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Open Access Research article

Knowledge and beliefs concerning evidence-based practice amongst complementary and alternative medicine health care practitioners and allied health care professionals: A questionnaire survey

Julie Hadley1*, Ismail Hassan1 and Khalid S Khan12

Author Affiliations

1 The Education Resource Centre. Birmingham Women's Health Care NHS Trust, Edgbaston, Birmingham, B15 2TG, UK

2 The University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK

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BMC Complementary and Alternative Medicine 2008, 8:45  doi:10.1186/1472-6882-8-45


The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1472-6882/8/45


Received:14 September 2007
Accepted:23 July 2008
Published:23 July 2008

© 2008 Hadley et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Evidence-based practice (EBP) has become an important competency in many allied and complementary and alternative medicine (CAM) health care practitioners' professional standards of proficiency.

Methods

To compliment an EBP course for allied health care professionals and CAM practitioners, we undertook a questionnaire survey to assess learning needs. We developed a questionnaire to measure allied health care professionals and CAM practitioners' basic knowledge, skills and beliefs concerning the main principles of EBP. The questionnaires were administered to all attendees of one-day EBP workshops.

Results

During 2004–5 we surveyed 193 allied health care professionals and CAM practitioners who attended one-day EBP courses prior to commencement of teaching. Of the respondents 121 (62.7%) were allied health care professionals and 65 (33.7%) practitioners stated that they work in the CAM field Our survey found that the majority of the respondents had not previously attended a literature appraisal skills workshop (87.3%) or received formal training in research methods (69.9%), epidemiology (91.2%) or statistics (80.8%). Furthermore, 67.1% of practitioners specified that they felt that they had not had adequate training in EBM and they identified that they needed more training and education in the principles of EBM (86.7%). Differences in knowledge and beliefs concerning EBP amongst allied and CAM practitioners were found and length of time since qualification was also found to be an important factor in practitioner's beliefs. More CAM practitioners compared to allied health professionals accessed educational literature via the Internet (95.3% v 68.1%, p = 0.008). Whilst, practitioners with more than 11 years experience felt that original research papers were far more confusing (p = 0.02) than their less experienced colleagues.

Conclusion

The results demonstrate that practitioner's learning needs do vary according to the type of profession, time since graduation and prior research experience. Our survey findings are exploratory and will benefit from further replication, however, we do believe that they warrant consideration by allied health care and CAM tutors and trainers when planning EBP teaching curricula as it is important to tailor teaching to meet the needs of specific subgroups of trainees to ensure that specific learning needs are met.

Background

Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care [1]. Regardless of speciality, teaching of evidence-based medicine (EBM) or EBP has become part of the core medical training in the United Kingdom [2] and has also become recognised as an important competency in many allied [3-10] and complementary (CAM) [11-13] health care practitioners' professional standards of proficiency. Furthermore, a report from the UK House of Lords [14] has recommended that that every therapist working in CAM should have a clear understanding of the principles of evidence-based healthcare.

The opportunities for CAM practitioners to learn the principles of EBP are limited. We found no courses available in our region. As both allied health care professionals and CAM practitioners are not catered for in traditional EBM postgraduate medical training, we developed an EBP course for allied health care professionals and CAM practitioners. The course was designed so that it had a core curriculum, which could be adapted specifically to the individual needs of the students [15]. To ensure that relevant teaching and learning opportunities were realised, a needs assessment exercise was undertaken, as recommended by Harden [16] as an essential criteria which should be carried out when designing and developing any course and particularly because EBP has not been a mandatory requirement of their training until recently. The findings of such an exercise can provide critical evidence for development and tailoring of EBP curricula improving the effectiveness of teaching. We undertook a needs assessment exercise using a questionnaire survey of allied health care professionals and CAM practitioners' knowledge, skills and beliefs regarding EBP in the West Midlands region. This allowed us the opportunity to compare and contrast different needs of groups according to specialty and time since qualification and to tailor our course to meet their specific needs

