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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 209-214

A distance clinical research training course in Ghana

1 Department of Emergency Medicine, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Emergency Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
2 Department of Emergency Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
3 Department of Emergency Medicine; University of Michigan Injury Prevention Center, University of Michigan, Ann Arbor, MI, USA, USA
4 Department of Epidemiology, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI, USA

Date of Submission21-May-2020
Date of Acceptance14-Jul-2020
Date of Web Publication26-Sep-2020

Correspondence Address:
Dr. Ronald Frank Maio
Department of Emergency Medicine, University of Michigan Medical School, University of Michigan Injury Research Center, 2800 Plymouth Road, Suite G080, NCRC Building 10, Ann Arbor, MI 48109-2800
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_62_20

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Clinical research training in low- and middle-income countries (LMICs) has not been adequately incorporated into local physicians' education. The lack of trained physician–scientists in LMICs is due in part to poor research infrastructure in these areas including limited funding support and scarcity of senior-level physician–scientists to provide training in research methodology. This article describes the structure, content, and evaluation of a combined synchronous/asynchronous distance and onsite learning program implemented in Kumasi, Ghana, to train physicians in clinical research. The course was delivered over 18 months and was associated with a clinical research study for which the participants were coinvestigators. A substantial increase in clinical research self-efficacy, as measured by the Clinical Research Appraisal Inventory, was found at the end of the course compared to baseline. This course could serve as a model for the delivery of clinical research training in other LMICs.
The following core competencies are addressed in this article: Medcal knowledge, Practice-based learning and improvement.

Keywords: Distance learning, clinical research training, research infrastructure low- and middle-income countries

How to cite this article:
Oteng R, Arhin B, Boakye-Yiadom J, Goldstick J, Eastman MR, Maio RF. A distance clinical research training course in Ghana. Int J Acad Med 2020;6:209-14

How to cite this URL:
Oteng R, Arhin B, Boakye-Yiadom J, Goldstick J, Eastman MR, Maio RF. A distance clinical research training course in Ghana. Int J Acad Med [serial online] 2020 [cited 2022 Dec 10];6:209-14. Available from: https://www.ijam-web.org/text.asp?2020/6/3/209/296145

  Introduction Top

Challenges and barriers to pursuing clinical research in Africa include lack of protected time dedicated to research activities among clinical providers, inadequate funding opportunities, insufficient training in study design, data analysis, and presentation/writing skills, limited opportunities for collaboration with researchers from other countries, and meager institutional support for developing, submitting, and administering research applications and awards.[1],[2] In this article, we describe a combined synchronous/asynchronous distance and onsite learning course on clinical research delivered to practicing emergency medicine physicians at a tertiary level referral hospital in Kumasi, Ghana.

  Methods Top

Course objectives

  1. To provide students with the knowledge and understanding to design, implement, and conduct clinical research with a particular focus on traumatic brain injury (TBI)
  2. To promote a setting that encourages the exchange of ideas and experiences among all class participants
  3. To increase the student's self-efficacy in conducting clinical research.

Course participants

The participants were a group of four Ghanaian physicians who had completed a 3-year emergency medicine residency program at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and were practicing emergency medicine physicians at KATH. None of the participants had any formal training in clinical research prior to this training course other than isolated information provided in lectures during their residency program. The participants were also coinvestigators on an NIH-funded R-21 research grant studying TBI in Ghana. The research course was delivered by three senior-level researchers from the University of Michigan, Ann Arbor, USA, and KATHKumasi, Ghana, between October 31, 2017, and March 15, 2019.

