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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 33  |  Issue : 2  |  Page : 86-94

An interventional study: impact of an evidence-based medicine educational program on knowledge, attitude, and practice of physicians in Benha University Hospitals


1 Professor of Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
2 Professor and Head of Department of Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
3 Assistant Professors of Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
4 Assistant Lecturer of Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt

Date of Submission12-Dec-2015
Date of Acceptance17-Apr-2016
Date of Web Publication1-Mar-2017

Correspondence Address:
Hala A Abed
Assistant Lecturer of Public Health and Community Medicine, Faculty of Medicine, Benha University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-208X.201283

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  Abstract 

Objective
The aim of the present study was to examine the changes in knowledge, attitude, and practice of evidence-based medicine (EBM) among physicians.
Patients and methods
The present interventional study was conducted from December 2012 to December 2013 at Benha University Hospitals in the Qualibia governorate, Egypt. Data were collected in three stages: first, by determining the physicians’ knowledge, attitude, and practice toward EBM; second, by conducting an educational program to increase awareness and improve attitude and practice of physicians toward EBM; and, third, by determining their knowledge, attitude, and practice toward EBM after the program. A total of 220 self-administrated questionnaires were distributed to physicians in different specialties.
Findings
The response rate was 70.5% across different specialties. Overall, 73.2% of the physicians had poor knowledge of EBM before the program, which decreased to 40.2% after the program. This change was statistically significant. Most of the physicians had a high attitude score (92.3 and 97.3%) toward EBM before and after the program, respectively. Poor percentage of physicians (before and after the program) reported attending any courses in EBM (18.2 and 24.5%). More than 60% physicians (before and after the program) used the Internet to inform their practice. The most prevalent barrier against the use of EBM among physicians was the attitude of colleagues (94.6% before and 89% after the program).
Conclusion
After the educational program, knowledge on evidence-based practice improved markedly. Physicians’ attitude towards EBM was positive before and after the program. Changes in practice were small, and were based on the frequency of searching and appraisal activities.

Keywords: attitude, evidence-based medicine, knowledge, physicians, practice


How to cite this article:
Wassef OM, EL-Gendy MF, Dawah AA, Shaker RH, Abed HA. An interventional study: impact of an evidence-based medicine educational program on knowledge, attitude, and practice of physicians in Benha University Hospitals. Benha Med J 2016;33:86-94

How to cite this URL:
Wassef OM, EL-Gendy MF, Dawah AA, Shaker RH, Abed HA. An interventional study: impact of an evidence-based medicine educational program on knowledge, attitude, and practice of physicians in Benha University Hospitals. Benha Med J [serial online] 2016 [cited 2022 Jan 25];33:86-94. Available from: http://www.bmfj.eg.net/text.asp?2016/33/2/86/201283


  Introduction Top


Evidence-based medicine (EBM) is the process of identifying and assessing the best available scientific evidence and integrating this evidence with the clinician's judgment and the patient's values to make medical decisions [1].

Awareness of the latest scientific evidence and the ability to critically appraise the literature and assess its applicability has been identified as integral to the practice of EBM [2].

There are many advantages of practicing EBM. Those patients who receive evidence-based therapies have better outcomes than do those who do not [3]. Many studies have been conducted all over the world to evaluate the awareness, attitudes, and practices of EBM. In a study conducted for general practitioners in England, respondents welcomed EBM and agreed that its practice would improve patient care [4].

In another study in Jordan, 95% of the family physicians had positive attitudes toward EBM. Knowledge of absolute risk and systematic review accounted for 29% of physicians. In addition, 9.9% of the studied sample reported using EBM in 75–100% of their clinical practices [5].

In Egypt, a study conducted in Ain Shams University to determine the knowledge, attitudes, and practices of EBM among residents revealed that, the highest awareness of EBM resources (73.6%) was reported for PubMed, with poor awareness of other resources, and that most of the residents (98%) were aware of some EBM-related technical terms. The majority of the residents welcomed EBM. Lack of personal time was reported by 76.8% as a barrier against practicing EBM [6].

