Accessing research literature : A mixed-method study of academics in Higher Education Institutions in Nepal

2 Honorary Lecturer, University of Aberdeen, UK 3 Visiting Fellow, Bournemouth University, UK. 4Adjunct FacultyDatta Meghe Institute of Medical Sciences (Deemed University) Nagpur, India 5 Visiting Professor, Manmohan Institute of Health Science, Tribhuvan University, Nepal. 6 Visiting Professor, Nobel College, Pokhara University, Kathmandu, Nepal. 7 Professor, School of Health & Social Care, Bournemouth University, Bournemouth, UK. 8 Reader-Faculty of Education, Tribhuvan University Kathmandu, Nepal 9 ChairpersonDevelopment Resource Centre, Kathmandu, Nepal 10 Professor & Head of Central Department of Population Studies, Tribhuvan University, Kathmandu, Nepal


Introduction
Nepal has made strides of progress in health sciences and medical education over the past decade.Over 18 medical colleges have already been established and a few are on the pipeline.There are more than 70 nursing colleges (both in private and public sectors) and equal number of other health science colleges and courses, e.g.public health, pharmacy, physiotherapy and radiography 1 .
The overall health research environment is still relatively poor in Nepal 2 .Nepali researchers have limited publications in peer reviewed journals compared to their non-Nepali counterparts.The number of publications seems lower in the public university compared to the private universities 3 .
The use of available evidence-based information is necessary before we can address health problems in Nepal, however Higher Education (HE) institutions lack knowledge as well as resources for utilising research published even in free and low priced journals Access to research information is an essential element in strengthening health sciences and medical practices, and empowering local experts to find solutions to health problems and to encourage the evidence based practice.Evidence-based practice is important to deliver the quality of care.However lack of research literature tends to be a serious obstacle for health professionals and researchers in the developing world.According to a World Health Organization survey, of the 75 countries with an annual income per capita of less than US $1000, 56% of medical institutions have had no subscriptions to journals over the last five years 6 .Despite the enormous disease burden in Nepal, research is often viewed as expenditure rather than an investment.Moreover, case studies from Nepal, Bangladesh, and Pakistan report that most government funding for research goes towards training, salaries, and infrastructure, resulting in research projects being largely funded (and influenced) by external donors 7 .Due to high subscription fees and complicated licensed agreements, many medical schools and HE institutions in Nepal are unable to subscribe the health-science related journals.Therefore, many researchers, HE teachers and students often have little access to the published research literature 2 .The advent of electronic publishing over the Internet generally improved global distribution of research information.Scientists, researchers, academics, policymakers and medical practitioners in developing country institutions now can have access to advanced and up-todate peer-reviewed research literature.Thousands of international scientific journals can be accessed online.Moreover, specialist databases, indexes, and reference books also available in several languages.Full-text articles can be downloaded for saving, printing or reading on screen.Many articles are available online before they are published in print.Accessing the available research information is very essential for institutions to bridge the research information gap.Therefore, there is need to improve the access to research information for Nepalese academics and researchers.This study aimed to assess HE teachers' knowledge, skills and competence on accessing electronic research literature on health sciences in Nepal.

Study design and the participants:
A descriptive research design with a mixed-methods approach was used for the study during the period first half of 2009 to first half of 2010.The research comprised a questionnaire survey of HE staff and interviews with key informants in the HE sector.In view of higher concentration of the medical institutions around the capital Kathmandu, this study covered all the medical, nursing and public health institutions providing higher education above Bachelor's level within the Kathmandu Valley.Furthermore, it included the three major institutions located in different parts outside Kathmandu: BPKIHS (BP Koirala Institute of Health Sciences), the only institution outside Kathmandu Valley with a Masters in Public Health at the time of study; Manipal College in Pokhara; and Kathmandu University School of Medical Science (KUMS) in Dhilukhel.Out of the total 1088 HE teachers on the HE institutions' records, 360 were physically available during the study visits and were willing to participate in the self-administered questionnaire.Of the 360 HE teachers who were given the questionnaire, 244 (68%) returned a completed questionnaire.

Questionnaire design
An extensive review of the literature, combined with exploratory research 5 and qualitative piloting 8 contributed to the development and refinement of a structured questionnaire in English.

