FEATURE ARTICLE
Factors Affecting Self-reported Implementation of Evidence-based Practice Among a Group of Dentists Asim Al-Ansari, BDS, MDSc, DScD, and Maha ElTantawi, BDS, MSc, PhD Department of Preventive Dental Sciences, College of Dentistry, University of Dammam,Dammam, Saudi Arabia
Abstract
Objective: The study aimed at assessing the factors affecting the implementation of evidence-based practice (EBP) among a group of dentists in Saudi Arabia. Methods: A cross sectional study design was used where a link to an electronic questionnaire was posted on the websites of the Saudi Dental Society and a social networking site for dentists. The questionnaire was available for three months after which responses were downloaded and analyzed. Descriptive statistics were calculated for various variables and logistic regression analysis was used to identify factors with significant effect on the implementation of EBP. Results: Implementation of EBP was reported by 69.3% of respondents. Most respondents reported knowing and using MEDLINE and being able to search for evidence. The most frequently reported barriers were lack of time and availability of evidence. Factors that significantly affected the implementation of EBP were 1) having some knowledge of terms related to EBP, 2) reporting lack of EBP skills as a barrier, and 3) reporting resistance to change as a barrier. Conclusions: Background knowledge related to EBP and training in its skills are needed for the implementation of EBP whereas the presence of resistance to change does not necessarily prevent its implementation. Keywords: Evidence-based practice, Saudi Arabia, Barriers, Literature appraisal, Searching for evidence.
INTRODUCTION Evidence-based practice (EBP) has been introduced to Medicine in the 1990s1 with dentistry following afterwards with the ultimate objective of improving health care outcomes. It is defined as the ‘‘integration of the best available evidence with clinical experience and patient preferences in making clinical decisions,’’1 the stress being on the integration of the different aspects rather than relying on one
Corresponding author. Tel.: +966 566064142; E-mail: aaalansari@ud.
edu.sa. J Evid Base Dent Pract 2014;14:2-8 1532-3382/$36.00 Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2013.11.001
approach to clinical decision making. In dentistry, the implementation of EBP is reported to be progressing at a slower pace compared to medicine.2 Several studies were conducted to assess knowledge and awareness as well as attitude and perception of dentists toward EBP.2–5 Other studies assessed barriers perceived by dentists to prevent the implementation of EBP.6,7 Studies were also conducted to assess certain aspects of EBP such as how dentists seek and understand new knowledge,8,9 how they acquire and utilize scientific information,10 the extent of research utilization among dental hygienists11 and the frequency and type of information seeking behaviors used by dental hygiene practitioners and dental hygiene educators.12 A limited number of studies assessed the implementation of EBP as a comprehensive process.13,14 Given the
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
time since the inception of EBP, there is a noticeable scarcity of studies assessing the factors affecting the implementation of EBP. Such studies would help in the assessment of the promoters of this implementation against the barriers that can potentially prevent it. Results from studies conducted in countries where EBP has been introduced for almost two decades cannot be generalized to settings where EBP and, to some extent, health care systems have more recent histories. The present study proposes to fill this gap by identifying the factors affecting self-reported implementation of EBP among a group of dentists in Saudi Arabia.
MATERIALS AND METHODS A cross sectional study design was used. Approval for the study was obtained from the Research Committee of the College of Dentistry, University of Dammam. The target population was dentists practicing in Saudi Arabia, nationals and expatriates. A self-administered, anonymous questionnaire was developed based on previous studies.13,15 The questionnaire started with a brief introduction to the study purpose, stressing data confidentiality and indicating the estimated time needed to complete it. It consisted of five parts. The first part collected personal and practice information data including nationality, gender, age, time since graduation, type of practice (private or governmental), specialization (general dentist or specialist/consultant) and having access to a dental library and the internet at practice. The second part assessed EBP-related knowledge including whether the respondent had previously heard about EBP, when and how, how well he/she rates his/her understanding of EBP and self-reported understanding of 13 terms commonly used in EBP. The third part of the questionnaire assessed the implementation of EBP and use of EBP-related resources. It included questions about whether the respondent implemented EBP in practice, self-rated ability to perform some skills required for EBP such as formulating a PICO question, searching for evidence and critical appraisal of literature, whether the respondent used books or peer reviewed journals as sources of evidence and if the respondent was aware of and/or used a number of EBP resources. The fourth part of the questionnaire assessed the barriers the respondents considered to prevent the implementation of EBP. The fifth and last part of the questionnaire asked the respondent about his/her attitude and his/her level of agreement with whether he/she considered that EBP has the potential to improve health care outcomes, whether he/she was willing to attend training sessions related to EBP and whether he/she was willing to support the implementation of EBP. The questionnaire was offered in English and all questions were close ended. Volume 14, Number 1
The questionnaire was pilot tested on 9 teaching staff members at the College of Dentistry, University of Dammam to assess clarity of questions, face and content validity as well as ease of using the electronic format of the questionnaire. Minor modifications in questions phrasing were performed accordingly. The modified questionnaire was uploaded to online survey website (www.fluidsurveys.com/; Bridgewater, New Jersey, United States) and a link to the survey was posted on the Saudi Dental Society website (www.sds.org.sa/) and a social networking site for dentists (www.saudident.com/). A reminder to respond to the survey was posted on each website three times over a period of three months. The latest estimate of the number of members of the Saudi Dental Society stands at 3000, although it is not known how many of them access the website regularly enough to notice the survey. In other polls posted on www. saudident.com/, the number of dentists responding to surveys ranged from 45 to 180. Hypothetically, a degree of overlap could have existed between the users of both sites since each website targeted dentists practicing in Saudi Arabia although the degree of overlap in the number of users cannot be known. It is unlikely that any user/ dentist would have answered the questionnaire twice given its length. An Excel file of the responses to the questionnaire was downloaded at the end of three months. The file was cleaned of personal identifiers to maintain confidentiality and imported to SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis. Descriptive statistics were calculated as frequencies and percents of responses to questions. A knowledge score of EBP terms was calculated by summing responses indicating understanding and ability to explain each of the 13 terms. Cronbach alpha of this knowledge score was calculated to assess its internal consistency. The EBP terms knowledge score was dichotomized into 0, no knowledge of any of the terms and >0, some knowledge of terms. The relation between applying EBP and various factors was assessed using chi-square (or Fisher exact test as indicated). Variables with statistically significant association at the 5% level were entered into logistic regression analysis to identify factors that affected the implementation of EBP and odds ratios calculated to assess strength of association. Bar charts were used for graphical presentation.
