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eTable 1. List of Chronic Pain Conditions and Associated ICD-9 and 10 Codes

eTable 2. List of Mental Health Conditions and Associated ICD-9 and 10 Codes

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Schoenfeld AJ , Cirillo MN , Gong J, et al. Development of Chronic Pain Conditions Among Women in the Military Health System. JAMA Netw Open. 2024;7(7):e2420393. doi:10.1001/jamanetworkopen.2024.20393

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Development of Chronic Pain Conditions Among Women in the Military Health System

• 1 Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
• 2 Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
• 3 Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
• 4 Harvard Medical School, Boston, Massachusetts
• 5 Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
• 6 Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Question   Did the incidence of chronic pain among active-duty servicewomen (ADSW) and women civilian dependents differ between 2006 to 2013, a period of heightened combat and deployment intensity, and 2014 to 2020, a period of reduced combat intensity?

Findings   This cohort study including 3 473 401 ADSW and dependents identified significant differences in the diagnosis of chronic pain among ADSW and dependents in 2006 to 2013 compared with 2014 to 2020. Chronic pain was documented in 14.8% of ADSW in service during 2006 to 2013 and in 11.3% of dependents from this period, compared with 7.1% in ADSW and 3.7% of dependents from 2014 to 2020.

Meaning   This cohort study found strong and pervasive signals for the association of combat exposure with the subsequent diagnosis of chronic pain.

Importance   The incidence of chronic pain has been increasing over the last decades and may be associated with the stress of deployment in active-duty servicewomen (ADSW) as well as women civilian dependents whose spouse or partner served on active duty.

Objective   To assess incidence of chronic pain among active-duty servicewomen and women civilian dependents with service during 2006 to 2013 compared with incidence among like individuals at a time of reduced combat exposure and deployment intensity (2014-2020).

Design, Setting, and Participants   This cohort study used claims data from the Military Health System data repository to identify ADSW and dependents who were diagnosed with chronic pain. The incidence of chronic pain among individuals associated with service during 2006 to 2013 was compared with 2014 to 2020 incidence. Data were analyzed from September 2023 to April 2024.

Main Outcomes and Measures   The primary outcome was the diagnosis of chronic pain. Multivariable logistic regression analyses were used to adjust for confounding, and secondary analyses were performed to account for interactions between time period and proxies for socioeconomic status and combat exposure.

Results   A total of 3 473 401 individuals (median [IQR] age, 29.0 [22.0-46.0] years) were included, with 644 478 ADSW (18.6%). Compared with ADSW in 2014 to 2020, ADSW in 2006 to 2013 had significantly increased odds of chronic pain (odds ratio [OR], 1.53; 95% CI, 1.48-1.58). The odds of chronic pain among dependents in 2006 to 2013 was also significantly higher compared with dependents from 2014 to 2020 (OR, 1.96; 95% CI, 1.93-1.99). The proxy for socioeconomic status was significantly associated with an increased odds of chronic pain (2006-2013 junior enlisted ADSWs: OR, 1.95; 95% CI, 1.83-2.09; 2006-2013 junior enlisted dependents: OR, 3.05; 95% CI, 2.87-3.25).

Conclusions and Relevance   This cohort study found significant increases in the diagnosis of chronic pain among ADSW and civilian dependents affiliated with the military during a period of heightened deployment intensity (2006-2013). The effects of disparate support structures, coping strategies, stress regulation, and exposure to military sexual trauma may apply to both women veterans and civilian dependents.

Chronic pain is a condition whose prevalence is increasing worldwide. 1 In the US, chronic pain is one of the leading causes of disability in the working-age population, affecting as many as 100 million individuals. 2 The treatment of chronic pain and its ramifications, including opioid dependence, addiction, substance abuse, and lost productivity, result in annual costs of $560 to $635 billion, which exceeds health care expenditures associated with heart disease and cancer combined. 1

Chronic pain is also a pressing issue among US veterans, among whom the prevalence of this condition is documented to be several times higher than in the general population. 3 Diagnoses of chronic pain, along with conditions like posttraumatic stress, anxiety, and substance abuse, have been found to be higher among individuals exposed to combat. 4 This is important, as the US military recently completed the longest sustained period of combat exposure in its history (2001-2021). 5 - 7 This timeframe also coincided with increased numbers of women entering uniformed service, and there are now more women combat veterans than at any other time in US history. 7 The rigors of multiple deployments to combat zones have the potential to exert adverse effects on active-duty servicewomen (ADSW) 3 , 7 - 9 as well as civilian women dependents whose spouse or partner served on active duty. This includes not just the potential for actual combat injury but secondary effects from psychological stress, anxiety, and emotional trauma. 3 , 8 The impact of these repeated aspects of combat deployments on the development of chronic pain in women servicemembers and dependents has not been adequately studied.

In this context, we used data from the Military Health System (MHS) to examine the associations of service during a time period of heightened deployment intensity (eg, the most intense phases of the wars in Afghanistan and Iraq, 2006-2013) 5 with the subsequent diagnosis of chronic pain among ADSW and women civilian dependents of active-duty personnel. Data from the MHS have been successfully used in the past to examine aspects of clinical care and health policy in relation to pain disorders and the opioid epidemic. 10 - 12 We compared ADSW and women civilian dependents with service during 2006 to 2013 with like individuals serving at a time of reduced deployment intensity (2014-2020). We hypothesized that service in the period of heightened deployment intensity would be associated with an increased risk of a subsequent chronic pain diagnosis among ADSW compared with civilian dependents and servicewomen serving on active duty in 2014 to 2020.

