David Sackett and colleagues defined evidence-based practice (EBP) as ‘the integration of the best research evidence with clinical expertise, patient values and the use of current best evidence in making decisions about the care of individual patient’.1
For many years, the integration of up-to-date and available evidence with the medical practice has been limited. In major clinical areas, such as hospitals, it has long been acknowledged that the findings of research studies are not often translated into actual clinical practice. As a result, many patients receive suboptimal care, and some of them suffer from serious and avoidable harm to their health. To date, a large gap remains between the best evidence and its implementation in clinical practice. Therefore, several surveys concluded that clinical decisions are rarely based on the best available evidence.2,3
The current shape of the EBP is highly influenced by the multi-institutional collaboration group, Evidence-Based Clinical Practice Working Group (EBCP), led by Gord Guyatt, Deborah Cook and colleagues at McMaster University. This initiative has contributed several EBP guidelines to facilitate the use of scientific literature in the daily medical practice.4 This working group has inspired North American medical practice, the promotion of educational innovation and the use of scientific literature for patient care.
EBP, from the time when the evidence-based working group first established the concept, nowadays is a global approach to improve healthcare.5 In order to meet the changing needs of both consumers and providers of healthcare, healthcare providers need to shift from traditional practices to evidence-driven healthcare services.6 The demand for maximum quality of care combined with the need for prudent use of resources has increased the pressure on healthcare professionals to ensure that clinical practice is based on sound evidence. With longer life expectancies, an exponentially increasing volume of research information, availability of sophisticated medical care, increasing expectations from clients to provide the best possible care and compounded by the rising healthcare expenditures compel the governments around the globe to embrace EBP as an essential tool to deliver quality healthcare.5
EBP is most prominent in the United Kingdom, Canada and the United States, where outcomes measurement and effectiveness in public services are increasingly seen as important by governments and citizens.7 Other similar findings from the developed world implies that integrating EBP into routine primary care practice is practical and attainable.8
Conversely, EBP in healthcare has been challenging in developing countries due to lack of resources, nature of the healthcare workforce and the limitation of available interventions.5 There is a view that EBP approaches have the potential to have even greater impact on outcomes in developing countries, where better use of evidence in healthcare system could dramatically help improve healthcare delivery performance. This is because EBP tends to be less well established in developing countries than in developed ones, and healthcare is often not based on evidence.7,9
Health sector of many developing countries including Ethiopia face a heat of challenges due to their complicated health problems, unavailability of adequate medical tools and low score proven interventions. Hence, evidence-based healthcare faces obstacles though there is the need to implement it. In most African countries, local health systems are inadequate in terms of infrastructure and facilities available. The healthcare service of many of these countries suffer from not only a scarcity of healthcare research but also from a low utilization of evidence in clinical service.
In Ethiopia, the Federal Ministry of Health lacks skilled health professionals who could help synthesize evidence for policy-making. At all levels of the health systems, there is little culture of trusting or using evidence for decision-making. Hence, it has been challenging for policy makers as to which evidence they should use to develop policies and strengthen health systems.10
According to the WHO, most research activities in Africa are linked to educational or academic institutions. Additionally, it is not known how much health-related research is being utilized to improve healthcare practice in order to ensure high-quality healthcare delivery and improve standards and quality of life.11 Hence, this study aimed at determining the level of EBP utilization and identify associated factors among health professionals in North Gondar Administrative Zone hospitals, Northwest Ethiopia.
An institution based cross-sectional study was carried out from 20 March to 29 May 2015 in North Gondar Zone, Northwest Ethiopia. North Gondar Zone has two district hospitals and one referral hospital. During the study period, University of Gondar Referral Hospital had 764 health professionals including 40 medical doctors, 428 nurses and 296 other health professionals, whereas Debark and Metema Hospital had 83 and 114 health professionals, respectively.
Private health institutions were excluded from the study to avoid double counting since government health workers could possibly be part-timers in the private institutions. Participants who were ill and unable to respond were also excluded from the study.
The sample for this study was calculated by using a single population proportion formula, 95% confidence interval (CI) and a proportion of the magnitude of EBP of 19%,12 absolute precision to be 5%, and 10% nonresponse rate. Accordingly, the total sample size was calculated to be 438.
Proportionate stratified simple random sampling technique was deployed to select study participants from all public hospitals in North Gondar Zone (Fig. 1). The Human Resource list of health professionals in each hospital was used as a sampling frame to identify potential study participants. We assumed that all healthcare providers working in the same hospital were homogenous regarding EBP. Study participants were then selected randomly using record identification numbers retrieved from the sampling frame. Lottery method was used to randomly select a set of healthcare providers as respondents of our study.
