Knowledge, attitudes, and barriers towards evidence-based practice among physiotherapists in Malaysia.

BACKGROUND: Recently, there has been an increased need for all healthcare disciplines to provide interventions that are effective and evidence based. This has led to more implementation of evidence-based practice (EBP) in clinical settings. Following this, research regarding EBP gained attention to determine its uptake into the physiotherapy profession. Although there are numerous studies to determine the attitudes and barriers of physiotherapists towards EBP, most of them were done in developed nations. As for Malaysia, little research has been carried out, much less among physiotherapists.
PURPOSE: The purpose of this study was to identify the knowledge, attitude, and barriers towards the implementation of EBP among physiotherapists in Malaysia.
METHODS: A survey was conducted among the members of the Malaysian Physiotherapy Association and other practicing therapists in Malaysia. One hundred and two responses were collected throughout a span of 2 months.
RESULTS: Respondents agreed that EBP is necessary to practice and that it helps in decision making as well as improving patient care. Eighty-one percent of the respondents either agreed or strongly agreed that they had received formal training in EBP. However, 61% of the respondents reported that strong evidence is lacking to support their interventions. Thirty percent of the respondents reported reading <2 articles per month, with 57% stating that they read two to five articles in a typical month. This study also found time constraints, limited access to search engines, and lack of generalizability of research evidence as the top three barriers to implementing EBP.
CONCLUSION: Physiotherapists in Malaysia had a positive attitude towards EBP and are inclined towards implementing evidence into their clinical practice. They are interested in attending courses to improve their knowledge and skills in EBP.

Introduction

Evidence-based practice (EBP) is considered as a cornerstone in the current era of clinical practice. In line with other healthcare professionals, physiotherapists are also using highest quality of research evidence in their clinical practice. In 2003, the World Confederation of Physical Therapists declared a policy statement on EBP, in which they stated that “physical therapists have a responsibility to use evidence to inform practice and ensure that the management of patients/clients, carers, and communities is based on the best available evidence” [1].

The implementation of EBP in any clinical setup involves five As: (1) ask a clinical question; (2) acquire the best evidence; (3) appraise the evidence for its validity; (4) apply the evidence with clinical expertise and patient values; and (5) assess the effectiveness of the process. Inability to carry out any one of these steps may constitute a barrier to EBP. Several studies conducted among various healthcare professionals have identified lack of time as the greatest barrier to implement EBP [2-7], apart from limited access to information and a lack of good information technology support [8,9]. Other barriers reported include a lack of search skills [2,3,7,9] and difficulty in applying evidence in the patient population [2,6-8].

Besides, the use of evidence in practice also relies on the physiotherapists’ knowledge in searching for and appraising journal articles, and their attitudes regarding EBP. Research regarding the knowledge and attitudes of physiotherapists towards EBP has mostly been done in developed countries. In Malaysia, little research has been done and has focused on healthcare professionals in general, with fewer responses from the perspective of a physiotherapist [4]. The objectives of this study were to: (1) identify the Malaysian physiotherapists’ knowledge and skills in searching for evidence and evaluating available evidence; (2) attitude towards the value of EBP; and (3) perceived barriers towards the implementation of EBP.

Materials and methods

A survey was conducted using a structured questionnaire among the physiotherapists of Malaysia. The survey tool was developed based on published literature, and content of the survey tool was validated by three experts [4] (Appendix). The constructed questionnaire contained two sections. The first section enquired about the sociodemographic data, while the second section consisted of questions related to the knowledge, attitudes and barriers towards EBP. The questionnaire consisted of a four-point Likert scale, dichotomous, and open-ended questions. The final questionnaire consisted of questions to identify knowledge about the EBP process, literature retrieval, and critical appraisal skills, apart from questions to explore the attitudes and beliefs about EBP. Respondents’ perceived barriers on implementing EBP were also questioned. This study was approved by the Institutional Review Board.

In the first phase participants were approached with permission during the Malaysian Physiotherapy Association annual general meeting. The study was explained to the participants and written informed consent was obtained. Out of 80 distributed questionnaires, 75 were returned. The practicing therapists were approached through the Facebook group, with 274 members yielding 27 responses. A total of 102 participants completed the survey.

Data analysis

Data were analyzed using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Response frequencies to the survey questions were determined and presented in tabular and graphic formats. After examining the response frequencies, the variable categories were collapsed, and the Likert scale data were collapsed in to two categories instead of four (agree and strongly agree as one category and disagree and strongly disagree as another category) prior to analysis of the associations between the variables.