RESULTS Responses were received from 201 dentists. Half of the responding dentists were Saudi, in the age group 24–35 and graduated in the last 10 years (54.5%, 52% and 48.7% respectively). Most respondents were male, working in governmental positions and general dentists (61.7%, 72.7% and 58.5% respectively). Most of them had access to a dental library and internet in their practices (59.2% and 79.6% respectively). 3
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Figure 1. Self reported knowledge of some terms used in EBP.
The majority of respondents heard about EBP (78.6%) and did so within the last five years (54%). They heard about EBP from lectures (50%), articles (23.8%), workshops (6.7%), books (5.5%) or other sources (14%). Most of them (69.3%) reported they implemented EBP in their professional lives. Figure 1 shows the self-reported knowledge of respondents as regards some terms commonly used in EBP. The greatest number of dentists reported they understood and could explain terms as ‘‘randomization,’’ ‘‘systematic reviews’’ and ‘‘blinding’’ (71.2%, 68.6% and 60.9% respectively). Dentists were least familiar with terms such as ‘‘meta analysis,’’ ‘‘confidence interval’’ and ‘‘likelihood ratio’’ where 44.2%, 38.5% and 27.6% respectively reported understanding and being able to use these terms. Dentists’ responses indicating levels of understanding of these 13 terms showed consistency (Cronbach alpha for internal consistency of EBP terms knowledge score ¼ 0.92). Most respondents reported using journals as a source of evidence (68.6%), whereas 22.4% reported using books and 9% reported using a combination of different sources. Figure 2 shows the levels of knowledge and use of some EBP resources. MEDLINE (www.ncbi.nlm.nih.gov/ pubmed) – a primary source of evidence – was the most widely known and used (78.7%). Among the secondary sources of evidence, the Evidence Based Dentistry Journal (www.nature.com/ebd) and the Journal of Evidence Based Dental Practice (www.jebdp.com/) were the most known and used (41.9% and 37.4% respectively) whereas internet-based, freely-accessible resources such as The Dental Elf (www.thedentalelf.net/) and TRIP (www. tripdatabase.com/) were not known by two thirds of the respondents (63.2% and 63% respectively). Respondents were split about the Cochrane database where 34.8% re4
Figure 2. Knowledge and use of some EBP resources.
ported knowing about and using it and 38.1% reported not knowing about it. More dentists reported being able to search for evidence and critically appraise it than those reporting being able to formulate a PICO question (87.8%, 59.6% and 36.5% respectively). Only 0.6% of respondents reported they were unable to search for evidence. The most commonly reported barriers against implementing EBP were lack of EBP skills, unavailability of evidence, lack of time and resistance to change (69.2%, 60.3%, 59.6% and 50% respectively). The least frequently reported barriers were financial constraints, not having access to the internet and poor understanding of English (45.5%, 33.5% and 28.2% respectively). Almost all respondents agreed that EBP has the potential to improve health care (95.5%) and the majority indicated they were willing to attend EBP workshops and training events and support the implementation of EBP in their professional life (84.6% and 92.3% respectively). No significant association existed between implementing EBP and each of nationality, gender, age, graduation and type of practice dentists work in (P ¼ 0.31, 0.51, 0.13, 0.32 and 0.10 respectively). In addition, no significant association was observed with having barriers as financial constraints, not having access to the internet, poor understanding of English or unavailability of evidence (P ¼ 0.93, 0.14, 0.24 and 0.94 respectively). Table 1 shows the variables that were significantly related to implementing EBP in bivariate analysis and those that still had significant association in the multivariate logistic regression model. In bivariate analysis, some variables increased the odds of implementing EBD including having a library close to practice, having internet access in practice, rating oneself as having good understanding of EBD concept, having some knowledge of EBD terms, being able to formulate a PICO March 2014
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TABLE 1. Relation between factors affecting the implementation of EBP using bivariate and multivariate analysis.
Factors General dentist vs specialist Library close to practice: presence vs absence Internet access in practice: presence vs absence Heard about EBD: #5 years vs >5 years Self rating of understanding of EBD concept: good vs fair or poor EBD terms knowledge: some vs none Primary source of evidence: books vs peer reviewed journals Formulate a PICO question: yes vs no Search for evidence: yes vs no Appraise literature: yes vs no Lack of time: yes vs no Lack of EBD skills: yes vs no Resistance to change: yes vs no
Bivariate relation
Multivariate relation
OR
95% CI
OR
95% CI
0.23* 4.66* 2.83* 0.27* 16.16*
0.11, 0.46 2.30, 9.42 1.28, 6.25 0.13, 0.57 4.75, 54.93
0.42 2.10 1.05 0.47 3.07
0.13, 1.35 0.69, 6.36 0.27, 4.08 0.14, 1.56 0.62, 15.11
11.72* 0.31* 8.39* 3.61* 8.85* 0.43* 0.22* 2.61*
4.33, 31.72 0.14, 0.69 2.81, 25.07 1.35, 9.66 3.89, 20.18 0.20, 0.94 0.08, 0.60 1.24, 5.48
6.18* 0.79 2.63 1.38 1.13 0.41 0.19* 3.42*
1.19, 32.01 0.26, 2.44 0.58, 11.84 0.31, 6.19 0.33, 3.83 0.13, 1.26 0.05, 0.79 1.15, 10.22
OR: odds ratio, CI: confidence interval. *Statistically significant at P # 0.05.
question, being able to search for evidence, being able to appraise literature and experiencing resistance to change as a barrier (OR ¼ 4.66, 2.83, 16.16, 11.72, 8.39, 3.61, 8.85 and 2.61 respectively). Other factors decreased the odds of implementing EBD including being a general dentist compared to being a specialist, hearing about EBD recently within the last 5 years, using books as a primary source of evidence, reporting lack of time as a barrier and reporting lack of EBD skills as a barrier (OR ¼ 0.23, 0.27, 0.31, 0.43 and 0.22 respectively). Three factors significantly affected the implementation of EBP in multivariate analysis: 1) having some vs no knowledge of terms commonly used in EBP, 2) reporting lack of EBP skills as a barrier, and 3) reporting resistance to change as a barrier. Having some understanding of terms used in EBP increased the odds of implementing EBP 6 times (OR ¼ 6.18, CI ¼ 1.19, 32.01). Lack of EBP skills decreased the odds of implementing EBP to the fifth (OR ¼ 0.19, CI ¼ 0.05, 0.79). On the other hand, resistance to change increased the odds of implementing EBP almost three and half times (OR ¼ 3.42, CI ¼ 1.15, 10.22).