Sample size calculation
The sample size calculation suggested that for a 95% confidence interval and significance level α = 5%, P = 0.5, Q = 0.5, allowable error = 14%, whereby P = Proportion of HE teachers had access to electronic research databases among the 50 respondents of the pilot study sample from Nepal, the required sample size was 205 9 .

Qualitative Research design
Interviews were conducted face-to-face with principals or campus chiefs, head of the departments and subject committee members.In total twelve key informant interviews were conducted.The qualitative interviews were analyzed thematically by reading transcriptions repeatedly to generate key themes 10 .

Outcome variable
The main outcome variable was the HE teachers access to electronic research databases.

Explanatory variables
Factors which are taken into account at individual level were: gender, institution, designation and discipline.

Data management and statistical analysis
The data collected were analyzed using Excel 2003, Statistical Package for the Social Sciences (SPSS) for Windows Version 16.0 (SPSS Inc; Chicago, IL, USA) and EPI Info 3.5.1 Windows Version.The chi square test was used to observe the relationship between the variables, and p < 0.05 was considered as statistically significant.

Ethical committee approval:
The study received ethical approval from the Nepal Health Research Council (NHRC) and individual consent was taken by all participants.

Results:
Out of the total 244 higher education (HE) teachers, fewer men completed the questionnaire (n=108 or 44.3%) than women (n=136 or 55.7%).By discipline or educational programme, the majority was from nursing (36.1%) followed by public health (17.6%) and pharmacy (11.9%).
The majority of staff was lecturer (47.5%) and nearly threequarters (72%) had completed Masters degree, the single largest proportion of the sample was aged 30 to 39 years (43.4%),whilst 28.8% was younger (20-29 years).Overall, 42% of HE teachers had been educated abroad.The proportion seems higher at BPKIHS (66%) followed by 55% at TU (Tribhuvan University) and 52% at PoU (Pokhara University).The proportion of females educated abroad (42%) was lower than that of males (55%).Two-thirds of staff had a work email account, the lower raking staff less (60.6%) than readers/professors (77.2%), but there was no statistically significant difference between HEIs.There was a significant gender difference, with 75.9% of men having work email and only 58.8% of female staff (χ2=7.891;p=0.006).
The availability of computers for academic use seemed good at all level of HE teachers, at different universities and for both sexes.Availability was little higher at BPKIHS and PoU, but this was not statistically significant (p=0.067).Internet was available in all HEIs.When it comes to the question of access of personal computer and internet access, it was reported only in BPKIHS where every faculty member had a personal laptop and 7/24 access to internet, including the online journals.The qualitative findings reiterated this, for example: " Here every faculty has a personal computer and space with regular internet facility, 24 hours a day, seven days a week.They can access online journals anytime they like".
-Key informant, BPKIHS Most students (89%) had access to internet.Almost all students from BPKIHS and 96% from KU (Kathmandu University) had access to the internet, but a lower proportion at Pokhara University.One key informant reported that students often visit other organisations to access the literature: " .. (students) are far better than us (teachers) using internet and are very curious to learn.They also visit different organisations (NHRC, Family Health Division Teku, Primary Health Care Center, Bagbazar) to get other grey literatures.We usually ask them to visit these organisations because they have systematic management of reading materials and updated literature in their library.
-Interviewee 1 However, some staff thought students did not want to make the effort to learn about accessing electronic journals: "Students … always seek for easy way that makes them lazy."-Interviewee 2 Staff from all colleges reported in interviews that they had had IT facilities, but they recognised the following problems: (a) not all computers were equally good; (b) not having enough computers for all students; or (c) no generator when there was load-shedding.The following quote illustrates several issues: "You can see the computer with internet at our tables.However, it is too slow and boring to wait for downloading, no free access of websites.I have heard that the staff in lab is highly qualified in computer".

Access to Electronic Research Database
Table 1 shows that less than half of HE teachers (49%) had access to electronic research databases.A small proportion (14%) even didn't know whether it was available at their HEI.The self-reported access was highest in BPKIHS and lowest at TU and PU (Purbanchal University).The data disaggregated by academic programme shows access to research database was highest in dentistry (Fig. 1).