Pearson’s χ2 test for independence was conducted to examine the following associations: (1) responses to items measuring education, knowledge, and skills; attitudes and beliefs; use of literature; and access to and availability of evidence with items measuring age, highest degree attained, and work experience (years); (2) responses to items measuring attitudes and beliefs with items measuring access to information; (3) responses to items measuring use of the literature with items measuring the number of physical therapists in practice settings, number of patients seen in an average day, and the number of hours worked in an average day; and (4) responses to items measuring access to and availability of evidence with items measuring the type of practice facility and the number of physical therapists in the facility. Cramer’s V was then used to determine the strength of correlation where associations were found. The level of significance was set at p < 0.05.

Results

The characteristics of the respondents are presented in Table 1. The majority of the respondents were from the age group of 25–34 years (85.3%), and 52.9% had a Bachelor’s degree. A small majority (57.8%) of respondents had 2–5 years of work experience. More than half of the respondents reported that they had undergone formal EBP training (Figure 1); 72.5% of them were confident with search skills; and 57.8% were confident about appraisal. Among the respondents, 66.7% expressed interest in using evidence in practice, whereas 95.1% perceived that EBP is helpful in clinical decision making (Figure 2).

Table 1

Characteristics of respondents.

Characteristics	No.	%
Sex
Male	27	26.5
Female	75	73.5
Age (y)
25–34	87	85.3
35–44	11	10.8
45–54	3	2.9
≥55	1	1
Working experience (y)
2–5	59	57.8
>5	24	23.5
>10	7	6.9
>15	7	6.9
>20	5	4.9
Highest degree
Diploma certificate	45	44.1
Bachelor’s degree	54	52.9
Master’s degree	1	1
Doctoral degree	2	2
Area of practice
Government hospital	22	21.6
Government health clinics	1	1
Private hospitals	30	29.4
Private clinics	33	32.4
Home care	3	2.9
University	4	3.9
Own practice	9	8.8
Geographical area of practice
Kuala Lumpur	41	40.2
Selangor	26	25.5
Melaka	10	9.8
Negeri Sembilan	5	4.9
Perak	1	1.0
Penang	5	4.9
Johor	4	3.9
Terengganu	1	1.0
Pahang	1	1.0
Kedah	2	2.0
Kelantan	1	1.0
Sabah	2	2.0
Sarawak	3	2.9
Work (h/wk)
<20	10	9.8
20–30	10	9.8
30–40	34	33.3
>40	48	47.1

Figure 1

Self-reported education, knowledge and skills on evidence-based practice.

Figure 2

Self-reported attitudes and beliefs. EBP = evidence-based practice.

When questioned about accessibility to the evidence, 88.3% of respondents had access to the search engine (Figure 3). There were significant associations between qualifications, specialization, and work experience, and the number of articles read monthly (Table 2). Insufficient time has been identified as the top barrier for implementing EBP by the respondents, followed by limited access to search engines (Figure 4). Inability to apply EBP to the population, and lack of research skills and interest were also perceived as barriers by the respondents (Figure 5).

Figure 3

Self-reported access to search engines. (A) Self-reported articles read per month; (B) self-reported use of evidence.

Table 2

Factors associated with the literature consultation.

Variables		Results
Dependent	Independent	χ2 (df)*	pa	Vb
No. of research papers read per mo	Age	7.405 (9)	0.595	—
	Highest degree	24.615 (9)	0.003*	0.284
	Specialization	11.222 (3)	0.011*	0.332
	Working experience (y)	28.359 (12)	0.005*	0.304
	Type of practice facility (public/private sector)	3.380 (3)	0.337	—
	No. of physiotherapists in practice setting	12.014 (12)	0.445	—
	No. of patients seem in an average d	14.985 (12)	0.242	—
	No. of h worked in an average d	9.086 (9)	0.429	—
Use of literature in decision making	Age	9.497 (12)	0.660	—
	Highest degree	27.3727 (12)	0.006*	0.301
	Specialization	4.734 (4)	0.316	—
	Working experience (y)	20.505 (16)	0.198	—
	Type of practice facility (public/private sector)	4.944 (4)	0.293	—
	No. of physiotherapists in practice setting	14.658 (16)	0.550	—
	No. of patients seen in an average d	16.615 (16)	0.411	—
	No. of hours worked in an average d	15.254 (12)	0.228	—

Significant at p ≤ 0.05, n = 102.

Pearson χ2 test for independence, n = 102.

Cramer’s V test.

Figure 4

Self-reported access to search engines (in percentage).

Figure 5

Self-reported ranking of barriers to evidence-based practice (in percentage).