DISCUSSION The study was conducted to assess the factors affecting the implementation of EBP among a group of dentists. Distributing the questionnaire through a link posted on the two websites returned responses from 201 dentists. This method was the most logistically feasible to reach dentists in different regions of the country. Other studies using mailed or electronic surveys sent to health profesVolume 14, Number 1
sionals reported low response rates2,6,14,16 raising the concern that response rates of health professionals to surveys are decreasing.17 Among the limitations of the study is that it relied on self-reported implementation of EBP where the participants may give responses that are socially acceptable (such as implementing EBP) even if this is not true.18 It is difficult however to use other definitions of the study outcome since it is mostly a decision making process that is not associated with more tangible evidence. The percentage of dentists in this study reporting the implementation of EBP was higher than that of Kuwaiti dentists reporting it in another study (69.3% and 60% respectively).13 It is lower than the 88% of American dentists reporting practicing EBP in another study.6 However, those American dentists were reported by the authors of the study to be early adopters of EBP who volunteered to join their study from a group of dentists attending an event to promote EBP. Participants in the present study reported better knowledge of EBP terms related to methodological issues (randomization, blinding, publication bias.) than terms expressing statistical measures and concepts (absolute risk, confidence interval, likelihood ratio,.). For example, they reported understanding ‘‘systematic reviews’’ better than ‘‘meta analysis’’ although both are related with mostly the inclusion of statistical procedures differentiating the latter from the former. Terms describing methodological concepts were also reported to be known and/or understood by >50% of respondents in different studies2,4,5 whereas statistical terms were comparatively usually less understood.2,13,15,19 5
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In the present study, three times as many respondents reported using journals as sources of evidence as those reporting using books for the same purpose (68.6% and 22.4% respectively). This greater reliance on journals and electronic resources was also reported in other studies.2,10 Studies conducted a few years earlier reported greater use of textbooks and traditional resources compared to journals and electronic databases.4,8,20 Using textbooks is problematic due to the duration that usually elapses between publication of research findings and their incorporation in textbooks. They remain, however, a source for background information that many practitioners prefer.10 The greatest majority of respondents reported knowing and using MEDLINE whereas secondary sources of evidence as CATs, TRIP database and Dental Elf were known by a minority. Evidence-based journals and the Cochrane database occupied a middle position between MEDLINE and other secondary sources of evidence. Although MEDLINE and the Cochrane Collaboration and its Oral Health Group were established at around the same time,21,22 practitioners report more knowledge and use of the former than the latter.2,23 Several studies reported modest knowledge and/or use of the Cochrane Reviews that is increasing slowly with time.4,5,19 Using secondary sources of evidence such as the Cochrane library and other databases can save the time required to search for evidence11 and thus reduce the impact of lack of time as a barrier.24 However, it is reported that the number of systematic reviews in dentistry is less compared to their counterparts in medicine which stresses the importance of primary sources of evidence and the associated skills of appraising evidence retrieved from them.4,25 In the present study, only 0.6% reported being unable to search for evidence. This percentage is similar to the small percentage of Iowa dentists reporting in a previous study that their search for information was never efficient or effective.10 Although lower percentage of respondents in the present study reported being able to formulate a PICO question and appraise literature than to search for evidence, these percentages were higher than those in other studies.2,5 In the present study, lack of EBP skills, unavailability of evidence and lack of time were the most important barriers cited by respondents against the implementation of EBP. Subject related barriers such as lack of EBP skills were also reported by other studies to varying degrees4,13 and so was time constraint.2,4,5 Barriers related to the concept of EBP itself – such as unavailability of evidence – were also reported in other studies.2,3 Financial constraints were cited in other studies.4,5,19 In the present study, the effect of limited access to the internet on the implementation of EBP seemed less critical than in other studies.13,19 Half the respondents indicated that resistance to change is a barrier to the implementation of EBP, similar to other studies.6,7 In 6
contrast, a study conducted among a group of primary health care physicians in Riyadh region indicated that respondents thought their colleagues’ attitude toward EBP was welcoming.15 It is interesting that almost 70% of respondents reported that lack of EBP skills was a barrier to its implementation and 85% indicated they were willing to attend EBP training workshops although about 70% reported they implemented EBP. This can be explained by respondents feeling justified to claim they implemented EBP when they might have been using scientific evidence in their practice to various degrees without actually implementing EBP as a complete process. On the other hand, they may have been just referring to barriers facing others and expressing willingness to get additional EBP training. In the present study, neither age of respondents nor time since graduation significantly affected implementing EBP. Another study11 and a systematic review26 confirmed that age did not affect research utilization. Some studies reported better outcomes for younger practitioners as regards knowledge of EBP terms2,13 whereas another study9 reported that older dentists used peer reviewed resources more than others. In the present study, twice as many specialists reported implementing EBP as general dentists. Several studies reported associations between different aspects of EBP and increasing duration of education whether through postgraduate studies and specialization8,14,23 or by longer duration of undergraduate programs.11 This difference may be attributed to better opportunities for training, application of research methods and development of critical thinking skills.10,12,23 In the present study, the presence of enabling resources such as a dental library and access to the internet were positively associated with implementing EBP. Although having a dental library at practice was less prevalent than having access to the internet (59.25% and 79.6% respectively), having a library had the greater odds of affecting the implementation of EBP (OR ¼ 2.10 and 1.05 for library and internet availability respectively). In both cases, the effect was not statistically significant. This may indicate a greater reliance on print journals than electronic resources similar to what was reported by others.10 In a study conducted among primary health care physicians in Riyadh region in 2002, only 10.2% reported having access to the internet15; a much lower percent than that in the current study possibly due to the high cost of high speed internet in Saudi Arabia at that time. As time passes and internet access becomes more common place in different countries, more reliance on electronic resources would be expected and internet accessibility issues will affect EBP implementation even less. Understanding terms associated with EBP was significantly related to the actual implementation of EBP March 2014
