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KNOWLEDGE, ATTITUDE, AND PERCEPTION OF NURSES AND PHYSICIANS REGARDING PHARMACEUTICAL-INITIATED CLINICAL RESEARCH IN UAE, QATAR, OMAN, BAHRAIN, AND JORDAN

Objective: The objective of the study was to understand the reasons for the limited number of pharmaceutical-initiated clinical studies in the Middle East region, by assessing the knowledge, attitudes, and perceptions related to pharmaceutical-initiated clinical trials among health-care professionals (HCPs) in UAE, Qatar, Oman, Bahrain, and Jordan. Methods: The study was conducted using an online questionnaire-based survey. The HCP respondents were from UAE, Qatar, Oman, Bahrain, and Jordan and had a good understanding of the English language. Descriptive statistical analysis was used to analyze the responses. Results: The HCPs were not inclined toward participation in clinical trials and research activities. The reasons for their limited participation included a lack of time, resources, and limited awareness about their legal protection associated with such studies, and the lack of necessary training and education related to clinical research. Conclusions: Although there is a willingness to participate in clinical trials conducted by pharmaceutical companies, HCPs face various ethical, administrative, and academic barriers. Addressing these issues would help increase the number of trials conducted in the Middle East region.


INTRODUCTION
The Middle East region has a population of 381 million [1]. However, it sponsors only under 1% of clinical trials globally [2]. While the pharmaceutical industry predicts that about 4% of its sales will come from the Middle East region in the future, currently only 0.4% of trial participants are from the region [3]. This study aimed to understand the probable reasons for the reduced number of pharmaceuticalinitiated clinical trials and research initiatives. It assessed the knowledge, attitudes, and perceptions of nurses and physicians toward pharmaceutical-initiated trials in UAE, Qatar, Oman, Bahrain, and Jordan.

Study design
The study was a quantitative, descriptive, cross-sectional, questionnaire-based survey involving HCPs. The survey questions were designed to gather insights related to the research question, i.e., "what are the perceptions, attitudes, and knowledge of nurses and physicians toward clinical research sponsored by pharmaceutical companies?" The questionnaire for the online survey was shared with the participants on their contact/email addresses that were available in the public domain. The survey was sent through a software called Survey Monkey. Before conducting the survey, a pilot study was carried out to analyze the acceptability of the questionnaire. As part of the pilot study, the questionnaire was first shared with two physicians and two nurses, who met the inclusion criteria. Questions that were unclear were reframed, and necessary feedback was addressed to ensure that the survey questions were in line with the objectives and goals of the questionnaire and well understood by the respondents.

Subject participation
The participants of the survey included nurses and physicians of varied specialties from UAE, Qatar, Oman, Bahrain, and Jordan, regardless of their experience in previously conducted clinical research programs.

Inclusion criteria
The following criteria were included in the study: • Adults 18 years or older • Proficiency in the English language • Nurses and physicians from different specialties working in medical institutions in UAE, Qatar, Oman, Bahrain, and Jordan • Individuals were complying with the above criteria and willing to participate in the survey

Exclusion criteria
The following criteria were excluded from the study: • Individuals not proficient in the English language • Individuals that were not medical staff working in medical institutions of selected countries • Individuals not willing to participate in the survey The list of HCPs was shortlisted by retrieving their details from the public domain; this was achieved by conducting a secondary research of hospital websites in UAE, Qatar, Oman, Bahrain, and Jordan. Individuals with accessible email addresses were contacted. Consent forms were sent to confirm their acceptance to participate in the survey. In addition to the consent form, an introductory email briefly highlighting the objectives of the survey was shared with them. The survey consent was received through email and participants were finalized. Fig. 1: Survey questionnaire. Section A assesses the demographics, Section B assesses the knowledge, attitude, and perception of health-care professionals, and Section C assesses the challenges and opportunities faced in a few Middle East regions

