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Attitudes, barriers, and enablers towards conducting primary care research in Banda Aceh, Indonesia: a qualitative research study

Attitudes, barriers, and enablers towards conducting primary care research in Banda Aceh,... Background: Conducting university‑ based research is important for informing primary care, especially in lower‑ and middle‑ income countries (LMICs) such as Indonesia. Syiah Kuala University (SKU), the largest educational institution in Aceh province, Indonesia, is actively establishing itself as a leader in research innovation; however, this effort has not yet demonstrated optimum results. Understanding faculty members’ perceptions of how research is conducted in this setting is crucial for the design and implementation of successful and sustainable research strategies to increase the quantity and quality of primary care research conducted at LMIC universities. The objective of this study was to identify current attitudes, barriers and enablers/facilitators towards primary care research participation and implemen‑ tation in this higher education institution. Methods: A descriptive‑ interpretive qualitative study was conducted. 29 participants, representing 90% of all faculty members providing primary care, were included. A mixed‑ methods approach was used, combining the use of a participant survey with 10 focus group discussions. Participants were encouraged to complete the survey in either English or Bahasa Indonesia. All of the focus group discussions were recorded, transcribed and translated into English. Thematic content analysis of these transcripts was carried out. Results: The majority of participants agreed that SKU has set research as a priority, as it is one of the three pillars of higher education, mandatory in all Indonesian higher education institutions. This research identified many barriers in conducting research, i.e. weak research policy, lack of research funding and infrastructure, complicated research bureaucracy and administrative process, as well as time constraints for conducting research relative to other duties. Participants expressed that personal motivation was a very important enabler/facilitator for increasing research activi‑ ties. In order to improve research productivity, the majority of participants suggested that having local awards and formal recognition, having the opportunity to partner with local business and communities, provision of incentives, and having access to a research help‑ desk would be beneficial. Conclusions: Generally, participants showed a supportive and positive attitude towards research, and provided examples of how to improve research productivity in the Asian university context. Keywords: Research, Primary health care, Physicians, Primary care, Qualitative research, Asia, southeast, Indonesia, Developing countries *Correspondence: ichsan@unsyiah.ac.id Medical Research Unit, Faculty of Medicine, Syiah Kuala University, Jl. T. Tanoeh Abe, Darussalam, Banda Aceh 23111, Indonesia Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 2 of 8 students towards research practice in LMICs. Addition- Background ally, one paper was identified that explored the perspec - Research capacity has long been the hallmark of edu- tives of junior faculty members of Pakistani medical cational institutions. In medicine, the quality of care schools on the topic of health research. provided to patients is often dictated by the ability of physicians to apply high-quality research to their clini- State of health research in Indonesia cal practice. Research in primary care largely aims to The World Health Organization (WHO) estimates that seek a better understanding of disease management in countries in the South East Asia Region (SEAR), includ- relation to the individuals, families and the community, ing Indonesia, bear approximately 30% of global disease and to evaluate the effectiveness and efficiency of health - burden [18]. Despite this, Indonesia spends approxi- care practices and health policies. Continuous advances mately 2.2% of its gross domestic product (GDP) on in disease prevention and management through relevant health expenditures, the lowest of all SEAR countries research creates the foundation for a dynamic health- [5]. Between 2000 and 2010, approximately 5.0% of peer- care system that can soundly address the needs of a reviewed epidemiological publications from the SEAR community. In many lower- and middle-income coun- region were from Indonesia, a lower proportion than tries (LMICs), tremendous strain is placed on health other countries in the area [5]. Data from the University care systems by both the increasing burden of chronic, of Indonesia shows that approximately 1168 research non-communicable disease and high rates of infec- studies were conducted between 2013 and 2017, of which tious disease [1–7]. Prevalence of chronic and infectious only about 64 (39%) have had their results published [19, disease may be combated and controlled by increased 20]. There appears to be a disparity between the actual research capacity, and by improving the evidence base disease burden in Indonesia and the amount of health used to inform clinical practice [8, 9]. However, unlike expenditure and epidemiological research output [5]. high-income countries, many LMICs lack the human Moreover, the 2014 literature review by Widyahening resources and financial resources to sustain high-level et al. Estimated that only 21% of published articles from research [1, 8, 10]. Furthermore, LMICs have unique Indonesia between 2008 and 2010 were of high reporting clinical contexts and research needs that are often not quality, and only 15% were of high methodological qual- adequately addressed by research carried out in North ity [9]. Several barriers to performing clinical epidemiol- America and Europe. Of the approximately US$ 240 bil- ogy and evidence-based medicine have been identified: lion dollars spent worldwide on health research each year underutilization of data for planning; need for capac- (2010 data), approximately 90% is used to fund research ity building; linking of evidence to practice and policy; on health conditions that affect approximately 10% of the developing collaborative research networks (both nation- global population [11, 12]. ally and internationally); and need for improved infra- Nevertheless, there is an increasing demand for the structure, funding and technical expertise [15, 21]. use of evidence-based practice around the world [13, 14]. Countries in the Asia Pacific region, such as Indo - Perspectives of medical students and faculty members nesia, have recently seen an increase in both support for on health research and interest in evidence-based medical research, and are The majority of research on this area has been conducted becoming increasingly engaged in clinical epidemiology in South Asia, Northern Africa, and the Middle East. and clinical research [9, 15–17]. However, challenges to Studies from India (n = 2), Iran (n = 2), Pakistan (n = 3), research practice and implementation still exist [9]. Sudan (n = 1) and Saudi Arabia (n = 2), as well as a multi- In order to increase sustainable research capacity in centre study across three Middle Eastern countries (Saudi developing countries such as Indonesia, it is important to Arabia, Bahrain, and Kuwait), were identified. General - understand the context of the local health research land- izability of results to SEAR countries such as Indonesia scape, and to gain insight into factors that influence clini - may be limited, however, a number of consistent barriers cal research both positively and negatively. and facilitators to health research were identified. Overall, medical students in LMICs were found to have Literature review a favourable view of research, with 82–97% of surveyed There is a paucity of research exploring the various barri - students indicating that research was important to the ers and facilitators to implementation