Few studies have been carried out in Egypt to assess the awareness of physicians toward EBM. Most studies assessing the impact of teaching EBM have focused on medical students and residents, rather than on practicing physicians. Our aim was to establish an educational program on EBM and to measure the change in physician's knowledge and attitudes toward EBM, their skills to practice it, and barriers to move from opinion-based to evidence-based practices. The results would help to establish the educational requirements necessary for a greater use of EBM in medicine. Benha Faculty of Medicine Hospitals was chosen as the site of the study as it is the only university hospital present in the Al Qualibia governorate, Egypt.


  Aim of the work Top


Objective

The aim of the present study was to examine the change in knowledge, attitude, and practice of EBM among physicians (residents, demonstrators, and assistant lecturers) working at Benha University Hospitals after conducting an educational program.


  Patients and methods Top


This interventional study was conducted from December 2012 to December 2013.

Study type

This was an interventional study 1++, which measured the change in knowledge, attitude, and practice of participants before and after the medical educational program.

Study setting

The study was carried out at Benha University Hospitals. The educational hospitals of Benha Faculty of Medicine have a capacity of 940 beds, distributed among all specialties, serving about 160 000 patients annually at its outpatient clinics and inpatient departments. The following hospitals were included: Internal Medicine Hospital and Surgery Hospital.

Participants

The study was conducted on those physicians (residents, demonstrators, and assistant lecturers) working at Benha University Hospitals who accepted to participate in the study.

Sample size

Sample size was estimated to be 220 physicians using the Epi info statistical package (EPI info version 6, CDC).

The calculation of sample size based on this concept requires the knowledge of the following:

  1. Total number of physicians (residents, demonstrators, and assistant lecturers) in Benha University Hospitals was 312 [7].
  2. The sample size at 95% confidence interval and 80% power would be as follows:
    1. For knowledge (60.3 ± 5%), a sample size of at least 169 is required.
    2. For positive attitudes (95 ± 5%), a sample size of at least 59 is required.


For practices (9.9 ± 5%), a sample size of at least 95 is required [5]. Therefore, based on 60.3 ± 5% as the percentage of EBM knowledge and after adjusting for a 20% dropout, a sample size of 220 physicians was suggested.

Data collection and study tools

Collection of data was conducted in three stages:

(1) Stage 1:

The data were collected from physicians using ready, self-administrated questionnaire guided by researcher's instructions to determine their knowledge, attitude, and practice toward EBM. The questionnaire was modified from the study of McColl et al. [8].

The questionnaire consisted of five items:

  1. Cover letter, sociodemographic data, knowledge assessment (physicians’ awareness of extracting journals and review publications and their understanding of technical terms used in EBM), questions to describe attitude of physicians towards EBM, questions to describe practicing of EBM, methods of moving from opinion-based medicine to EBM, methods the physicians seek to solve clinical problems in their daily practice, and perceived major barriers to practicing EBM in medical practice from their point of view.
  2. Knowledge score:
    1. It consisted of 15 items (eight items to determine physicians’ awareness of journal sites and seven items to reveal awareness of statistical terms used in scientific articles).
    2. The eight items had a four-response format: (0) unaware, (1) aware but not used, (2) read, and (3) used to help in decision-making. The seven items had a four-response format: (0) It would not be helpful to me to understand, (1) do not understand but would like to, (2) some understanding, and (3) understand and could explain to others. Subscale scores ranging from 0 to 3 were achieved by summing the items in each subscale and then calculating the score percentage. Knowledge scores were classified as high (>60%), fair (40–60%), and poor knowledge (<40%).
  3. The attitude score: It consisted of three items, with a five-response format (Likert scale) from (1) strongly unwelcoming to (5) strongly welcoming. Subscale scores ranging from 1 to 5 were achieved by summing the items in each subscale and then calculating the score percentage. Attitude scores were classified as high (>60%), fair (40–60%), and poor attitude (<40%).
  4. Stage 2 (medical educational program):
    1. The objectives of the medical educational program were increasing awareness and improving the attitude of physicians, and enhancing the practice of EBM.
    2. The message of the program was to demonstrate the definition and importance of EBM, reason for training in EBM methodology and skills, and to find the best evidence and steps to practice EBM.