This study was deemed exempt by the Uniformed Services University of the Health Sciences and Partners institutional review boards with a waiver of informed consent because data were retrospectively reviewed and deidentified. The work was conducted in line with the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

This investigation used administrative and health care data (fiscal years 2006-2020) obtained from the MHS Data Repository. The means by which data were collected, prepared, made available for research, and accessed has been described in detail in prior publications. 10 , 12 , 13 The study cohort included all adult (age 18-64 years) ADSW serving in the 4 constituent branches of the Department of Defense (Army, Air Force, Navy, and Marine Corps) at any time point in the period under study, as well as adult civilian women dependents of active-duty servicemembers serving in the same timeframe. Cohorts were established based on the time periods of 2006 to 2013 and 2014 to 2020, with the former timeframe indicative of heightened combat exposure and deployment intensity. 5

Claims data of eligible individuals were surveyed for the diagnosis of a chronic pain condition using an International Classification of Diseases, Ninth Revision ( ICD-9 ) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) coding algorithm (eTable 1 in Supplement 1 ) aligned with previously published approaches. 11 , 14 Eligible ADSW and dependents were surveyed from the initial medical encounter within our dataset to an end point of discharge from service or December 31, 2020. We were able to continue to observe ADSW who retired or were separated with a 30% disability or greater, irrespective of the site of service, as these individuals retain their military insurance benefit. 10 , 12 , 13 Individuals who received a chronic pain diagnosis at any time over the surveillance period were considered in the chronic pain group. Individuals who did not receive a chronic pain diagnosis were included in the denominator population for both time periods.

We obtained sociodemographic and additional clinical data from the MHS Data Repository, including age (categorized as 18-24, 25-34, 35-44, 45-54, and ≥55 years), race (obtained by self-report as standard collection with enlistment and categorized as American Indian or Alaska Native, Asian or Pacific Islander, Black, White, and other), branch of service, census region, sponsor rank (junior enlisted, senior enlisted, warrant officer, junior officer, senior officer, other), presence of Charlson index comorbidities, and the presence of a comorbid mental health condition (eTable 2 in Supplement 1 ) based on prior literature that has suggested that these factors are associated with the development of chronic pain. 7 - 10 Hispanic ethnicity was not available in our dataset. Among the active-duty cohort, we also surveyed for the development of the polytrauma clinical triad, as defined by Laughter et al 11 and consisting of comorbid diagnoses of traumatic brain injury; chronic pain, sciatica, or backache; and posttraumatic stress. 11

In all analyses, the diagnosis of chronic pain was considered the primary outcome and the interaction of active-duty status and time of service the primary exposure, with dependent women in 2014 to 2020 considered the reference group. As chronic pain is a disqualifying condition, it would not have been present at the time of enlistment. Initial, unadjusted, bivariate comparisons were made between variables using the χ 2 test. We then used multivariable logistic regression to adjust for confounding using a term for active duty vs dependent, a term for the time period, and an interaction term. In adjusted analyses, we used reweighted estimating equations 15 to handle missing race based on the recommendations of the JAMA Surgery guide for military claims data. 13 Secondarily, and in line with previous investigations, 10 , 12 , 16 we used sponsor rank as a proxy for socioeconomic status and assessed the interactions among this variable, ADSW status, and time of service. In all these analyses, senior officers were used as the reference group and junior enlisted status was considered representative of lower socioeconomic strata, based on prior work indicating those with junior enlisted sponsor rank have attitudes toward health care use, risk behaviors, and medical outcomes similar to civilian counterparts of lower socioeconomic status. 10 , 12 , 16 As the development of chronic pain in this population is postulated to exist at the intersection of baseline risk, sociodemographic characteristics, and combat exposure, 3 , 8 , 9 , 17 we addressed this by assessing for an interaction between sponsor rank and branch of service, using senior officer sponsor rank in the Air Force as the reference group. Here, enlisted ranks in the Army or Marine Corps were considered indicative of more intense combat exposure. 5 - 7

The results of all analyses are presented using odds ratios (ORs) and 95% CIs with 2-sided P values. Statistical significance was established for variables with OR and 95% CI exclusive of 1.0 and P  < .05. All analyses were performed using SAS software version 9.4 (SAS Institute). Data were analyzed from September 2023 to April 2024.

We included 3 473 401 individuals (median [IQR] age, 29.0 [22.0-46.0] years; 1 200 787 [34.6%] aged 18-24 years; 644 478 ADSW [18.6%]). Data collection was complete for all variables except race and Census region ( Table 1 ). Among 1 087 899 individuals who self-reported race, the population consisted of 16 532 American Indian or Alaska Native individuals (1.5%), 83 910 Asian or Pacific Islander individuals (7.7%), 265 451 Black individuals (24.4%), 658 236 White individuals (60.5%), and 63 770 individuals who identified as other race (5.9%).