Course content

[Table 1] lists the course content by week. The main resources used throughout the course were “Designing Clinical Research” written by Hulley et al. and an online biostatistics course of prerecorded lectures made available from Stanford University.[3],[4] The biostatistics course was publicly available and could be used on-demand. Supplemental texts (primarily journal articles) and supplemental video modules were included from multiple sources as needed. The articles assigned were focused on the area of emergency care and described pertinent research includingTBI. In the later blocks of the course, students were taught basic data analysis using Stata version 13(StataCorp LLC, College City, Texas, USA) and how to properly manage data using Research Electronic Data Capture (REDCap).[5],[6] The study data were collected and managed using REDCap electronic data capture tools hosted at KATH.[6] REDCap is a secure, web-based application designed to support data capture for research studies, providing: (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.
Table 1: Course content areas

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[Table 2] lists the expected competencies upon course completion. Participants were also required to complete a 10–15-page research proposal in the area of TBI.
Table 2: Exit competencies

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Course structure

[Table 3] shows the course schedule. The course consisted of 12 and 6-week blocks that addressed a variety of subtopics within “Research Design,” “Biostatistics,” and “Software Training.” Throughout each block, trainees were assigned relevant readings and exercises from the course's main text, “Designing Clinical Research,” modules from the online biostatistics course, supplementary journal articles, and, occasionally, other online resources. The textbook assignments were made to correlate with topics relevant to the current phase of the R-21 study.
Table 3: Block schedule and course resources

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At the end of each 6-week block, trainees and instructors participated in a 60–90-min meeting to discuss the material related to the current block. Nine of the meetings took place via BlueJeans (Verizon) conferencing software. Three of the block meetings took place face to face while the lead instructor was in Ghana. Throughout the course, participants were free to contact the instructors as needed and via e-mail, voice/video calls, or in-person when available.

Course evaluation

Unstructured evaluation consisted primarily of informal discussions between the instructors and participants. The topics of these discussions were broad and included areas of technical issues, logistics, quantity and nature of material, perceived value of the material, and recommendations for improvement. We did not conduct any structured analysis of whether or not exit competencies were met or a gain of knowledge was obtained Astructured evaluation was administered before and after the course using the Clinical Research Appraisal Inventory (CRAI-92), a measure of clinical research self-efficacy.[7],[8]

The CRAI-92 is a 92-item assessment tool used to assess students' confidence in performing common clinical research tasks. The CRAI was administered to participants prior to the start of the course to measure their baseline understanding and comfort with 10 domains of clinical research and again following completion of the course. Items were rated on an 11-point Likert scale ranging from 0 (no confidence) to 10 (total confidence), indicating the participant's level of confidence in performing elements of clinical research. The CRAI was administered via computer using SurveyMonkey and was kept anonymous. The course was included in an R-21 protocol that was approved by the University of Michigan IRB, Kwame Nkrumah University of Technology and Science (KNUST) IRB, Kumasi, Ghana, RB, and the KATH research office. Participants signed a consent explaining the nature of the survey and the fact that aggregate data would be used in reports, presentations, and papers; and no scores for specific participants would be presented.

The 10 domains assessed were (1) conceptualizing a study, (2) designing a study, (3) collaborating with others, (4) funding a study, (5) planning and managing a research study, (6) protecting research subjects and the responsible conduct of research, (7) collecting, recording, and analyzing data, (8) interpreting data, (9) reporting a study, and (10) presenting a study.

Mean scores and mean differences were calculated from the pooled results of the pre- and post-CRAI. The mean scores and mean differences were calculated for each domain and were then combined to produce an overall pre- and overall post-mean score. These mean scores were compared by obtaining the mean difference.

  Results Top

Meetings were successfully conducted after each of the 12 blocks but sometimes needed to be rescheduled due to technical difficulties associated with limited bandwidth available at the Ghana site. Viewing the online biostatistics course also required adequate bandwidth and were large files. This translated into very long viewing times for the participants as well as data costs if they were viewing the files at home. Therefore, we downloaded the biostatistics video modules to a portable drive and shared it with participants so they could download the modules to their own computers.

Although the meeting schedule was determined with input from the participants, occasionally, clinical responsibilities prevented one or more participants from attending all or part of the meeting. Instructors contacted participants who missed all or part of a meeting, usually by e-mail, to review the discussion they missed and to answer any of their questions.

