MR: Medical Research, OR: Odds Ratio, AOR: Adjusted Odds Ratio, CI: Confidence interval

Table 2. Univariable and multivariable analysis of characteristics and medical research experiences by medical research publishing experience (N=262)

B. Confirmatory Factor Analysis of Practices, Perceptions, Attitudes, Barriers and Motivation toward Medical Research

Table 3 demonstrates the confirmatory factor analysis (CFA) of practices, perceptions, attitudes, barriers and motivation Likert scores and MR publishing experience. In the practice section, all questions had a loading factor of approximately 0.80. The loading factors for perception range from 0.74 to 0.79, except for two questions: (1) research or publication should be mandatory and (2) research experience should be a criterion for residency training. For the attitude section, the CFA found that MR is exciting and MR is enjoyable, with high impacts of 0.89 and 0.87, respectively, followed by MR being valuable and essential for the medical profession, with loading factors of 0.58 and 0.54, respectively. However, for the questions where MR is complicated and time-consuming, the loading factor was relatively low, under 0.30. Regarding barriers, lack of exposure and opportunities, training and support, mentoring and guidance, and lack of personal knowledge of the research process all had a high loading factor of over 0.70. Lack of statistical support, funding, and lack of rewards or motivations had relatively lower loading factors between 0.60 and 0.69. For motivation, pursuit of further education, pursuit of personal interest, improving their potential in research skills, having mentor guidance/role model and to be a part of solving medical problems in society had high loading factors over 0.70.

Table 3. Confirmatory factor analysis of practice, perception, attitude, barrier and motivation Likert-score and medical research publishing experience

C. SEM of Practices, Perceptions, Attitudes, Barriers and Motivation and MR Publishing

The SEM is developed from five latent variables, leading to the outcome, including medical research presentation and publication (Figure 1). We found that perception has a direct effect on both practices (0.27, p<0.001) and motivation (0.12, p= 0.087). Perceptions and attitudes also correlated (0.57, p<0.001). Practices and attitudes have a direct effect on motivation, 0.49 and 0.30, respectively (p<0.001 for both). The indirect effect of attitudes through practices on motivation was 0.71 * 0.49 = 0.35, all coefficients p<0.001. Practices also exhibited a direct negative effect on barriers (-0.13, p= 0.072). Regarding our primary outcome, both motivation and, surprisingly, barriers also revealed a positive direct effect on MR publishing (0.28, p<0.001 for motivation and 0.15, p= 0.014 for barriers). The MR presentation experience also showed a direct effect on MR publication (0.26, p<0.001). Furthermore, MR presentation also acted as a mediator for motivation, with an indirect effect of 0.08 and a total effect of motivation on MR publication of 0.36. The SEM model provided a good fit for the data (χ²/df= 1.67, CFI= 0.96, TLI= 0.95, RMSEA= 0.05, SRMR= 0.05).

*= P<0.05

Figure 1. SEM of practices, perceptions, attitudes, barriers and motivation and MR publishing

IV. DISCUSSION

We successfully enrolled 139 PCM senior medical students, and 123 interns graduated from PCM. This study is the first to formulate a SEM on the relationship between practices, perceptions, attitudes, motivation and barriers to MR publication and presentation. We found that attitudes, practices and motivation significantly contribute to MR publication and presentation. The roles and experiences that medical students have in medical research during their medical student years are also important to the success of MR publications. However, because our population only includes those who have studied or are studying at PCM, additional external validation may be required.

This study described how baseline characteristics and MR experiences were associated with MR publication. Unsurprisingly, a higher proportion of interns had published MR. GPAX, on the other hand, were not associated with MR publication, which is a common factor in a relative study with positive associations toward perceptions, attitudes and practices (El Achi et al., 2020). A large study in China also reported that research engagement was associated with improving overall learning outcomes (Zhang et al., 2022). This controversy may be explained by two reasons. First, the time required for developing MR and publications is large and might interfere with normal curriculum activity. A study in Colombia noted that their students believed that they could obtain higher GPAs if they were not involved in research (Bonilla-Escobar et al., 2017). The latter is that MR skills and academic skills might not completely overlap. While MR engagement might improve science, scholarship, and professionalism, other domains, such as clinical practice, require more time and effort to learn (Zhang et al., 2022).