Methods: The message was formulated to cover all the information about EBM by using appropriate methods such as giving lectures and conducting group discussions. Handouts containing the topics of EBM were given to the participants. Projected materials were used to underline the most important points in the talk. Two workshops were held for physicians in coordination with the training department in Benha University Hospitals.

Place: The program was conducted at a comfortable place, with the size of the group ranging from five to 20 participants. The total number of sessions was about four/week, with about 20 physicians/week (about 80/month) for 2 months.

Time: Each session took 50 min.

Stage 3:

It involved measuring the change in physician's EBM knowledge, attitude, and practice after the medical education program, using the questionnaire used in phase 1. A total of 220 physicians completed the questionnaire. The incomplete ones were discarded from the analysis.

Ethical aspect and administrative approach

Approval from the Ethical Committee of Benha Faculty of Medicine and from the heads of different hospitals was obtained before starting the study. In addition, all the physicians signed an informed consent before participation in the study.

Statistics

A pilot study was conducted to test the questionnaire and evaluate the interviewer performance. Ten individuals included in the pilot study were assistant lecturers in different specialties (surgery, internal medicine, and pediatric).

Stage 1 took 2 months, the educational program took another 2 months, and the third stage was conducted 4 months after the application of the educational program. The collected data were processed and analyzed using the SPSS program version 16 (SPSS; Version 16.0 for Windows, SPSS Inc., Chicago, IL). The appropriate tests of significance were applied based on a P value of less than or equal to 0.05. The accuracy and uniformity of the collected data was assured by checking the completed questionnaires.


  Results Top


For items with a four-point Likert scale, categories were collapsed into two categories: unaware and aware. Category aware included ‘Aware but not used’, ‘read’, and ‘used to help in decision-making’. Categories ‘Not helpful to understand’ and ‘Don’t understand but would Like’ were combined; moreover, categories ‘Some understanding’ and ‘Understand and could explain to others’ were combined, so that the response fell into one of the two categories: don’t understand and understand. For items with a five-point Likert scale, categories were collapsed into three categories. ‘Unwelcoming’ and ‘strongly unwelcoming’ categories were combined as were ‘welcoming’ and ‘strongly welcoming’ so that the response fell in one of the three categories: unwelcoming, neutral, and welcoming.

[Table 1] shows that nearly half (49.1%) of the respondents were males, with a mean age of 28.8 ± 2.6 years. In all, 51% were assistant lecturers and only 14.5% reported currently studying fellowships. The mean years since graduation was 6.18 ± 2.87 years. In addition, it revealed that internal medicine residents account for 69%, followed by surgery residents (31%).
Table 1 Demographic characteristics of the participants

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[Table 2] reveals a statistically significant difference between knowledge and attitude scores after and before the educational program.
Table 2 Comparison between knowledge and attitude scores, before and after the program

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[Table 3] shows that nearly three-fourth of the participants had poor knowledge (73.2%) about EBM before the program, which decreased to 40.2% after the program. This change was statistically significant.
Table 3 Comparison between knowledge score before and after the program

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[Table 4] reveals that most of the physicians had a high attitude score (92.3 and 97.3%) toward EBM before and after the program, respectively, with statistically significant differences.
Table 4 Comparison between attitude scores before and after the program

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[Table 5] shows that there were statistically significant correlations between age of physicians, years since graduation, and knowledge score before and after the program. Moreover, statistically significant correlation was observed between years since graduation and attitude score before the program. The correlation between age and attitude score before and after the program was statistically significant.
Table 5 Spearman's correlation between age of physicians, years since graduation, and knowledge and attitude scores

