Knowledge, behaviours and attitudes towards Evidence-Based Practice amongst physiotherapists in Poland. A nationwide cross-sectional survey and focus group study protocol.

OBJECTIVES: Evidence-Based Practice, EBP, is recognised, along with team work and patient-centred care, as a core competency in contemporary healthcare. However, dissemination and implementation of EBP remains problematic and is dependent on various external and internal factors, from personal through institutional to systemic, factors, with specific characteristics for different professions, contexts and settings. Knowledge, behaviours, attitudes, as well as facilitators and barriers towards EBP amongst physiotherapists, have been widely explored worldwide, but never in Poland. This study is part of a nationwide project, including dissemination actions addressing EBP in physiotherapists registered in Poland. Our purpose is to explore the issues of knowledge, behaviours, experiences, and attitudes of physiotherapists in Poland towards EBP. Descriptive research studies are warranted before analytical investigations and dissemination activities are conducted.
METHODS: We plan to conduct a quantitative, cross-sectional study-an online survey amongst the total population of physiotherapists registered in Poland to assess knowledge, behaviours and use of EBP (Study 1), and a qualitative study to allow physiotherapists to voice their opinions and to explore their experiences and attitudes towards EBP (Study 2). The EBP2 questionnaire, Polish validated translation, will be used for Study 1, in a web-based survey. A focus group approach will be applied for Study 2, with purposive sampling to achieve a representative picture of physiotherapists with respect to setting, specialty, seniority, educational degrees, and age. We will follow an inductive approach, using topics rather than questions.
RESULTS: We will present the results of the studies separately, as typically presented in relevant study types: Study 1 will be reported addressing the domains and items of the EBP2, in relation to the independent variables, and Study 2 will be discussed using the themes and illustrative quotes analyses. DISCUSSION: We are aware that significant non-response, spin and Hawthorne effect may potentially bias our findings.

Introduction

It is now thirty years since the Evidence-Based Medicine Working Group coined the term and set the principles of the paradigm shift of the practice and teaching of medicine [1]. Since that time, evidence-based medicine, EBM, with terminology then evolved to evidence-based practice, EBP, and other corresponding terms, has become a principle of healthcare [1-4]. Among many definitions, the World Confederation for Physical Therapy defines EBP as “an approach to practice wherein health professionals use the best available evidence from systematic research, integrating it with clinical expertise to make clinical decisions for service users, who may be individual patients/clients, carers and communities/populations (…) [which] involves complex and conscientious decision-making based not only on the best available evidence but also on patient/client characteristics, situations, and preferences (…)” [5].

Healthcare practitioners and other professionals are expected to implement research evidence in daily practice to improve the quality of care and patient outcomes [2-8]. Implementation of EBP is recognised not only as an improvement in understanding and optimising the process of care in terms of knowledge and abilities, but as a moral obligation. It is unethical to deliver suboptimal, ineffective, dangerous, or cost-ineffective interventions to patients and clients, as well as the unethical practice of conducting unneeded and flawed research [2, 7, 8].

EBP has become a necessary competency for rehabilitation [9] and physiotherapy practice [3, 4, 6]. Important initiatives, such as the World Confederation for Physical Therapy Policy Statement on Evidence based Practice [3], the Sicily statement on evidence-based practice [4], the Physiotherapy Evidence Database, PEDro [10], and focus on EBP in physiotherapy curricula [6], have grounded EBP as a core of physiotherapy education and practice.

Why it is important to do this study

Further developments and evolution of the EBP movement, such as shifting from the traditional hierarchy of evidence to the GRADE approach, stressing patient values and shared decision-making in the process of EBP, and introduction of systematically developed, evidence-based clinical practice guidelines [2, 11], have been recognised in the standards of physiotherapy education and practice [5, 6]. Nonetheless, the barriers and difficulties to the implementation and dissemination of the process of EBP [11-13], also regard physiotherapy [14, 15], with significant discrepancies across countries and contexts [16-18], and specific features of physiotherapists amongst other healthcare professionals [13, 19, 20].