We identified the diagnosis of chronic pain in 324 499 individuals (9.3%). The polytrauma clinical triad was identified in 2280 of 631 270 ADSW (0.3%). We identified chronic pain in 58 484 of 394 429 ADSW in service during 2006 to 2013 (14.8%) and in 212 954 of 1 887 117 dependents from this period (11.3%). Among 250 049 ADSW serving in 2014 to 2020, 17 790 had chronic pain (7.1%), while among 941 806 dependents in this time period, 35 271 (3.7%) had chronic pain. In adjusted analyses, compared with ADSW in 2014 to 2020, ADSW in 2006 to 2013 had a 53% increase in the odds of chronic pain (OR, 1.53; 95% CI, 1.48-1.58) ( Table 2 ). The odds of chronic pain among dependents in 2006 to 2013 was also significantly higher compared with dependents from 2014 to 2020 (OR, 1.96; 95% CI, 1.93-1.99). The odds of chronic pain were elevated among ADSW in 2014 to 2020 compared with dependents in this same time period (OR, 1.20; 95% CI, 1.19-1.24). In this model, both comorbid mental conditions (OR, 1.67; 95% CI, 1.65-1.69) and service in the Army or Marine Corps were associated with elevated odds of chronic pain ( Table 2 ).

In the primary model, our proxy for socioeconomic status was also significantly associated with increased odds of chronic pain (junior enlisted ADSW and dependents: OR, 1.49; 95% CI, 1.45-1.53). This was reinforced in further interaction analysis, which found that junior enlisted ADSW in 2006 to 2013 had a 95% increase in the odds of chronic pain (OR, 1.95; 95% CI, 1.83-2.09) ( Table 3 ), while junior enlisted dependents in 2006 to 2013 experienced more than a 3-fold increase in the odds of chronic pain (OR, 3.05; 95% CI, 2.87-3.25) compared with senior officers.

In our secondary analysis relying on the interaction between sponsor rank and branch as a proxy for combat exposure, we found significant elevations in the odds of chronic pain among junior enlisted ADSW in the Army (OR, 2.69; 95% CI, 2.57-2.81) and Marine Corps (OR, 1.58; 95% CI, 1.49-1.67), as well as senior enlisted in both branches (Army: OR, 1.91; 95% CI, 1.83-1.99; Marine Corps: OR, 1.36; 95% CI, 1.30-1.44) ( Table 4 ) compared with senior officers in the Air Force.

ADSW serving in 2006 to 2013 with chronic pain were significantly more likely to be diagnosed with the polytrauma clinical triad compared with ADSW with no chronic pain from 2014 to 2020 (OR, 7.63; 95% CI, 6.49-8.98) ( Table 5 ). ADSW with chronic pain from 2006 to 2013 were also significantly more likely to be diagnosed with the polytrauma clinical triad than ADSW with chronic pain serving in 2014 to 2020 (OR, 1.69; 95% CI, 1.38-2.07).

This cohort study represents the first work to longitudinally examine chronic pain development in a population of US women, to our knowledge. Our study cohort includes ADSW routinely exposed to combat environments and the rigors of war-related deployments, as well as the women civilian dependents of individuals on active duty. This effort is advantaged by the larger number of individuals considered, as well as the ability to longitudinally survey for the development of chronic pain irrespective of the time of onset, or the environment of care in which the diagnosis was made. Further, the sociodemographic, educational, and vocational diversity of the modern US armed forces 10 - 13 allowed us to assess for intersectionality among socioeconomic status, proxies for combat exposure, and the development of chronic pain in ways that smaller studies with more restricted populations are otherwise unable to achieve. Furthermore, these same characteristics of our cohort enable the translation of our findings to the working-age population of the US as a whole, as previous work has found that the composition of individuals covered by the MHS are comparable with the US population aged 18 to 64 years. 10 , 12 , 13

The overall incidence of chronic pain in our cohort was 9.3%, which is comparable with prior estimates for chronic widespread pain among women as a whole 1 and the incidence of chronic pain reported in the Health and Retirement Study. 18 Our findings that comorbid mental health conditions were associated with an increased likelihood of chronic pain are also supported by previous investigations among purely civilian cohorts. 1 , 19 We believe these facts reinforce the face validity of our results and the capacity for their translation to the broader population of US women, outside of the immediate implications they may hold for the MHS.

While the predilection for chronic pain disorders among US veterans and others exposed to combat has been widely recognized in the literature 3 , 4 , 9 we believe that our investigation presents several novel paradigms. First, our study suggests a greater adverse impact from heightened deployment schedules, given the statistical difference between the rates of chronic pain development between ADSW serving in 2006 to 2013 compared with ADSW in 2014 to 2020. That some of this difference is directly due to exposure to combat and related trauma is reinforced by the significant association between the polytrauma clinical triad and ADSW with chronic pain who were serving in 2006 to 2013. However, the fact that the likelihood of chronic pain development was also significantly elevated among civilian dependent women from this same time period attests to the fact that the risk of chronic pain does not derive solely from combat exposure and the operational environment. The finding that civilian women dependents from 2006 to 2013 were at an even higher odds of chronic pain than ADSW in this time frame was particularly surprising to us and indicates that the inimical effects of heightened deployment cycles extend well beyond the active-duty individual to include stressors, such as fear and worry for the safety of the deployed spouse or partner, assuming duties of a single parent, income alterations, and disruptions in social support.

