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Original Article

Journal of Health Services Research &

Policy
Knowledge, attitude and practice 0(0) 1–10
! The Author(s) 2020
towards health research and its Article reuse guidelines:
sagepub.com/journals-permissions
utilization among health professionals DOI: 10.1177/1355819620954481
journals.sagepub.com/home/hsr

in Bhutan: Results of a nationwide

cross-sectional survey in 2019

Thinley Dorji1,2 , Shacha Wangmo3, Mongal Singh Gurung4 ,

Karma Tenzin5, Tashi Penjore6 and
Don Eliseo Lucero-Prisno III7

Abstract
Objectives: Research is an important tool for sustainable development and the advancement of health. In Bhutan, the
need for strengthening the national health research effort has been recognized only in recent years. As a part of research
capacity building, this study was conducted to assess the knowledge, attitude and practices of the country’s health care
professionals towards research.
Methods: This was a nationwide cross-sectional study. Simple random sampling was used to obtain a proportionate
composition of health professionals. A self-administered questionnaire was developed to assess knowledge through 10
multiple-choice questions, attitude through rating statements, and practices through assessing experiences with
research. Knowledge was scored out of 10. Besides analysing proportions, correlation and simple linear regression
coefficients were calculated to assess the association of knowledge score with age, work experience, qualification, and
the number of research projects undertaken.
Results: A total of 420 valid questionnaires were collected (response rate ¼ 95.2%). The mean knowledge score was
6.2 (2.0) out of 10. There was a negative correlation between the knowledge score and the participant’s age (r ¼ –0.15,
p ¼ 0.002) and work experience (r ¼ –0.17, p < 0.001). Participants’ knowledge score increased by 0.58 (95% CI: 0.50–
0.65, p < 0.001) for each unit increase in qualification level and by 0.75 (95%CI: 0.64–0.87, p < 0.001) for every research
project conducted. The majority believed that local research would contribute to better clinical decision making (92.8%)
by building local evidence (90.3%). Four out of five participants expressed interest in conducting research. However, only
27.4% had ever conducted research, 6.0% had published in journals and 4.3% had presented in scientific conferences.
Less than half of the respondents had read (35.2%) or participated in discussions (42.1%) of research articles in their
workplace. The major challenges were lack of knowledge (61.2%), time (49.9%) and resources to undertake literature
searches (42.6%).
Conclusions: Self-reported knowledge about health research was fair, and the conduct of research and utilization of
research articles were poor. However, the majority hold positive attitudes and there is a need for supporting profes-
sional development in this area.