of health research practice of medicine [22–26], and 64–91% agreeing that in Indonesia, especially with respect to the views of cli- conducting research in medical school is important and nicians and university faculty members. There is, how - should be included in the curriculum [22–28]. When ever, a small amount of literature describing the research medical students were asked about their participation in output from Indonesia, and a moderate amount of lit- research, the percentage of students who had experience erature exploring the knowledge and attitudes of medical Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 3 of 8 conducting research varied greatly. Results from six Indonesia, and was performed in collaboration with the studies ranged from 52 to 61% [23–28]. The study by Department of Family Medicine at McMaster Univer- Osman found that 94% of medical students had partici- sity in Hamilton, Ontario, Canada. SKU Department of pated in research under a supervisor [22], and the study Family Medicine faculty members working as primary by Memarpur et  al. found that all surveyed participants care physicians were invited to participate in this study. had participated in research [29]. Overall knowledge of Participants were recruited using a purposive sampling research concepts was low to moderate [22–28], and the method. 29 participants who consented to participate percentage of students who had published was also low, were enrolled. This number represented 90% of all fac - ranging between 7 and 34% [25, 26, 30]. ulty members providing primary care at SKU. This study Barriers to conducting and participating in research was approved by the Hamilton Integrated Research Eth- included: insufficient time for research [23, 24, 26, 28– ics Board, and the Syiah Kuala University Research Ethics 30], lack of adequate funding and financial incentives [22, Board. 23, 26, 28, 29, 32], lack of supervisors and mentors [22– 24, 26, 28, 30], lack of training and research curriculum Design [23–26, 29], and lack of adequate research facilities [26, This study used a mixed-methods approach, combining 28]. Facilitators of research amongst medical students the use of a participant survey with focus group discus- included: formal training in research skills [24–28, 30], sions, focusing on qualitative descriptive-interpretive competent and motivated supervisors [22, 24, 29], inclu- analysis. Participants were encouraged to complete the sion of research in the curriculum [24, 25], and having survey in either English or Bahasa Indonesia. All of the time set aside for research activities [23]. focus group interviews were digitally recorded, tran- The 2009 study by Sabzwari et al. Focused on the atti - scribed and translated into English. tudes and experiences of junior faculty members at four The participant survey contained 28 questions, includ - medical schools and teaching hospitals. They found that ing demographic questions (age, gender, level of train- 42% of surveyed participants were currently involved in ing, additional degrees), questions regarding previous clinical research. 85% of participants felt that research research experience (yes/no), questions on attitudes was helpful; however, 83% admitted that research was towards research and research skills (5 point Likert difficult to conduct. Barriers to participation in clinical scale), and questions on perceived barriers and facilita- research included: lack of training, lack of time to per- tors to conducting research (5 point Likert scale). Faculty form research, lack of statistical support, lack of men- members who agreed to complete the survey were sub- torship, and lack of financial incentives. Facilitators to sequently invited by the Principal Investigator to partici- conducting research included prior formal training in pate in focus group discussions, which were held at the research, having dedicated time for research activities, Faculty of Medicine. and availability of mentors and research support [31]. The semi-structured focus group discussions utilized a mixture of both closed- and open-ended questions in Objectives order to collect demographic data, as well as eliciting fac- It is clear that there are many barriers in performing ulty member perspectives on the definition and require - health research in LMICs, however, there is very lit- ments of research, general attitudes towards conducting tle available literature exploring the research needs of research, barriers to conducting research, and incentives Indonesian primary care researchers. Thus, this study and facilitators to conducting research. Ten focus group sought to explore the environment and culture of health discussions (including 29 participants) were conducted. research in the Family Medicine department of a major They were facilitated by a member of the research team (a Indonesian university. The objectives of this study were: lecturer at the Faculty of Medicine at SKU). Focus group (1) to explore current attitudes of faculty members interviews were audio recorded, and then transcribed towards primary care research, including participation and translated into English by an external translator. and implementation; (2) to identify any perceived bar- riers in conducting and producing research; and (3) to Data analysis identify enablers/facilitators for promoting an environ- Participant surveys were organized using Microsoft ment conducive to research. Excel. Mean aggregate scores were calculated based on individual subject area. To simplify analysis, Likert scale Methods values of 1 and 2 were combined to represent disagree- Setting and participants ment with the study statement, whereas scale values of This study took place at Syiah Kuala University (SKU), 4 and 5 were combined to represent agreement with the located in Banda Aceh, in the province of Aceh, study statement. A value of 3 was considered neutral. Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 4 of 8 Focus group interview transcripts were analyzed by Table 3 Research attitudes amongst  study participants, n (%) five research team members using a qualitative, descrip - tive approach. Each transcript was coded independently Research attitudes and skills (n = 29) Agree Neutral Disagree to capture emerging themes and sub-themes. These were I am interested in conducting research 29 (100.0) 0 (0.0) 0 (0.0) discussed, organized and consolidated by all members Research should be a top university 29 (100.0) 0 (0.0) 0 (0.0) of the research team in a collaborative manner. Analy- priority sis focused on understanding current attitudes towards Research has a positive effect on SKU 29 (100.0) 0 (0.0) 0 (0.0) research and addressing current barriers and enablers/ Research promotes critical thinking 29 (100.0) 0 (0.0) 0 (0.0) facilitators to conducting research. Data collection Research improves patient care 25 (86.2) 4 (13.8) 0 (0.0) occured alongside data analysis, so as to ensure that new Research helps professional enhance‑ 29 (100.0) 0 (0.0) 0 (0.0) emerging themes were fully explored. Themes from qual - ment itative analysis were triangulated with the survey results Research helps to change health policy 28 (96.6) 1 (3.4) 0 (0.0) to ensure convergence of information and agreement There should be dedicated time allot‑ 27 (93.1) 1 (3.4) 1 (3.4) between the two different modalities of data collection. ted for research I am confident in my abilities to con‑ 27 (93.1) 2 (6.9) 0 (0.0) duct research Results Participant survey This study included 29 participants, all of whom were members of the Faculty of Medicine at SKU. The major - Table 4 Enablers/facilitators to conducting research, n (%) ity of participants were female (65.5%), aged 27–38 years Enablers/facilitators to conducting Agree Neutral Disagree (75.9%), serving as a medical doctor (86.2%), and holding research (n = 29) a master’s degree (79.31%). Results from the participant Career advancement 27 (93.1) 1 (3.4) 1 (3.4) survey are presented in Tables 1, 2, 3, 4, 5. Support from administrators 18 (62.1) 9 (31.0) 2 (6.9) Pursuit of personal interest 18 (62.1) 11 (37.9) 0 (0.0) Pursuit of further education 26 (89.7) 3 (10.3) 0 (0.0) Release time from teaching duties 11 (37.9) 10 (34.5) 8 (27.6) Opportunity to involve students 26 (89.7) 2 (6.9) 1 (3.4) Table 1 Demographic data of  participants (faculty members), n (%) Opportunity to work with business and 27 (93.1) 2 (6.9) 0 (0.0) community partners Sex Formal recognition by university 27 (93.1) 2 (6.9) 0 (0.0) Male 10 (34.5) Other enablers/facilitators There should be allocated Female 19 (65.5) time for three pillars of higher education: Age range research, education, com‑ 27–38 years old 22 (75.9) munity services 41–57 years old 7 (24.1) Lecturer’s performance Level of training appraisal and career rank system Medical doctor 25 (86.2) Establishment of research Non medical doctor 4 (6. 