Methods

During 2004–5 we surveyed 193 allied health care professionals and CAM practitioners who attended one-day EBP courses prior to commencement of teaching. Allied health care professionals included Physiotherapists, Chiropodists, Dentists, Nurses, Midwives, Sport injuries specialists, Nursing assistants and Pharmacists. CAM practitioners included Osteopaths, Chiropractors, Alexander technique practitioners, Acupuncturists, Herbalists, Feng Chui practitioners, Homoeopaths, Hypnotherapists, Shiatsu practitioners, and Reflexologists. Invitations were sent out to all CAM practitioners and allied health care professionals listed in a database of all registered practitioners that we developed by interrogating the West Midlands regional directory and relevant professional associations. In total 859, CAM practitioners and allied health care professionals were approached and 193 (22.5%) completed the questionnaire. Attendance to these courses was free and not mandatory. The courses were funded from a grant received from the Learning and Skills Council and European Social Fund (European Union Grant LSE31068WM2). The study was planned prospectively using recommended methods for educational needs analyses[16] and questionnaire surveys [17]. Ethical approval for the study was not required. Participants were made aware of the purpose of the survey, the anonymous nature of the dataset generated and the option to not respond if they so wished. This information served as the basis for an informed consent from each respondent.

We developed a questionnaire to measure allied health care professionals and CAM practitioners' basic knowledge, skills and beliefs concerning the main principles of EBP including questions from previously published and validated questionnaires [18-21]. The questionnaire included questions relating to the practitioners' self assessment of their literature searching behaviour, their self perceived knowledge of their own critical appraisal skills and beliefs. Multiple choice answers and six-point Likert scales were used to measure responses, without a 'don't know' or neutral point on the scale. However, participants were instructed to tick a box if they did not understand the question. Questions about knowledge included statements relating to how confident the respondents feel about assessing research methodology. The statements address perceived self-confidence in interpreting statistical tests, evaluating bias and assessing sample size. Answers were scored from '1' not confident at all to '6' very confident. Items on beliefs about EBP included statements such as 'EBP is essential in my practice', 'clinical judgement is more important than EBP' and 'I feel that I need more training in EBP'. Participants scored their answers on a range from '1–6', with '1' indicating that they disagreed strongly with the statement and '6' suggesting that they agreed strongly with the statement [see Additional file 1].

Additional file 1. Copy of developed questionnaire. A copy of the developed questionnaire used to measure allied health care professionals and CAM practitioners' basic knowledge, skills and beliefs concerning the main principles of EBP.

Format: DOC Size: 76KB Download file

This file can be viewed with: Microsoft Word ViewerOpen Data

The questionnaires were self-administered by the candidates on arrival to the teaching session. All data obtained were entered into a Microsoft Excel spreadsheet and exported for analyses using SPSS software version 14.0 (SPSS Inc., Chicago, IL., USA). The data then was coded and participants categorised into groups according to their background. Descriptive statistics were computed when possible. The data was summarized as counts (or percentages) occurring in the various response categories. Paired Likert-type items or sets of items were compared using nonparametric statistical techniques (e.g. chi-square homogeneity tests, Mann-Whitney-Wilcoxon U test) [22]. Differences on categorical measures were reported as P value. The result was significant if P < 0.05. We compared responses from allied health care professionals with those from CAM practitioners.

Results

In total, 193 allied health care professionals and CAM practitioners completed the questionnaire. Of the respondents 121 (62.7%) were allied health care professionals and 65 (33.7%) practitioners stated that they work in the CAM field (7 missing responses). Furthermore, 91 (47.1%) had qualified or had been working in their chosen health care fields within the last 10 years, whilst 82 (42.5%) had been qualified or working for 11 years and over.

Figure 1 illustrates the respondents' background of exposure to research and EBP and current use of health research literature. It was found that the majority of the respondents had not attended a literature appraisal skills workshop (87.3%) or received formal training in research methods (69.9%), epidemiology (91.2%) or statistics (80.8%). However, 58 (31%) stated that they had actually been personally involved in conducting some research activity. Questions regarding the participants' access to medical literature and evidence showed that only 60 (32.1%) had access to a medical library. The majority of respondents stated that they did not search for medical literature on a regular basis (86.1%), and only 75 (39.9%) respondents reported that they read every week regularly to keep up to date with their professional literature.

thumbnailFigure 1. Background of allied health care professionals and CAM practitioners' prior exposure to research and evidence-based practice and current use of health research literature.

Table 1 illustrates computer usage by allied health professionals and CAM practitioners. Far more CAM practitioners compared to allied health professionals accessed educational literature via the Internet (95.3% v 68.1%, p = 0.008), used email on a regular basis (90.8% v 55.4%, p = 0.001) and explored and searched the Internet for information more than once a week (93.8% v 67.2%, p = 0.001 and 98% v 86.6%, p = 0.001 respectively). However, both allied health professionals and CAM practitioners identified that a vast majority of them did not have access to a library or used email discussion groups in their work.