Data were collected by trained data collectors using a pre-tested, structured and self-administered questionnaire, which was adopted from the existing literature.13–15 The questionnaire was translated into local language (Amharic) from its English version then back to English with the help of two language experts. One day training was provided for the data collectors on how the data should be obtained and recorded. Pre-test was conducted on a similar setting before the actual data collection time on 5% of the sample size in order to check the reliability of the instrument, to estimate the time needed to collect data and to modify the questionnaire accordingly. Using the data obtained from the pre-test, the questionnaire was checked for reliability (internal consistency) using the Cronbach alpha test. The reliability for knowledge questions had a Cronbach's alpha value of 0.853, and attitude had a Cronbach's alpha value of 0.731 and practice (Cronbach's alpha = 0.878). These values indicate that the questionnaire has very good reliability.
Data collectors were supervised while collecting the data by four data collection supervisors and the principal investigator. Data were checked daily for completeness and consistency throughout the data collection period.
Data were coded and entered into Epi Info version 7.0 (Centers for Disease Control and Prevention, Atlanta, Georgia, USA) and then exported to SPSS version 20.0 (IBM, Armonk, New York, USA) for analysis. Descriptive summaries using frequencies, proportions, graphs and cross tabs were used to present study results. Odds ratios (ORs) with 95% CIs were used to determine the strength of association between independent and dependent variables. Those variables with P value of less than 0.2 in the binary logistic regression analysis were selected for further analysis. Multivariable logistic analysis was finally used to control the effect of confounding. Variables with a P value of less than 0.05 in the multivariable analysis were considered as having statistically significant association.
In total, six self-reported questions were asked to measure EBP utilization. These are self-reported responses to questions that measure the respondent's capacity of formulating questions, skills of evidence searching, appraising evidence using existing critical appraisal tools, integrating and implementing evidence with medical expertise considering patient preferences, evaluation and sharing of the outcome. Each question had a four-point response scale (never, monthly or more, weekly, daily). These categories were coded as numerical values from 1 to 4 (Never ‘1’, Monthly ‘2’, Weekly ‘3’, Daily ‘4’). Therefore, each respondent had a total EBP utilization score (from minimum 6 to a possible maximum of 24). The average of each question can be calculated as (1 + 2 + 3 + 4)/4 = 10/4 = 2.5. Those answering above this point are considered as desirable responses to the EBP questions. EBP utilization was assessed by using the average score for of the six questions. Hence, 2.5 × 6 = 15 is used as the cut-off point. Respondents having a total EBP utilization score above the cut point (average = 15) are considered as having ‘good EBP’ while those below were labelled as having ‘poor EBP’.
In total, 26 questions assessing EBP knowledge were asked to indicate the level of EBP knowledge, with each of them having a Yes/No response. These questions range from basic questions such as knowledge of main source of evidence (MEDLINE, PubMed) to self-reported level of knowledge on statistical and epidemiological terms important to understand medical literature such as relative risk, odds ratios, systematic reviews, meta-analysis, and others. The average score for each question was used to determine knowledge. Yes answers were coded as ‘1’ and ‘no’ answers as ‘0’. A total EBP knowledge score (from minimum 0 to a possible maximum 26) was calculated for all respondents. After checking for normal distribution, the mean knowledge score was calculated because knowledge score was normally distributed. Normal distribution was checked using Shapiro–Wilk test (W statistic 0.98 with a P value of 0.23). Skewness was 0.74 and kurtosis 0.65. The mean knowledge score was 16.37 (SD 5.05). Respondents having knowledge score above the mean value, 16.37, were labelled as having ‘good knowledge’ otherwise as ‘poor knowledge’.
Similarly, nine questions were asked to determine the level of attitude towards EBP. Each attitude question has a five-point Likert scale (strongly agree coded as 5, agree coded as 4, neutral coded as 3, disagree coded as 2, and strongly disagree coded as 1). Each respondent had a total attitude score of from a minimum 9 to a possible maximum level of 45 points. Using the Shapiro–Wilk test, attitude towards EBP score was checked for normal distribution. Hence, attitude towards EBP was not normally distributed (W statistic 0.896, P value <0.001). Skewness was −1.48 and kurtosis 4.73. The median of the attitude towards EBP was 34.0 (interquartile range = 5.0). Respondents with attitude towards EBP score above the median, 34.0 were categorized as having ‘favourable attitude’ and those below as having ‘unfavorable attitude’.
This study was conducted after receiving official permission from the ethical review committee of the University of Gondar, Institute of Public Health. Permission letter was also received from the North Gondar Zone Health Office. Informed verbal consent was obtained from each respondent. Each respondent was informed about the objective of the study, and privacy during the interview was secured.