9) networks, both within the Additional degree university and with other Ph.D. degree 6 (20.9) institutions Master degree 23 (79.3) Personal interest Table 2 Research experience among  study participants, n Focus groups (%) Attitudes Research experience (n = 29) Yes No There was a consensus amongst the respondents that Have you conducted research before? 28 (96.6) 1 (3.4) SKU had already set research as a high priority. In Indo- Are you currently involved in a research project? 16 (55.2) 13 (44.8) nesia, research is considered one of three mandatory Received formal training in conducting research? 25 (86.2) 4 (13.8) pillars of higher educational programs, along with educa- tion and community service. Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 5 of 8 Table 5 Barriers to conducting research, n (%) and various national and international institutions; an increasing number of international meetings, seminars, Barriers to conducting research Agree Neutral Disagree and conferences being held on-site; high rates of tropical (n = 29) diseases; local traditions and natural resources; as well as Lack of research experience 20 (69.0) 2 (6.9) 7 (24.1) strong communication between the university and the Lack of training 23 (79.3) 2 (6.9) 4 (13.8) government. In contrast, many of the research grants Lack of release time by university 15 (51.7) 6 (20.7) 8 (27.6) provided by local, national, and international institu- Lack of administrative support 19 (65.5) 4 (13.8) 6 (20.7) tions are only available for applicants with PhD or Mas- Lack of infrastructure 26 (89.7) 2 (6.9) 1 (3.4) ter’s degrees, which participants felt created obstacles for Lack of grants/bursaries available 15 (51.7) 7 (24.1) 7 (24.1) beginner researchers in certain circumstances. Lack of recognition by university 7 (24.1) 9 (31.0) 13 (44.8) Lack of financial incentives 23 (79.3) 3 (10.3) 3 (10.3) Enablers/facilitators Other barriers identified Personal time management The majority of participants felt that personal motivation Personal motivation for conducting research was one of the most important Research funds should be aspects for increasing the number of research activities. allocated per faculty to In order to improve research productivity, the partici- reduce the bureaucratic procedures for obtaining pants suggested that the university provide local awards, funds expand opportunities to work with local businesses and Complicated procedures for communities, institute a formal recognition initiative, submitting final research provide incentives for conducting research, and imple- reports to the university ment a research help desk to support those engaging in Lack of mutual support and self‑motivation research. Inadequate laboratory facili‑ “I think ambition or personal desire was indeed ties and relatively limited research grants quite an important role in conducting research” Lack of rewards (FGD5 116–117) Division of research groups, lack of research on specific “Recognition will make the purpose become stronger. and sustainable topics So the new spirit will be born” (FGD4, 179) Additionally, building teamwork with students was felt to be a positive factor for improving motivation for con- “We have like 3 pillars, one is the research obliga- ducting research. This collaboration was found to give tion” (FGD3, 83–4) credence to faculty members with respect to implement- ing research and building capacity. “(research serves to) increase my personal or institu- tional pride (FGD2, 45–6) Working with students; “It seems like the chance to facilitate students’ need makes lecturers are very “For me it is a passion for research, and it is also our enthusiastic to do research–than just doing it for duty as a faculty member” (FGD5, 142–43) their own” (FGD9, 188–189) This institution has also established a research master plan; however, results from this study found that this plan Barriers is not supported by an effective research policy, especially Participants indicated that university-provided research at the faculty and study program levels. For example, grants are not always distributed in an equitable manner participants identified a lack of research administrative amongst all faculties or individual faculty members; this support at the faculty level, which has lowered faculty led to a reduction in research capabilities. The availabil - member’s interest in conducting primary care research. ity of research grants was not thought to be equal to the In Indonesia, all higher education institutions are faculty members’ research interests, leading to high levels ranked by a third-party agency according to three pos- of competition for access. It was also felt that these grants sible levels of accreditation, with A-level being the high- are not sufficient to cover all research needs, including est. All participants agreed that SKU provides many primary care research. There was a consensus amongst research opportunities, especially since 2015 when it the majority of participants that the university should obtained A-level accreditation. These opportunities arise allocate a certain amount of grant funding to each faculty from good working relationships between the university Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 6 of 8 to be managed independently and distributed to each “lack of training is not a problem” (FGD8 94–95) department. Participants believed that this strategy may Additionally, gender and traditional gender roles boost faculty member interest in research. Complicated appear to be prominent obstacles to conducting research research bureaucracy and financial administrative pro - amongst women participants. cesses (including a lack of administrative support staff ) was felt to be a major barrier amongst participants. “because when (women) get home, they instinctively change their function. They will be in housewives “I believe all Universities in Indonesia provide grants mode.” (FGD2, 280–281) for research. But here, the main problem is the com- plicated bureaucracy that makes the fund can’t be Many female participants felt that their home and received as soon as possible” (FGD8, 121–123) domestic duties imposed additional time constraints that further prevented them from conducting research. Due to the university’s mandate of actualizing the three pillars of higher education, the majority of participants agreed that the amount of time available for conducting Discussion research is inadequate. This study provides an important overview of the atti - tudes towards research held by faculty members in pri- “I am eager to conduct as much research as possi- mary care at a higher education institution in an LMIC, ble, but I don’t have any spare time to conduct the as well as the barriers and enablers/facilitators that influ - research.” (FGD2, 63–4) ence research capacity and production. It is likely that other universities and institutions in LMICs and across “We don’t have any time released from university the Asia Pacific region face the same challenges. to conduct research, but the university demands as It is widely accepted in the Indonesian context that much