
==== Front
Lancet Reg Health West Pac
Lancet Reg Health West Pac
The Lancet Regional Health: Western Pacific
2666-6065
Elsevier

S2666-6065(24)00175-5
10.1016/j.lanwpc.2024.101181
101181
Comment
Challenges or opportunities in developing clinical research in resource-limited regions? Insights from a province-wide survey of Chinese health professionals
Zheng Hua ae
Liu Fangfang be
Ke Ji be
Qiao Guangli ce
Wang Yanfu c
Ma Ling c
He Zhonghu zhonghuhe@foxmail.com
d∗∗
Lv Jinhan lvjhan@163.com
a∗∗∗
Ke Yang keyang@bjmu.edu.cn
d∗
a Health Commission of Ningxia Hui Autonomous Region, Yinchuan, Ningxia 750004, PR China
b Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genetics, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
c Reproductive Health Technology Guidance Service Center of Health Commission of Ningxia Hui Autonomous Region, Yinchuan, Ningxia 750010, PR China
d State Key Laboratory of Molecular Oncology, Beijing Key Laboratory of Carcinogenesis and Translational Research, Department of Genetics, Peking University Cancer Hospital & Institute, Beijing 100142, PR China
∗ Corresponding author. keyang@bjmu.edu.cn
∗∗ Corresponding author. zhonghuhe@foxmail.com
∗∗∗ Corresponding author. lvjhan@163.com
e These authors contributed equally to this work.

27 8 2024
9 2024
27 8 2024
50 10118119 6 2024
7 8 2024
14 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
==== Body
pmcClinical research, essential for medical advancements, has thrived in China thanks to increased government funding, the establishment of National Clinical Research Centers,1 and streamlined regulatory approvals.2 However, regional disparities persist,3 with resource-limited regions producing far less research compared with affluent areas like Beijing, Shanghai, and Guangzhou (Supplementary Fig. S1). To bridge the gap and learn from both successes and failures in resource-rich areas, it is crucial to identify challenges and opportunities facing clinical research in resource-limited areas for informed decision-making and strategic resource allocation. However, relevant evidence on research in such regions in China is lacking, hindering effective policy formulation.

In 2022, we randomly sampled 66 out of all the 89 hospitals at or above county level in Ningxia Hui Autonomous Region (Ningxia), an underdeveloped region in northwestern China (Supplementary Fig. S2), and investigated ∼20% of frontline health professionals per hospital on their motivations for participating in clinical research, capacity deficiencies, external barriers, and reasons for non-participation (more details in the Supplementary file). Through this province-wide survey, we propose policy recommendations for future reforms in similar settings.

A total of 6833 healthcare professionals provided valid responses, with 22.2% (1516) reporting prior clinical research involvement (Table 1). Factors such as older age, male gender, higher education, and employment in tertiary hospital positively correlated with research involvement (all P < 0.001). Internists showed similar involvement as surgeons (P = 0.267), while nurses (P = 0.014) and medical technicians/pharmacists (P = 0.001) were less engaged. Staff from maternity and child health hospitals (P = 0.015) were less involved than those from general hospitals (Table 1).Table 1 Selected characteristics of survey subjects and their associations with ever participation in clinical research in Ningxia Hui Autonomous Region, China, 2022.

Characteristics	Total (N = 6833)	With clinical research experience (N = 1516, 22.2%)	Without clinical research experience (N = 5317, 77.8%)	Multivariable OR (95% CI)a	P valuea	
Age group						
 ≤30 years	2077 (30.4)	191 (12.6)	1886 (35.5)	Ref.	–	
 31–40 years	2941 (43.0)	714 (47.1)	2227 (41.9)	2.56 (2.07–3.16)	<0.001	
 41–50 years	1246 (18.2)	426 (28.1)	820 (15.4)	5.50 (4.34–6.97)	<0.001	
 >50 years	569 (8.3)	185 (12.2)	384 (7.2)	5.80 (4.35–7.72)	<0.001	
Sex						
 Female	5334 (78.1)	977 (64.4)	4357 (81.9)	Ref.	–	
 Male	1499 (21.9)	539 (35.6)	960 (18.1)	1.58 (1.32–1.89)	<0.001	
Education level						
 Junior college	1402 (20.5)	102 (6.7)	1300 (24.4)	Ref.	–	
 Undergraduate	4796 (70.2)	900 (59.4)	3896 (73.3)	1.92 (1.52–2.44)	<0.001	
 Graduate	635 (9.3)	514 (33.9)	121 (2.3)	17.83 (12.75–24.94)	<0.001	
Specialties						
 Surgery	764 (11.2)	275 (18.1)	489 (9.2)	Ref.	–	
 Internal medicine	1805 (26.4)	656 (43.3)	1149 (21.6)	1.14 (0.91–1.43)	0.267	
 Nursing	3059 (44.8)	364 (24.0)	2695 (50.7)	0.72 (0.56–0.94)	0.014	
 Medical technology/Pharmacy	1205 (17.6)	221 (14.6)	984 (18.5)	0.64 (0.49–0.84)	0.001	
Hospital type						
 General hospital	3372 (49.3)	807 (53.2)	2565 (48.2)	Ref.	–	
 Traditional Chinese medicine hospital	2436 (35.7)	550 (36.3)	1886 (35.5)	1.16 (1.00–1.36)	0.054	
 Specialized hospital	113 (1.7)	58 (3.8)	55 (1.0)	6.68 (4.25–10.51)	<0.001	
 Maternity and child health hospital	912 (13.3)	101 (6.7)	811 (15.3)	0.71 (0.54–0.93)	0.015	
Hospital tierb						
 Primary or secondary	4257 (62.3)	362 (23.9)	3895 (73.3)	Ref.	–	
 Tertiary	2576 (37.7)	1154 (76.1)	1422 (26.7)	5.75 (4.93–6.71)	<0.001	
CI, confidence interval; OR, odds ratio.