Sociodemographic characteristics of participants
A total of 431 health professionals returned the questionnaire, which yields a response rate of 98.4%. Two hundred seventy-four (63.6%) of the respondents participants were male. Three hundred thirty-six (78%) were in the age group 20–29 years. The mean age of the respondents was 27.5 (SD + 4.97) years. Concerning educational status, 324 (74.9%) of the respondents were Bachelor's degree holders, and 89 (20.4%) and 16 (3.7%) of the participants have Diploma and Master Degree, respectively (Table 1).
Knowledge about evidence-based practice
The level of good knowledge was found to be 64%. Most participants (57.8%) were aware that practice guidelines are available online. Sixty-five percent (282) of the respondents stated evidence from all published articles in scientific journals can be used for medical practice and 74% of health professionals were familiar with medical literature and search engines. The self-reported knowledge of respondents on statistical and epidemiological concepts relevant to understand medical literature vary across the terms. More than half of the respondents, 54.1% (233), mentioned that they understand relative risk. Only one-third, 32% (138), 44.1% (190), 33.2% (143) and 17.6% (76) of the respondents mentioned they fully understand odds ratio, CI, systematic reviews and meta-analysis, respectively (Table 2).
Attitude towards evidence-based practice
Sixty-five percent of the respondents had favourable attitude towards EBP. Based on the findings, 48.5% of the respondents strongly agreed that EBP improves the quality of healthcare whereas 53.1% of the respondents agreed that their reimbursement rate will increase if they incorporate EBP into their practice (Fig. 2).
Magnitude of evidence-based practice utilization
Fifty-three percent (53%) participants have previously used EBP. About 39% of the respondents formulated questions daily. Furthermore, 38.7% of the respondents integrate EBP in to their medical practice. However, only 26.5% of the participants appraise the literature daily and 12.3% of the respondents never evaluated the outcome of their practice (Fig. 3).
Environmental and organizational factors
Fifty-five percent of respondents reported that they have enough time to use EBP and from the total respondent, 141 (32.7%) had formal training on EBP. More than half, 249 (57.8%), of the respondents reported that they do not have access to online databases when they are away from work (Table 3).
Factors associated with evidence-based practice
Bivariate logistic regression analysis identified sex, perceived availability of strong evidence in the health facility, knowledge about EBP, attitude, training about search strategies for finding research, having enough time to apply EBP and Internet access as significantly associated with the utilization of EBP (P < 0.05). These variables were included in multivariate analysis considering the cut-off point as P value <0.2.
In the multivariable analysis, knowledge, training about search strategies for finding research, having enough time and Internet access were factors significantly associated with utilization of EBP.
Training about search strategies for finding research was important predictor to the utilization of EBP. Health professionals who attended training about search strategies were 1.91 times more likely to use EBP compared with those who did not attend training about search strategies [adjusted odds ratio (AOR): 1.91, 95% CI = (1.22–2.97)]. Health professionals who had good EBP knowledge were 1.61 times more likely to use EBP compared with those who had poor EBP knowledge [AOR: 1.61, 95% CI = (1.06–2.45)]. Similarly, health professionals who had enough time to apply EBP were 1.70 times more likely to use EBP compared to those who did not have enough time to apply EBP [AOR: 1.70, 95% CI = (1.12–2.57)] (Table 4). Health professionals who had Internet access were 1.83 times more likely to utilize EBP compared with those who did not have Internet access [AOR: 1.83, 95% CI = (1.19–2.85)] (Table 4).
This study aimed to determine the level of EBP utilization and identify factors associated with EBP utilization. In this study, EBP among health professionals of the North Gondar Administrative Zone was found to be 53%. EBP knowledge, access to Internet, training on search strategies for finding journal articles, and self-reported availability of enough time were significantly associated with improved utilization of EBP.
Over half, 53%, of health professionals used EBP at a daily and weekly basis. Comparable results of EBP utilization when ordering test or treatment were reported among Jordanian healthcare providers.16 Conversely, our finding was higher than a study conducted among healthcare professionals working in regional hospitals of Taiwan, Iran and Uganda, which was 41.9, 41 and 19%, respectively.12,17,18 This might be due to poor knowledge about EBP and qualification of professionals.5,9 However, it was less than the study conducted among primary healthcare professionals from Scotland. This is possibly due to higher Internet access in Scotland, access to up-to-date sources and databases in their clinical practice, better EBP knowledge and favourable attitudes towards EBP.19 In addition, it might also be due to the reason that health professionals who graduated from improved medical and health science curriculums that included EBP courses have improved level of EBP.20
In this study, more than two-thirds of the respondents had good knowledge of EBP. Similar studies supported this finding in showing that a majority of the respondents who had heard of EBP had some knowledge of EBP particularly with regard to the concept and process involved.21 This finding is essential and echoes a vigorous quality of contemporary health professionals in which individual professionals need to incorporate the latest evidence into their daily practice to bridge the gap between scientific evidence and patient care for best practice and clinical decision-making.
