Research involvement among undergraduate health profession students in a resource-limited setting: awareness, attitude, motivators and barriers

Background Involvement of undergraduate health professions students (HPS) in research will facilitate evidence-based clinical practice among future healthcare practitioners. This study aimed to assess research involvement among undergraduate HPS students and associated factors in Uganda. Methods A cross-sectional study was conducted using an online assessment tool sent through WhatsApp groups and E-mail addresses of HPS in 12 medical schools in Uganda between 20th September and 5th October 2021. Results We enrolled 398 participants with a mean age of 23.9 ± 3.7 years. Of this, 267 (67.1%) were male. One hundred twenty (30.2%) participants previously participated in a research activity: 90 (58.4%) as research assistants, 39 (25.3%) published as first authors, and 25 (16.2%) as co-authors. Training on the conduct of research was received by 242 (65.8%) participants, and 326 (81.9%) had intentions of conducting research in the future. Factors influencing participation in research activities were, age ≥ 25 years (adjusted odds ratio (aOR): 1.9, 95% confidence interval (95% CI): 1.2–3.2, p = 0.012), being male (aOR: 2.1, 95%CI: 1.2–3.6, p = 0.008), and being in a clinical year i.e., year 3 (aOR: 3.2, 95% CI: 1.1–9.3, p = 0.033), year 4 (aOR: 3.3, 95% CI: 1.1–9.5, p = 0.028) and year 5(aOR: 11.6, 95% CI: 3.2–42.1, p < 0.001). Lack of funds (79.6%), and mentorship (63.3%) were reported as major barriers to research. Conclusions Despite a high proportion of HPS showing interest in getting involved in research, less than one-third reported previous involvement. Addressing barriers such as funding could potentially improve research involvement and output among undergraduate HPS in resource-limited settings.


Background
Globally, medical research and innovation remains a basic cornerstone upon which new advancements and guidelines in clinical practice are based [1]. Provision of adequate health care services for the best patient management outcomes is pivoted on the interplay between health research scientists whose work is more dedicated to carrying out medical research and clinicians who are mainly in direct patient care [2]. A balance between these two professions is therefore crucial for continuous delivery of evidence-based care [3]. Unfortunately, the medical field is still and has for decades suffered a global shortage of health research scientists [3][4][5], a problem which if not curbed early could retard progress in evidence-based clinical practice [2].
HPS are generally looked at as the primary pool from which emerge majority of the various health care professionals with clinicians and health research scientists inclusive. However, a great tendency to later prefer clinical practice to health research as a career has been reported among many HPS worldwide [6,7] despite many of them showing good attitudes towards scientific research earlier [8][9][10][11]. This has become among the leading causes of insufficient health research-scientists worldwide. Delayed exposure to research during undergraduate HPS' training has been a commonly reported reason for this imbalance [12,13]. Though the primary objective of undergraduate HPS' education is to train students in providing safe and effective patient care [14,15], the expeditious advancements in the health care system and the increasing amount of easily accessible information demand that health care practitioners make decisions based on reliable scientific evidence [15].
Sub-Saharan Africa (SSA) has continued to suffer the world's biggest burden of disease and mortality. This has been linked to its suboptimal quality of health care delivery, which is fueled by insufficient research evidence [16]. Evidence can only be derived through carrying out high standard quality research to generate local data based on common health problems that can be used to inform guidance [16]. Despite employing various interventions to boost research such as incorporating research methods into education curriculum by many African countries [17,18], the overall research output from SSA is still low [19]. This paucity of research has led to over dependence by many African countries' clinical practice on research findings from developed countries, which have different disease burden and level of medical advances compared to SSA. This could result in undesirable outcomes as observed in West Africa where shortage of skilled clinical scientists just fueled disease progression and mortality instead of its containment during the Ebola virus disease outbreak [20].
In Uganda, despite the increasing number of undergraduate HPS' schools in the last two decades from only two in 2003 to now 12 in 2021 [21], the volume of undergraduate research output has slightly improved, but still very low. In 2003, research done at one public HPS' school reported that the major barriers for students to do undergraduate research were lack of collaborations, lack of guidance and lack of funding [22]. However, this study was done 18 years ago when the country had only two undergraduate HPS' schools and involved only one HPS' school.
Because different HPS' schools may operate on different curricular, timetables, and administrative bodies, it is critical to know whether similar factors exist currently in other public and private universities, or they differ and in the different health care (HC) courses offered. Therefore, in this study, we aimed to assess research involvement of undergraduate students exploring awareness, barriers and motivators in all the 12 undergraduate HPS' schools in Uganda.

Study design
Between 20 th September and 5 th October 2021, we conducted an online, descriptive and cross-sectional study across 12 universities in Uganda.