Figure 1: Teacher access to electronic database by discipline
Fewer than half of HE teachers from other programmes had access to it (P=0.001).
The key informants however expressed that younger staff were more familiar with IT in general, e.g.: "I'm sure teachers are not up to date on this matter … the teachers who are young are somehow okay, they have at least email ID." -Key Informant, KU Of the total 119 HE teachers who reported their HEIs had subscribed electronic research database, more than one third (43%) had access to HINARI followed by a combination of PubMed and HINARI (16%) and PubMed (3.4%).In interviews HE teachers, particularly from BPKIHS mentioned Blackwell Synergy, HINARI, PubMed and Cochrane (6 out of 7 respondents).Key informants had mixed responses regarding subscription of online databases.* Multiple answers are possible for each respondent, hence total >100%.Table 2 shows the distribution of various method of accessing research currently being taught.HE teachers indicated that they used online materials other than electronic database (e.g.Google) (63%) followed by manual search (61%).In total, only 42% of the HE teachers used searching of online electronic research databases.Table 2 also shows a difference between academic disciplines.Interestingly, only 44 % HE teachers were themselves trained on accessing electronic database during their study in HEIs.The responses seem similar in all universities.By discipline more than half of the HE teachers teaching pharmacy (52%) and public health (51%) reported that they were taught accessing research literature while they were student but medical biology and nursing reported it the least (35% and 39% respectively).
The reasons behind why they were not taught accessing online research materials included, 'It was not incorporated into the curricula'(88 %),'Due to lack of computer'(10%) , 'internet facility'(5%) , and 'Due to lack of trained teacher' (9%).Key informant interviews from across universities revealed that their academic curricula have certain topics on general research methodology, sampling , field survey and literature review but specific topics on accessing electronic research literature and systematic reviews were  Less than half of the HE teachers (48%) have published research papers in peer-reviewed journals (Table 3).The proportion of HE teachers from BPKIHS seems higher (74%) and least in PoU (26%).The trend is similar in TU (57%) and KU (54%).Table 3 also shows that by discipline the difference in publishing research papers between dentistry teachers and medical microbiology teachers, on the one hand, and pharmacy and nursing teachers, on the other, is statistically significant (p=0.001).At the same time the gender difference is also significant as less than a third of the females (32%) have published research papers against 68% of their male counterparts, while by designation, readers and professors are most likely to have produced research publications (75%).

Table 4: HE teachers who have published journal articles based on systematic review
Table 4 shows that only 18.5% of HE teachers (18.5%) have published a paper based on a systematic review.The proportion was highest amongst HE teachers from BPKIHS.As expected, more men than women had published a systematic review paper (P<0.001).By designation, a little more than one-third of the Readers/Professors reported that they have published a systematic review paper.
One-third of the total HE teachers (35%) have participated in international workshop and seminars.The proportion is highest from BPKIHS (74%) followed by KU (43%) and TU (395).The proportion seems lower in PU (14%) and PoU (26%) (P=<0.001).By sex, female participation in international research seminars tends to be very low (21%) compared to the males (52%) (P=<0.001).Key informants, particularly the principals from nursing colleges from all HEIs alike, reiterated that female teachers from nursing backgrounds were not getting fair opportunity for any research training conducted by either the university or by the outside organisations.