Keywords
research capacity building, evidence-based health care, research ethics

1
Medical Officer, Jigme Dorji Wangchuck National Referral Hospital,
Bhutan
2 6
Medical Officer, Kidu Mobile Medical Unit, His Majesty’s Peoples’ Medical Officer, Central Regional Referral Hospital, Bhutan
7
Project, Bhutan Tutor, London School of Hygiene and Tropical Medicine, UK
3
Medical Officer, Royal Bhutan Army Medical Services, Bhutan
4
Senior Research Officer, Health Research and Epidemiology Unit, Corresponding author:
Ministry of Health, Bhutan Thinley Dorji, Kidu Mobile Medical Unit, His Majesty’s Peoples’ Project,
5
Assistant Professor, Faculty of Postgraduate Medicine, Khesar Gyalpo Menkhang Lam, Thimphu 11001, Bhutan.
University of Medical Sciences of Bhutan, Bhutan Email: dorji.thinleydr@gmail.com
2 Journal of Health Services Research & Policy 0(0)
Introduction
Health research is an important tool for sustainable
development and global improvements in health1,2.
Research for health is vital in developing the technol-
ogy, systems and services needed to achieve universal
health coverage and development goals3. The World
Health Organization has called for four areas of inter-
ventions in the field of health research: prioritization of
health research to meet the health needs of countries,
strengthening health research systems, promotion of
good research practice to meet scientific and ethical
standards, and translation of evidences into practice2.
Recognizing that some questions require local evidence
and to close the ‘10/90 gap’ (only 10% of global resour-
ces on health research are spent on diseases and con-
ditions that cause 90% of the global burden of ill-
health), it is important for all countries to be producers
of research as well as consumers of it3.
The World Health Organization defines ‘research’ as
a set of formal methods that turns promising ideas into
practical solutions for improving health services, and
consequently improving health3. This includes research
of all designs using both primary and secondary data.
Many countries and organizations across the globe
have responded to health research capacity building
through various training modules and platforms4,7.
The Americas and Asia have seen significant growth
in research measured in terms of the number of pub-
lications or systematic reviews3. Investment in research
and development in low- and middle-income countries
has been growing at 5% per year faster than economic
output3. The World Health Report 2013, however,
acknowledged that health research development is not
uniformly high standard3. Many low- and middle-
income countries (LMICs), like Bhutan, critically lack
behind in the four strategic areas of interventions in
promotion and utilization of health research8,9.
Bhutan is a small country situated in the eastern
Himalayas with a population of 0.7 million10. It is
classed as a lower-middle income country, and
embarked on modern development in the 1960s11.
The country’s health system was established against
the background of a poor socioeconomic condition,
low literacy, limited infrastructure and limited health
human resources12. In the subsequent decades,
Bhutan’s focus was on strengthening primary health
care, expansion of services, and training of selected cat-
egories of health human resources – health assistants,
technicians and nurses12. As a result, Bhutan achieved
major successes in health indicators. The maternal
mortality rate decreased from 255 deaths per 100,000
live births in 2000 to 86 per 100,000 live births in
201213. The infant mortality rate has reduced from 61
per 1000 live births in 2000 to 30 per 1000 live births in
201213. The neonatal mortality rate was 21 per 1000
live births in 201213. The rate of stillbirth in 2015
among institutional deliveries was 10 per 1000 live
births, much lower than the global estimate of 18.4
per 1000 live births14. The country eliminated smallpox
in 1974 and eradicated polio in 1986 (two years prior to
the launch of the Global Polio Eradication
Initiative)15,16. To sustain these gains and to achieve
universal health coverage, health research is a vital
means in the delivery of high-quality, equitable and
sustainable health services. This is especially so in
Bhutan, where health care is delivered free.
Health research was prioritized only relatively
recently in Bhutan. The Ministry of Health established
the Health Research and Epidemiology Unit in 1995
and Bhutan’s first ethics review board for biomedical
research was established in 200917. The Bhutan Health
Journal, the country’s only medical journal, was
launched in 2015, and a medical education and
research centre was established in 2016 at the Khesar
Gyalpo University of Medical Sciences of Bhutan
(KGUMSB), the country’s only medical university.
The current study was conducted to assess the base-
line situation on the knowledge and attitude of
Bhutanese health professionals towards health
research. We have limited the scope of ‘research’ to
operational research, which is more relevant and feasi-
ble in the current settings. We also assessed Bhutanese
health professionals’ practice in terms of the number of
research projects and publications and utilization of
published research articles in their clinical, public
health and administrative practices.
Method
Study design, study setting and the study population
This was a cross-sectional study conducted among
licensed health professionals working at all three
levels of the health care facilities. Bhutan has a three-
tiered health system (Basic Health Units at the primary
level, general/district hospitals at the secondary level
and referral hospitals at the tertiary level) and has
four major categories of health human resource related
to clinical and public health delivery of services – doc-
tors, nurses, allied health professionals and traditional
medicine practitioners (Table 1)18. With a density of 5
doctors and 18.4 nurses for every 10,000
population, health care professionals are primarily
tasked by the Ministry of Health with clinical job
responsibilities19.
Dorji et al. 3

Table 1. Number of health professionals, by major professional job discipline, in the Bhutanese health system in 2019 and the
proportion of participants of the Health Research Capacity KAP study 2019.

Total number of health

professionals, 2018d Participants for this study

Actual
Total numbere Percentage Percentage to Number to number Percentage in Percentage
Professional job discipline (2018) (2018) be sampled be sampled sampled the sample of response

Doctorsa 345 9.9 19.8* 87 83 19.8 95.4

Nursesb 1264 36.1 36.1 159 152 36.2 95.6
Drungtsho/sMenpac 168 4.8 7.4 33 27 6.4 81.8
Technicians, physiotherapists, 1723 49.2 36.7 162 158 37.6 97.5
pharmacists, dieticians,
health assistants, medical
lab technologistsd
Total 3500 100 100 441 420 100 95.2
a
The Annual Health Bulletin considers all these categories as one – Bachelor of Medicine and Surgery (MBBS), Bachelor/Master of Dental Surgery
(BDS/MDS), specialists (Postgraduate degree in Medicine or Surgery).
b
The Annual Health Bulletin and the Bhutan Medical and Health Council considers all nurses with various levels of qualifications as one category –
Assistant nurse (Certificate in Nursing), Diploma in General Nursing and Midwifery (GNM), Bachelor/Master of Nursing (BSc/MSc Nursing).
c
Traditional healers and their apprentices.
d
The Bhutan Health and Medical Council considers these as one category.
e
Annual Health Bulletin, Ministry of Health, Bhutan 201818. Data from 2018 was used to calculate sample size for the study conducted in 2019.
*Since the survey sample was not self-weighting, weighted analysis was carried out.