Study area and setting
The study was conducted in Uganda. There are currently 54 universities in Uganda turning out over 40,000 graduates annually. However, only 12 universities offer health professional courses with an estimated population of 10,000 students. These include both private and public Undergraduate HPS' schools and they are Makerere

Target population
All undergraduate students, 18 years or older, from year 1 to year 5 of study pursuing a health profession program at any of the above-mentioned universities. Programs included were Bachelor of Medicine and Surgery

Sample size
A sample size of 420 participants was calculated using the modified Kish-Leslie formula for infinite population, with a prevalence of 50%, margin of error of 5% at 95% confidence interval, and a 10% non-response rate.

Study variables
The independent variables included were sex, age, year of study, university of study, type of university ownership and program of study. Dependent variables included questions on students' awareness about research, attitudes, anticipated motivational factors and barriers for research involvement.

Data collection tool
The questionnaire used had 33 questions and was adopted from previously validated questionnaires by Sayedalamin et al. [19] and Lloh et al. [20]. It consisted of 5 sections as below: Section l. Had 7 Questions about participants' demographics. Section II. Had 10 questions assessing for participants' awareness about Research. Section III. Had 9 questions, assessing for participants' attitudes towards research. Section IV. Had 3 questions, assessing for participants'perceived motivational factors and benefits for engaging in research. Section V. Had 4 questions, assessing for participants' perceived barriers for research involvement and intentions of doing research as a career.

Data collection procedure
Data was collected by convenience sampling method. The survey link to the online questionnaire was sent to eligible participants via students WhatsApp groups, personal WhatsApp inboxes plus personal email addresses. We assigned a research assistant to each class and program of study per participating HPS' school. These were mainly influential people of good reputation among their colleagues, such as class representatives and program association leaders, who continuously shared the link to all the eligible WhatsApp groups and students in their contacts inviting students to participate in the study. To reduce bias due to imbalances/ poor representation of participants from different programs, year of study and school of study among others, we ensured that we assign data collectors in each category and in numbers appropriate to the population of students per category. The questionnaire was self-administered written in simple English for effective understanding by the participants.

Quality assurance
The questionnaire was pre-tested among 15 undergraduate students from the College of Veterinary Medicine, Makerere University, and the identified corrections necessary were made before administering the tool to the final study participants. The questionnaire had check points that ensured that only completed forms could be submitted, and that each participant could submit only one response form, hence excluding duplication of responses from participating more than once.

Data management and analysis
Upon completion of data collection, entries were downloaded. Data cleaning and coding were done using Microsoft Excel 2016 and coded data exported to STATA 15.0 for analysis. Demographic characteristics, awareness, barriers, benefits, and motivational factors to participate in research were first summarized as in tables with frequencies and percentages for categorical variables and mean and standard deviation for numerical variables. Attitude was summarized on a figure format. Associations between independent and dependent variables were assessed using Chi-square or Fisher's exact tests. Multivariable logistic regression was performed adjusting for confounders (course and institutions). A p < 0.05 was considered statistically significant.

Results
A total of 406 responses were obtained. After data cleaning, 398 entries were eligible for analysis (response rate, 398/420 (95%).

Awareness about research
Most (92.7%, n = 369) respondents had ever heard of the concept of medical research and 297 (80.7%) knew a colleague who had participated in research. One-hundred and twenty (32.6%) respondents had personally participated in research outside academic requirements. Of this, 90 (58.4%) participated as research assistants, 39 (25.3%) as principal investigators and 25 (16.2%) as coinvestigators. Of those that had participated in research before this survey, 27 (22.5%) had published a paper in a  (Table 2).

Attitudes towards undergraduate research
Three hundred and twenty-five(81.6%) respondents strongly agreed that research is an important aspect in human health, and that it plays a significant role in making clinical decisions and policies (n = 306, 76.1%).
Majority (n = 349, 87.6%) also believed that undergraduate research can have a significant impact on the health system of the country and 243(61.1%) were open to taking on research in their future careers (Fig. 2).

