The Pan African Thoracic Society Methods in Epidemiologic, Clinical and Operations Research Program: A story of success told through a history of publications

INTRODUCTION

Low- and middle-income countries (LMICs), especially in Africa, bear a substantial global burden of communicable and non-communicable diseases such as tuberculosis, pneumonia, asthma, HIV, and chronic obstructive pulmonary disease.^[1-4] Despite this burden, there is a low research spending and a correspondingly limited contribution to the research literature.^[5-9] Indeed, the Commission on Health Research had previously described the “10/90” gap which highlights the disparity in disease burden and research output from African countries.^[10,11] Further, despite hosting 15% of the global population, African countries contribute only about 1.5% of the global health research publications, which emanate mostly from South Africa, Egypt, and Nigeria.^[7,12,13] Limited research activities in LMIC have been strongly associated with the perpetuation of poverty and provide a basis for actions to improve research capacity and output in these regions.^[12]

High-quality research conducted in relevant local contexts is critical for informing strategies to control some of the prevalent diseases and setting national health priorities toward meeting the sustainable development goals.^[14-16] One factor that may have contributed to low research output in Africa and other LMIC is the very low number of well-trained researchers relative to the population compared to high-income countries that fall in the range of 5 versus 363 full-time researchers per million population.^[17,18]

A review of 1593 articles on randomized controlled trials for HIV/AIDS, malaria, and tuberculosis in LMICs revealed that although there was significant year-to-year rise in published articles from the African continent, most were first authored by researchers from high-income countries.^[15] This inequity is due to a wide range of issues ranging from inadequate funding, poor training and expertise, poor institutional support, and capacity to absent mentorship.^[7,11,19,20]

Recognizing these problems, the American Thoracic Society in collaboration with the Pan African Thoracic Society (PATS) set up a research capability strengthening program – Methods in Epidemiologic, Clinical, and Operations Research (PATS-MECOR) program – which seeks to improve global lung health through the development of local research capacity in Africa. “PATS-MECOR” commenced in 2007 and is organized as a three-level training course such that attendees can progress from one level each year to completion. The process and method of running the program has been more adequately written about by Buist and Parry.^[21] Over the years, the course has drawn participants from different African countries, however, the level of achievement of its core mandate of improving research capacity through publications by participants has not been assessed.

There is always a need for the evaluation of the effectiveness of public health programs including research capacity building programs both as a learning and planning tool.^[22] One approach is by evaluation of the publication history of participants using bibliometric methods that quantitatively and qualitatively evaluate published literature. This method has become a key part of modern assessment of academic productivity.^[23,24] This study set out to objectively evaluate the research productivity of previous participants of the PATS-MECOR course through their publication history as a proxy measure of the effectiveness of the training program.

MATERIALS AND METHODS

RESULTS

Effect of PATS-MECOR training on publication

There was a doubling of the total publication output in the 1^st year following PATS-MECOR training compared to the year before attending PATS-MECOR course (123 articles vs. 58 articles) among the 143 participants who had published within 4 years before or post attending PATS-MECOR training. This trend was sustained when matched to comparable years prior and post-exposure to the program as shown in [Figure 1].

Close

Figure 1:

Effect of exposure to PATS-MECOR training on publication by PATS-MECOR attendees (n = 143).

Export to PPT

Furthermore, the number of participants who had published in the 1^st year following attendance of the PATS-MECOR program was about twice the number that had published 1 year before attending the course (62 vs. 34).

In the 4 consecutive years following training, participants published an average and standard deviation of 0.84 ± 1.46 articles (1^st year), 0.99 ± 1.61 articles (2^nd year), 0.98 ± 1.70 articles (3^rd year), and 1.06 ± 2.06 articles (4^th year). This rate was higher compared to their 4 years consecutive rate of publication before attending the course where they published an average and standard deviation of 0.40 ± 1.13 articles in the 1^st year, 0.38 ± 0.92 in the 2^nd year, 0.37 ± 1.29 articles in the 3^rd year, and 0.21 ± 0.89 articles in the 4^th year before attending the PATS-MECOR training. In the whole 4 years period following first exposure to PATS-MECOR training, the median (IQR) publication rate of participants 2 (1–4) was far higher compared to their median publication outputs 4 years before attending PATS-MECOR 0 (0–1).