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[Table 6] and [Table 7] show that poor percentage of physicians (before and after the program) reported attending courses in EBM (18.2 and 24.5%) and critical appraisal (10 and 25.9%), respectively.
Table 6 Practicing of evidence-based medicine among physicians before and after the program

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Table 7 Percentage of practice of evidence-based medicine among physicians before and after the program

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In addition, the tables show that more than 50% of the physicians believed that their percentage of EBM practice exceeded 50% before and after the program.

[Table 8] and [Table 9] show that, most of the physicians had Internet access before and after the program (95.5 and 97.3%, respectively). More than 60% (before and after the program) used this search to inform their practice.
Table 8 Access of physicians to Internet before and after the program

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Table 9 Accessing Internet before and after the program

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[Table 10] shows that there was a general agreement about the educational methods to be used to move toward EBM practices with the highest percentage (83.2 and 88.2%) for EBM integration in the undergraduate course, before and after program, respectively, with statistically significant results for EBM workshops and other educational methods of EBM.
Table 10 Physicians' opinions on educational methods to move toward evidence-based medicine practice before and after the educational program

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[Table 11] shows that, verbal consultation from senior staff was 68.6% before and 79.7% after the program; reading textbooks and handbooks accounted for 68.6% before and 75% after the program. Those methods were the commonest methods used by physicians to solve clinical problems during patient management. The method used least was searching on the Internet (29.6% before and 37.3% after the program). Statistically significant difference was observed in physician's choice of verbal consultation to solve clinical problems before and after the program.
Table 11 Sources of information used by physicians when facing clinical problems, before and after the educational program

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[Table 12] shows that the most prevalent barriers against using EBM among physicians were attitudes of the colleagues (94.6% before and 89% after the program), no financial gains in practicing EBM (92.9% before and 86.6% after the program), and insufficient resources (92.9% before and 81.4% after the program). Statistically significant differences were observed for the lack of personal time, patient overload, insufficient resources, and lack of skills to practice EBM.
Table 12 Perceived barriers to practice evidence-based medicine from physicians' opinions, before and after the educational program

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  Discussion Top


In the present study, we found a statistically significant difference between knowledge scores after and before the educational program. This was in agreement with the findings of a study conducted by McCluskey and Lovarini [9], who measured the changes in knowledge, attitude, and behavior toward EBM after 2-day workshops. There were statistically significant differences in knowledge when scores before the workshop and those after the workshop were compared: there were significant gains in knowledge, which were maintained at follow-up.

This study revealed statistically significant correlations between age of physicians and knowledge scores, and between age and attitude scores. There was a significant positive correlation between years since graduation and knowledge scores. A significant correlation between years since graduation and attitude scores was also observed.

However, the above-mentioned findings differ from those of a study by Rashidbeygi and Sayehmiri [10], who found that physicians’ attitude toward EBM were not significantly different between general practitioners, specialists, and subspecialists. There was a significant negative association between knowledge of physicians and years since graduation.

Positive attitude toward the current promotion of EBM was observed in the present study, as 73.4 and 82.3% of the physicians showed positive attitude (welcoming, strongly welcoming) toward EBM before and after the program, respectively. This was in agreement with the findings of a study conducted by Hart et al. [11], who found statistically significant differences in attitude and beliefs about EBM on the basis of the scores before and those after the survey.

The percentage of physicians that attended courses in EBM and critical appraisal increased after the educational program (24.5 and 14.5%, respectively). This was in line with the results of a study conducted by Farihan et al. [5], which revealed that 20 and 17% of the respondents had training courses in EBM and critical appraisal, respectively.

The majority of the physicians had access to the Internet before and after the educational program (95.5 and 97.3%, respectively). This was in line with the findings of a study by Al-Kubaisi et al. [12], as, in their study, most of the physicians had access to the Internet (92.2%).