Discussion

Results of this survey demonstrated an association between age and learning the foundations of EBP. The majority of respondents were from the younger generation, and they have learned the foundations of EBP during their entry level program, compared with respondents who were in the older age group. This may be due to the introduction of EBP in the physiotherapy curriculum in the most recent decade. Dorsch et al [10] and Green and Ellis [11] both reported that the introduction of EBP in the academic curriculum improves the physician residents’ skills in critical appraisal.

The participants of this survey had a positive attitude towards EBP. Most of the participants (57.8%) agreed that EBP is necessary for their day-to-day practice and EBP is required to provide higher quality service for their patients (60.8%). Findings of this survey are similar to those of Iles and Davidson [9] and Akinbo [12].

Most (61.7%) of the respondents observed a lack of strong evidence in their interventions for their patients. This was reflected in a study by Cup et al [13], in which they found limited evidence to support the interventions used for the management of chronic neurological conditions.

Only 30% of the respondents reported that they read <2 articles in a typical month, and 20% of the respondents reported that they either never or rarely consulted literature and research findings for their clinical decision making. This finding did not correlate with the studies by Jette et al [2] and Akinbo et al [12], in which 17% and 8% of their study respondents read <2 articles in a typical month, respectively. This could be attributed to the fact that there is lack of access or awareness to journal articles among physiotherapist in Malaysia [4]. However, according to a study of 124 Australian physiotherapists by Iles and Davidson [9], it was found that 43.9% indicated they either “never” or “less often than monthly” integrated research evidence with their expertise [9]. A study of 106 musculoskeletal Kuwaiti physiotherapists [14] found that physiotherapists relied very minimal research findings for day-to-day clinical decision making.

This survey found relations between the respondents’ highest earned qualification and the number of research articles read per month, and the rate of use of literature in decision making. These associations were reflected in a study of 270 Canadian physiotherapists by Salbach et al [15], in which a relationship was found between academic preparations in EBP and self-efficacy to implement EBP. The respondents who do not possess a postgraduate degree and who have less working experience are less likely to be engaged in EBP.

For EBP to be used effectively in clinical practice, consideration should be given to the availability of information technology support. Most of the respondents reported that they have access to search engines, although more had access at home (81%) than at work (68%). This finding was consistent with that of Jette et al [2] and Ramirez-Velez et al [3].

A study by Brown et al [16] among 40 physiotherapists in the United States reflected similar results to the present study. They reported that all respondents had computer access either at their facility or at home, with 80% of the respondents stating that they have computer access at home. The greatest proportion of respondents accessed the internet two to five times per week, which is consistent with the present study.

The barriers identified in this study were reflected in other studies among physiotherapists [2,3,8,9,12], nurses [17-20], and physicians [21,22]. The primary barrier to implementing EBP was lack of time. Respondents to this survey also mentioned that they found it difficult to consult related literature due to high workload, which resonated with a study by Hannes et al [8] among physiotherapists in Belgium. In the UK, Igo [23] found that, although the respondents understood the process of appraising a research article, it was still considered a demanding and time-consuming process. Organizations may therefore discourage activities related to EBP during working hours, as it is more cost effective for employees to spend time attending to patients than to be involved in EBP.

Other barriers identified in this study were a limited access to search engines and journal articles and an inability to apply research findings to their patient population. Even though journal articles are now available online through various databases, some of them requires a fee or membership for access. Another study among Malaysian healthcare practitioners also found that a lack of information technology support in their facilities increased the difficulty of implementing EBP [4]. This was not reflected in a study among physiotherapists in the United States [2], in which only ~20% of the respondents chose lack of information resources as a barrier.

Our study had some limitations. Although all efforts were made to reach out to a population as diverse as possible, the dissemination of the questionnaire did not match the expectations of the authors. The respondent population was not big enough for the findings of this study to be generalized among the whole country. Some of the cited papers were published prior to 2006 and the current situation in other parts of the world may be different.

The findings of this study, in the authors opinion, have implications for the educational, clinical, and research communities. A majority of the respondents in this study have <5 years of work experience, and thus it can be assumed that most of the respondents only graduated recently. However, journal readership is low among the majority of the respondents, therefore, the education community may have a role to play in promoting the use of evidence bases in their education curricula, so that students develop the habit of referring to journal articles to answer their clinical questions.

Conclusion

Physiotherapists in Malaysia have good knowledge on EBP and show a positive attitude towards implementing it. Furthermore, the respondents also have generally positive attitudes towards EBP. A majority of the respondents indicated an interest in adopting EBP in their clinical setup. Findings of this study may provide a base for implementing EBP in different clinical settings by understanding the barriers from the perspectives of different countries.