researches as possible in a year.” (FG2 263–4) the availability of a research master plan is important for Participants perceived that most available time is higher education institutions; however, results from this spent on the educational pillar (i.e. teaching). This is study find that this alone may not be enough to increase made worse by a workload that is not evenly distributed the culture and productivity of research. This study amongst faculty members. Faculty members who also shows that the implementation of the three pillars of work as a practicing physician have an especially hard higher education is not fully facilitated by the university time due to the additional responsibility of patient care. with regards to research obligation. Results found that a It was suggested that the time allotted for implementa- lack of research support prevents faculty members from tion of each of the three pillars should be clearly regu- fully engaging in research activities, findings that are sup - lated, especially for research. While the university has ported by previous published research. This suggests that seen improvements in infrastructure over the past few many of the barriers faced by researchers are common years, these have not yet helped improve research infra- across various LMIC settings and contexts, including: structure. The majority of participants agreed that there inadequate funding and financial incentives [31, 32], lack is a lack of research laboratories equipped with sufficient of available time for conducting research [23, 24, 26, 28– instruments, as well as a lack of adequate power sup- 31], poor research policy [23–26, 29], lack of adequate ply to run necessary activities. The availability of skilled research infrastructure and facilities [26, 28], and a lack human resources (Master-and/or Ph.D.-level graduates of financial and administrative support [31]. both from national and international universities), while Nevertheless, this study also supports the overall posi- improving, still contributes to poor research infrastruc- tive attitude that researchers in LMICs tend to have ture. The lack of a high-quality research infrastructure towards research [22–28, 31]. The three pillars of higher has been identified as one of the most important prob - education (research, education and community service), lems faced by faculty members, which has led many, mandated as national requirements for higher education especially those from the Faculty of Medicine, to conduct institutions, have become a unique cardinal enabler/facil- more community-based research. itator in strengthening research capacity in the Indone- sian context. This system could potentially be adapted by “Many of us have taken our masters…..But when we other LMICs as a means of increasing research capacity, return to our faculty….still lack of those tools, we especially in the Asia Pacific region. na fi lly decide to only do the survey….So lack of infra - As one of many Indonesian universities, SKU, situated structure makes our talent not amplified, and our in the province of Aceh, has many unique opportunities interest not distributed.” (FGD6, 75–80) for research. Aceh is known as being a “living laboratory” for many researchers from around the world, due in part Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 7 of 8 Abbreviations to the fact that it is a tropical region, and thus is home GDP: gross domestic product; LMIC: lower‑ and middle ‑income country; to many endemic tropical diseases. A rich Acehnese tra- SEAR: south east Asia region; SKU: Syiah Kuala University; WHO: World Health dition and plentiful natural resources can be leveraged Organization. and explored by faculty members looking to expand their Authors’ contributions research practices and scope. It is likely that many other II: conceptualized and designed the study, supervised data collection, drafted areas in the Asia Pacific region would have their own the initial manuscript, and approved the final manuscript as submitted. Co ‑ PI for study funding. NW: carried out the analysis, drafted the initial manuscript, similar yet unique contexts that might make them attrac- and approved the final manuscript as submitted. RM: analysis instruments, tive locations for prospective researchers. Additionally, carried out the analysis, reviewed the manuscript, and approved the final the growing involvement of local faculty members in manuscript as submitted. LL: carried out the analysis, reviewed the manu‑ script. KL: drafted the initial manuscript, performed the literature review, and international meetings, seminars, and conferences adds edited and revised the manuscript. LRC: conceptualized and designed the positive value to research initiatives across Indonesia and study, supervised data collection, critically reviewed the manuscript. Co‑PI for the Asia Pacific region. Faculty members are often aware study funding. All authors read and approved the final manuscript. of these opportunities, however, they may face difficulties Author details in the operationalizing and production of high-impact Medical Research Unit, Faculty of Medicine, Syiah Kuala University, Jl. T. research. Tanoeh Abe, Darussalam, Banda Aceh 23111, Indonesia. Department of Fam‑ ily Medicine, McMaster University, 100 Main St W, Hamilton, ON L8P 1H6, On the other hand, results from this study indicate Canada. that the interest level of faculty members in conducting research is low, due to inequality of funding, and a lack Acknowledgements None. of resources, infrastructure, and research support at the faculty and study program levels. In order to promote Competing interests and support successful research initiatives, tools such as The authors declare that they have no competing interests. a comprehensive and effective research policy (available Availability of data and materials at the faculty and study program levels), are required. The datasets used and/or analysed during the current study are available from This study also found that female faculty members of the corresponding author on reasonable request. higher education institutions may also face additional Consent for publication time constraints, due in part to traditional gender roles. Not applicable. In general, women in many Asian countries often have Ethics approval and consent to participate additional responsibilities, both professionally and at This study received approval from the Hamilton Integrated Research Ethics home. As faculty members, women are required to par- Board, as well as the Syiah Kuala University Research Ethics Board. All partici‑ ticipate in teaching, research, and community service. If pants signed an informed consent package prior to participation in this study. they are also practicing primary care doctors, they will Funding have additional patient care duties. Women faculty mem- Funding for this study has been provided through a pilot grant from the bers may also have increased amounts of domestic duties McMaster University Department of Family Medicine. outside of work relative to their male counterparts, which may decrease the amount of time they have available to Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub‑ conduct research. This disparity needs to be addressed, lished maps and institutional affiliations. not only in Indonesia, but also in many other LMICs. Received: 22 January 2018 Accepted: 17 July 2018 Conclusions This study served as a critical needs assessment that evaluates the research environment of primary care References physicians at a major Asian university. By identifying 1. World Health Organization. The world health report 2003: shaping the future. 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Pay‑ .php?uPage =dashb oard.grafi ktipe &smod=dashb oard&sp=publi c . ment as motivator in Iranian medical students’ attitudes toward research. Accessed 08 Sep 2017.(Archived by WebCite at http://www.webci tatio South Med J. 2006;99:1403. n.org/6tKEG 14qK). Ready to submit your research ? Choose BMC and benefit from: fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Attitudes, barriers, and enablers towards conducting primary care research in Banda Aceh, Indonesia: a qualitative research study