No significant difference was observed in using the Internet search to inform the clinical practice before and after the educational program (69.1 and 72.9%, respectively). This was similar to the results obtained by Hussein [6], as more than three-quarter (76.4%) in that study reported using the Internet in their clinical practices.

This study showed that more than 80% of the physicians reported reading medical journals: 82.4% before and 86.4% after the program. This was in agreement with the findings of a study by Al-Kubaisi et al. [12], who mentioned that more than one-third of the physicians (35.0%) read journals on demand, 34.6% read them regularly, and 28.0% read them occasionally.

There was a general agreement about the educational methods to be used to move toward EBM practices, with the highest percentage of 83.2 and 88.2% for the integration of EBM in the undergraduate course, followed by workshops for training physicians (67.3%). This was in agreement with the findings of a study by Hussein [6], as the most popular method was the integration of EBM in undergraduate courses (80.8%), followed by a case review in the departments (80.4%) and workshops for training residents (79.6%).

These percentages are different from those reported in the study conducted by Farihan et al. [5], as the respondents’ opinions to move toward EBM had the following order: training courses (58.3%) and followed by case review (52%). This difference in opinions between physicians in the previous studies could be due to that participants in the present study still making postgraduate studied, and thus the integration of EBM courses in undergraduate and postgraduate curriculums will be more beneficial to them compared with other educational methods.

In the present study, the physicians mentioned the different sources of information they used when they faced problems during patient management. Verbal consultation from a senior staff was 68.6% before and 79.7% after the program; reading textbooks and handbooks accounted for 68.6% before and 75% after the program. Those methods were the commonest methods used by physicians to solve clinical problems during patient management. The method used least was searching on the Internet (29.6% before and 37.3% after the program).

This same order was reported in the study conducted by Isamail et al. [13], as the most common source was taking consultations from senior staff (71.6%), followed by searching in textbooks (46.6%).

After the educational program, a higher percentage of participants (57%) reported that they did not believe in EBM as a barrier than those who had done so before (51%), as they complained that doctor experience was of no value compared with evidence-based facts. This difference was not statistically significant. There were significant differences (a decrease) in the proportion of physicians reporting insufficient resources (92.9% before and 81.4% after the program) as barriers to practice EBM, as they became aware of the advantages of practicing EBM.

These findings differ from those reported by McCluskey and Lovarini [9], as after the workshop, a higher percentage of participants (94%) reported lack of time as a barrier than had done so before (75%), as they became aware of what evidence-based practice involved. The proportions reporting limited search skills as a perceived barrier changed from 61% before to 53% after the workshop, and 24% at follow-up. The proportions reporting limited appraisal skills as a perceived barrier changed from 60% before to 65% after the workshop, and 41% at follow-up.


  Conclusion Top


After conducting the educational program, knowledge of evidence-based practice improved markedly with a targeted educational intervention. Physicians’ attitude toward EBM was positive before and after the program. However, changes in practice were small, based on the frequency of searching and appraisal activities. Physicians need more teaching and training to ensure they correctly apply EBM in their daily patient care. These trainings should be integrated in both undergraduate and postgraduate courses taking into consideration the barriers that were mentioned by the physicians, which interfere with their use of EBM.

Recommendations

Implementation of EBM needs further improvement. Several interventions have become clear from our findings and experience in creating a professional environment that incorporates EBM in daily medical practice. Incorporating and inflating time spent on EBP by refining and modifying curriculum and education style in postgraduate and undergraduate medical curricula; interactive, face-to-face education in clinical practice; allowing for optimum content at the bedside; and accessing, appraising, and interpreting guidelines, research and protocols, basic statistical analysis, and research training are recommended. Physicians may further enhance their efficiency by using computerized decision support systems, which, embedded in clinical information systems, aid in decision-making.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Table 10], [Table 11]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 12]



 

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Introduction
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