MR experiences and roles during MR learning also play an important part in MR publication. Experience in MR presentation was strongly associated with MR publication. This may be partially explained by the student’s readiness before the research presentation; students need to be highly knowledgeable about their own research, and knowledge is a key to success and behavioural change (Bettinghaus, 1986; Pengpid et al., 2016). Furthermore, presentation requires planning, preparation, creating visual aids, and practicing one’s presentation skills. The effort and time spent on this process might be motivation to achieve a higher goal, namely publication. Our study demonstrates that MR presentations, whether nationally, internationally, oral, or poster, are highly associated with MR publication. Thus, MR presentations should be promoted.

Those who had been group leaders had a higher chance of MR publication. During the PCM curriculum, the group leader for MR conduct was never assigned and was elected in each group. Northouse mentioned two forms of leadership: assigned and emergent. Those assigned leadership positions were given the role of group leader. When an individual is perceived as one of the most influential members of a group or organization, that person is exhibiting emergent leadership (Northouse, 2021). Medical leadership development was seen to improve outcomes at the individual, organizational and clinical levels (Lyons et al., 2021). Several leadership training programs in medicine and clinical practices were widely visible. However, to our knowledge, no curriculum focusing on medical research leadership was available.

Perception is described as a method for identifying and interpreting the environment and the meaning of sensual motivations. Cognition may influence perception, which can also occur subconsciously and without cognizance (Saini et al., 2020). Some literature has been carried out showing perceptions, attitudes, and motivation toward research among medical students, in which those with positive perceptions mostly had positive attitudes and motivation (AlGhamdi et al., 2014; El Achi et al., 2020; Osman, 2016). These were similar to our research showing that perception impacts positively on practices and motivation.

In line with the current study, the theory of planned behaviour describes that one’s attitude and how they perceive the behaviour directly affect their intention to perform the behaviour (Bosnjak et al., 2020). The SEM also demonstrated that perception and attitude directly affect the population’s intention to conduct MR (practice). Moreover, a study in Turkey on the predictiveness of attitude and motivation on achievement (vocational English course scores) found a significant positive relationship between attitude and motivation, attitude and achievement, and motivation and achievement (Özer, 2020). Therefore, a positive attitude may positively impact their motivation and their willingness to practice MR. The feeling that MR is exciting and enjoyable had the greatest impact on the attitude domain. Hence, activities that increase the excitement and joy of conducting MR should be encouraged.

The main factors impacting MR publication are motivation, practices, attitudes and perceived barriers. Based on the health-belief model (HBM), providing motivation as needed might help students overcome the triggers of MR barriers so that correct thoughts and perceptions about MR will arise. Thus, techniques derived from motivational interviews might be a useful option for encouraging students toward MR publication (Tober, 2013). One of the most important motivations in our study is having a mentor or role model, and the lack of a mentor constitutes a high-impact barrier. Therefore, mentors should play an important role in guiding their students toward research success. Based on motivational interview techniques, active listening might be the key skill for mentors to better understand their students’ motivations and empower them toward success (Rollnick et al., 2010).

Surprisingly, our study showed that perceived barriers had a positive impact on MR publication. The perception of a barrier greatly influences the likelihood of an individual’s uptake of that behaviour (Becker & Maiman, 1975). Usually, a barrier is a resistance to achieving a goal, which negatively affects achievement. However, the barriers included in our study consisted of a lack of exposure and opportunities, training and support, mentoring and guidance, and statistical support. As a result, those who had not yet published any medical research may not have had the prestige of encountering these barriers, which is why they are perceived as insignificant.

The practice domain included three questions: (1) willingness to participate in any research-related task; (2) willingness to spend more than two months on a research project; and (3) willingness to devote the same amount of time to medical research as they did to their university studies, indicating a willingness to practice medical research. Willingness is the quality or state of being prepared to accomplish something. A study in China about speaking English demonstrated that the willingness to communicate is directly related to motivation and mastery approach (Turner et al., 2021). Furthermore, passion and obsession are what drive an individual to succeed (Dange, 2016).