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Springer Journals
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Copyright © 2018 by The Author(s)
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/s12930-018-0045-y
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Abstract

Background: Conducting university‑ based research is important for informing primary care, especially in lower‑ and middle‑ income countries (LMICs) such as Indonesia. Syiah Kuala University (SKU), the largest educational institution in Aceh province, Indonesia, is actively establishing itself as a leader in research innovation; however, this effort has not yet demonstrated optimum results. Understanding faculty members’ perceptions of how research is conducted in this setting is crucial for the design and implementation of successful and sustainable research strategies to increase the quantity and quality of primary care research conducted at LMIC universities. The objective of this study was to identify current attitudes, barriers and enablers/facilitators towards primary care research participation and implemen‑ tation in this higher education institution. Methods: A descriptive‑ interpretive qualitative study was conducted. 29 participants, representing 90% of all faculty members providing primary care, were included. A mixed‑ methods approach was used, combining the use of a participant survey with 10 focus group discussions. Participants were encouraged to complete the survey in either English or Bahasa Indonesia. All of the focus group discussions were recorded, transcribed and translated into English. Thematic content analysis of these transcripts was carried out. Results: The majority of participants agreed that SKU has set research as a priority, as it is one of the three pillars of higher education, mandatory in all Indonesian higher education institutions. This research identified many barriers in conducting research, i.e. weak research policy, lack of research funding and infrastructure, complicated research bureaucracy and administrative process, as well as time constraints for conducting research relative to other duties. Participants expressed that personal motivation was a very important enabler/facilitator for increasing research activi‑ ties. In order to improve research productivity, the majority of participants suggested that having local awards and formal recognition, having the opportunity to partner with local business and communities, provision of incentives, and having access to a research help‑ desk would be beneficial. Conclusions: Generally, participants showed a supportive and positive attitude towards research, and provided examples of how to improve research productivity in the Asian university context. Keywords: Research, Primary health care, Physicians, Primary care, Qualitative research, Asia, southeast, Indonesia, Developing countries *Correspondence: ichsan@unsyiah.ac.id Medical Research Unit, Faculty of Medicine, Syiah Kuala University, Jl. T. Tanoeh Abe, Darussalam, Banda Aceh 23111, Indonesia Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 2 of 8 students towards research practice in LMICs. Addition- Background ally, one paper was identified that explored the perspec - Research capacity has long been the hallmark of edu- tives of junior faculty members of Pakistani medical cational institutions. In medicine, the quality of care schools on the topic of health research. provided to patients is often dictated by the ability of physicians to apply high-quality research to their clini- State of health research in Indonesia cal practice. Research in primary care largely aims to The World Health Organization (WHO) estimates that seek a better understanding of disease management in countries in the South East Asia Region (SEAR), includ- relation to the individuals, families and the community, ing Indonesia, bear approximately 30% of global disease and to evaluate the effectiveness and efficiency of health - burden [18]. Despite this, Indonesia spends approxi- care practices and health policies. Continuous advances mately 2.2% of its gross domestic product (GDP) on in disease prevention and management through relevant health expenditures, the lowest of all SEAR countries research creates the foundation for a dynamic health- [5]. Between 2000 and 2010, approximately 5.0% of peer- care system that can soundly address the needs of a reviewed epidemiological publications from the SEAR community. In many lower- and middle-income coun- region were from Indonesia, a lower proportion than tries (LMICs), tremendous strain is placed on health other countries in the area [5]. Data from the University care systems by both the increasing burden of chronic, of Indonesia shows that approximately 1168 research non-communicable disease and high rates of infec- studies were conducted between 2013 and 2017, of which tious disease [1–7]. Prevalence of chronic and infectious only about 64 (39%) have had their results published [19, disease may be combated and controlled by increased 20]. There appears to be a disparity between the actual research capacity, and by improving the evidence base disease burden in Indonesia and the amount of health used to inform clinical practice [8, 9]. However, unlike expenditure and epidemiological research output [5]. high-income countries, many LMICs lack the human Moreover, the 2014 literature review by Widyahening resources and financial resources to sustain high-level et al. Estimated that only 21% of published articles from research [1, 8, 10]. Furthermore, LMICs have unique Indonesia between 2008 and 2010 were of high reporting clinical contexts and research needs that are often not quality, and only 15% were of high methodological qual- adequately addressed by research carried out in North ity [9]. Several barriers to performing clinical epidemiol- America and Europe. Of the approximately US$ 240 bil- ogy and evidence-based medicine have been identified: lion dollars spent worldwide on health research each year underutilization of data for planning; need for capac- (2010 data), approximately 90% is used to fund research ity building; linking of evidence to practice and policy; on health conditions that affect approximately 10% of the developing collaborative research networks (both nation- global population [11, 12]. ally and internationally); and need for improved infra- Nevertheless, there is an increasing demand for the structure, funding and technical expertise [15, 21]. use of evidence-based practice around the world [13, 14]. Countries in the Asia Pacific region, such as Indo - Perspectives of medical students and faculty members nesia, have recently seen an increase in both support for on health research and interest in evidence-based medical research, and are The majority of research on this area has been conducted becoming increasingly engaged in clinical epidemiology in South Asia, Northern Africa, and the Middle East. and clinical research [9, 15–17]. However, challenges to Studies from India (n = 2), Iran (n = 2), Pakistan (n = 3), research practice and implementation still exist [9]. Sudan (n = 1) and Saudi Arabia (n = 2), as well as a multi- In order to increase sustainable research capacity in centre study across three Middle Eastern countries (Saudi developing countries such as Indonesia, it is important to Arabia, Bahrain, and Kuwait), were identified. General - understand the context of the local health research land- izability of results to SEAR countries such as Indonesia scape, and to gain insight into factors that influence clini - may be limited, however, a number of consistent barriers cal research both positively and negatively. and facilitators to health research were identified. Overall, medical students in LMICs were found to