Our results also demonstrate the disparate impact that combat exposure has based on socioeconomic status. In the main analysis, we found a significant increase in the odds of a chronic pain diagnosis among junior enlisted sponsor rank ADSW, our proxy for socioeconomic status. The association with combat exposure was evident in secondary testing, where we considered the interaction between time of service and the polytrauma clinical triad in a cohort restricted to ADSW. Here, ADSW from 2006 to 2013 with chronic pain were at significantly higher odds of receiving a diagnosis of the polytrauma clinical triad, with a more than 7-fold increase in likelihood compared with ADSW from 2014 to 2020 without chronic pain.

The development of chronic pain following military service has been postulated to result from a combination of background predilection, exposure to trauma, and the effects of comorbid medical and behavioral conditions that may have been preexisting or developed as direct sequelae of the traumatic event. 3 , 4 , 9 The potential for higher rates of chronic pain in women veterans has been theorized to result from differences in support structures, family conflict, coping strategies, stress regulation, and exposure to military sexual trauma. 3 , 8 Our results suggest that these contributing factors may carry over to the women dependents of combat veterans in addition, indicating a line of research that requires urgent further exploration.

At a minimum, our results hold immediate meaning for the MHS, Department of Veterans Affairs, and civilian health care systems that provide services for large numbers of civilian dependents of military servicemembers. The results regarding the associations of combat exposure and operational intensity with chronic pain development can be used by stakeholders in the future for resource allocation and deployment of support services that could mitigate risk. In light of our other findings, such approaches could be specifically targeted to individuals at greatest risk of chronic pain development, including those from lower socioeconomic strata or individuals with behavioral health conditions. We would also stress the importance of offering these services to civilian dependents of servicemembers who have these characteristics or who possess such risk factors themselves. Due to the representative nature of the MHS population in relation to the US national population, we believe that these recommendations could also apply to civilian women who are exposed to firearm injuries or mass casualty events as well as the spouses or partners of individuals who experience such types of trauma.

This study has some limitations. We were limited by our reliance on claims-based data, with inherent issues in terms of coding accuracy and limited clinical granularity. As a result, we cannot be certain of the specific diagnostic criteria that were used to support determinations of chronic pain or any of the other conditions documented within the MHS claims. If these or other temporal factors changed in the periods under study, there could be an impact on our findings. However, we are unaware of large-scale systemic differences in the MHS in terms of diagnosis and management of chronic pain in the time periods under study. There were issues around reporting of race, which were handled to the best of our ability using validated statistical methods. We are also reliant on the use of time periods as proxies for exposure to the combat environment and operational intensity. There were reductions in the population over time due to downsizing of the military. Changes in the population at risk were addressed in our analytic approach. We do not possess data on deployment locations or length, type of combat experienced, or the nature of specific injuries sustained as a result of combat. While there may be prospect for some confounding in this regard, we would emphasize that our secondary testing around the associations of chronic pain with service branch and the polytrauma clinical triad all reinforce our postulates regarding the association of the combat environment with the development of this condition. Although our ability to capture longitudinal data and remote diagnoses exceeds that of many other retrospective investigations, we are still restricted to data captured by the MHS in association with the delivery of health care. Individuals with chronic pain who did not report symptoms, or those who may have been diagnosed after separation from service, or once receiving care through the VA would not be identified in the datasets we used. Therefore, we do acknowledge that the prevalence of chronic pain in our population is likely underestimated.

This cohort study represents one of the largest and most comprehensive longitudinal assessments of the diagnosis of chronic pain in ADSW and civilian dependents. We found strong and pervasive signals for the association of combat exposure with the development of chronic pain in active-duty personnel and civilian dependents. The likelihood of chronic pain was further increased in the setting of lower socioeconomic status and mental health conditions. More intentional resource allocation and preventative services targeted to servicemembers and civilian dependents with these characteristics may address a potential missed opportunity to reduce the risk of chronic pain development in at-risk individuals. In light of the representative nature of the population served by the MHS, these findings may apply to the civilian health sector as well.

Accepted for Publication: May 6, 2024.

Published: July 5, 2024. doi:10.1001/jamanetworkopen.2024.20393

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Schoenfeld AJ et al. JAMA Network Open .

Corresponding Author: Andrew J. Schoenfeld, MD, MSc, Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 ( [email protected] ).

Author Contributions: Dr Schoenfeld and Ms Cirillo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Schoenfeld, Koehlmoos.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Schoenfeld, Gong, Bryan.

Critical review of the manuscript for important intellectual content: Schoenfeld, Cirillo, Banaag, Weissman, Koehlmoos.

Statistical analysis: Schoenfeld, Cirillo, Banaag.

Obtained funding: Schoenfeld, Weissman, Koehlmoos.

Administrative, technical, or material support: Schoenfeld, Gong, Bryan, Weissman, Koehlmoos.

Supervision: Schoenfeld, Koehlmoos.

Conflict of Interest Disclosures: Dr Schoenfeld reported receiving grants from National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases (paid to institution) and Orthopaedic Research and Education Foundation (paid to institution), personal fees from Wolters Kluwer and Springer, serving as a consultant for Vertex Pharmaceuticals, serving as editor in chief for Spine , serving on the editorial board for Journal of Bone and Joint Surgery , and serving on the board of directors for North American Spine Society outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded through a grant from the US Department of Defense, Defense Health Agency (award No. HU00012320021).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US government.