Discussion
This study, aimed at assessing the awareness, attitude, motivation factors and barriers to research involvement among health professional students in Uganda revealed that over three-quarters of respondents were aware of medical research and with a positive attitude towards it. The major motivators for research involvement were the desire for personal development and contributing towards patient care, while lack of funds and mentorship were the main barriers for the majority.
The very high awareness (92.7%) and positive attitude towards research reported in this study could be possibly because most HPS' schools in the country have course units on research methods incorporated in their curricular. In addition, the introduction of programs aimed at boosting undergraduate research at a few Universities such as the Health Professionals Education Partnership Initiative (HEPI) at Makerere, Busitema and Kabale Universities have strived to expose students to more research work outside the one they do for their academic requirements.
Our finding agrees with those reported by previous studies among medical and Nursing students where more than half of participants reported to be aware about research [23,24] and had positive attitude towards it [8,24,25], but in contrast with that by Chellaiyan and colleagues in India [26] where less than a quarter of students had a positive attitude towards medical research. Such and more programs like research results dissemination conferences aimed at exposing students to research are encouraged to better this awareness and positive attitudes. Despite this good awareness and attitude however, only one-third (32.5%) of students had engaged in research activities outside their class research work. This could be to the fact that most HPS' schools have tight schedules with overwhelming workload that limits time for most students to engage in co-curricular activities including research. This finding is almost like one reported in India where only 34.3% of students had engaged in research activities [26] but in contrast to one by Mubuuke et al. among Ugandan graduate radiographers where 70% had actively engaged in research activities [11]. Mentorship on how to plan and balance classwork alongside co-curricular activities during medical school could help more students to actively engage in research work.
Our findings showed that less than one-fourth (22.5%) of participants had published at least one research article, and this finding is similar to previous studies in India [26] and Sweden [10] that reported that only 15 and 17.4% students respectively had published their work in peer reviewed journals. However, this finding is Lower compared to one reported among medical practitioners in Nigeria [20] where more than one-fourth (34.3%) of participants had published at least one article in a peer reviewed journal. Nevertheless, in our study, 70 % of those who had published had done so in international journals as opposed to local or regional journals. This is possibly because more international journals waiver either partially or fully on article processing charges (APCs) for authors from low-income countries compared to regional journals. APCs have been reported in the past as one of the major factors considered by Authors from resource limited settings when choosing a journal to publish their articles from [20]. Also, the perceived increased visibility and acknowledgement to the authors in international journals compared to local and regional journals could be another trigger for this preference.
Three-fourth of respondents were motivated to involve in research for personal development and contribution to patient care. This finding is congruent with that reported in Nigeria among medical practitioners [20] but in contrast with that by Pallampathy and others among students in India who reported personal interest, facilitation of foreign exams, and peer pressure as their main motivational factors for research involvement [23]. Majority (80%) of students expressed the desire to pursue a career in research. This outcome is like those reported in South Africa [24] and England [25], where majority of students exhibited a high interest in doing research as a career. With such high interests kept to implementation, more research scientists will be anticipated in future and could lead to tremendous advancements in evidence-based medical practice, hence improved quality, and outcomes of patient care. Concerned stake holders such as medical education heads, ministry of health and other drivers of the health care system are recommended to take appropriate supportive interventions for such dreams to remain vibrant and with the motivation for better health. Majority of respondents reported lack of funds, mentorship, and collaboration as the perceived barriers to research involvement. This could be because currently, there are generally very few research grants for undergraduate students both locally and globally, the generally suboptimal mentorship programs in most Ugandan universities, as well as the relatively bigger age gap between the famous research scientists in the country and the students. This result is congruent with that found in Malaysia that reported lack of skills, funding [27] and among Pharmacy students in Saudi Arabia who reported lack of funding, lack of encouragement [10] but in contrast with that reported among medical students in India who reported difficulty in choosing a topic, collecting data, lack of time [26] and difficulty in follow up of patients [23] as the major barriers. Improvement in early mentorship in medical schools as already suggested by participants in the study by Munabi and colleagues [28] could help in curbing such obstacles.
We also report that participants aged 25 years or older, being male, and in a higher academic year of study had higher odds of being involved in research compared to those younger than 25 years, females, and in earlier years of study, respectively. This is possibly because participants at a higher age and class of study have had more exposure to the various health disciplines including research course units, seen and interacted with senior researchers in the field, hence more chances of obtaining inspiration, mentorship, and collaboration for active research. Also, students in higher years of study have adapted to the general HPS school pressure and can easily plan well to balance their academics with co-curricular activities including research-a very time requiring activity. This finding concurs with that reported by Kyaw and colleagues in Malaysia [27] and another in Sweden [10] where students of older age and in higher years of study were more knowledgeable about research than the younger and in lower years of study. It also agrees with various studies that found a higher association between male sex and research involvement [24,25]. However, it contrasts with that reported in Saudi Arabia where age above 25 years was associated with less involvement in research [20].
Our study has some important limitations. Firstly, we used convenience method hence only responses from respondents who could manage to answer the online questionnaire were captured, and they may not be the actual representative of all health profession students in the country. Secondly, the results are based on participants' self-reported answers without proof confirmation by the investigators, such as one's total number of publications and the journals used, hence liable to possibility of recall bias and telling lies. However, it is a nationwide study, covering all the 12 medical schools and their respective programs of study in the country, with significant representation from each medical school, hence these results can be generalized.

Conclusion
Despite the massive awareness for and good attitude towards research among the respondents, active research involvement and publication is still very low. Lack of funding and mentorship are the perceived barriers to research involvement. Future investments in small grant acquisition, research training and mentorship programs are recommended.