In view of all the factors presented, mentors have an important role to play in guiding and facilitating the students’ acquisition of adequate experience in medical research during their medical school years. A good extracurricular MR learning environment might be needed to ensure statistical confidence and exposure to conducting research. Actively listening to students and empowering and motivating them to break through barriers may result in successful MR publications. In addition, a different approach to learning MR might be needed to promote attitudes, perceptions and motivations toward MR. According to Self-Determination Theory (SDT), when students perceive that the primary purpose of learning is to obtain external rewards, such as exam grades, they may perform less well due to a detrimental effect on their intrinsic motivation (Deci et al., 1999).

SDT revealed that three basic needs must be fulfilled to empower one’s attitude and motivation, including autonomy, competence, and a feeling of belonging (Deci et al., 1999). To promote these basic needs, faculty members could provide extracurricular research time, give choice to research topics and mentors, and hire students to be research assistants, if possible, to promote their autonomy (Rosenkranz et al., 2015). Competence could be enhanced by early research skills introduction and practical training (Rosenkranz et al., 2015). Research mentors may play a crucial role in fostering a sense of belonging toward MR by promoting well-functioning group work through guidance and evaluation (Dorrance et al., 2008). Furthermore, portfolios, logbooks and reflective journals are particularly useful to improve the students’ attitude and motivation (Taylor & Hamdy, 2013). Constant positive feedback from mentors during MR activities is encouraged to improve the learning environment (Peifer et al., 2020). A different approach to learning MR might also benefits the MR learning environment, for example, through game-based learning and other collaborative learning models (Blakely et al., 2009).

The present study encountered several limitations. First, the study included only senior medical students and interns who graduated from PCM, so the model might not be accurately applied to other universities with different curricula and further validation might be needed. Even though most participants who had published a MR were interns (81%), the medical research published was composed while they were medical students. Second, the study was a cross-sectional study, and causal relationships were unavailable. However, according to PCM curricula, for most participants, the MR presentation and their experience with medical research came before the MR publication. Furthermore, personal beliefs change over time, and recall bias might have affected the study results. (Seitz et al., 2017). The beliefs elicited by the questionnaire comprised the participants’ current beliefs, rather than beliefs formed during their participation in medical research publications. As a result, our study investigated only the participants’ current beliefs and their impact on the publication of medical research. A further prospective cohort or qualitative study on whether the students’ current beliefs toward MR are related to successful MR publication is encouraged. Finally, because only participants who volunteered to take part in the study were included, selection bias may also be a significant limitation of this study. Our study had considerable strengths, there had been no reports describing practices, perceptions, attitudes, motivation and barriers toward medical research. However, this is the first study to formulate a SEM model displaying factors related to MR publication.

V. CONCLUSION

Medical research experience and positive practices or willingness, perception, attitude, and motivation in medical research might pave the road to a successful MR publication. Medical research experience and extracurricular activities should be supported by both teachers and faculties through active policies. A different approach to medical research learning might also be needed to promote enjoyment and excitement. Finally, external validation needs to be explored to generalise the model.

Notes on Contributors

SL reviewed the literature, designed the study, collected the data, data analysis and wrote the manuscript. KT, KJ and BS collected the data, developed the methodology framework and developed the manuscript. AK reviewed the literature, designed the study, data analysis and wrote the first draft.

Ethical Approval

The study was approved by the Medical Department Ethics Review Committee for Research in Human Subjects, Institutional Review Board, Royal Thai Army (Approval no. S060q/65_Exp), according to the international guidelines including the Declaration of Helsinki, the Belmont Report, CIOMS Guidelines, and the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use – Good Clinical Practice (ICH-GCP). A documentation of informed consent was used, and was granted permission by the Institutional Review Board, RTA Medical Department.

Data Availability

The datasets used and/or analysed during the current are available from https://doi.org/10.6084/m9.figshare.22128725

Acknowledgement

We thank professors Mathirut Mungthin, Ram Rangsin Panadda Hattachote, Phunlerd Piyaraj and Picha Suwannahitatorn for validating our questionnaire and providing support. This work would not have been possible without the active support of Phramongkutklao College of Medicine and its academic leaders.