Data Sharing Statement: See Supplement 2 .

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There are significant gaps in research output and authorship in low- and middle-income countries. Research dissemination events have the potential to help bridge this gap through knowledge transfer, institutional collaboration, and stakeholder engagement. These events may also have an impact on both clinical service delivery and policy development. King Faisal Hospital Rwanda (KFH) is a tertiary-level teaching hospital located in Kigali, Rwanda. To strengthen its research dissemination, KFH conducted an inaugural Research Day (RD) to disseminate its research activities, recognize staff and student researchers at KFH, define a research agenda for the hospital, and promote a culture of research both at KFH and in Rwanda.

RD was coordinated by an interdisciplinary committee of clinical and non-clinical staff at KFH. Researchers were encouraged to disseminate their research across all disciplines. Abstracts were blind reviewed using a weighted rubric and ranked by overall score. Top researchers were also awarded and recognized for their work, and equity and inclusion was at the forefront of RD programming.

RD had over 100 attendees from KFH and other public, private, and academic institutions. Forty-seven abstracts were submitted from the call for abstracts, with the highest proportion studying cancer (17.02%) and sexual and reproductive health (10.64%). Thirty-seven researchers submitted abstracts, and most of the principal investigators were medical doctors (35.14%), allied health professionals (27.03%), and nurses and midwives (16.22%). Furthermore, 30% of principal investigators were female, with the highest proportion of them being nurses and midwives (36.36%).

RD is an effective way to disseminate research in a hospital setting. RD has the potential to strengthen the institution’s research agenda, engage the community in ongoing projects, and provide content-area support to researchers. Equity and inclusion should be at the forefront of research dissemination, including gender equity, authorship representation, and the inclusion of interdisciplinary health professionals. Stakeholder engagement can also be utilized to strengthen institutional research collaboration for greater impact.

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Significant gaps in research output and author representation exist based on geographic region, particularly in low- and middle-income countries (LMICs). For example, one study conducted by The Lancet Global Health found that while 92% of articles target interventions in LMICs, only 35% of authors are actually from or work in those LMICs [ 1 ]. The Initiative to Strengthen Health Research Capacity in Africa identified nine key requirements for strengthening health research on the continent, including institutional support, providing research funding, promoting networks and research dissemination, and providing tools for conducting research [ 2 ]. In line with this, research dissemination events can be utilized to strengthen the research culture, institutional collaboration and knowledge transfer, and to engage stakeholders. Alongside knowledge transfer, these events can also impact both clinical service delivery and policy development [ 3 ]. This is further corroborated by an article on establishing a clinical research network in Rwanda, highlighting the importance of strengthening research partnerships and dissemination opportunities to mitigate the disease burden in Rwanda and the region [ 4 ].

King Faisal Hospital Rwanda (KFH) is a tertiary-level teaching hospital in Kigali, Rwanda. As a teaching hospital, KFH hosts hundreds of health professional students, including medical students, residents, fellows, allied health professionals, and nurses. Furthermore, KFH hosts some of Rwanda’s most highly specialized medical services and their respective subspecialty fellow trainees, including a catheterization laboratory, cardiothoracic surgery, and renal transplant surgery. While KFH previously had a focal person for education and research activities, there was no full-time team in place to manage this. Therefore, to mitigate this, KFH established a Division of Education, Training, and Research in 2021 to oversee the ongoing teaching and learning activities, including research capacity building and output. KFH also has its own Institutional Review Board (IRB) to review and approve research projects conducted at the hospital, and to monitor the overall uptake in research activity. Alongside the highly specialized services and training hosted at KFH, the hospital is putting significant effort into strengthening its research capacity and culture to ensure that evidence-based practice is at the forefront of strengthening these clinical services.

The trend of research activity at KFH is also increasing, and Fig.  1 outlines the trend of KFH IRB submissions from 2009 to 2023. From 2009 to 2020, the trend in research activity was inconsistent and without a significant increase in activity. However, since 2020, there has been a significant upward trend in research activity. This is most likely attributed to the emphasis placed on evidence-based research and practice by the hospital’s leadership over the past several years. However, the numbers are still low, and further interventions are needed to improve this activity.

Trend of KFH IRB Submissions

Research institutions and teaching hospitals are mandated to provide clinical serives, train health professionals, and conduct research. However, researchers in these institutions may not have institutionalized means of sharing their research findings with the relevant departments and leadership upon completing their research. This can result in a lack of known or implemented findings in the institutions where the research was conducted. This can also lead to the duplication of efforts, especially when research findings have not been locally disseminated or published. In response to this, having dedicated dissemination events will not only support clinical researchers to share their findings, but will also support institutions in conducting more meaningful research in relation to the institutional or national priorities, and building off of previously conducted studies.

The aim of this narrative report is to document the development and implementation of KFH’s inaugural Research Day (RD), which aimed to disseminate its research activities, recognize staff and student researchers at KFH, define a research agenda for the hospital, and promote a culture of research at KFH and more broadly in Rwanda. Furthermore, based on the output of RD, this report proposes recommendations to further strengthen research capacity and culture at KFH or through similar RD events going forward.