Both participants and the instructors thought that although the biostatistics video presentations were of high quality, the volume of the material was too large for the course. Participants agreed that the course would have benefitted by limiting the biostatistics material and providing more synchronous interaction to cover that material. For all other areas of the course, the participants thought that the quantity and quality of the material as well as the manner of its presentation was excellent. Participants particularly liked how the course was blended into the R-21 study as they could immediately see the relevance of what they were learning and apply those skills during the implementation of the project as well as the analysis of its data.

Two of the four participants actually developed proposals during the training course and implemented them soon after the course was completed. The other two began developing proposals during the course and are in the process of implementing them as of the writing of this article.

In regard to the CRAI, the overall mean preassessment score was 3.35 and postassessment was 7.48 [Table 4]. Differences for each domain are shown in [Table 5]. Substantial improvements were noted overall and for all domains.
Table 4: Trainees' overall Clinical Research Appraisal Inventory scores pre- and post-course

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Table 5: Trainees' pre- and postcourse Clinical Research Appraisal Inventory scores and standard errors per domain

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  Discussion Top

In this article, we present a unique clinical research training program that was delivered to emergency medicine physicians in Ghana. The program was primarily an asynchronous distance learning course but also included elements of synchronous distance learning and onsite face-to-face learning. An especially unique aspect of this course was that it was embedded in an R-21 clinical research study. Both participants and instructors thought that the course was excellent overall. Participant's CRAI scores improved substantially from baseline. Increases were noted across all domains of the CRAI. Changes ranged from 3.32 to 4 0.55. The largest change was noted for the domain “Planning and mananging a study;” the smallest for the domain “Interpreting data.” Both participants and instructors thought that less biostatistical content should have been presented. Issues with bandwidth were the primary technical problem.

Currently, research from sub-Saharan Africa (SSA) contributes to less than 1% of the world's biomedical publications, pointing to a small body of physician–scientists engaged in scientific research, as well as a distinct lack of resources and training opportunities needed to conduct sound research.[9],[10],[11] Previous literature estimates the density of scientists within SSA to be 56/1 million population, which is compared to 4650/1 million population in the United States.[11],[12] This stark difference contributes to sizable disparities in global health research and reinforces reliance on multinational collaborations to conduct research in developing countries.[13],[14]

Distance learning methods are commonly incorporated in course development in high-income settings, like the United States. Distance learning techniques can provide an appealing, efficient, and scalable alternative to onsite teaching, as it incorporates the use of web-based tools delivered in synchronous and asynchronous styles. Distance learning methods include online lectures, internet-based text resources, various exercises and assessment tools, video conferencing, distribution of portable media, and discussions. Delivering distance learning courses in low-and middle-income countries (LMICs) can be technically challenging.[1] Although Ghana is one of the most technically advanced countries in West Africa, we experienced problems due to inadequate bandwidth. We speculate that within several years this will not be a considerable issue: however, we will be more sensitive to this issue when we deliver future courses.

To date, only one study has evaluated the effectiveness of distance learning in health research methodology to onsite training in an LMIC.[1] This study was a randomized controlled trial conducted in India comparing distance learning for teaching biostatistics and research ethics to onsite training of these subjects. The main outcome of interest in this study was knowledge gained immediately after completion of a biostatistics course and research ethics course as well as knowledge retained after 3 months of course completion. The results of student satisfaction surveys were similar between instruction methods, except the onsite course scored higher in the area of faculty–trainee interaction and biostatistics.

Compared to the course described above, our evaluation did not include tests of knowledge but did show substantial improvement in clinical research self-efficacy as measured by the CRAI. Furthermore, from a qualitative perspective, both instructors and participants were generally very pleased with course but felt that the biostatistics portion should be presented with less material and better focus. We think that this could have resulted in domain “Interpreting data” having the smallest improvement in CRAI. A unique aspect of this course, and one that participants thought was very valuable, was that it was embedded into an R-21 study. Participants could readily appreciate the usefulness of the skills they were learning as well applying them. We think the value of incorporating a clinical research training program into a clinical study is also reflected by the fact that the largest improvement of the CRAI score was noted for the domain “Planning and managing a study.”