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in bivariate and multivariate analysis whereas overall self-rated understanding of EBP concept lost statistical significance in multivariate analysis. Only when the practitioner understands EBP-related terms would he/she be able to appraise the evidence and then decide whether to apply it to the patient. This is real understanding of EBP as needed in practical life. It differs from the overall perceived understanding of EBP that some practitioners may think they have. The three EBP skills; formulating a PICO question, searching for evidence and literature appraisal were significantly associated with implementing EBP in bivariate analysis but lost this significance in multivariate analysis. All of them were significantly associated with and logically included when participants reported lack of EBP skills as a barrier to its implementation. The effect of the latter barrier on the implementation of EBP remained statistically significant in multivariate analysis and markedly reduced the odds of this implementation. Rather than being a deterrent, resistance to change increased the odds of implementation of EBP about three and half times when all other factors were considered. This was the only one among all studied factors whose effect intensified in multivariate analysis (in this case, increased the odds of implementing EBP). This relation is difficult to interpret because of the cross sectional nature of the study so that it cannot be known whether the presence of resistance to change motivated the respondents to conquer this resistance and thus implement EBP or if the implementation of EBP by respondents in their different organizations triggered various forms of resistance to change, and consequently the resistance was the effect of the implementation rather than the cause. A third explanation could be that dentists – faced in their organizations by resistance to change current practices and reluctance to adopt modern techniques – had to resort to hard evidence based on scientific findings and thus implemented EBP because of this. Whatever the truth behind this situation is, it shows that the presence of resistance is not by itself associated with the nonimplementation of EBP. At the very least, it is not an effective barrier.
CONCLUSION The present study attempted to identify factors affecting implementing EBP among a group of dentists. After almost two decades of introducing EBP into health care, it may be appropriate to focus on the actual implementation of EBP after many studies have assessed the awareness, knowledge and attitude of practitioners to EBP as well as barriers to its implementation. The main points to be concluded from the present study are that background knowledge in research methods as well as training Volume 14, Number 1
in EBP-specific skills are major determinants affecting the implementation of EBP. The presence of barriers per se does not preclude the implementation of EBP. However, more research is required to understand the interaction between practitioner professional attributes and training and the environment in which he/she practices on one hand and their effect on the implementation of EBP on the other hand. It would be interesting also to assess the factors affecting the implementation of EBP from the patient’s perspective.
REFERENCES 1. Guyatt G, Cairns J, Churchill D, et al. Evidence Based Medicine: a new approach to teaching the practice of medicine. J Am Med Assoc 1992;268:2420-5. 2. Madhavji A, Araujo EA, Kim KB, Buschang PH. Attitudes, awareness and barriers towards evidence based practice in orthodontics. Am J Orthod Dentofacial Orthop 2011;140:309-16. 3. Rabe P, Holmen A, Sjogren P. Attitudes, awareness and perceptions on evidence based dentistry and scientific publications among dental professionals in the county of Halland, Sweden: a questionnaire survey. Swed Dent J 2007;31:113-20. 4. Yusof ZYM, Han LJ, San PP, Ramli AS. Evidence-based practice among a group of Malaysian dental practitioners. J Dent Educ 2008;72:1333-42. 5. Iqbal A, Glenny A-M. General dental practitioners’ knowledge of and attitudes towards evidence-based practice. Br Dent J 2002; 193:587-91. 6. Spallek H, Song M, Polk DE, Bekhuis T, Frantsve-Hawley J, Aravamudhan K. Barriers to implementing evidence-based clinical guidelines: a survey of early adopters. J Evid Based Dent Pract 2010;10:195-206. 7. Hannes K, Norre D, Goedhuys J, Naert I, Aertgeerts B. Obstacles to implementing evidence-based dentistry: a focus group-based study. J Dent Educ 2008;72:736-44. 8. Wardh I, Axelsson S, Tegelberg A. Which evidence has an impact on dentists’ willingness to change their behavior? J Evid Based Dent Pract 2009;9:197-205. 9. Botello-Harbaum MT, Demko CA, Curro FA, et al. Informationseeking behaviors of dental practitioners in three practice-based research networks. J Dent Educ 2013;77:152-60. 10. Straub-Morarend CL, Marshall TA, Holmes DC, Finkelstein MW. Informational resources utilized in clinical decision making: common practices in dentistry. J Dent Educ 2011;75:441-52. 11. Ohrn K, Olsson C, Wallin L. Research utilization among dental hygienists in Sweden - a national survey. Int J Dent Hyg 2005;3: 104-11. 12. Finley-Zarse SR, Overman PR, Mayberry WE, Corry AM. Information seeking behaviors of US practicing dental hygienists and full time dental hygiene educators. J Dent Hyg 2002;76:116-24. 13. Haron IM, Sabti MY, Omar R. Awareness, knowledge and practice of evidence-based dentistry amongst dentists in Kuwait. Eur J Dent Educ 2012;16:e47-e52. 14. Straub-Morarend CL, Marshall TA, Holmes DC, Finkelstein MW. Toward defining dentists’ evidence-based practice: influence of decade of dental school graduation and scope of practice on implementation and perceived obstacles. J Dent Educ 2013;77:137-45. 15. Al-Ansary LA, Khoja TA. The place of evidence-based medicine among primary health care physicians in Riyadh region, Saudi Arabia. Fam Pract 2002;19:537-42. 16. Ashri NY, Al Ajaji N, Al Mozainy M, Al Sourani R. Career profiles of dentists in Saudi Arabia. Saudi Dent J 2009;21:28-36.