Utilisation of research-based information among the HE Teachers
The global information and communication revolution is not only challenging teaching and learning, but also the way that academe conventionally reaches its audience and gains academic reputation.Both public and private funders of research pressure higher education institutions to make research findings more readily and quickly available, for example, through free-access on the Internet 12 .There is substantial increase in on-line academic journals and a movement in some countries to place the onus and cost of an individual's publication with her/his academic home institution.Also, the number of academics who publish their own work on the Internet is growing [13][14] .Since universities are traditionally engaged in both education and research (and, more recently, the validation of research), they are in a good position to help make research-based knowledge benefit society at large.Collaboration between active researchers and students is one of the best channels for new scholarly knowledge to be spread, contested and advanced in the professional community.Furthermore, learning from the most up-to-date scholarly knowledge and experience is a key ingredient in good teaching.Paradoxically, researchers are expected to introduce the most complex research findings to students who have much less disciplinary knowledge, but in many settings teachers are not offered adequate support to develop such pedagogic competence [14][15] .
Although there are programmes intended to enhance faculty development in health-care professions, few of these have been adequately evaluated concerning their impact on science and clinical science faculty members including clinician-teachers 16 .The lack of published information regarding faculty development strongly suggests a lack of evidence-based programmes.Substantial steps are now required toward the development of faculty development programmes.Furthermore, evaluations must encompass all faculty subgroups, including tenure and nontenured track, women, and underrepresented minorities [17][18][19] .
In our study just over one in four HE teaching staff (41.7%) had published in an academic peer reviewed journal, and men were considerably more likely to have published (60.9%) than women (30.6%), and higher ranking staff such as Readers and Professors were considerably more likely to publish (71.4%) than Instructors and Assistant Lecturers (28.1%).Just 13.8% had published in international peer reviewed journals and only marginally more had published in national peer-reviewed journals, although more had participated in international research conferences or workshops (28.0%).There was a clear gender difference in the latter, with 42.2% of men taking part in international conferences or workshops but only 19.8% of women.It supports the studies done in other part of the world [19][20][21][22] .Across the five universities, some 85% claimed to have basic computer skills.Almost all HE teachers at BPKIHS (96%) claimed this.However, key informant interviews reported that significant minority of teachers from across all universities lack computer skills.Only 14% HE teachers selfreported they had 'advance' computer skills.KU teachers were most likely to have advanced computer skills (21%) followed by PU (16%).In the other three universities, this proportion was less than one in ten.More than nine in ten (93%) had a computer at home.Female staff were considerably less likely to have work email than men (59% versus 76%) were, and all men and 87.5% women had a personal email account.Key informant interviews revealed that young faculties are more likely to have access to computer and personal email address.
The key informants considered that majority of teachers were not confident enough on accessing online research literature, as they were not taught this at the postgraduate level.Nor they had opportunity to take part in any shortterm training on accessing research literature during their professional career.The study participants suggested focusing on full time, female, young, and motivated HE teachers for any future training on accessing research literature.Almost all HE teachers (94%) were keen to participate in a learning workshop on accessing research literature.The majority was willing to come for four or more days training.A number of factors that could enable or hinder accessing of research literature by the HE teachers and students were explored.Availability of physical facilities was considered one main prerequisite for this.The study revealed that computers and internet were available at nearly all HE institutions (98.8%), and all had a library.Nine out of ten (89.3%) teachers had computer access for academic purpose.The proportion of male staff (92.6%) was a litter higher than for females (86.8%) and instructors and assistant lecturers had lower access (83%) to computers for academic use, a finding which was slightly low compared to the study by Bediang et  Nearly one fifth of the HE teachers (19.3%) were even unaware whether they could get support from a librarian at their HEI.Others (11.9%) reported that a librarian was not physically present to providing support needed by them.Two out of 12 principals were even not aware about the kind of support that their librarians could provide to the students and teachers.Cooper and Crum explored the new activities and changing roles of health sciences librarians in their systematic review 23 .Whether or not electronic research databases were available and used by the HE teachers was the another key question of the study.On the whole, 119 out of 244 (48.8%)HE teachers reported that they had access to electronic research databases at their HEIs.The study suggests that having access to electronic databases varied widely between institutions and disciplines.HINARI, an online research database made freely accessible by WHO, was the most used electronic databases mentioned (43%), it was followed by PubMed (16%).There was confusion amongst the HE teachers that statistical packages such as SPSS and Epi-Info belong to the research databases.Key informant interviews informed that students and faculties mostly use HINARI and PubMed.Many of them used Google for relevant materials but suspected on their authenticity.Our study finding was contradictory to the study by Maggio et al. which proved PubMed as the most commonly used database 24 .Almost all key informants and HE teachers, except from BPKIHS, reported their institutions had not subscribed to online journal that involved a subscription fee, i.e. had a cost.As external funding support is very important to strengthen research capacity of HEIs, particularly in a resource poor setting, we had asked the HE teachers whether their institutions had received any funding support from the external development partners.In total only 22.9 % respondents reported that their institutions had received funding to strengthen research capacity of teachers and students.Moreover, the key informants reiterated that there was a lack of institutional linkage among the key stakeholders involved in health research in Nepal such as NHRC, universities and medical colleges, external development partners and WHO, among others.Our findings suggest that research in general and accessing of research literature in particular was included with different approaches and the scope of contents was also variable.Less than half of the teachers (48.8%) were involved in teaching a course on health or medical research.Out of those 199 teachers, 98(82.4%)self-reported they teach accessing research literature.When this number was matched with the total number of teachers (N=244), only 40% teachers appeared to be involved in teaching accessing research literature to the students.Most HE teachers (84%) have taught research courses for less than five years.Those who teach research methods were more likely to include manual search (61.2%) and online search other than electronic database (63.3%).But only 41.8% HE teachers teach access to the online research literature, ranging from 20.8 % to 57.1% across institutions.By discipline, it varies from 38.7% in nursing to 50% each in pharmacy and dentistry.Those who taught research methods were more likely to give their students assignments based on accessing the research literature (63%) against the total teachers (30.7%).Less than half of the HE teachers were taught about accessing electronic research databases (43.9%), 'it was not in the curriculum' was the main reason for not teaching it (88.3%).Key informants informed that many students copy thesis from their seniors and no software is being used to measure plagiarism.Furthermore, the issue of plagiarism is not included in the HE courses and teachers not been sensitised.This is one area the DelPHE project should focus while at designing a teacher training manual in the future.The study recommends to Improve facilities such as computers, broadband internet access, back-up power supply, furniture and space for computer labs for teaching faculty, librarians and students; subscribe to online journals; Secure more funding for research in HEIs, Establish institutional links with national research institutions such as NHRC, and universities, and international research organizations/universities; and provide research methods training to staff (librarians and HE teachers).Moreover, females, young and motivated faculties, specifically working