We did not measure clinical knowledge in our evaluation due to resource limitations in developing and validating a test to measure the knowledge gained by participants. However, we were able to see participants apply what they were being taught to the R-21 project. Furthermore, all participants either developed a full proposal or developed portions of proposals during the course that were or are currently being implemented. This course was limited to teaching participants in one LMIC, potentially limiting generalizability to other areas. However, we think that Ghana is similar to many other LMICs and speculate that this type of course could be successfully implemented in other settings whether or not it is given in conjunction with an ongoing clinical research study.

  Conclusion Top

This combined synchronous and asynchronous distance and onsite clinical research training program successfully trained LMIC physicians to conduct clinical research as well as enhanced their clinical research self-efficacy.

Financial support and sponsorship

5 R21 NS103754-02: The characteristics and outcomes of traumatic brain injuries in the Ashanti region of Ghana NIH-DHHS-US- 17-PAF04243.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The course was included in an R-21 protocol that was approved by the University of Michigan IRB, Kwame Nkrumah University of Technology and Science (KNUST) IRB, Kumasi, Ghana, RB, and the KATH research office. Applicable EQUATOR network (https://www.equator-network.org/) research reporting guidelines were followed.

  References Top

Bollinger RC, McKenzie-White J, Gupta A. Building a global health education network for clinical care and research. The benefits and challenges of distance learning tools. Lessons learned from the Hopkins Center for Clinical Global Health Education. Infect Dis Clin North Am 2011;25:385-98.  Back to cited text no. 1
Roane DM, Inan E, Haeri S, Galynker II. Ensuring research competency in psychiatric residency training. Acad Psychiatry 2009;33:215-20.  Back to cited text no. 2
Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing Clinical Research. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.  Back to cited text no. 3
Stanford University School of Medicine. Statistics in Medicine; 2013. Available from: https://online.stanford.edu/courses/som-xche0002-medical-statistics-i-introduction-data-analysis-and-descriptive-statistics. [Last accessed on 2019 Jul 30].  Back to cited text no. 4
StataCorp. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017.  Back to cited text no. 5
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81.  Back to cited text no. 6
Mullikin EA, Bakken LL, Betz NE. Assessing research self-efficacy in physician-scientists: The clinical research appraisal inventory. J Career Assess 2007;15:367-87.  Back to cited text no. 7
Lipira L, Jeffe DB, Krauss M, Garbutt J, Piccirillo J, Evanoff B, et al. Evaluation of clinical research training programs using the clinical research appraisal inventory. Clin Transl Sci 2010;3:243-8.  Back to cited text no. 8
Crisp N. Global health capacity and workforce development: Turning the world upside down. Infect Dis Clin North Am 2011;25:359-67.  Back to cited text no. 9
Khan H, Khan S, Iqbal A. Knowledge, attitudes and practices around health research: The perspective of physicians-in-training in Pakistan. BMC Med Educ 2009;9:46.  Back to cited text no. 10
Gachuno OW, Oyugi J. Distance learning approach to train health sciences students at the University of Nairobi. East African Medical Journal Vol: 94 No. 2 February 2017:101-5.  Back to cited text no. 11
Lopez AD. The global burden of disease, 1990-2020. Nat Med 2020;4:1241-3.  Back to cited text no. 12
Emanuel EJ, Wendler D, Killen J, Grady C. What makes clinical research in developing countries ethical? The benchmarks of ethical research. Res Ethics 2018;189:241-8.  Back to cited text no. 13
Sexton TL. Reconstructing clinical training: In pursuit of evidence-based clinical training. Couns Educ Superv 2000;39:218-27.  Back to cited text no. 14


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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