The present study illustrates 65% of the respondents had positive attitude towards EBP. Such finding is consistent with the results of previous studies conducted in many countries which reported that healthcare professionals have positive attitudes towards EBP.5,22–24 Recent studies also reported largely positive attitude towards EBP among nurses25 and US herbal medicine providers.26 However, this finding is lower than a study from Nigeria27 and Canada (75%).28 This might be due to the difference in the qualification level of health professionals, experience and training which have the potential to significantly improve beliefs and attitudes about EBP.9,24,28,29 The study from Canada was conducted among medical doctors.30 Health and medical professionals with higher level of qualification have better knowledge, which improves their attitude towards EBP.
Furthermore, this study demonstrated that nearly half (48.5%) of the study participants indicated practicing EBP improves patient care. This result is consistent with other similar studies.13,19,31,32 In contrast, two-thirds of chiropractioners from US believed that EBP improves patient care.33 The difference is due to the level and experience of the respondents included in the studies. Professionals with higher level of qualification are better equipped with knowledge and skills to retrieve, appraise and utilize the available evidence.
Knowledge, access to Internet, training on search strategies for finding journal articles, and self-reported availability of enough time were the factors identified by the multivariable logistic regression analysis. Health professionals who have good EBP knowledge are more likely to use EBP compared to those health professionals who had poor knowledge. The results of this study are similar to findings in other countries.5,12,34 In addition, knowledge towards EBP was reported as a significant predictor of readiness to implement EBP in a study conducted to identify the social cognitive predictors of EBP utilization.35 This is due to the observed association that good knowledge improves the confidence and readiness of health professionals to carry out routine medical tasks, appraise, integrate and manage the available evidence.9,35 Confidence in utilizing EBP was also directly correlated with level of education in a study from Norway.9 Higher level of education enhances basic research knowledge, which helps health professionals to understand the standard terminologies in scientific articles such as odds ratios, risk ratios, systematic reviews and meta-analysis. Basic research experience was also reported to be significantly correlated with both knowledge and attitude of nurses towards EBP.36 Knowledge of EBP improves the skills important for applying EBP which leads to adoption and utilization of EBP in a clinical service. However, the quality and level of EBP skills need to be further investigated with qualitative observational studies.
Training about search strategies was also one of the factors associated with utilization of EBP in this study. Health professionals who attended training about search strategies are 1.9 times more likely to use EBP compared to those who did not attend training about search strategies (Table 3). Findings from other studies support the idea that training in EBP enables health professionals to implement EBP in their daily clinical service.29,30,37,38 Training was proved to be a significant predictor to improve EBP competence, knowledge, attitude and utilization of EBP in studies from Spain and Finland.39,40
In this study, Internet access and availability of time were also associated factors to utilize EBP. Previous studies conducted in other countries revealed that lack of time and Internet access are significant factors to implement EBP.7,19,20 A scoping review reported that work load is the most frequently mentioned barrier of utilizing EBP. Health and medical professionals work under extreme degree of pressure. Staffs are continually asked to deal with more accurately ill patients quickly. In such situations providers will not have time to utilize EBP.41
Our study has limitations. First: even though this quantitative study identified the factors associated with EBP utilization, we believe that qualitative study could have supplemented the results. Qualitative studies aimed at exploring the organizational culture, actual behaviours, as well as identifying the perceived barriers and enablers of EBP need to be further investigated.
Second, as most of survey designs our results rely on self-reported responses, which has inherent limitations. The responses of respondents to measure attitude, knowledge and practice scores might have been affected by the social desirability biases. Third, the study was conducted in hospitals set-up. The organization structure, human resource dynamics, level and quality of medical service provided in hospitals in contrast to lower level facilities is more advanced. Hence, the results of our study need to be interpreted with caution.
Our study revealed that health professionals have good knowledge about EBP, but the utilization of EBP is insufficient even if they intend to use it. There was a positive association between training about search strategies, Internet access, sufficient time and utilization of EBP. Improving the Internet access of hospitals, giving more time for EBP, and training about search strategies are essential to improve EBP.
We thank all health professionals for participating in the study.
M.A.B. made substantial contributions to conception and design, or acquisition of data, data collection supervision, data analysis, interpretation of data and drafting of the manuscript. S.A.W. agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. M.K. supervised the study, was involved in drafting the manuscript or revising it critically for important intellectual content and had given final approval of the version to be published. All authors read and approved the final manuscript.
Conflicts of interest
There are no conflicts of interest.
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