Funding

The authors report that there is no funding associated with the work featured in this article.

Declaration of Interest

The authors declare they have no competing interests.

References

AlGhamdi, K. M., Moussa, N. A., AlEssa, D. S., AlOthimeen, N., & Al–Saud, A. S. (2014). Perceptions, attitudes and practices toward research among senior medical students. Saudi Pharma- ceutical Journal, 22(2), 113–117. https://doi.org/10.1016/j.jsps.2013.02.006

Al–Shalawy, F. A.-N., & Haleem, A. (2015). Knowledge, attitudes and perceived barriers towards scientific research among undergraduate health sciences students in the central province of Saudi Arabia. Education in Medicine Journal, 7(1), e16-e21. https://doi.org/10.5959/eimj.v7i1.266

Arif, A., Siddiqui, M. A., Aziz, K., Shahid, G., Shiekh, A., & Fahim, M.F. (2018). Perception towards research among undergraduate physical therapy students. Biometrics & Biostatistics International Journal, 7(3), 171–175. https://doi.org/10.15406/bbij.2018.07.00206

Becker, M. H., & Maiman, L. A. (1975). Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care, 13(1), 10–24. https://doi.org/10.1097/00005650–197501000–00002

Bettinghaus, E. P. (1986). Health promotion and the knowledge–attitude–behavior continuum. Preventive Medicine, 15(5), 475–491. https://doi.org/10.1016/0091–7435(86)90025–3

Blakely, G., Skirton, H., Cooper, S., Allum, P., & Nelmes, P. (2009). Educational gaming in the health sciences: Systematic review. Journal of Advanced Nursing, 65(2), 259–269. https://doi.org/10.1111/j.1365-2648.2008.04843.x

Bonilla–Escobar, F. J., Bonilla–Velez, J., Tobón–García, D., & Ángel–Isaza, A. M. (2017). Medical student researchers in Colombia and associated factors with publication: A cross–sectional study. BMC Medical Education, 17(1), Article 254. https://doi.org/10.1186/s12909–017–1087–9

Bosnjak, M., Ajzen, I., & Schmidt, P. (2020). The theory of planned behavior: Selected recent advances and applications. Europe’s Journal of Psychology, 16(3), 352–356. https://doi.org/10.5964/ejop.v16i3.3107

Carberry, C., McCombe, G., Tobin, H., Stokes, D., Last, J., Bury, G., & Cullen, W. (2021). Curriculum initiatives to enhance research skills acquisition by medical students: A scoping review. BMC Medical Education, 21(1), Article 312. https://doi.org/10.1186/s12909–021–02754–0

Dange, J. K. (2016). Perception, passion and obsession: The three elements of theory of success. International Journal of Advanced Education and Research, 1(7), 1–3.

Davila, J. R. (2016). The physician–scientist: Past trends and future directions. Michigan Journal of Medicine, 1(1), 66-73. https://doi.org/10.3998/mjm.13761231.0001.112

Deci, E. L., Koestner, R., & Ryan, R. M. (1999). A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin, 125(6), 627–668. https://doi.org/10.1037/0033-2909.125.6.627

Dorrance, K. A., Denton, G. D., Proemba, J., La Rochelle, J., Nasir, J., Argyros, G., & Durning, S. J. (2008). An internal medicine interest group research program can improve scholarly productivity of medical students and foster mentoring relationships with internists. Teaching and Learning in Medicine,20(2), 163–167. https://doi.org/10.1080/10401330801991857

El Achi, D., Al Hakim, L., Makki, M., Mokaddem, M., Khalil, P. A., Kaafarani, B. R., & Tamim, H. (2020). Perception, attitude, practice and barriers towards medical research among undergraduate students. BMC Medical Education, 20(1), Article 195. https://doi.org/10.1186/s12909–020–02104–6

Funston, G., Piper, R. J., Connell, C., Foden, P., Young, A. M. H., & O’Neill, P. (2016). Medical student perceptions of research and research–orientated careers: An international questionnaire study. Medical Teacher, 38(10), 1041–1048. https://doi.org/10.3109/0142159X.2016.1150981