Sample size Study instrument

In the absence of any sort of assessment in this field,
we assumed that 50% of the respondents would
have good knowledge of conducting health
research and the utilization of health research articles.
The sample size was calculated for proportions consid-
ering a 95% confidence level and 0.05 margin of error.
Allowing for a 15% dropout rate, the final sample size
was 441.
Sampling method and data collection
With the exception of doctors, a simple random
sampling method was used to obtain a proportionate
percentage composition of health workers. For
doctors, double the proportion in population was
taken, as the number of doctors in the country is
relatively low and doctors are at the centre of clinical
decision making. All categories of doctors were
grouped together. Random sequences were generated
using Microsoft Excel and matched against the list
of health professionals registered under the
Bhutan Medical and Health Council. The selected
individuals were contacted through phone, and the
questionnaires were delivered through email or
post between March to May 2019. Participants were
provided with a set of the information sheet, informed
consent form and a self-administered questionnaire in
English.
The questionnaire was designed to collect respondents’
basic information and assessment of knowledge, atti-
tude, and the practice of conducting ‘operational health
research’, as well as utilization of research articles (the
questionnaire can be viewed online). There were 10
multiple-choice questions to assess the knowledge on
the key steps in conducting health research. The atti-
tude questions were designed, with four-point Likert
scale responses (strongly disagree, disagree, agree and
strongly agree), to assess the intrinsic and extrinsic fac-
tors of motivation to conduct research. The questions
also assessed how health workers perceived their work-
ing department and the government’s support for
research. To determine whether a respondent has con-
ducted research, we asked whether they had produced
publications and conference presentations. The utiliza-
tion of research was measured in terms of how many
research articles or clinical guidelines related to patient
care were read or discussed in respondents’ depart-
ment/hospital in the past six months. These questions
were developed through a review of literature5,20 and
through a brainstorming session with the teachers of
health research at the KGUMSB, and the directors and
trainers of Bhutan’s Structured- and Mentoring-
Approach to Research Training (B-SMART), an oper-
ational research training programme.
To assess its face validity, the questionnaire was
tested by a set of five doctors and 10 nurses at the
4 Journal of Health Services Research & Policy 0(0)

National Referral Hospital in Thimphu, Bhutan’s cap- Table 2. The basic characteristics of the health professionals
ital city. Various dimensions of face validity were con- surveyed for the Health Research Capacity KAP study, Bhutan,
sidered – readability and ease of understanding, 2019.
likelihood that the target audience would understand Participants
the questions, layout and formatting – and changes
made accordingly. For content validity, the question- Characteristics n %
naire was scored by a panel of nine reviewers knowl- Total participants 420 100.0
edgeable in conducting research. The reviewers were Age group
from Thailand, Hong Kong, USA, Sri Lanka, 18 to 24 years 32 7.6
Cambodia and Bhutan. It was reviewed in two steps 25 to 34 years 295 69.5
and its S-CVI was 0.93. For this questionnaire, 35 to 44 years 69 16.4
Cronbach’s alpha for internal consistency was 0.90. 45 to 54 years 26 6.2
55 to 64 years 1 0.3
Work experiencea
Data processing and analysis
0 to 5 years 260 62.1
The questionnaire was coded and double entered into 6 to 10 years 72 17.2
Epi-data Entry version 3.1 (EpiData Association, 11 to 20 years 65 15.5
Odense, Denmark) and analysed in STATA Version 21 to 30 years 22 5.2
13.1 (StataCorp. 2013. Stata Statistical Software: Highest qualification
Release 13. College Station, TX: StataCorp LP). PhD 0 0.0
Masters or postgraduate degree 34 7.9
Knowledge was rated from a score of 10. For the
Undergraduate 134 31.2
attitude questions, responses ‘strongly disagree’ and
Diploma 147 34.2
‘disagree’ are presented as ‘disagree’, and responses Certificate 115 26.7
‘agree’ and ‘strongly agree’ are presented as ‘agree’. Primary employerb
Since the survey sample was not self-weighting, a Ministry of Health 388 93.5
weighted analysis was carried out. The weights were Royal Bhutan Army medical services 7 1.7
derived using the sampling weight with adjustment Khesar Gyalpo University 19 4.6
for non-response. Correlation and linear regression of Medical Sciences of Bhutan
coefficients were calculated to predict knowledge Private diagnostic firms 1 0.2
score based on the age and sex of the participant, Missing ¼ 1.
a

years of work experience, qualification, whether Missing ¼ 5.