have Literature review a favourable view of research, with 82–97% of surveyed There is a paucity of research exploring the various barri - students indicating that research was important to the ers and facilitators to implementation of health research practice of medicine [22–26], and 64–91% agreeing that in Indonesia, especially with respect to the views of cli- conducting research in medical school is important and nicians and university faculty members. There is, how - should be included in the curriculum [22–28]. When ever, a small amount of literature describing the research medical students were asked about their participation in output from Indonesia, and a moderate amount of lit- research, the percentage of students who had experience erature exploring the knowledge and attitudes of medical Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 3 of 8 conducting research varied greatly. Results from six Indonesia, and was performed in collaboration with the studies ranged from 52 to 61% [23–28]. The study by Department of Family Medicine at McMaster Univer- Osman found that 94% of medical students had partici- sity in Hamilton, Ontario, Canada. SKU Department of pated in research under a supervisor [22], and the study Family Medicine faculty members working as primary by Memarpur et  al. found that all surveyed participants care physicians were invited to participate in this study. had participated in research [29]. Overall knowledge of Participants were recruited using a purposive sampling research concepts was low to moderate [22–28], and the method. 29 participants who consented to participate percentage of students who had published was also low, were enrolled. This number represented 90% of all fac - ranging between 7 and 34% [25, 26, 30]. ulty members providing primary care at SKU. This study Barriers to conducting and participating in research was approved by the Hamilton Integrated Research Eth- included: insufficient time for research [23, 24, 26, 28– ics Board, and the Syiah Kuala University Research Ethics 30], lack of adequate funding and financial incentives [22, Board. 23, 26, 28, 29, 32], lack of supervisors and mentors [22– 24, 26, 28, 30], lack of training and research curriculum Design [23–26, 29], and lack of adequate research facilities [26, This study used a mixed-methods approach, combining 28]. Facilitators of research amongst medical students the use of a participant survey with focus group discus- included: formal training in research skills [24–28, 30], sions, focusing on qualitative descriptive-interpretive competent and motivated supervisors [22, 24, 29], inclu- analysis. Participants were encouraged to complete the sion of research in the curriculum [24, 25], and having survey in either English or Bahasa Indonesia. All of the time set aside for research activities [23]. focus group interviews were digitally recorded, tran- The 2009 study by Sabzwari et al. Focused on the atti - scribed and translated into English. tudes and experiences of junior faculty members at four The participant survey contained 28 questions, includ - medical schools and teaching hospitals. They found that ing demographic questions (age, gender, level of train- 42% of surveyed participants were currently involved in ing, additional degrees), questions regarding previous clinical research. 85% of participants felt that research research experience (yes/no), questions on attitudes was helpful; however, 83% admitted that research was towards research and research skills (5 point Likert difficult to conduct. Barriers to participation in clinical scale), and questions on perceived barriers and facilita- research included: lack of training, lack of time to per- tors to conducting research (5 point Likert scale). Faculty form research, lack of statistical support, lack of men- members who agreed to complete the survey were sub- torship, and lack of financial incentives. Facilitators to sequently invited by the Principal Investigator to partici- conducting research included prior formal training in pate in focus group discussions, which were held at the research, having dedicated time for research activities, Faculty of Medicine. and availability of mentors and research support [31]. The semi-structured focus group discussions utilized a mixture of both closed- and open-ended questions in Objectives order to collect demographic data, as well as eliciting fac- It is clear that there are many barriers in performing ulty member perspectives on the definition and require - health research in LMICs, however, there is very lit- ments of research, general attitudes towards conducting tle available literature exploring the research needs of research, barriers to conducting research, and incentives Indonesian primary care researchers. Thus, this study and facilitators to conducting research. Ten focus group sought to explore the environment and culture of health discussions (including 29 participants) were conducted. research in the Family Medicine department of a major They were facilitated by a member of the research team (a Indonesian university. The objectives of this study were: lecturer at the Faculty of Medicine at SKU). Focus group (1) to explore current attitudes of faculty members interviews were audio recorded, and then transcribed towards primary care research, including participation and translated into English by an external translator. and implementation; (2) to identify any perceived bar- riers in conducting and producing research; and (3) to Data analysis identify enablers/facilitators for promoting an environ- Participant surveys were organized using Microsoft ment conducive to research. Excel. Mean aggregate scores were calculated based on individual subject area. To simplify analysis, Likert scale Methods values of 1 and 2 were combined to represent disagree- Setting and participants ment with the study statement, whereas scale values of This study took place at Syiah Kuala University (SKU), 4 and 5 were combined to represent agreement with the located in Banda Aceh, in the province of Aceh, study statement. A value of 3 was considered neutral. Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 4 of 8 Focus group interview transcripts were analyzed by Table 3 Research attitudes amongst  study participants, n (%) five research team members using a qualitative, descrip - tive approach. Each transcript was coded independently Research attitudes and skills (n = 29) Agree Neutral Disagree to capture emerging themes and sub-themes. These were I am interested in conducting research 29 (100.0) 0 (0.0) 0 (0.0) discussed, organized and consolidated by all members Research should be a top university 29 (100.0) 0 (0.0) 0 (0.0) of the research team in a collaborative manner. Analy- priority sis focused on understanding current attitudes towards Research has a positive effect on SKU 29 (100.0) 0 (0.0) 0 (0.0) research and addressing current barriers and enablers/ Research promotes critical thinking 29 (100.0) 0 (0.0) 0 (0.0) facilitators to conducting research. Data collection Research improves patient care 25 (86.2) 4 (13.8) 0 (0.0) occured alongside data analysis, so as to ensure that new Research helps professional enhance‑ 29 (100.0) 0 (0.0) 0 (0.0) emerging themes were fully explored. Themes from qual - ment itative analysis were triangulated with the survey results Research helps to change health policy 28 (96.6) 1 (3.4) 0 (0.0) to ensure convergence of information and agreement There should be dedicated time allot‑ 27 (93.1) 1 (3.4) 1 (3.4) between the two different modalities of data collection. ted for research I am confident in my abilities to con‑ 27 (93.1) 2 (6.9) 0 (0.0) duct research Results Participant survey This study included 29 participants, all of whom were members of the Faculty of Medicine at SKU. The major - Table 4 Enablers/facilitators to conducting research, n (%) ity of participants were female (65.5%), aged 27–38 years Enablers/facilitators to conducting Agree Neutral Disagree (75.9%), serving as a medical doctor (86.2%), and holding research (n = 29) a master’s degree (79.31%). Results from the participant Career advancement 27 (93.1) 1 (3.4) 1 (3.4) survey are presented in Tables 1, 2, 3, 4, 5. Support from administrators 18 (62.1) 9 (31.0) 2 (6.9) Pursuit of personal interest 18 (62.1) 11 (37.9) 0 (0.0) Pursuit of further education 26 (89.7) 3 (10.3) 0 (0.0) Release time from teaching duties 11 (37.9) 10 (34.5) 8 (27.6) Opportunity to involve students 26 (89.7) 2 (6.9) 1 (3.4) Table 1 Demographic data of  participants (faculty members), n (%) Opportunity to work with business and 27 (93.1) 2 (6.9) 0 (0.0) community partners Sex Formal recognition by university 27 (93.1) 2 (6.9) 0 (0.0) Male 10 (34.5) Other enablers/facilitators There should be allocated Female 19 (65.5) time for three pillars of higher education: Age range research, education, com‑ 27–38 years old 22 (75.9) munity services 41–57 years old 7 (24.1) Lecturer’s performance Level of training appraisal and career rank system Medical doctor 25 (86.2) Establishment of research Non medical doctor 4 (6. 