Measures/tools
The HCPs were sent screening questions to assess their eligibility for the survey. The finalized respondents were then sent a link directing them to the final survey questionnaire (Fig. 1).
The main questionnaire was divided into three sections (Fig. 1). Section A captured the demographics of the participants, i.e., age, gender, profession, specialty, nationality, experience in previous research, etc. Section B was designed to evaluate the first objective of the study, i.e., to assess the knowledge, attitudes, and perceptions of nurses and physicians related to clinical trials sponsored by the pharmaceutical industry in UAE, Qatar, Oman, Bahrain, and Jordan. Section C was designed to assess the second objective of the study, i.e., to identify the challenges and opportunities related to pharmaceutical-initiated clinical research in the medical communities in UAE, Qatar, Oman, Bahrain, and Jordan.

Statistical analysis
Once the survey results were obtained, a descriptive analysis of the data was performed. For each question, a response percentage was determined to better understand the trend of responses.

Confidentiality and ethical considerations
The survey was conducted after receiving approval from the Ethics Committee of the University of Liverpool. The survey responses were not linked to email addresses to maintain confidentiality of the participants and to avoid bias. Participant recruitment was coordinated in a non-coercive manner. Participant names or contact information was neither requested nor published in the results obtained from the survey. The methodology of the study is summarized in Fig. 2.

RESULTS
Two hundred HCPs were contacted; 75 participated in the survey, while 125 refused to participate. There were 52 physicians and 22 nurses in all. One of the participants did not wish to reveal their profession.

Demographics
The percentage of responses was calculated based on the total number of participants who attempted the question. The detailed responses for Section A of the questionnaire are provided in Table 1.

Knowledge, attitudes, and perceptions of nurses and physicians toward pharmaceutical-initiated clinical research
The percentage of responses was calculated based on the total number of participants who attempted the question. The detailed responses for Section B of the questionnaire are given in Table 2.

Challenges and opportunities faced by the medical community toward pharmaceutical-initiated clinical research
About 21.6% participants stated that it was permissible to conduct pharmaceutical-initiated research in their institution. The detailed responses for Section C of the questionnaire are given in Table 3.

Shereen Hammad
The study by Sulthan studied the attitudes of clinical investigators toward conducting clinical trials in Saudi Arabia and the barriers they encounter. The study showed that the majority of clinical investigators who worked at therapeutic departments of various academic hospitals intended to conduct research. Barriers such as lack of time, financial compensation, and encouragement were more apparent [5].
This is the first study to report the knowledge, attitude, and perception of HCPs regarding pharmaceutical-initiated clinical research in UAE,

Shereen Hammad
Qatar, Oman, Bahrain, and Jordan. It is also the first study that assessed the reasons for the lack of pharmaceutical-initiated clinical research and trials in the Middle East region. The limitation of the study is a smaller participation size; applying the results to a larger population would thus be difficult.

CONCLUSIONS
There are several barriers related to the knowledge, attitude, and perspective of nurses and physicians on the conductance of pharmaceutical-initiated clinical trials. Identifying barriers that could be administrative, cultural, and academic in nature; tackling them; and helping HCPs understand the importance of trials may change the status quo and increase the number of trials in the Middle East region. Future prospects include conducting a more detailed questionnairebased survey specific to individual barriers. This will help narrow down the exact cause of the reduced number of trials in the region. A questionnaire specific to therapeutic areas should be developed, as the answers may be different based on various specialties. Questionnaires specific to individual countries could be considered rather than a common questionnaire for all countries and a larger population could be targeted to better understand the gaps across countries. Now that nurses and physicians have been surveyed, more surveys on the barriers and challenges faced by medical research departments in the pharmaceutical companies could be conducted to further analyze the exact reasons for the reduced number of trials in the Middle East region.

AUTHOR'S CONTRIBUTION
The author was actively involved in conducting the survey as part of a research assignment/thesis with University of Liverpool.

CONFLICTS OF INTEREST
The author has no conflicts of interest to share.