Conclusion
The study indicates that there is a growing need for the periodic review of health and medical sciences curricula and teaching methodologies.The findings of this study should be used to advocate and sensitise curriculum development centres and university authorities for the review and revision of the curricula and include accessing of research literature with considerable importance.Finally, the authors would like to note that intra-university variations in findings in terms of curricula, research infrastructure, teaching methods and publications should not be taken as an evaluation findings, hence they are presented here as a snap-shot during the point of time study was undertaken.

4 . 5 .
Moreover, many of the curricula of HE institutions do not seem strong on research methodology training Simkhada and colleagues (2013) argued that health profession curricula should include clearer instructions to students on how to access the mostup-to-date research literature and how to appraise research articles 5 .

"
No online journal or data base are subscribed.We actually don't know that, basically we search information in Google."-Interviewee 5Teaching Research and Accessing Literature Overall, only 49% HE teachers had taught research-related subjects.The proportion was consistent across all universities, except BPKIHS (100% say they teach research) whilst HE teachers from public health (74%) and medical microbiology (65%) were more likely to have taught research methods.The majority (84%) of the HE teachers had taught research for less than five years.Of the total HE teachers who taught research, 82% had taught how to access research literature.While the proportion of teachers who taught accessing research literature of all HE teachers (N=244) only 40 % taught accessing electronic research databases.
lacking."Our curricula cover importance of research in medical/public health, research design, methodology, literature review, data analysis and use of research findings.The faculty members/students (of MPH) have to devote about 25 % of their time in delivering/engaging in research activities.MPH students are fully engaged a six month long research for their thesis However, we have very brief teaching on accessing online research and systematic reviews."-Key Informant, BPKIHS Research Publications by the HE Teachers on full time should be selected for any training on accessing research literature.Future Scope of the Study It is promising for DelPHE partners to discuss and decide on the modality of the training; whether to provide a Master Training of Trainers (MTOT) to selected teachers or basic training to as many teachers as possible.Possibility of developing and implementing modular training to faculty/students on accessing research literature could also be considered.Perhaps start by organising training on systematic reviews.To create research-friendly environment and develop a research culture, there should be provision of research fellowships and small grants to encourage and motivate young faculty members who are early career research professionals in the faculty.

Table 3 : HE teachers who have published research papers in peer reviewed journals 1. By University
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