b

respondents had received research training, and wheth-

er they had conducted and published health research. P
values less than 0.05 were considered significant.
Attitude towards health research is reported according
to themes expressed in the statements. Practices on the
conduct of health research and its utilization are pre-
sented in terms of research outputs.
Ethical considerations
The study was conducted in compliance with the ethi-
cal principles of the Helsinki Declaration. Ethics review
was exempted by the Research Ethics Board of Health,
Ministry of Health, Bhutan as this was a non-
biomedical research. However, informed consent was
obtained during data collection. For confidentiality,
the data were anonymized and only the pooled/aggre-
gate results are presented.
Results
Background characteristics of the study sample
A total of 420 valid questionnaires were collected
(response rate ¼ 95.2%). The mean age was 30.9
( SD 6.5) years and the median duration of work
experience was 4 years (IQR 1–28 years). There were
255 (60.7%) males. Three-quarters of the participants
were younger than 35 years (397, 77.9%) and had work
experience less than 10 years (332, 79.0%), and very few
had postgraduate degrees (34, 8.1%) while none had
PhDs. The basic details of the survey participants are
shown in Table 2.
Knowledge and attitude towards conducting research
The self-rating of knowledge on how to conduct and
utilize research was ‘good’ in 97 (24.6%), ‘fair’ in 233
(53.5%) and ‘poor’ in 90 (21.9%) health care profes-
sionals. The majority had not received in-service train-
ing on research (363, 88.0%).
The majority (287, 65.3%) knew that the definition
of research was a scientific analysis of health and med-
ical problems and that all categories of healthcare
workers can conduct operational research (361,
83.5%). Two-thirds (304, 70.4%) knew the ethics
review organization in the country. However, only a
Dorji et al. 5

Table 3. Self-reported knowledge on health research among health professionals surveyed in the Health Research Capacity KAP
study, Bhutan, 2019.*

Participants

Characteristics Responses n Weighted %

Total participants 420 100.0

Which of the following is a definition Correct 287 65.3
of “research”? Incorrect 133 34.7
Who can conduct research? Correct 361 83.6
Incorrect 59 16.4
Which of the following is the first step Correct 148 34.4
in conducting research? Incorrect 272 65.6
What is a research question? Correct 334 78.6
Incorrect 86 21.4
What does a research proposal include? Correct 305 71.3
Incorrect 115 28.7
What is a “literature review”? Correct 257 58.5
Incorrect 163 41.5
After writing the proposal for research in health in Correct 304 70.4
Bhutan, which organization issues the ethical Incorrect 116 29.6
clearance as of 2019?
Regarding data collected for research, at which Correct 284 65.1
of the following steps can errors occur? Incorrect 136 34.9
Which of the following are media through which Correct 303 69.2
research findings can be disseminated? Incorrect 117 30.8
Journals are rated by their impact factor. Correct 129 28.5
Which of the following is the journal with Incorrect 291 71.5
the maximum number of citations?
*The study questionnaire can be viewed online.