9) networks, both within the Additional degree university and with other Ph.D. degree 6 (20.9) institutions Master degree 23 (79.3) Personal interest Table 2 Research experience among  study participants, n Focus groups (%) Attitudes Research experience (n = 29) Yes No There was a consensus amongst the respondents that Have you conducted research before? 28 (96.6) 1 (3.4) SKU had already set research as a high priority. In Indo- Are you currently involved in a research project? 16 (55.2) 13 (44.8) nesia, research is considered one of three mandatory Received formal training in conducting research? 25 (86.2) 4 (13.8) pillars of higher educational programs, along with educa- tion and community service. Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 5 of 8 Table 5 Barriers to conducting research, n (%) and various national and international institutions; an increasing number of international meetings, seminars, Barriers to conducting research Agree Neutral Disagree and conferences being held on-site; high rates of tropical (n = 29) diseases; local traditions and natural resources; as well as Lack of research experience 20 (69.0) 2 (6.9) 7 (24.1) strong communication between the university and the Lack of training 23 (79.3) 2 (6.9) 4 (13.8) government. In contrast, many of the research grants Lack of release time by university 15 (51.7) 6 (20.7) 8 (27.6) provided by local, national, and international institu- Lack of administrative support 19 (65.5) 4 (13.8) 6 (20.7) tions are only available for applicants with PhD or Mas- Lack of infrastructure 26 (89.7) 2 (6.9) 1 (3.4) ter’s degrees, which participants felt created obstacles for Lack of grants/bursaries available 15 (51.7) 7 (24.1) 7 (24.1) beginner researchers in certain circumstances. Lack of recognition by university 7 (24.1) 9 (31.0) 13 (44.8) Lack of financial incentives 23 (79.3) 3 (10.3) 3 (10.3) Enablers/facilitators Other barriers identified Personal time management The majority of participants felt that personal motivation Personal motivation for conducting research was one of the most important Research funds should be aspects for increasing the number of research activities. allocated per faculty to In order to improve research productivity, the partici- reduce the bureaucratic procedures for obtaining pants suggested that the university provide local awards, funds expand opportunities to work with local businesses and Complicated procedures for communities, institute a formal recognition initiative, submitting final research provide incentives for conducting research, and imple- reports to the university ment a research help desk to support those engaging in Lack of mutual support and self‑motivation research. Inadequate laboratory facili‑ “I think ambition or personal desire was indeed ties and relatively limited research grants quite an important role in conducting research” Lack of rewards (FGD5 116–117) Division of research groups, lack of research on specific “Recognition will make the purpose become stronger. and sustainable topics So the new spirit will be born” (FGD4, 179) Additionally, building teamwork with students was felt to be a positive factor for improving motivation for con- “We have like 3 pillars, one is the research obliga- ducting research. This collaboration was found to give tion” (FGD3, 83–4) credence to faculty members with respect to implement- ing research and building capacity. “(research serves to) increase my personal or institu- tional pride (FGD2, 45–6) Working with students; “It seems like the chance to facilitate students’ need makes lecturers are very “For me it is a passion for research, and it is also our enthusiastic to do research–than just doing it for duty as a faculty member” (FGD5, 142–43) their own” (FGD9, 188–189) This institution has also established a research master plan; however, results from this study found that this plan Barriers is not supported by an effective research policy, especially Participants indicated that university-provided research at the faculty and study program levels. For example, grants are not always distributed in an equitable manner participants identified a lack of research administrative amongst all faculties or individual faculty members; this support at the faculty level, which has lowered faculty led to a reduction in research capabilities. The availabil - member’s interest in conducting primary care research. ity of research grants was not thought to be equal to the In Indonesia, all higher education institutions are faculty members’ research interests, leading to high levels ranked by a third-party agency according to three pos- of competition for access. It was also felt that these grants sible levels of accreditation, with A-level being the high- are not sufficient to cover all research needs, including est. All participants agreed that SKU provides many primary care research. There was a consensus amongst research opportunities, especially since 2015 when it the majority of participants that the university should obtained A-level accreditation. These opportunities arise allocate a certain amount of grant funding to each faculty from good working relationships between the university Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 6 of 8 to be managed independently and distributed to each “lack of training is not a problem” (FGD8 94–95) department. Participants believed that this strategy may Additionally, gender and traditional gender roles boost faculty member interest in research. Complicated appear to be prominent obstacles to conducting research research bureaucracy and financial administrative pro - amongst women participants. cesses (including a lack of administrative support staff ) was felt to be a major barrier amongst participants. “because when (women) get home, they instinctively change their function. They will be in housewives “I believe all Universities in Indonesia provide grants mode.” (FGD2, 280–281) for research. But here, the main problem is the com- plicated bureaucracy that makes the fund can’t be Many female participants felt that their home and received as soon as possible” (FGD8, 121–123) domestic duties imposed additional time constraints that further prevented them from conducting research. Due to the university’s mandate of actualizing the three pillars of higher education, the majority of participants agreed that the amount of time available for conducting Discussion research is inadequate. This study provides an important overview of the atti - tudes towards research held by faculty members in pri- “I am eager to conduct as much research as possi- mary care at a higher education institution in an LMIC, ble, but I don’t have any spare time to conduct the as well as the barriers and enablers/facilitators that influ - research.” (FGD2, 63–4) ence research capacity and production. It is likely that other universities and institutions in