Table 1. Background of allied health care professionals and complementary health practitioners concerning computer usage.

Respondents generally indicated that the majority of them did not feel confident at assessing research study design, generalisability, evaluating bias, sample size and statistical tests. Furthermore, 67.1% of practitioners felt that they had not had good or adequate training in EBM and 86.7%identified that they needed more training and education in the principles of EBM (Some confusion regarding the relationship between EBM and the process of clinical decision-making was found, with many practitioners feeling uncertain whether or not their own clinical judgement and patient choice should override the evidence. However, the majority of the practitioners agreed that they felt that EBM was essential to their practice (75.6%) and not a passing fashion (74.6%).

Respondents who reported that they had not previously attended a literature appraisal workshop stated that they felt that they needed more training in EBM compared to those that had (91.4% v 72.7%, p = 0.007), but felt that EBM has little impact on their clinical practice (26.4% v 50%, p = 0.33). The respondents who reported that they had not been involved in conducting any type of research also felt that they needed more training in EBM than those who had been involved in any research activity. However, the result was not statistically significant (91.2% v 84.5%, p = 0.09).

Table 2 examines the effect of years since qualification on practitioners' beliefs relating to EBM. We used the threshold of 11 years and over as it is unlikely that CAM practitioners who have been qualified for over ten years would have received teaching in EBP as part of their initial training. Practitioners with more than 11 years experience stated that they had not had good training previously in EBM (p = 0.04) and they felt that original research papers were confusing (p = 0.02) more often than their less experienced counterparts. The more experienced practitioners also felt that clinical judgment was more important than EBM (p = 0.005) than those with shorter length of time since qualification. More allied health care professionals stated that EBM was essential for their clinical practice and also that they needed more training in EBM than CAM practitioners (p = 0.02 and p = 0.05 respectively).

Table 2. Effect of profession and years since qualification (<5 years, 6–10 years, 11 years and over) on allied health care professionals and complementary health practitioners' beliefs relating to Evidence-based Medicine (EBM)

Discussion and Conclusion

Our study identified several issues that require addressing in the provision of EBP training for allied health care professionals and CAM practitioners. Amongst allied and CAM practitioners the perceived need to obtain training in EBM was high and perception of competence was low. Comparatively, allied health care professionals and those with longer length of time since qualification fared worse than CAM practitioners and those with recent qualification respectively. Furthermore, learning needs varied according to the type of profession, time since graduation and prior research experience.

To ensure the validity and generalisability of our findings, we selected questions from reliable and previously validated questionnaires [18,19]. One of the strengths of our study is that we surveyed a large sample of both allied health care professionals and CAM practitioners from a variety of professions and with varying lengths of time since qualification. However, we did not employ a random sampling process and the sample was from participants who voluntarily attended the courses. Therefore our sample was restricted to those individuals who may have been more aware and self-motivated than other practitioners. Furthermore, our respondents were all based within the West Midlands region and as such our findings may not entirely reflect the knowledge and beliefs of other allied health care professionals and CAM practitioners outside of the region. We, therefore, acknowledge that the generalisability of our findings may be limited but our study does provide a starting point for further research in these groups of practitioners. However, we feel that our findings do merit consideration by teachers and trainers in these health care fields and in particular those providing continuing professional development training programmes.

Our survey suggests that like previous studies [18,19,23] that found that medical doctors lack methodological competence in critical appraisal skills and EBM, CAM practitioners and allied health care professionals also need skills. Our survey also correlates with the findings of a previous study [19] where we examined medical doctors' knowledge and beliefs concerning EBM. We found that doctors within our deanery also reported that they did not feel confident at assessing study design, generalisability of the research or evaluating sample size and statistical tests. Furthermore, many junior doctors stated that they support the principles of EBM, but they are undecided regarding whether patient choice and their own clinical judgment are more important and should override research evidence. The doctors were also in agreement with the allied health care professionals and CAM practitioners and confirmed that EBM was essential to their practice but they felt that they required further training in the subject. It is therefore, apparent that both groups have identified that EBP training is important and has not previously met their needs.