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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE 17. McAvoy B, Kaner E. General practice postal surveys: a questionnaire too far? Br Med J 1996;313:732-4. 18. Bourhaimed M, Thalib L, Doi SAR. Perception of the educational environment by medical students undergoing a curricular transition in Kuwait. Med Princ Pract 2009;18:204-8. 19. Al Omari M, Khader Y, Jadallah K, Dauod AS, Al-shdifat AAK, Khasawneh NM. Evidence-based medicine among hospital doctors in Jordan: awareness, attitude and practice. J Eval Clin Pract 2009;15:1137-41. 20. Haj-Ali RN, Walker MP, Petrie CS, Williams K, Strain T. Utilization of evidence-based informational resources for clinical decisions related to posterior composite restorations. J Dent Educ 2005;69:1251-6. 21. US National Library of Medicine. OLDMEDLINE data. Available at: http://www.nlm.nih.gov/databases/databases_oldmedline.html; Accessed January 7th, 2014.
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22. The Cochrane Collaboration. Cochrane Oral Health Group. Available at: http://ohg.cochrane.org/cochrane-oral-health-group; Accessed January 7th, 2014. 23. Novak K, Miric D, Jurin A, et al. Awareness and use of Evidence-Based Medicine databases and Cochrane library among physicians in Croatia. Croat Med J 2010;51:157-64. 24. Guyatt GH, Meade MO, Jaeschke RZ, Cook DJ, Haynes RB. Practitioners of evidence based care. Not all clinicians need to appraise evidence from scratch but all need some skills. Br Med J 2000;320:954-5. 25. Forrest J, Miller S. Evidence-based decision making in action: Part 2 – evaluating and applying the clinical evidence. J Contemp Dent Pract 2003;4:1-13. 26. Estabrooks C, Floyd JA, Scott-Findlay S, O’Leary KA, Gusha M. Individual determinants of research utilization: a systematic review. J Adv Nurs 2003;43:506-20.
March 2014
Factors Affecting Self-reported Implementation of Evidence-based Practice Among a Group of Dentists Asim Al-Ansari, BDS, MDSc, DScD, and Maha ElTantawi, BDS, MSc, PhD Department of Preventive Dental Sciences, College of Dentistry, University of Dammam,Dammam, Saudi Arabia
Abstract
Objective: The study aimed at assessing the factors affecting the implementation of evidence-based practice (EBP) among a group of dentists in Saudi Arabia. Methods: A cross sectional study design was used where a link to an electronic questionnaire was posted on the websites of the Saudi Dental Society and a social networking site for dentists. The questionnaire was available for three months after which responses were downloaded and analyzed. Descriptive statistics were calculated for various variables and logistic regression analysis was used to identify factors with significant effect on the implementation of EBP. Results: Implementation of EBP was reported by 69.3% of respondents. Most respondents reported knowing and using MEDLINE and being able to search for evidence. The most frequently reported barriers were lack of time and availability of evidence. Factors that significantly affected the implementation of EBP were 1) having some knowledge of terms related to EBP, 2) reporting lack of EBP skills as a barrier, and 3) reporting resistance to change as a barrier. Conclusions: Background knowledge related to EBP and training in its skills are needed for the implementation of EBP whereas the presence of resistance to change does not necessarily prevent its implementation. Keywords: Evidence-based practice, Saudi Arabia, Barriers, Literature appraisal, Searching for evidence.
INTRODUCTION Evidence-based practice (EBP) has been introduced to Medicine in the 1990s1 with dentistry following afterwards with the ultimate objective of improving health care outcomes. It is defined as the ‘‘integration of the best available evidence with clinical experience and patient preferences in making clinical decisions,’’1 the stress being on the integration of the different aspects rather than relying on one
Corresponding author. Tel.: +966 566064142; E-mail: aaalansari@ud.
edu.sa. J Evid Base Dent Pract 2014;14:2-8 1532-3382/$36.00 Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2013.11.001
approach to clinical decision making. In dentistry, the implementation of EBP is reported to be progressing at a slower pace compared to medicine.2 Several studies were conducted to assess knowledge and awareness as well as attitude and perception of dentists toward EBP.2–5 Other studies assessed barriers perceived by dentists to prevent the implementation of EBP.6,7 Studies were also conducted to assess certain aspects of EBP such as how dentists seek and understand new knowledge,8,9 how they acquire and utilize scientific information,10 the extent of research utilization among dental hygienists11 and the frequency and type of information seeking behaviors used by dental hygiene practitioners and dental hygiene educators.12 A limited number of studies assessed the implementation of EBP as a comprehensive process.13,14 Given the
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
time since the inception of EBP, there is a noticeable scarcity of studies assessing the factors affecting the implementation of EBP. Such studies would help in the assessment of the promoters of this implementation against the barriers that can potentially prevent it. Results from studies conducted in countries where EBP has been introduced for almost two decades cannot be generalized to settings where EBP and, to some extent, health care systems have more recent histories. The present study proposes to fill this gap by identifying the factors affecting self-reported implementation of EBP among a group of dentists in Saudi Arabia.