DISCUSSION

This study has demonstrated a significant success of the PATS-MECOR program in improving publication trends among attendees. A significant proportion (more than three-quarter) of the past attendees has published with slightly more than 20% being the first author in their publications. There is also a good median citation record of their publications and nearly half were published in top choice journals with impact factor. The number of publications per year increased in the years following attendance of PATS-MECOR.

Compared to the impact of similar courses on publication trend among attendees, our finding that more than three quarters of our participants had published at least a paper is higher than what was reported by the “The Structured Operational Research and Training Initiative (SORT-IT)” program organized by the International Union Against Tuberculosis and Lung Disease, MSF, and the World Health Organization (WHO) which was about 50%.^[37] Furthermore, the publication output for PATS-MECOR participants for a comparable period of their assessment, 2007–2014, showed a higher publication output per year compared to the SORT-IT cohort. The publication output of PATS-MECOR attendees is likely to have contributed to the positive findings in a recent review that reports that Africans are now represented in about 49.9% of publications in the four most prominent general medicine and five most prominent general global health journals, respectively, based on impact factor.^[9]

Author position on publications is recognized as a representative measure of participation and leadership in research. This study showed that more participants had a higher proportion who had served as the first authors or last authors in their studies compared to a study by Schneider and Maleka which found lower level of being the first authors and last authors at 14% and 11% for authors from low- and middle-income countries.^[10] Furthermore, the proportion of first authorship in this present study was higher than found in the previous studies which sought to evaluate the scientific productivity primarily of country-based authors in Angola (19%)^[38] and Malawi (20.9%).^[39] The first authorship in our study is lower than that of a study evaluating global health research among LMIC affiliated authors which was over 50%.^[10] This is not surprising considering that global health research is usually a global North-South collaboration and at present often led by authors from the global north who have more access to funding as has been alluded to Masekela et al.^[40] More so, the study by Schneider and Maleka used institutional affiliations which may be misleading in representing the nationality of the authors, for example, in cases of temporary international mobility.

The last author position which usually denotes the most senior author in some settings is not high among our participants compared to that of authors with African institutional affiliation in a study assessing COVID-19 publications (53.5%).^[41] This study by Guleid et al. evaluated the studies based on database from pre-print such as medRXiv, African Journals Online (AJOL), Collabovid, the WHO Global Research Database, and Google which are less restrictive compared to ours that used only PubMed database. Again, this depicts that attendees at the PATS-MECOR training are emerging and young investigators who are honing their skills in research and this meets the mandate of the program to build research capacity. Another dimension to the last author position is that some African academic institutions do not give as much importance to the position for the purposes of academic progression and recognition, thus making it less attractive for young African investigators.

The finding that participants from Nigeria and Kenya produced more publications compared to other participants was in line with other studies that have evaluated publications of health research in African countries^[7,41-45] However, the finding that when adjusted for GDP and the number of participants other countries, especially those from low-income countries such as Malawi and Uganda were in the top five, is consistent with other previous studies.^[46] This may also be a proxy indicator of the effect of the training in aiding participants irrespective of their background to become more productive researchers.

The citation rate for the papers authored by the participants appears higher compared to the rates achieved by authors with LMIC institutional affiliation as described by Gonzalez-Alcaide et al. While in this study, the articles median citation was 11, the work by Gonzalez-Alcaide et al. was <8 depending on the position and coauthors institutional affiliation.^[47] Thus, the finding that participant’s publication has a good citation rate is indicative of the high quality of research conducted by the PATS-MECOR attendees.

The significant higher publication output by male participants compared to the female participants is in keeping with other studies that have pointed to gender differences in publications.^[48,49] The reason for this may be due to the challenges females face in pursuing their career path early due to family considerations compared to their male counterparts. Given this situation, there may be need to be more deliberate in recruiting more females into the program and to encourage some of the outstanding ones to be mentors and serve as role models to encourage other females to become more active in pursuing research careers.

CONCLUSION

The PATS-MECOR program is a valuable research capacity building training for emerging African investigators as evidenced by an increased publication rate in reputable journals with good citation and visibility. With improving research capacity among Africans, there is a need to encourage sustained collaboration and networking among the trained critical mass of researchers in the continent. This will engender multidisciplinary research with greater policy impact across the continent. Future assessments of this program should include mapping of the research partnership and funding streams of the participants as well as the use of qualitative methodology to deeply explore the effects of the program and challenges to productivity.