Habineza, H., Nsanzabaganwa, C., Nyirimanzi, N., Umuhoza, C., Cartledge, K., Conard, C., & Cartledge, P. (2019). Perceived attitudes of the importance and barriers to research amongst Rwandan interns and pediatric residents – A cross–sectional study. BMC Medical Education, 19(1), Article 4. https://doi.org/10.1186/s12909–018–1425–6

Ichsan, I., Wahyuniati, N., McKee, R., Lobo, L., Lancaster, K., & Redwood–Campbell, L. (2018). Attitudes, barriers, and enablers towards conducting primary care research in Banda Aceh, Indonesia: A qualitative research study. Asia Pacific Family Medicine, 17(1), Article 8. https://doi.org/10.1186/s12930–018–0045–y

Kamwendo, K. (2002). What do Swedish physiotherapists feel about research? A survey of perceptions, attitudes, intentions and engagement. Physiotherapy Research International, 7(1), 23–34. https://doi.org/10.1002/pri.238

Laidlaw, A., Aiton, J., Struthers, J., & Guild, S. (2012). Developing research skills in medical students: AMEE Guide No. 69. Medical Teacher, 34(9), 754–771. https://doi.org/10.3109/0142159X.2012.704438

Lev, E. L., Kolassa, J., & Bakken, L. L. (2010). Faculty mentors’ and students’ perceptions of students’ research self-efficacy. Nurse Education Today, 30(2), 169–174. https://doi.org/10.1016/j.nedt.2009.07.007

Lyons, O., George, R., Galante, J. R., Mafi, A., Fordwoh, T., Frich, J., & Geerts, J. M. (2021). Evidence–based medical leadership development: A systematic review. BMJ Leader, 5(3), 206–213. https://doi.org/10.1136/leader–2020–000360

Ma, X., & Xu, J. (2004). Determining the causal ordering between attitude toward mathematics and achievement in mathematics. American Journal of Education, 110(3), 256–280. https://doi.org/10.1086/383074

Memarpour, M., Fard, A. P., & Ghasemi, R. (2015). Evaluation of attitude to, knowledge of and barriers toward research among medical science students. Asia Pacific Family Medicine, 14(1), Article 1. https://doi.org/10.1186/s12930–015–0019–2

Northouse, P. G. (2021). Leadership: Theory and practice (9^th ed.). SAGE publications.

Okoduwa, S. I. R., Abe, J. O., Samuel, B. I., Chris, A. O., Oladimeji, R. A., Idowu, O. O., & Okoduwa, U. J. (2018). Attitudes, perceptions, and barriers to research and publishing among research and teaching staff in a Nigerian research institute. Frontiers in Research Metrics and Analytics, 3, Article 26. https://doi.org/10.3389/frma.2018.00026

Osman, T. (2016). Medical students’ perceptions towards research at a Sudanese University. BMC Medical Education, 16(1), Article 253. https://doi.org/10.1186/s12909–016–0776–0

Özer, S. (2020). The predictiveness of attitude and motivation on achievement in ESP: The mediating role of anxiety. International Journal of Curriculum and Instruction, 12(2), 25-41.

Pallamparthy, S., & Basavareddy, A. (2019). Knowledge, attitude, practice, and barriers toward research among medical students: A cross–sectional questionnaire–based survey. Perspectives in Clinical Research, 10(2), 73.

Parker, S. M., Vona-Davis, L. C., & Mattes, M. D. (2021). Factors predictive of publication among medical students participating in school-sponsored research programs. Cureus, 13(9), e18176. https://doi.org/10.7759/cureus.18176

Peifer, C., Schönfeld, P., Wolters, G., Aust, F., & Margraf, J. (2020). Well done! Effects of positive feedback on perceived self-efficacy, flow and performance in a mental arithmetic task. Frontiers in Psychology,11, Article 1008. https://doi.org/10.3389/fpsyg.2020.01008