MATERIALS AND METHODS A cross sectional study design was used. Approval for the study was obtained from the Research Committee of the College of Dentistry, University of Dammam. The target population was dentists practicing in Saudi Arabia, nationals and expatriates. A self-administered, anonymous questionnaire was developed based on previous studies.13,15 The questionnaire started with a brief introduction to the study purpose, stressing data confidentiality and indicating the estimated time needed to complete it. It consisted of five parts. The first part collected personal and practice information data including nationality, gender, age, time since graduation, type of practice (private or governmental), specialization (general dentist or specialist/consultant) and having access to a dental library and the internet at practice. The second part assessed EBP-related knowledge including whether the respondent had previously heard about EBP, when and how, how well he/she rates his/her understanding of EBP and self-reported understanding of 13 terms commonly used in EBP. The third part of the questionnaire assessed the implementation of EBP and use of EBP-related resources. It included questions about whether the respondent implemented EBP in practice, self-rated ability to perform some skills required for EBP such as formulating a PICO question, searching for evidence and critical appraisal of literature, whether the respondent used books or peer reviewed journals as sources of evidence and if the respondent was aware of and/or used a number of EBP resources. The fourth part of the questionnaire assessed the barriers the respondents considered to prevent the implementation of EBP. The fifth and last part of the questionnaire asked the respondent about his/her attitude and his/her level of agreement with whether he/she considered that EBP has the potential to improve health care outcomes, whether he/she was willing to attend training sessions related to EBP and whether he/she was willing to support the implementation of EBP. The questionnaire was offered in English and all questions were close ended. Volume 14, Number 1
The questionnaire was pilot tested on 9 teaching staff members at the College of Dentistry, University of Dammam to assess clarity of questions, face and content validity as well as ease of using the electronic format of the questionnaire. Minor modifications in questions phrasing were performed accordingly. The modified questionnaire was uploaded to online survey website (www.fluidsurveys.com/; Bridgewater, New Jersey, United States) and a link to the survey was posted on the Saudi Dental Society website (www.sds.org.sa/) and a social networking site for dentists (www.saudident.com/). A reminder to respond to the survey was posted on each website three times over a period of three months. The latest estimate of the number of members of the Saudi Dental Society stands at 3000, although it is not known how many of them access the website regularly enough to notice the survey. In other polls posted on www. saudident.com/, the number of dentists responding to surveys ranged from 45 to 180. Hypothetically, a degree of overlap could have existed between the users of both sites since each website targeted dentists practicing in Saudi Arabia although the degree of overlap in the number of users cannot be known. It is unlikely that any user/ dentist would have answered the questionnaire twice given its length. An Excel file of the responses to the questionnaire was downloaded at the end of three months. The file was cleaned of personal identifiers to maintain confidentiality and imported to SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis. Descriptive statistics were calculated as frequencies and percents of responses to questions. A knowledge score of EBP terms was calculated by summing responses indicating understanding and ability to explain each of the 13 terms. Cronbach alpha of this knowledge score was calculated to assess its internal consistency. The EBP terms knowledge score was dichotomized into 0, no knowledge of any of the terms and >0, some knowledge of terms. The relation between applying EBP and various factors was assessed using chi-square (or Fisher exact test as indicated). Variables with statistically significant association at the 5% level were entered into logistic regression analysis to identify factors that affected the implementation of EBP and odds ratios calculated to assess strength of association. Bar charts were used for graphical presentation.
RESULTS Responses were received from 201 dentists. Half of the responding dentists were Saudi, in the age group 24–35 and graduated in the last 10 years (54.5%, 52% and 48.7% respectively). Most respondents were male, working in governmental positions and general dentists (61.7%, 72.7% and 58.5% respectively). Most of them had access to a dental library and internet in their practices (59.2% and 79.6% respectively). 3
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Figure 1. Self reported knowledge of some terms used in EBP.
The majority of respondents heard about EBP (78.6%) and did so within the last five years (54%). They heard about EBP from lectures (50%), articles (23.8%), workshops (6.7%), books (5.5%) or other sources (14%). Most of them (69.3%) reported they implemented EBP in their professional lives. Figure 1 shows the self-reported knowledge of respondents as regards some terms commonly used in EBP. The greatest number of dentists reported they understood and could explain terms as ‘‘randomization,’’ ‘‘systematic reviews’’ and ‘‘blinding’’ (71.2%, 68.6% and 60.9% respectively). Dentists were least familiar with terms such as ‘‘meta analysis,’’ ‘‘confidence interval’’ and ‘‘likelihood ratio’’ where 44.2%, 38.5% and 27.6% respectively reported understanding and being able to use these terms. Dentists’ responses indicating levels of understanding of these 13 terms showed consistency (Cronbach alpha for internal consistency of EBP terms knowledge score ¼ 0.92). Most respondents reported using journals as a source of evidence (68.6%), whereas 22.4% reported using books and 9% reported using a combination of different sources. Figure 2 shows the levels of knowledge and use of some EBP resources. MEDLINE (www.ncbi.nlm.nih.gov/ pubmed) – a primary source of evidence – was the most widely known and used (78.7%). Among the secondary sources of evidence, the Evidence Based Dentistry Journal (www.nature.com/ebd) and the Journal of Evidence Based Dental Practice (www.jebdp.com/) were the most known and used (41.9% and 37.4% respectively) whereas internet-based, freely-accessible resources such as The Dental Elf (www.thedentalelf.net/) and TRIP (www. tripdatabase.com/) were not known by two thirds of the respondents (63.2% and 63% respectively). Respondents were split about the Cochrane database where 34.8% re4
Figure 2. Knowledge and use of some EBP resources.
ported knowing about and using it and 38.1% reported not knowing about it. More dentists reported being able to search for evidence and critically appraise it than those reporting being able to formulate a PICO question (87.8%, 59.6% and 36.5% respectively). Only 0.6% of respondents reported they were unable to search for evidence. The most commonly reported barriers against implementing EBP were lack of EBP skills, unavailability of evidence, lack of time and resistance to change (69.2%, 60.3%, 59.6% and 50% respectively). The least frequently reported barriers were financial constraints, not having access to the internet and poor understanding of English (45.5%, 33.5% and 28.2% respectively). Almost all respondents agreed that EBP has the potential to improve health care (95.5%) and the majority indicated they were willing to attend EBP workshops and training events and support the implementation of EBP in their professional life (84.6% and 92.3% respectively). No significant association existed between implementing EBP and each of nationality, gender, age, graduation and type of practice dentists work in (P ¼ 0.31, 0.51, 0.13, 0.32 and 0.10 respectively). In addition, no significant association was observed with having barriers as financial constraints, not having access to the internet, poor understanding of English or unavailability of evidence (P ¼ 0.93, 0.14, 0.24 and 0.94 respectively). Table 1 shows the variables that were significantly related to implementing EBP in bivariate analysis and those that still had significant association in the multivariate logistic regression model. In bivariate analysis, some variables increased the odds of implementing EBD including having a library close to practice, having internet access in practice, rating oneself as having good understanding of EBD concept, having some knowledge of EBD terms, being able to formulate a PICO March 2014
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TABLE 1. Relation between factors affecting the implementation of EBP using bivariate and multivariate analysis.