third of the respondents (148, 34.4%) knew that fram-
ing the research question was the first step in initiating
the process of research and only just over half (257,
58.5%) knew that literature review involves a critical
assessment of existing scientific publications. With
regard to publication knowledge, only a quarter (129,
28.5%) knew about the impact factor of scientific jour-
nals. The details on the knowledge assessment are
shown in Table 3.
The mean knowledge score on how to conduct
research was 6.2 (2.0) out of 10. There was a negative
correlation between the knowledge score and the par-
ticipant’s age (r ¼ –0.15, p ¼ 0.002) and work experi-
ence (r ¼ –0.17, p < 0.001). A simple linear regression
showed a significant relationship between the knowl-
edge score and the qualification of the participant
(p < 0.001) and the number of research projects the
participant had undertaken (p < 0.001), with an adjust-
ed R2 of 0.17. Participant’s knowledge score increased
by 0.58 (95% CI: 0.50–0.65) for unit increase in qual-
ification level and by 0.75 (95%CI: 0.64–0.87) for every
research project conducted.
The majority of respondents (344, 83.1%) said that
they were interested in conducting research to contrib-
ute to society, clinical and policy decision making
(389, 92.8%) and generate local evidence for Bhutan’s
health system (377, 90.3%). However, half of the
respondents felt research may not influence govern-
ment and policy decisions (196, 49.4%). The details
on respondents’ attitudes towards health research are
shown in Table 4.
Conduct and utilization of research articles
Almost three-fourths (305, 77.3%) of the respondents
had never conducted any health research. Among those
who were interested in conducting research, only 98
(24.0%) had actually done at least one research project.
Overall, only 44 participants (13.4%) had received in-
service training on health research. Among those who
received research training, just under half of them (20,
45.5%) had conducted research projects with a mean of
1.7 (range 1–14) projects. Journal articles (25, 22.9%)
and books (19, 20.7%) were the main research outputs.
Among those who conducted research, the commonest
challenges were lack of knowledge (74, 61.2%), time
(59, 49.9%) and resources to conduct literature
search (52, 42.6%). The details of research outputs
and challenges in conducting health research in
Bhutan are shown in Table 5.
6 Journal of Health Services Research & Policy 0(0)

Table 4. The attitude ratings toward health research among health professionals surveyed in the Health Research Capacity KAP
study, Bhutan, 2019.

Participants

Characteristics Responses n Weighted %

Total participants 420 100.0

Very interested to conduct research1 Agree 344 83.1
Disagree 73 16.9
Wants to conduct research to contribute to society, clinical Agree 389 92.8
decision making and policy formulation1 Disagree 28 7.2
Wants to conduct research to contribute to building local Agree 377 90.3
evidence for Bhutan’s health system1 Disagree 40 9.7
Wants to conduct research for promotion Agree 135 31.0
Disagree 285 69.0
Wants to conduct research for monetary incentive Agree 106 25.7
Disagree 314 74.3
Wants to conduct research to be employed in an international organisation1 Agree 172 40.5
Disagree 245 59.5
Wants to conduct research because of chances to attend Agree 301 72.7
international conferences Disagree 119 27.3
Feels encouraged by seniors and peers to conduct research2 Agree 315 76.1
Disagree 99 23.9
Boss is supportive of conducting research2 Agree 303 77.2
Disagree 111 22.8
Department is supportive of research Agree 290 70.1
Disagree 130 29.9
Government policies encourage the conduct of research2 Agree 282 70.9
Disagree 132 29.1
Feels research may NOT influence government and policy decisions3 Agree 196 49.4
Disagree 219 50.6
1
missing ¼ 3;
2
missing ¼ 6;
3
missing ¼ 5

In the past six months prior to the survey, half of
participants (214, 50.8%) had read research articles
related to their work and 176 (42.1%) had participated
in a discussion of research articles at department-level
fora. The majority of readers used online journal mate-
rials (148, 65.7%) and print journal was available only
to 80 (36.2%).
Discussion
Research capacity
This is the first assessment of the individual capacity
for performing health research among health workers
in Bhutan. Only about one-fourth of respondents had
‘good’ self-rated ability to conduct research and the
mean knowledge score on how to conduct research
was 6.2 out of 10. Many lacked understanding on
basic knowledge on key steps in conducting operation-
al research such as framing research questions, review-
ing existing literature and journal’s publication indices.
This is consistent with the findings of poor capacity
among health workers in LMICs to conduct academic,
operational or clinical research8,9,21. Many countries
responded to the Commission on Health Research for
Development’s 1990 report and the World Health
Report 2013, resulting in increased publications and
outputs3. Research knowledge was shared through
many platforms around the globe with a specific
focus on areas of interest such as mental health, mater-
nal health and in operational research5,7,22. However,
global research capacity strengthening interventions
and donor funds among LMICs have remained
uneven. In South Asia, the distribution of training
resources is skewed towards India, Sri Lanka,
Bangladesh and Pakistan7,8. Very few health workers
in our survey had received in-service training in health
research capacity building within and/or outside the
country.
The World Health Organization strategy on
research for health advocates for the enhancement of
research capacity of organizations and health research
Dorji et al. 7

Table 5. The practice, conduct and utilization, of health research among health professionals surveyed in the Health Research
Capacity KAP study, Bhutan, 2019.