Knowledge, skills, beliefs, and attitudes towards EBP (the EBP profiles [19, 21]) have been studied amongst physiotherapists worldwide [14, 15, 19, 22–27] since the first study addressing this problem was published in 2003 [28].

In contrast, to the best of our knowledge, no such research has been completed in Poland. There are unique contextual factors on EBP profiles and, more widely, on EBP culture amongst physiotherapists in Poland, so that descriptive research studies are needed first to allow further analytical investigations and dissemination activities regarding this crucial issue.

Objectives

The overall aim of the project is to improve and facilitate the process of the dissemination of EBP in Polish physiotherapy. We need data on EBP profiles of physiotherapists in Poland to follow with further dissemination and implementation steps [5, 7–9]. Therefore, the specific objectives of the presented studies are:

to assess EBP profiles of physiotherapists registered in Poland,

to allow physiotherapists to voice their opinions and explore their experiences and attitudes towards EBP,

to explore the association of a range of contextual factors and characteristics with their EBP profiles, and

to investigate their experiences as regards the facilitators and barriers towards EBP in their everyday practice.

Methods

The procedure comprises of two complementary and corresponding investigations–a quantitative, nationwide cross-sectional study (Study 1), and a qualitative, focus group study (Study 2). We describe the studies in subsequent paragraphs. The flow chart of the procedure is provided as S1 File.

Quantitative study (Study 1)

This is a nationwide study of EBP profiles–knowledge, attitudes, and use of EBP–amongst physiotherapists registered in Poland.

Methods

Design

This will be a cross-sectional, online survey, addressed to the whole population of physiotherapists registered in the Polish National Registry of Physiotherapists. We will apply the Evidence-Based Practice Profile Questionnaire (EBP2Q) [21], validated Polish version [29]. Personal, professional and demographic characteristics will be collected using additional questions in the survey, as well as the data available through the National Registry.

Setting and participants

All registered physiotherapists will be invited to participate in the study. The criterion is the record from the National Registry, i.e. confirmation that a person has the legal status of a registered physiotherapist in Poland. Therefore, registered physiotherapists located in Poland, regardless of their nationality or country of origin, as well as Polish physiotherapists listed in the Registry, but living outside Poland, meet this formal eligibility criterion. We will also invite people who will have obtained the status of a registered physiotherapist within two weeks of the first dispatch of the study. At the submission of this protocol report, the Registry comprised 70,052 records. The Registry is administered by the Polish Chamber of Physiotherapists, KIF. The project, including the study, is conducted in partnership with KIF so that current e-mail addresses and other contact details of all eligible participants are located and accessible.

In Poland, most of the registered physiotherapists are graduates of physical therapy education at master’s or bachelor’s degree studies. Physiotherapists, who obtained their vocational training prior to 2015, are also eligible for registration. Currently, the Polish entry-level physiotherapy education programme comprises of five years of master’s studies. There is currently neither vocational training nor first-stage (bachelor) academic physiotherapy undergraduate education provided in Poland.

Sociodemographic characteristics. As the original demographic variables of the EBP2Q were not validated in the Polish translation [29], and as we have specific needs for our study, we will supplement the original EBP2Q sociodemographic content form to collect characteristics of the respondents related to the context of the study, especially regarding education and employment (such as private practice or public sector, and speciality), and the main location of their practice. The list combines the original EBP2Q demographic data content and the issues specific to the context of the study (Table 1). A template EBP2Q survey form, including demographics, is provided as a S2 File. Responses will be treated anonymously and data will be stored respecting the requirements of personal data integrity and security.