Factors General dentist vs specialist Library close to practice: presence vs absence Internet access in practice: presence vs absence Heard about EBD: #5 years vs >5 years Self rating of understanding of EBD concept: good vs fair or poor EBD terms knowledge: some vs none Primary source of evidence: books vs peer reviewed journals Formulate a PICO question: yes vs no Search for evidence: yes vs no Appraise literature: yes vs no Lack of time: yes vs no Lack of EBD skills: yes vs no Resistance to change: yes vs no
Bivariate relation
Multivariate relation
OR
95% CI
OR
95% CI
0.23* 4.66* 2.83* 0.27* 16.16*
0.11, 0.46 2.30, 9.42 1.28, 6.25 0.13, 0.57 4.75, 54.93
0.42 2.10 1.05 0.47 3.07
0.13, 1.35 0.69, 6.36 0.27, 4.08 0.14, 1.56 0.62, 15.11
11.72* 0.31* 8.39* 3.61* 8.85* 0.43* 0.22* 2.61*
4.33, 31.72 0.14, 0.69 2.81, 25.07 1.35, 9.66 3.89, 20.18 0.20, 0.94 0.08, 0.60 1.24, 5.48
6.18* 0.79 2.63 1.38 1.13 0.41 0.19* 3.42*
1.19, 32.01 0.26, 2.44 0.58, 11.84 0.31, 6.19 0.33, 3.83 0.13, 1.26 0.05, 0.79 1.15, 10.22
OR: odds ratio, CI: confidence interval. *Statistically significant at P # 0.05.
question, being able to search for evidence, being able to appraise literature and experiencing resistance to change as a barrier (OR ¼ 4.66, 2.83, 16.16, 11.72, 8.39, 3.61, 8.85 and 2.61 respectively). Other factors decreased the odds of implementing EBD including being a general dentist compared to being a specialist, hearing about EBD recently within the last 5 years, using books as a primary source of evidence, reporting lack of time as a barrier and reporting lack of EBD skills as a barrier (OR ¼ 0.23, 0.27, 0.31, 0.43 and 0.22 respectively). Three factors significantly affected the implementation of EBP in multivariate analysis: 1) having some vs no knowledge of terms commonly used in EBP, 2) reporting lack of EBP skills as a barrier, and 3) reporting resistance to change as a barrier. Having some understanding of terms used in EBP increased the odds of implementing EBP 6 times (OR ¼ 6.18, CI ¼ 1.19, 32.01). Lack of EBP skills decreased the odds of implementing EBP to the fifth (OR ¼ 0.19, CI ¼ 0.05, 0.79). On the other hand, resistance to change increased the odds of implementing EBP almost three and half times (OR ¼ 3.42, CI ¼ 1.15, 10.22).
DISCUSSION The study was conducted to assess the factors affecting the implementation of EBP among a group of dentists. Distributing the questionnaire through a link posted on the two websites returned responses from 201 dentists. This method was the most logistically feasible to reach dentists in different regions of the country. Other studies using mailed or electronic surveys sent to health profesVolume 14, Number 1
sionals reported low response rates2,6,14,16 raising the concern that response rates of health professionals to surveys are decreasing.17 Among the limitations of the study is that it relied on self-reported implementation of EBP where the participants may give responses that are socially acceptable (such as implementing EBP) even if this is not true.18 It is difficult however to use other definitions of the study outcome since it is mostly a decision making process that is not associated with more tangible evidence. The percentage of dentists in this study reporting the implementation of EBP was higher than that of Kuwaiti dentists reporting it in another study (69.3% and 60% respectively).13 It is lower than the 88% of American dentists reporting practicing EBP in another study.6 However, those American dentists were reported by the authors of the study to be early adopters of EBP who volunteered to join their study from a group of dentists attending an event to promote EBP. Participants in the present study reported better knowledge of EBP terms related to methodological issues (randomization, blinding, publication bias.) than terms expressing statistical measures and concepts (absolute risk, confidence interval, likelihood ratio,.). For example, they reported understanding ‘‘systematic reviews’’ better than ‘‘meta analysis’’ although both are related with mostly the inclusion of statistical procedures differentiating the latter from the former. Terms describing methodological concepts were also reported to be known and/or understood by >50% of respondents in different studies2,4,5 whereas statistical terms were comparatively usually less understood.2,13,15,19 5
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In the present study, three times as many respondents reported using journals as sources of evidence as those reporting using books for the same purpose (68.6% and 22.4% respectively). This greater reliance on journals and electronic resources was also reported in other studies.2,10 Studies conducted a few years earlier reported greater use of textbooks and traditional resources compared to journals and electronic databases.4,8,20 Using textbooks is problematic due to the duration that usually elapses between publication of research findings and their incorporation in textbooks. They remain, however, a source for background information that many practitioners prefer.10 The greatest majority of respondents reported knowing and using MEDLINE whereas secondary sources of evidence as CATs, TRIP database and Dental Elf were known by a minority. Evidence-based journals and the Cochrane database occupied a middle position between MEDLINE and other secondary sources of evidence. Although MEDLINE and the Cochrane Collaboration and its Oral Health Group were established at around the same time,21,22 practitioners report more knowledge and use of the former than the latter.2,23 Several studies reported modest knowledge and/or use of the Cochrane Reviews that is increasing slowly with time.4,5,19 Using secondary sources of evidence such as the Cochrane library and other databases can save the time required to search for evidence11 and thus reduce the impact of lack of time as a barrier.24 However, it is reported that the number of systematic reviews in dentistry is less compared to their counterparts in medicine which stresses the importance of primary sources of evidence and the associated skills of appraising evidence retrieved from them.4,25 In the present study, only 0.6% reported being unable to search for evidence. This percentage is similar to the small percentage of Iowa dentists reporting in a previous study that their search for information was never efficient or effective.10 Although lower percentage of respondents in the present study reported being able to formulate a PICO question and appraise literature than to search for evidence, these percentages were higher than those in other studies.2,5 In the present study, lack of EBP skills, unavailability of evidence and lack of time were the most important barriers cited by respondents against the implementation of EBP. Subject related barriers such as lack of EBP skills were also reported by other studies to varying degrees4,13 and so was time constraint.2,4,5 Barriers related to the concept of EBP itself – such as unavailability of evidence – were also reported in other studies.2,3 Financial constraints were cited in other studies.4,5,19 In the present study, the effect of limited access to the internet on the implementation of EBP seemed less critical than in other studies.13,19 Half the respondents indicated that resistance to change is a barrier to the implementation of EBP, similar to other studies.6,7 In 6
