieve a place among advanced nations, it is mandatory to overcome all the obstacles that hinder the scientific research process.[7] These findings indicate that, despite the national policy plan by the Ministry of Economy and Planning in 2005, which aimed to increase research funding so it can reach 2.10% of the gross domestic product by 2015, researchers in KSA continue to experience problems pertaining to research funding.[8] Many of the problems of the scientific research state in the Arab world are attributed to a shortage of funding, old regulations, red tape, and a lack of cooperation.[7] In contrast, Bocar found that identification of a researchable issue and development of a research title are the most common difficulties faced by student researchers.[3] This finding is contrary to our results, which revealed that formulating a research title was the easiest step according to the participants. However, this difference might be explained by the difference in the research population of the two studies.

In their study on research training, productivity, and challenges among trainees of pediatric residency programs across KSA, Alhaider et al. found that the low research involvement level among the trainees could be attributed to a lack of structured regular research activities and a lack of protected time.[5] In contrast, Vinci et al. reported that positive factors in conducting research included protected research time, a formal research program that includes access to biostatisticians, as well as seminars addressing research methodology, contact with and guidance from mentors, an environment that supports research, and adequate funding to support conference attendance.[9] Statistical interpretation is difficult for researchers as well as clinicians. This important knowledge translation issue may exist because education has not been effective in improving statistical knowledge and interpretation among clinicians.[10] In this study, the healthcare practitioners reported that finding an available biostatistician was one of the major difficulties that they faced, and almost two-thirds indicated that developing a research methodology was somewhat difficult or moderately difficult. Moreover, in this study, more than two-thirds of the respondents identified that time management in the research process was moderately or extremely difficult.

According to previous literature, the frequency of attending or presenting at research conferences is positively related to research confidence, science self-efficacy, and intention to pursue a research degree in graduate school.[11] This supports our finding that the difficulties in conducting research decrease with the increase in the number of research workshops attended. This finding highlights the importance of attending research-oriented conferences and workshops.

According to the literature, males are nonsignificantly more likely to intend to pursue a research career compared with females.[11] In this study, males had lower difficulty scores as compared with females.

Finally, older participants, those with more experience, and those who were members of a research committee showed lower mean difficulty scores than other participants. This finding can be explained by the fact that their greater experience results in more knowledge and skills and more appropriate behaviors and values.

Limitations

This was a cross-sectional study using survey data with small sample size; therefore only limited generalizability of these findings can be claimed. However, future research specifically targeting a larger sample of healthcare practitioners in Saudi Arabia is recommended, as well as research examining the methodological difficulties before and after attendance at clinical research workshops might give a broader view of the effect of such workshops from different clinical research points of view.

Conclusion

Our study examined the methodological difficulties encountered by healthcare professionals when conducting clinical research in the KSA. Our findings showed that funding and biostatistician availability were considered the most difficult steps in research, as reported by more than half of the participating healthcare practitioners. Additionally, the difficulty score was found to decrease significantly for participants who had attended more research workshops. These workshops increase the opportunity for clinical research grants and provide more available biostatisticians to perform statistical services for clinical researchers, thus, encouraging clinical researchers to attend more research workshops will reduce the methodological difficulties in conducting and publishing the clinical healthcare research in Saudi Arabia.

Ethical approval and consent to participate

Ethical approval for the study was sought from the Research Ethics Committee at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. Participants consented to participate within the email through which the SurveyMonkey Questionnaire was provided.

Consent for publication

Not applicable

Availability of data and material

The anonymized datasets generated during this current study are available from the corresponding author upon reasonable request.

Authors’ contributions

SAD: involved in the conception and design of the study and critically reviewed the article for intellectual content; AA: involved in the design of the study and data collection and analysis; YA: analyzed data and drafted the article. SA, AA, and NA: analyzed data and critically reviewed the article for intellectual content. All authors have given their approval for the current version to be submitted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.