RD was coordinated by an interdisciplinary clinical and non-clinical committee at KFH. Researchers were encouraged to submit and disseminate their research across all disciplines at KFH. The committee also considered ways to award and recognize researchers for their work, and ensure that the program and other logistics promoted equity and inclusion. Additionally, the committee oversaw the call for abstracts, program and participant inclusion, and the selection and awards process.

Call for abstracts

The Directorate of Research disseminated a call for abstracts for researchers to submit their projects for poster and oral presentations. Eligible researchers included those who either work or study at KFH, or who conducted research at KFH. To encourage researchers at all stages of their study to participate, eligible abstracts included already published studies and those still in progress.

Program and participant inclusion

To promote the inclusion of KFH staff and students in the event, the organizing committee considered the best venue for RD. As a result, RD was hosted in the KFH inpatient reception area instead of being hosted offsite, with one area for the poster display and another for the main event program. This allowed KFH staff and students to come view the poster display during their working hours without it conflicting with their regular clinical schedules. This also aimed to increase staff awareness towards the ongoing research activities at the hospital and encourage them to also get involved in research going forward.

The program for the day had several components. It commenced with a poster display, where representatives from each research team were stationed with their respective posters to answer questions and provide more information on their studies. The main program included opening remarks from the KFH Chair of the Board of Directors, a keynote speech on the importance of research dissemination from Head of Health Workforce Development at the Ministry of Health, and an overview of the state of research at KFH. The main program concluded with oral presentations and the award ceremony.

Selection and awards

Before the event, an interdisciplinary selection committee composed of external reviewers blind-reviewed each abstract. Each abstract was evaluated using a weighted rubric, which was developed based on existing literature and the main components of an abstract. Specifically, the rubric considered 7 criteria, including clarity and organization; relevance and significance of the study; originality and innovation; methods and approach; results and findings; conclusions and implications; and grammar and writing. Within these criteria, the rubric also evaluated the overall quality of the study, adherence with ethical and legal requirements, and the validity of the findings against the methods and study design. The blind review was conducted individually by external reviewers to avoid potential biases, and reviewers were assigned to abstracts based on their expertise and the topics of the abstracts. The individual scores were then compiled, with an average taken for each abstract. The abstracts were then ranked from the highest to the lowest scores. The selection committee used these results to recommend oral and poster presenters, which included 40 posters and 7 oral presentations. In general, all abstracts meeting the minimum quality criteria were selected for poster displays. This was done to encourage researchers to disseminate their progress and increase the visibility of their work more inclusively. However, only completed studies were eligible for oral presentations.

During the event, three additional awards committees with external reviewers were established to evaluate the posters and oral presentations for one of three awards: best oral presentation, best poster presentation, and most impactful study. These committees utilized rubrics that were developed based on the main components of the abstract, along with the overall impact and presentation. The committee members reviewed the projects throughout research day, whereby the results were compiled and presented at the end of RD during the awards ceremony.

Over 100 attendees participated in the main program of RD, and additional participants attended in the poster presentation throughout the day. For the main program, attendees included key stakeholders and senior researchers from Rwanda and the region, including those with the ability to positively influence the research environment and mentor junior researchers. Specifically, participants included KFH leadership, professional councils (Rwanda Medical and Dental Council), government institutions (Ministry of Health and Rwanda Biomedical Centre), health sciences schools (University of Rwanda and University of Global Health Equity), and teaching hospitals (University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and Rwanda Military Hospital), among others.

Abstract submissions

Forty-seven abstracts were submitted from the call for abstracts, as outlined in Table  1 . The highest proportion of abstracts were studying cancer (17.02%), and primarily in colorectal and breast cancer. Sexual and reproductive health was the second most represented content area, making up 10.64% of abstract submissions, followed by anesthesia and pain management (8.51%) and data science/IT (8.51%).

Table  1 Outlines the submitted abstracts by content area.

Researcher profile

Eligible researchers included KFH staff and students, as well as external researchers with projects conducted at KFH. This was decided with the aim to ensure that all disseminated research either featured KFH staff and students, or was research conducted at the hospital. Overall, 37 researchers submitted 47 abstracts. Principal Investigators (PIs) were primarily medical doctors (35.14%), allied health professionals (27.03%), and nurses and midwives (16.22%). Amongst medical doctors, anesthesia and critical care professionals represented the highest proportion of PIs (38.4%), and amongst allied health professionals, imaging services represented the highest proportion (40%). Additionally, 30% of PIs were female, with most of them being nurses or midwives (36.36%). Females comprised at least half of PIs in administration, nursing and midwifery, and data science/IT. Table  2 outlines the PIs who submitted abstracts by department and sex.

Selection process and awards

The selection committee selected seven oral presentations. Table  3 outlines the oral presentations that were selected, along with those awarded for the best oral presentation and most impactful project. Additionally, the best poster presentation was awarded to a midwife staff member who presented on strengthening family-centered maternity care at KFH.