Our survey findings are exploratory and will benefit from further replication, but it does provide information for allied health care professionals' and CAM practitioners' teachers and trainers. In particular, our findings should be taken into consideration when planning EBP curricula as it is important to tailor teaching to the needs of specific subgroups of trainees to ensure that specific learning needs are met.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

JH contributed to the questionnaire design, co-ordination and collection of the data and drafted the manuscript. IH performed the statistical analysis and helped to draft the manuscript. KSK conceived the study, and participated in its design and contributed to the write up of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The courses were funded from a grant received from the Learning and Skills Council and European Social Fund (European Union Grant LSE31068WM2).

We would like to thank Dr James Davis, Dr Arri Coomarasamy and Miss Denise Hardy for all of their help and assistance in this project.

References

  1. Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, Porzsolt F, Burls A, Osborne J: Sicily statement on evidence-based practice.

    BMC Medical Education 2005, 5:1. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  2. The Foundation Programme Committee: Curriculum for the foundation years in postgraduate education and training. Department of Health; 2005.

  3. General Dental Council: Standards for Dental Professionals. [http://www.bda.org] webcite

    2005.

  4. Health Professionals Council: Standards of proficiency: Arts therapists. [http://www.hpc-uk.org] webcite

  5. Health Professionals Council: Standards of proficiency: Dietitians. [http://www.hpc-uk.org] webcite

    2003.

  6. Health Professionals Council: Standards of proficiency: Radiographers. [http://www.hpc-uk.org] webcite

    2003.

  7. Health Professionals Council: Standards of proficiency: Speech and language therapists. [http://www.hpc-uk.org] webcite

    2003.

  8. Health Professionals Council: Standards of proficiency: Chiropodists/Podiatrists. [http://www.hpc-uk.org] webcite

    2005.

  9. Health Professionals Council: Standards of proficiency: Physiotherapists. [http://www.hpc-uk.org] webcite

    2005.

  10. Nursing and Midwifery Council: The NMC code of professional conduct: standards for conduct, performance and ethics. [http://www.nmc-uk.org] webcite

    2004.

  11. General Osteopathic Council: Standard 2000: Standard of proficiency. [http://www.osteopathy.org.uk] webcite

    1999.

  12. The Aromatherapy Council: National Occupational Standards for Aromatherapy. [http://www.aromatherapycouncil.co.uk/] webcite

    2006.

  13. General Chiropractic Council: Code of Conduct and Standard of Proficiency. [http://www.gcc-uk.org] webcite

    2005.

  14. House of Lords: Science and Technology - sixth report: Complementary and Alternative Medicine. [http://www.parliament.the-stationery-office.co.uk] webcite

    2000.

  15. Hadley J, Davis J, Khan KS: Teaching and learning evidence-based medicine in complementary, allied and alternative health care: An integrated tailor-made course.

    Journal of Alternative and Complementary Medicine 2007, in press. OpenURL

  16. Harden RM: Ten questions to ask when planning a course or curriculum.

    Med Educ 1986, 20:356-365. PubMed Abstract OpenURL

  17. Morrison J: ABC of learning and teaching in medicine: Evaluation.

    BMJ 2003, 326:385-387. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  18. Awonuga AO, Dwarakanath LS, Khan KS, Taylor R: Post-graduate obstetrics & gynaecology trainees' views and understanding of Evidence-based Medicine.

    Medical Teacher 2000, 27-29. Publisher Full Text OpenURL

  19. Hadley J, Wall D, Khan KS: Learning needs analysis to guide teaching evidence-based medicine: knowledge and beliefs amongst trainees from various specialities.

    BMC Med Educ 2007, 7:11. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  20. Taylor R, Reeves B, Mears R, Keast J, Binns S, Ewings P, Khan KS: Development and validation of a questionnaire to evaluate the effectiveness of evidence-based practice teaching.

    Medical Education 2001, 35:544-547. PubMed Abstract | Publisher Full Text OpenURL

  21. Fritsche L, Greenhalgh T, Falck-Ytter Y, Neumayer HH, Kunz R: Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine.

    BMJ 2002, 325:1338-1341. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  22. Clason DL, Dormondy TJ: Analyzing data measured by individual likert-type items.

    Journal of Agricultural Education 1994, 35:31-35. OpenURL

  23. Olatunbosun OA, Edouard L, Pierson RA: Physicians' attitudes toward evidence based obstetric practice: a questionnaire survey.

    BMJ 1998, 316:365-366. PubMed Abstract | Publisher Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6882/8/45/prepub