Participants

Characteristics n Weighted %

Total participants 420 100.0

Conducted research wholly or partially
Yes 115 22.7
No 305 77.3
Publications in the last five years1
Books 19 20.7
Journal articles 25 22.9
Conference paper or poster 18 13.8
Others (brochures, standard operating procedures, etc) 10 7.6
None (No publication) 358 87.1
Challenges in the conduct of research1 (n ¼ 115)
Lack of knowledge 74 61.2
Lack of time 59 49.9
Lack of resources for literature search 52 42.6
Poor speed of internet for literature search 40 30.8
Long ethics approval time 36 33.0
Long administrative approval time 23 20.0
Research articles read in the past six months
0 articles 206 49.2
1 to 5 articles 186 45.3
6 to 10 articles 22 4.1
More than 10 articles 6 1.4
Sources of research articles1 (n ¼ 214)
Journal websites 148 65.7
Print journals 80 36.2
National conferences 75 34.1
International conferences 34 12.4
Others (internet, mobile applications, etc.) 9 4.2
1
Will not sum to total as multiple responses were allowed among those who published one or more articles in the past six months.

systems through the development of individual
research capacity2,8. In our study, research knowledge
score was higher among those with younger age and
lesser work experience groups. This is a reflection of the
adoption of a research culture in the country, as well as
among those in the region where most of Bhutan’s
health workers are trained. In providing postgraduate
and masters programmes, the KGUMSB has instituted
a student research culture. Moreover, publication in
peer-reviewed journals is a mandatory requirement
for appointment and promotion for all health care pro-
fessionals in the university. This is an important factor
in boosting research culture among the teaching facul-
ties and potential faculty members.
In our study, only a quarter of the health workers
surveyed had participated in at least one piece of
research, inclusive of those conducted as an academic
requirement. Further, the majority of the material was
published in journals that were not indexed. The
research output, therefore, (measured by the Global
Observatory for Health Research and Development)
in terms of publications score for Bhutan is minimal
and far behind output from the regional South Asian
nations23. But there is cause for optimism. Although
the number of health care professionals who have con-
ducted research is low, eight out of 10 health care pro-
fessionals in Bhutan are interested in conducting
research. The majority held a positive attitude that
research in Bhutan would contribute to generating
local evidence.
The major challenges in conducting research were
lack of capacity, time and resources. In addition,
there is lack of mentorship and limited access to statis-
ticians and research methodologists. These are chal-
lenges that echo throughout many LMICs1,24. With
one of the lowest densities of doctors and nurses in
the world, all the health workers in Bhutan are
employed in the clinical departments and lack the
time for other activities and initiatives25. However,
the gap in public health research to some extent is
8 Journal of Health Services Research & Policy 0(0)
filled by the Health Research and Epidemiology Unit
of the Ministry of Health and the Royal Centre for
Disease Control, which conduct surveillance of diseases
such as HIV/AIDS and outbreak investigations.
Research utilisation
The Ministry of Health’s National Health Policy 2011
established research as a part of the health system in
Bhutan and as the foundation of evidence-based med-
icine, both for the allopathic and the Bhutanese
Traditional Medicine systems26. However, this survey
shows that the utilization of research articles was poor
even though the Ministry of Health and the Bhutan
Medical and Health Council promotes it is an effective
method of providing continuing medical education.
The practice of journal club exists only at the
National Referral Hospital, which serves as the teach-
ing hospital for the Faculty of Nursing and Public
Health and Faculty of Postgraduate Medicine. A
strong academic experience in research through the
promotion of thesis and journal clubs should help indi-
viduals master core competencies in research, foster
favourable attitudes among incipient researchers and
achieve future research output27,28.
Developing a research system and building culture
Bhutan offers many unique areas of multidisciplinary
research in health and biomedical sciences, Bhutanese
Traditional Medicine, Gross National Happiness,
approaches to health and happiness, climate change,
health systems and health service delivery. However,
much of these areas and the public health interventions
of Bhutan’s Ministry of Health remain unstudied due
to the absence of a national health research system. A
national research framework is a key element in the
formulation of research priority areas that deliver to
the needs of the country based on their development
targets, social, political, environmental settings and the
country’s vision of research-driven development3. In
Bhutan, the Ministry of Health initiated the drafting
of the national health research strategy and action plan
for the country in 2018.
To help fill the gap in research knowledge, the
Ministry of Health and the KGUMSB has established
B-SMART, a national training scheme in operational
research for in-service candidates. It is modelled on the