a Multivariable OR and P values were calculated using a multivariable logistic regression model adjusted for age group, sex, education level, physician specialties, hospital type, and hospital tier. The group without clinical research experience was used as the reference group.

b Hospitals in China are categorized into three tiers, with tertiary hospitals representing the highest level of quality (as queried through http://zgcx.nhc.gov.cn:9090/unit/index).

For those with prior research experience, professional title promotion was the primary motivator (82.8%), followed by addressing clinical practice problems (68.0%), pursuit of socio-economic benefits (42.5%), personal interest (28.3%), and following orders of department/hospital leaders (16.2%) (Fig. 1). After age stratification, professional title promotion remained primary for respondents aged 31–50 (88.8%), while others (≤30 years, 65.4%; >50 years, 73.5%) prioritizing addressing clinical practice problems (Supplementary Fig. S3).Fig. 1 Motivations for participation, capacity deficiencies, external barriers, and reasons for non-participation in clinical research among the survey respondents in the Ningxia Hui Autonomous Region, China, 2022. Note: The information about motivations for participation in clinical research, deficiency in clinical research capabilities, and external barriers to clinical research were only collected among the survey subjects with prior clinical research experience (N = 1516). The information about reasons for not participating in clinical research were only collected from the respondents without prior clinical research experience (N = 5317).

The respondents reported deficiencies in research design (73.0%), statistical analysis (68.9%), academic writing (67.7%), research question identification (63.2%), and literature review (47.5%) (Fig. 1). Younger respondents reported fewer deficiencies (≤30 years: average 49.8%; >30 years: average 66.1%; P≤30 years vs. >30 years < 0.001), while deficiencies in statistical analysis increased with age (≤30 years: 46.6%; 31–40 years: 69.6%; 41–50 years: 74.9%; >50 years: 75.7%; Ptrend < 0.001; Supplementary Fig. S4).

Heavy clinical workload (78.4%) and lack of support (74.7%) were primary external barriers. Other barriers included publishing challenges (51.3%), inadequate funding (43.9%), lack of relevant training (40.5%), lack of supportive clinical research infrastructure (38.0%), and limited understanding of research policies/regulations (30.9%) (Fig. 1).

Top reasons for non-participation were deficiencies in research capacity (60.6%), lack of guidance (59.0%), and time constraints (53.0%), followed by pressure from clinical research (18.1%), not needing professional title promotion immediately (17.9%), and lack of interest (5.3%) (Fig. 1).

We also conducted sensitivity analysis stratified by age, sex, education level, specialties, hospital type, and hospital tier. Generally consistent patterns were observed across all these subgroups (Supplementary Figs. S3–S6).

This study, for the first time, comprehensively elucidated the current status of and barriers to clinical research in a typical resource-limited region in China. Based on the findings, the current national context in China, and experiences from developed regions, we propose the following recommendations concerning resource allocation and policy formulation to boost clinical research in such resource-limited regions.

Establishing a “dual career path” system of professional promotion for frontline medical staff

Our survey revealed that professional promotion is the primary motivator for engaging in clinical research, surpassing the desire to address clinical problems or personal interests. This trend, particularly prevalent among healthcare professionals aged 31–50, reflects the pervasive influence of cutthroat competition (involution, or “Neijuan” in Chinese) in China’s clinical research landscape. The current promotion criteria, which prioritize research output, risk incentivizing research that is repetitive, low-quality, and potentially fraudulent.4,5 To address this issue, we recommend a dual career path system that recognizes both clinical proficiency and research output. This system would allow individuals to fulfill different career aspirations and aptitudes, encompassing separate tracks for “physician/clinician-scientists” focusing on research and clinicians evaluated based on clinical experience.6 Extending this dual path system to hospital rankings would relieve the pressure on hospital leaders, potentially easing the burden on frontline healthcare professionals to produce research solely for promotion. Primary and secondary hospitals could prioritize standardized care and community engagement, while tertiary hospitals could focus on both research and clinical proficiency.6