Pengpid, S., Peltzer, K., Puckpinyo, A., Tiraphat, S., Viripiromgool, S., Apidechkul, T., Sathirapanya, C., Leethongdee, S., Chompikul, J., & Mongkolchati, A. (2016). Knowledge, attitudes, and practices about tuberculosis and choice of communication channels in Thailand. Journal of Infection in Developing Countries, 10(7), 694-703. https://doi.org/10.3855/jidc.6963

Puljak, L. (2007). An overlooked source of physician–scientists. Journal of Investigative Medicine, 55(8), 402–405. https://doi.org/10.2310/6650.2007.00029

Rollnick, S., Butler, C. C., Kinnersley, P., Gregory, J., & Mash, B. (2010). Motivational interviewing. BMJ, 340, c1900. https://doi.org/10.1136/bmj.c1900

Rosenkranz, S. K., Wang, S., & Hu, W. (2015). Motivating medical students to do research: A mixed methods study using self-determination theory. BMC Medical Education, 15, Article 95. https://doi.org/10.1186/s12909-015-0379-1

Saini, M., Kumar, A., & Kaur, G. (2020). Research perception, motivation and attitude among undergraduate students: A factor analysis approach. Procedia Computer Science, 167, 185–192. https://doi.org/10.1016/j.procs.2020.03.210

Schellenberg, B. J. I., Gaudreau, P., & Bailis, D. S. (2022). Lay theories of obsessive passion and performance: It all depends on the bottom line. Personality and Individual Differences, 190, Article 111528. https://doi.org/10.1016/j.paid.2022.111528

Seitz, R. J., Paloutzian, R. F., & Angel, H.-F. (2017). Processes of believing: Where do they come from? What are they good for? F1000Research, 5, Article 2573. https://doi.org/10.12688/f1000research.9773.2

Simpson, R. D., & Oliver, J. S. (1990). A summary of major influences on attitude toward and achievement in science among adolescent students. Science Education, 74(1), 1–18. https://doi.org/10.1002/sce.3730740102

Sobczuk, P., Dziedziak, J., Bierezowicz, N., Kiziak, M., Znajdek, Z., Puchalska, L., Mirowska–Guzel, D., & Cudnoch–Jędrzejewska, A. (2022). Are medical students interested in research? – Students’ attitudes towards research. Annals of Medicine, 54(1), 1538–1547. https://doi.org/10.1080/07853890.2022.2076900

Taylor, D. C. M., & Hamdy, H. (2013). Adult learning theories: Implications for learning and teaching in medical education: AMEE Guide No. 83. Medical Teacher, 35(11), e1561–e1572. https://doi.org/10.3109/0142159X.2013.828153

Tober, G. (2013). Motivational interviewing: Helping people change. Alcohol and Alcoholism, 48(3), 376–377. https://doi.org/10.1093/alcalc/agt010

Turner, J. E., Li, B., & Wei, M. (2021). Exploring effects of culture on students’ achievement motives and goals, self–efficacy, and willingness for public performances: The case of Chinese students’ speaking English in class. Learning and Individual Differences, 85, Article 101943. https://doi.org/10.1016/j.lindif.2020.101943

Valladares–Garrido, M. J., Mejia, C. R., Rojas–Alvarado, A. B., Araujo–Chumacero, M. M., Córdova–Agurto, J. S., Fiestas, J., Rojas–Vilar, F. J., & Culquichicón, C. (2022). Factors associated with producing a scientific publication during medical training: Evidence from a cross–sectional study of 40 medical schools in Latin America. F1000Research, 9, Article 1365. https://doi.org/10.12688/f1000research.26596.2

Wolf, E. J., Harrington, K. M., Clark, S. L., & Miller, M. W. (2013). Sample size requirements for structural equation models: An evaluation of power, bias, and solution propriety. Educational and Psychological Measurement, 76(6), 913–934. https://doi.org/10.1177/0013164413495237

Zhang, G., Wu, H., Xie, A., & Cheng, H. (2022). The association between medical student research engagement with learning outcomes. Medical Education Online, 27(1), Article 2100039. https://doi.org/10.1080/10872981.2022.2100039

*Anupong Kantiwong
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E-mail: anupongpcm31@gmail.com