international SORT IT programme, which is designed
to promote research in low- and middle-income coun-
tries5. Three batches of B-SMART course has resulted
in research publications in national and international
peer-reviewed journals and helped develop a pool of
health workers locally trained in operational research.
Such dedicated capacity development actors offer one
of the best approaches for building local capacity at a
more systematic level and to achieve scientific bench-
marks and ethical standards8.
Research capacity building requires multisectoral
collaboration with actors within a country and
beyond. For instance, the Bhutan Medical and
Health Council gives high credit points for continuing
professional development for research publications, the
KGUMSB gives promotion credits to faculty members
who publish research articles, and the World Health
Organization provides low- and middle-income coun-
tries access to biomedical and health research via the
HINARI portal. Civil society organizations, such as
the Bhutan Foundation, has invested considerable
resources in the KGUMSB and the Ministry of
Health by conducting workshops, providing small
grant awards and identifying key health research prior-
ity areas. Other organizations in Bhutan have con-
ducted research in cancer, renal health, mental health,
etc. Moreover, the annual International Conference on
Medical and Health Sciences hosted by the KGUMSB
provides a platform for the dissemination of health
research findings. The only ethics review board in the
country, the Research Ethics Board of Health, has
since 2010 been certified by both the Strategic
Initiative for Developing Capacity in Ethical Review
(SIDCER) and the Forum for Ethical Review
Committees in the Asian and Western Pacific Regions
(FERCAP). The board also has the Federal Wide
Assurance (FWA) from the US’s Office for Human
Research Protections (OHRP)17.
Limitations
There are three main limitations in our study. First,
using completed journal publications in the assessment
of practices in this survey was not ideal, given the time
lag from submission to publication in journals, some
competed research projects are not reflected as research
outputs. However, we measured research output in
conventional terms of journal publications as they are
more visible to policy makers within the country and
those outside.
Second, the educational preparation and training for
research are at different levels among the various pro-
fessions and academic institutions. Technicians with
certificate qualifications, and health assistants and
nurses with diploma qualifications may not have had
extensive exposure to research compared to a postgrad-
uate trainee. However, in the current setting in Bhutan,
research capacity strengthening interventions need to
involve all professional categories as they constitute
the majority of the health workforce in Bhutan.
Third, there might have been social desirability bias
in the assessment of motivation for conducting health
Dorji et al.
research. This is evidenced by the fact that majority of
the respondents reported that health research could
contribute to clinical and policy decision making but
only half felt that research could actually influence gov-
ernment and policy decisions.
Conclusion
Overall, Bhutanese health workers’ self-reported
knowledge about health research was less than optimal.
Their experience with the conduct of health research
and the utilization of health research articles was
poor. However, they hold positive attitudes towards
research and most are interested in conducting health
research.
The implementation of health research capacity
development strategies is needed to fill the existing
knowledge and practice gap. This requires the repriori-
tization of health research capacity development to
meet global quality standards in good research prac-
tice, scientific benchmarks and ethical guidelines. It
also requires identification of key research priority
areas, secure dedicated funding, translate findings
into policy and practice, and to assess their
impact29,30. A national health research organization
to this effect will play a crucial role in the consolidation
of capacity development efforts and result in short- and
long-term health and economic gains within Bhutan’s
free health care system.
Acknowledgments
The author(s) would like to express their gratitude to the
Ministry of Health, Royal Government of Bhutan; the
Bhutan Medical and Health Council and Mary Alice Lee
(Yale School of Public Health) for their help. We also express
our deep gratitude to all health workers who responded to
questionnaires, and all those who helped collect and enter the
data.
Declaration of conflicting interests
The Author(s) declare(s) that there is no conflict of interest.
Ethics approval
Ethical clearance was waived off by the Research Ethics
Board of Health, Ministry of Health, Thimphu. All study
participants provided written informed consent.
Administrative approval was given by the Ministry of
Health, Royal Government of Bhutan. The data (minus the
identifiers) are available upon request from the corresponding
author.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
9
ORCID iDs
Thinley Dorji https://orcid.org/0000-0003-4932-8704
Mongal Singh Gurung https://orcid.org/0000-0001-6481-
6242
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