LMICs and across “We don’t have any time released from university the Asia Pacific region face the same challenges. to conduct research, but the university demands as It is widely accepted in the Indonesian context that much researches as possible in a year.” (FG2 263–4) the availability of a research master plan is important for Participants perceived that most available time is higher education institutions; however, results from this spent on the educational pillar (i.e. teaching). This is study find that this alone may not be enough to increase made worse by a workload that is not evenly distributed the culture and productivity of research. This study amongst faculty members. Faculty members who also shows that the implementation of the three pillars of work as a practicing physician have an especially hard higher education is not fully facilitated by the university time due to the additional responsibility of patient care. with regards to research obligation. Results found that a It was suggested that the time allotted for implementa- lack of research support prevents faculty members from tion of each of the three pillars should be clearly regu- fully engaging in research activities, findings that are sup - lated, especially for research. While the university has ported by previous published research. This suggests that seen improvements in infrastructure over the past few many of the barriers faced by researchers are common years, these have not yet helped improve research infra- across various LMIC settings and contexts, including: structure. The majority of participants agreed that there inadequate funding and financial incentives [31, 32], lack is a lack of research laboratories equipped with sufficient of available time for conducting research [23, 24, 26, 28– instruments, as well as a lack of adequate power sup- 31], poor research policy [23–26, 29], lack of adequate ply to run necessary activities. The availability of skilled research infrastructure and facilities [26, 28], and a lack human resources (Master-and/or Ph.D.-level graduates of financial and administrative support [31]. both from national and international universities), while Nevertheless, this study also supports the overall posi- improving, still contributes to poor research infrastruc- tive attitude that researchers in LMICs tend to have ture. The lack of a high-quality research infrastructure towards research [22–28, 31]. The three pillars of higher has been identified as one of the most important prob - education (research, education and community service), lems faced by faculty members, which has led many, mandated as national requirements for higher education especially those from the Faculty of Medicine, to conduct institutions, have become a unique cardinal enabler/facil- more community-based research. itator in strengthening research capacity in the Indone- sian context. This system could potentially be adapted by “Many of us have taken our masters…..But when we other LMICs as a means of increasing research capacity, return to our faculty….still lack of those tools, we especially in the Asia Pacific region. na fi lly decide to only do the survey….So lack of infra - As one of many Indonesian universities, SKU, situated structure makes our talent not amplified, and our in the province of Aceh, has many unique opportunities interest not distributed.” (FGD6, 75–80) for research. Aceh is known as being a “living laboratory” for many researchers from around the world, due in part Ichsan et al. Asia Pac Fam Med (2018) 17:8 Page 7 of 8 Abbreviations to the fact that it is a tropical region, and thus is home GDP: gross domestic product; LMIC: lower‑ and middle ‑income country; to many endemic tropical diseases. A rich Acehnese tra- SEAR: south east Asia region; SKU: Syiah Kuala University; WHO: World Health dition and plentiful natural resources can be leveraged Organization. and explored by faculty members looking to expand their Authors’ contributions research practices and scope. It is likely that many other II: conceptualized and designed the study, supervised data collection, drafted areas in the Asia Pacific region would have their own the initial manuscript, and approved the final manuscript as submitted. Co ‑ PI for study funding. NW: carried out the analysis, drafted the initial manuscript, similar yet unique contexts that might make them attrac- and approved the final manuscript as submitted. RM: analysis instruments, tive locations for prospective researchers. Additionally, carried out the analysis, reviewed the manuscript, and approved the final the growing involvement of local faculty members in manuscript as submitted. LL: carried out the analysis, reviewed the manu‑ script. KL: drafted the initial manuscript, performed the literature review, and international meetings, seminars, and conferences adds edited and revised the manuscript. LRC: conceptualized and designed the positive value to research initiatives across Indonesia and study, supervised data collection, critically reviewed the manuscript. Co‑PI for the Asia Pacific region. Faculty members are often aware study funding. All authors read and approved the final manuscript. of these opportunities, however, they may face difficulties Author details in the operationalizing and production of high-impact Medical Research Unit, Faculty of Medicine, Syiah Kuala University, Jl. T. research. Tanoeh Abe, Darussalam, Banda Aceh 23111, Indonesia. Department of Fam‑ ily Medicine, McMaster University, 100 Main St W, Hamilton, ON L8P 1H6, On the other hand, results from this study indicate Canada. that the interest level of faculty members in conducting research is low, due to inequality of funding, and a lack Acknowledgements None. of resources, infrastructure, and research support at the faculty and study program levels. In order to promote Competing interests and support successful research initiatives, tools such as The authors declare that they have no competing interests. a comprehensive and effective research policy (available Availability of data and materials at the faculty and study program levels), are required. The datasets used and/or analysed during the current study are available from This study also found that female faculty members of the corresponding author on reasonable request. higher education institutions may also face additional Consent for publication time constraints, due in part to traditional gender roles. Not applicable. In general, women in many Asian countries often have Ethics approval and consent to participate additional responsibilities, both professionally and at This study received approval from the Hamilton Integrated Research Ethics home. As faculty members, women are required to par- Board, as well as the Syiah Kuala University Research Ethics Board. All partici‑ ticipate in teaching, research, and community service. If pants signed an informed consent package prior to participation in this study. they are also practicing primary care doctors, they will Funding have additional patient care duties. Women faculty mem- Funding for this study has been provided through a pilot grant from the bers may also have increased amounts of domestic duties McMaster University Department of Family Medicine. outside of work relative to their male counterparts, which may decrease the amount of time they have available to Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub‑ conduct research. This disparity needs to be addressed, lished maps and institutional affiliations. not only in Indonesia, but also in many other LMICs. Received: 22 January 2018 Accepted: 17 July 2018 Conclusions This study served as a critical needs assessment that evaluates the research environment of primary care References physicians at a major Asian university. By identifying 1. World Health Organization. The world health report 2003: shaping the future. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Jul 27, 2018

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