Because this was the first event of its kind at KFH, there were a few challenges in organizing and hosting the event. When the organizing committee started planning, there was a general lack of awareness on the event’s importance. Some staff questioned its benefit and why staff should be released from their clinical activities to attend. Additionally, there were few abstract submissions leading up to the submission deadline. To mitigate these issues, the committee intentionally engaged with the hospital leadership, departments, and individuals to strengthen buy in and participation in the event. This included individual meetings with department leadership to explain RD’s importance. Additionally, the RD committee membership was expanded to ensure better representation across departments and disciplines. Finally, the committee extended its submission deadline and approached researchers individually to encourage them to submit abstracts, regardless of their completion status. Because this was the first RD at KFH, engaging staff individually and at the team level helped build buy in across all levels of the institution, and ultimately increased participation in the event.

RD demonstrated the critical need to further strengthen research dissemination activities at KFH. The long-term aim at KFH is to promote knowledge transfer and translation through research. Research dissemination was highlighted as an initial step towards this to generate engagement and participation in the ongoing activities, and hopefully encourage junior or inactive researchers to start engaging. Specifically, RD highlighted the need to define a research agenda; promote equity and inclusion both in research activity and dissemination events; and ensure multi-institutional stakeholder collaboration in dissemination activities.

Defining a research agenda

Common research areas were revealed through the abstract submissions, including in internal medicine (45%), obstetrics and gynecology (14%), and pediatrics (12%). However, it also revealed the need to streamline dissemination efforts through a defined hospital research agenda. This will contribute to knowledge translation in those specialties in the future, as well as more initiatives to strengthen research in those specialties. The research agenda itself may be driven by the research interests generated by the departments and researchers seen in RD. These departmental interests can then be narrowed down to specific specialties. For example, among those conducted in internal medicine, the research mainly focused on cancer, infectious diseases, and cardiovascular diseases. Integrating department or specialty-driven research priorities requires a deeper investigation into why these research areas were more frequently represented.

Additionally, many of the research projects had simple study designs, which may be attributed to limited capacity to conduct more complex projects, likely due to limited financial capacity, skills, or time. Currently, there is no policy that defines time allocation for research as a clinician. To be able to implement this research agenda and strengthen the research culture, there is a need to mobilize financial and non-financial resources that will enable the institution and researchers to conduct impactful and complex research. Ensuring equity and the distribution of research support and resources across services and departments alongside this defined research agenda is critical.

Promoting equity and inclusion

Healthcare professionals exhibit a wide range of characteristics, including diverse social backgrounds, gender, experiences, and disability statuses [ 5 ]. As a result, healthcare institutions should adopt an inclusive research agenda that fosters cognitive diversity and encourages the sharing of innovative ideas. Such an approach ensures the development of a culturally competent workforce, ultimately reducing research biases [ 6 ]. Additionally, a culturally competent environment enhances individual motivation, leading to improved team performance [ 7 ]. This is because all healthcare providers, irrespective of their roles, contribute unique ideas and problem-solving techniques, often referred to as collective intelligence, which is essential in achieving comprehensive and unbiased research outcomes [ 8 ]. Having a diverse healthcare workforce engaged in research endeavors ensures the minimization of knowledge gaps. The multidisciplinary approach in healthcare has consistently been reflected in the highest quality of care, and it is therefore expected that it will similarly translate into the highest quality of research.

Additionally, gender equity in authorship aims to ensure equal opportunities for individuals of all genders to contribute to academic publications, which is a critical factor in professional success [ 9 , 10 ]. As highlighted at KFH’s RD, individuals of all genders were welcomed and provided equal submission opportunities. This is evident in our RD researcher profile, where female PIs were 50% of administrators and 67% of nurses and midwives. Having 70% of PIs being male overall was likely influenced by the existing gender gap in medical doctors, further emphasizing the need to empower and engage women in medicine and in academic publications. Globally, the progress in women’s empowerment is reflected in the increasing number of women pursuing careers in health and academia [ 11 ]. Statistics show a significant rise in female authors in major journals, from 6% to 10% in the 1970s to 54% and 46% for first and last authorship in 2019 [ 12 ]. This progress serves as motivation for KFH, where there were gaps in female participation, highlighting the need for more intentional efforts to promote equity and inclusion in research activity and dissemination platforms.

Stakeholder collaboration and engagement

RD revealed the importance of stakeholder collaboration to strengthen research dissemination and an overall research culture in health science institutions. As a lesson learned through RD, there is a need to streamline the way research is conducted and engage different stakeholders on this journey. To enhance and impact clinical outcomes, there is a need to strengthen research collaboration between academic institutions and hospitals. Evidence-based clinical decisions will ultimately result in higher quality healthcare by informing the development of policies and strategies. As these collective research endeavors advance, it is crucial to have a comprehensive health research policy alongside this engagement. This policy should not only serve as a guiding framework for health research within its institutions, but also ensure that the research addresses the specific needs of its communities. Students and researchers affiliated with academic institutions can contribute to fulfilling the mission of hospitals when a well-defined research agenda is in place and vice versa, and this policy will serve as the guiding principle for its implementation.

While other institutions were invited to the KFH RD, there is still a need for more intentional efforts towards institutional research collaboration and dissemination efforts. Specific ways that this can be achieved are through joint research dissemination opportunities, as well as the integration of professional societies in Rwanda, to ensure that institutions and health professions are equitably represented in these activities. Furthermore, utilizing technology can also allow for more collaboration and allow dissemination activities to be more accessible to a wider audience outside of the hospital.