contrast, a study conducted among a group of primary health care physicians in Riyadh region indicated that respondents thought their colleagues’ attitude toward EBP was welcoming.15 It is interesting that almost 70% of respondents reported that lack of EBP skills was a barrier to its implementation and 85% indicated they were willing to attend EBP training workshops although about 70% reported they implemented EBP. This can be explained by respondents feeling justified to claim they implemented EBP when they might have been using scientific evidence in their practice to various degrees without actually implementing EBP as a complete process. On the other hand, they may have been just referring to barriers facing others and expressing willingness to get additional EBP training. In the present study, neither age of respondents nor time since graduation significantly affected implementing EBP. Another study11 and a systematic review26 confirmed that age did not affect research utilization. Some studies reported better outcomes for younger practitioners as regards knowledge of EBP terms2,13 whereas another study9 reported that older dentists used peer reviewed resources more than others. In the present study, twice as many specialists reported implementing EBP as general dentists. Several studies reported associations between different aspects of EBP and increasing duration of education whether through postgraduate studies and specialization8,14,23 or by longer duration of undergraduate programs.11 This difference may be attributed to better opportunities for training, application of research methods and development of critical thinking skills.10,12,23 In the present study, the presence of enabling resources such as a dental library and access to the internet were positively associated with implementing EBP. Although having a dental library at practice was less prevalent than having access to the internet (59.25% and 79.6% respectively), having a library had the greater odds of affecting the implementation of EBP (OR ¼ 2.10 and 1.05 for library and internet availability respectively). In both cases, the effect was not statistically significant. This may indicate a greater reliance on print journals than electronic resources similar to what was reported by others.10 In a study conducted among primary health care physicians in Riyadh region in 2002, only 10.2% reported having access to the internet15; a much lower percent than that in the current study possibly due to the high cost of high speed internet in Saudi Arabia at that time. As time passes and internet access becomes more common place in different countries, more reliance on electronic resources would be expected and internet accessibility issues will affect EBP implementation even less. Understanding terms associated with EBP was significantly related to the actual implementation of EBP March 2014
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in bivariate and multivariate analysis whereas overall self-rated understanding of EBP concept lost statistical significance in multivariate analysis. Only when the practitioner understands EBP-related terms would he/she be able to appraise the evidence and then decide whether to apply it to the patient. This is real understanding of EBP as needed in practical life. It differs from the overall perceived understanding of EBP that some practitioners may think they have. The three EBP skills; formulating a PICO question, searching for evidence and literature appraisal were significantly associated with implementing EBP in bivariate analysis but lost this significance in multivariate analysis. All of them were significantly associated with and logically included when participants reported lack of EBP skills as a barrier to its implementation. The effect of the latter barrier on the implementation of EBP remained statistically significant in multivariate analysis and markedly reduced the odds of this implementation. Rather than being a deterrent, resistance to change increased the odds of implementation of EBP about three and half times when all other factors were considered. This was the only one among all studied factors whose effect intensified in multivariate analysis (in this case, increased the odds of implementing EBP). This relation is difficult to interpret because of the cross sectional nature of the study so that it cannot be known whether the presence of resistance to change motivated the respondents to conquer this resistance and thus implement EBP or if the implementation of EBP by respondents in their different organizations triggered various forms of resistance to change, and consequently the resistance was the effect of the implementation rather than the cause. A third explanation could be that dentists – faced in their organizations by resistance to change current practices and reluctance to adopt modern techniques – had to resort to hard evidence based on scientific findings and thus implemented EBP because of this. Whatever the truth behind this situation is, it shows that the presence of resistance is not by itself associated with the nonimplementation of EBP. At the very least, it is not an effective barrier.
CONCLUSION The present study attempted to identify factors affecting implementing EBP among a group of dentists. After almost two decades of introducing EBP into health care, it may be appropriate to focus on the actual implementation of EBP after many studies have assessed the awareness, knowledge and attitude of practitioners to EBP as well as barriers to its implementation. The main points to be concluded from the present study are that background knowledge in research methods as well as training Volume 14, Number 1
in EBP-specific skills are major determinants affecting the implementation of EBP. The presence of barriers per se does not preclude the implementation of EBP. However, more research is required to understand the interaction between practitioner professional attributes and training and the environment in which he/she practices on one hand and their effect on the implementation of EBP on the other hand. It would be interesting also to assess the factors affecting the implementation of EBP from the patient’s perspective.
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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE 17. McAvoy B, Kaner E. General practice postal surveys: a questionnaire too far? Br Med J 1996;313:732-4. 18. Bourhaimed M, Thalib L, Doi SAR. Perception of the educational environment by medical students undergoing a curricular transition in Kuwait. Med Princ Pract 2009;18:204-8. 19. Al Omari M, Khader Y, Jadallah K, Dauod AS, Al-shdifat AAK, Khasawneh NM. Evidence-based medicine among hospital doctors in Jordan: awareness, attitude and practice. J Eval Clin Pract 2009;15:1137-41. 20. Haj-Ali RN, Walker MP, Petrie CS, Williams K, Strain T. Utilization of evidence-based informational resources for clinical decisions related to posterior composite restorations. J Dent Educ 2005;69:1251-6. 21. US National Library of Medicine. OLDMEDLINE data. Available at: http://www.nlm.nih.gov/databases/databases_oldmedline.html; Accessed January 7th, 2014.
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22. The Cochrane Collaboration. Cochrane Oral Health Group. Available at: http://ohg.cochrane.org/cochrane-oral-health-group; Accessed January 7th, 2014. 23. Novak K, Miric D, Jurin A, et al. Awareness and use of Evidence-Based Medicine databases and Cochrane library among physicians in Croatia. Croat Med J 2010;51:157-64. 24. Guyatt GH, Meade MO, Jaeschke RZ, Cook DJ, Haynes RB. Practitioners of evidence based care. Not all clinicians need to appraise evidence from scratch but all need some skills. Br Med J 2000;320:954-5. 25. Forrest J, Miller S. Evidence-based decision making in action: Part 2 – evaluating and applying the clinical evidence. J Contemp Dent Pract 2003;4:1-13. 26. Estabrooks C, Floyd JA, Scott-Findlay S, O’Leary KA, Gusha M. Individual determinants of research utilization: a systematic review. J Adv Nurs 2003;43:506-20.
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