Enhancing education and training in clinical research methodology for clinician-scientists

Many respondents, regardless of previous research experience, cited a lack of training opportunities and deficient research capacity as significant barriers, highlighting the need for training in research topic selection, study design, research management, statistical analysis, academic writing, and literature review.7,8 Inadequate training, particularly in resource-limited areas, has led to deficiencies in research capacities and methodological knowledge,9 even among highly educated clinicians in tertiary hospitals, ultimately resulting in poor-quality clinical research.7, 8, 9 To fill the gaps, targeted education and training in clinical research methodology are essential. Incorporating clinical research courses into medical curricula offers foundational knowledge. Continuing education and tailored training can sharpen research skills, build confidence, and foster interest. These programs should address age-specific challenges8 and provide comprehensive, multi-stage learning opportunities that combine hands-on skills with theoretical guidance for optimal effectiveness.

Building platforms for intra- and inter-regional cooperation with outstanding research teams

Clinical research in resource-limited regions faces challenges like lacking scientific infrastructure and expert support. To optimize resource utilization, multicentric collaboration is crucial. Additionally, establishing multidisciplinary teams comprising experts in legal regulations, ethics, clinical practice, epidemiology, and statistics is essential for better protecting research participants’ rights, identifying clinical questions, developing rigorous research plans, performing robust analyses, and translating findings into improved patient care.10 Building multi-center, multidisciplinary cooperation platforms requires concerted internal and external efforts. Internally, resource-limited regions should mobilize specialized departments or experts from outstanding institutions to form leading research teams. Externally, collaborating with leading hospitals and institutions in resource-rich areas can address local needs and enhance research capabilities. Such collaborations should leverage the unique disease profiles and clinical demands of resource-limited regions with the research expertise of resource-rich areas.

Additionally, leveraging the advancements in artificial intelligence and mobile internet technology to enhance research efficiency and quality (e.g., Decentralized Clinical Trials), establishing third-party oversight for data security (e.g., Independent Data Monitoring Committees), implementing a regional Mutual Recognition Alliance of Medical Ethics Review to safeguard participants’ rights, and setting up dedicated, government-funded channels to ensure the sustainability of clinical research are all crucial issues that should be seriously considered in order to collectively boost clinical research efforts in resource-limited regions.

In summary, health professionals in resource-limited regions encounter significant obstacles hindering their engagement in high-quality clinical research. To overcome these challenges and achieve sustainable development, need-based strategies and tailored support policies are essential. Future policy implementation research is warranted to confirm the suitability and effectiveness of the recommendations proposed in this report.

Contributors

Conception and design: JL, HZ, YK, ZH. Acquisition of data: GQ, YW, and LM. Analysis and interpretation of data: JL, YK, ZH, FL, and JK. Manuscript drafting and final approval: all authors.

Data sharing statement

The primary data used to support the findings of this study are available from the corresponding authors (keyang@bjmu.edu.cn; zhonghuhe@foxmail.com; lvjhan@163.com) upon request.

Editor note

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

The authors declare no potential conflicts of interest.

Appendix A Supplementary data

Supplementary Figs. S1–S6

Acknowledgements

The authors are very grateful to all participants for supporting this study.

Appendix A Supplementary data related to this article can be found at https://doi.org/10.1016/j.lanwpc.2024.101181.
==== Refs
References

1 Yang Z. Jiang L. Building clinical research capacity in China: the national clinical research centres Lancet 383 9913 2014 200 201 24290403
2 Wu Y. Yin D. Abbasi K. China's medical research revolution BMJ 360 2018 k547 29437660
3 Fan R. Zheng Y. Zhou R. Chinese Clinical Trial Registry 13-year data collection and analysis: geographic distribution, financial support, research phase, duration, and disease categories Front Med 10 2023 1203346
4 Chen S. Pan Y. Yao Q. Yao L. Liu Z. Xiang L. Publication pressure on Chinese doctors--another view Lancet 384 9947 2014 956 25220974
5 Yuan H.F. Xu W.D. Hu H.Y. Young Chinese doctors and the pressure of publication Lancet 381 9864 2013 e4
6 Zhang Z. Winston G.P. Zhao H.T. Focus on China: should clinicians engage in research? and lessons from other countries Quant Imaging Med Surg 4 5 2014 413 425 25392826
7 Ji P. Chu H. Zhang C. How to strengthen clinical research in Shenzhen, China: qualitative study BMJ Open 9 4 2019 e024534
8 Liu W. Huang W. Liu C. Li P. Chen J. An exploratory study on needs for clinical research training: data from Chinese hospitals BMC Med Educ 21 1 2021 559 34727906
9 Hu Y. Huang Y. Ding J. Status of clinical research in China Lancet 377 9760 2011 124 125 21215881
10 Jing X. Hua G. Analysis of clinical research publication patterns to characterize the cooperation among China's "double first-class" construction medical universities: based on social network analysis Ann Transl Med 10 6 2022 320 35433964