Implications for policy and practice

RD also highlighted implications for policy and practice at KFH and teaching hospitals in general. In addition to the need to define an institutional research agenda, the gaps in authorship and topic area representation across all hospital specialties suggests the need to integrate research into staff performance appraisal and promotion systems to institutionally motivate staff to participate. In doing so, the representation of all staff and respective disciplines would become more representative of the hospital itself. Furthermore, although over 100 internal and external attendees participated, and the event was hosted in the hospital for free to promote engagement, the participant number still only reflects a small proportion of the hospital, which has over 800 staff. This suggests that KFH could implement other policies or practices to motivate or require staff to participate in research-related activities. Finally, informal feedback from RD participants suggested that RD is an important step towards knowledge translation, but that additional efforts are needed alongside this event, especially towards building staff research capacity, providing resources to conduct research, and supporting those researchers with in-progress projects towards completion. Going forward, KFH will implement these recommendations towards its practices and evaluate their impact.

RD provides an important platform for teaching hospitals to strengthen their research dissemination and overall research culture. RD is also an opportunity to implement the hospital’s research agenda and drive forward evidence-based practice in identified research areas. In LMICs, where there is already a significant gap in research output and authorship representation, this provides an opportunity for researchers to present and get feedback on their progress, and to motivate them to further engage in research activities. To sustain momentum and address the challenges encountered, teaching hospitals should consider RD as just one component of a broader research dissemination plan, with the wider aim of knowledge translation. By ensuring that RD is not hosted in isolation of other initiatives, this also strengthens the institutional, team-level, and individual buy in needed to strengthen RD engagement. Furthermore, when designing RD, emphasis should be given to promoting equity and inclusion in authorship, including gender, discipline, and professional experience levels. Stakeholder engagement should also be considered to strengthen institutional research collaboration for greater impact, as collaboration with other institutions can strengthen institutional research collaboration, maximizing the impact of research findings and fostering a culture of collaboration and knowledge dissemination. Going forward, KFH will continue to strengthen its research culture by leveraging RD as an initial step towards knowledge translation and implementing a defined research agenda geared towards strengthening clinical service delivery and patient outcomes.

Data availability

The data analyzed during this study are available from the corresponding author upon reasonable request.

Abbreviations

Institutional Review Board

King Faisal Hospital Rwanda

Low- and middle-income country

Principal Investigator

Research Day

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Acknowledgements

We would like to thank the leadership of King Faisal Hospital Rwanda for their significant support towards strengthening the Directorate of Research and the overall research culture at the hospital.

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Neil, K.L., Nduwayezu, R., Uwurukundo, B.S. et al. Strengthening a culture of research dissemination: A narrative report of research day at King Faisal Hospital Rwanda, a tertiary-level teaching hospital in Rwanda. BMC Med Educ 24 , 732 (2024). https://doi.org/10.1186/s12909-024-05736-0

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It is possible to find the Word template for any journal on Google. However, why use a template when you can write your entire manuscript on SciSpace , auto format it as per Military Medical Research - perspective's guidelines and download the same in Word, PDF and LaTeX formats? Give us a try!.

8. Can I reformat my paper to fit the Military Medical Research - perspective's guidelines?

Of course! You can do this using our intuitive editor. It's very easy. If you need help, our support team is always ready to assist you.

9. Military Medical Research - perspective an online tool or is there a desktop version?

SciSpace's Military Medical Research - perspective is currently available as an online tool. We're developing a desktop version, too. You can request (or upvote) any features that you think would be helpful for you and other researchers in the "feature request" section of your account once you've signed up with us.

10. I cannot find my template in your gallery. Can you create it for me like Military Medical Research - perspective?

Sure. You can request any template and we'll have it setup within a few days. You can find the request box in Journal Gallery on the right side bar under the heading, "Couldn't find the format you were looking for like Military Medical Research - perspective?”

11. What is the output that I would get after using Military Medical Research - perspective?

After writing your paper autoformatting in Military Medical Research - perspective, you can download it in multiple formats, viz., PDF, Docx, and LaTeX.

12. Is Military Medical Research - perspective's impact factor high enough that I should try publishing my article there?

To be honest, the answer is no. The impact factor is one of the many elements that determine the quality of a journal. Few of these factors include review board, rejection rates, frequency of inclusion in indexes, and Eigenfactor. You need to assess all these factors before you make your final call.

13. What is Sherpa RoMEO Archiving Policy for Military Medical Research - perspective?

• Pre-prints as being the version of the paper before peer review and
• Post-prints as being the version of the paper after peer-review, with revisions having been made.

14. What are the most common citation types In Military Medical Research - perspective?

15. How do I submit my article to the Military Medical Research - perspective?

16. can i download military medical research - perspective in endnote format.

Yes, SciSpace provides this functionality. After signing up, you would need to import your existing references from Word or Bib file to SciSpace. Then SciSpace would allow you to download your references in Military Medical Research - perspective Endnote style according to Elsevier guidelines.

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I spent hours with MS word for reformatting. It was frustrating - plain and simple. With SciSpace, I can draft my manuscripts and once it is finished I can just submit. In case, I have to submit to another journal it is really just a button click instead of an afternoon of reformatting.