Table 1

Items on demographics and professional characteristics of the participants included in the survey.

personal characteristics	gender
	age
location of residence	country of residence
	voivodship1
location of practice	rural
	town
	city
education and formal competencie	level of education:
	technician (vocational school)
	bachelor of physiotherapy
	master of physiotherapy
	specialist of physiotherapy2
academic degree or title3	PhD
	habilitation4
	professor
professional experience	years in profession
work setting	hospital, clinic
	ambulatory
	patient’s home
	residential medical care, nursing home
	private practice
	health spa
	academy
	sport club, gym
	other

1if Poland country of residence

2master of physiotherapy with specialisation

3if applicable

4the highest scientific degree in the Polish academic system

Sample size. To achieve the standard error level not higher than 3%, we design the sample size as around 1000. The actual sample will then be standardised according to sex, age, educational level, and living area (Polish voivodship) structure of the whole physiotherapist population, based on the National Registry. The procedure consists of applying the standard formula for the minimum sample size (n) with an assumed level of estimation error (3%) and a confidence level (95%): where 1.96 is the value of the normal distribution for the cumulative distribution of and 0.25 is the constant in the case of an unknown level of a fraction in the population.

Meeting these conditions will allow us to maintain the representativeness of the sample for the Polish physiotherapist population.

Data collection

The questionnaire. The EBP2Q is a self-reported questionnaire consisting of fifty-eight statements, grouped into five domains–relevance, terminology, confidence, practice, and sympathy, as well as non-domain items of sixteen additional statements addressing other aspects of EBP. The questions are close-ended, with replies ranging in a 5-point Likert scale, some of them reverse-coded. As six separate results are obtained for each respondent, analyses of both separate domains and the profiles of variables are possible. There are no standards for individual domains [20]. The structure and content of the domains of the questionnaire are presented in Table 2.

Table 2

The structure and content of the Evidence-Based Practice Profile Questionnaire, EBP2Q [20].

Domain	item numbers	description	scale1
Relevance	1–14 (14 items)	attitude towards expanding own EBP competence	1 –not at all true
			5 –very true
Sympathy	15–21 (7 items)	attitude towards selected aspects of EBP in work	1 –strongly disagree
			5 –strongly agree
Terminology	22–38 (17 items)	the level of knowledge about the terminology related to scientific research	1 –never heard the term
			5 –understand and could explain to others
Practice	39–47 (9 items)	frequency of use of individual elements of EBP in daily clinical work	1 –never
			5 –daily
Confidence	48–58 (11 items)	confidence in skills related to EBP	1 –not at all confident
			5 –very confident
non-domain items	59–74 (16 items)	other aspects of EBP	1 –strongly disagree
			5 –strongly agree

1 5-point Likert scale for each item

Conducting of the survey. The online survey form, supplemented with an invitation letter, will be distributed via e-mails to all physiotherapists listed in the Registry. Exceptions are people who decline to receive information e-mails from KIF (about 2% of all KIF members at the submission of this paper).

The survey link will be available for three weeks. In the invitation letter, we will present the idea of the project and the purpose of the study, the types of questions that participants could expect, as well as technical information regarding the time needed to complete the survey (S2 File). Recipients who will not open the first e-mail or will not open the survey form will be emailed with a reminder two weeks after the date of the first dispatch [26]. To reach and encourage everyone eligible, we will additionally distribute the survey messages using the KIF website, newsletter, and social media communication channels.

We will administer the study using the Webankieta web survey platform. It is a Polish design and language platform, dedicated to web-based surveys, and data collection and storage. The survey will be filled out anonymously, and responses cannot be traced back to respondents.

Data management and analysis

We will calculate descriptive statistics for the five EBP2Q domains for responses to individual questions and for each domain score, and supplement it with intra-subscale correlation coefficients. We will treat the Likert scores for the questionnaire as ordinal (quazi-quantitative) data. For sociodemographic information, we will calculate descriptive statistics as well.

The association of selected characteristics on the EBP profile of the respondents will be verified with the chi-square test of independence, one-way ANOVA, or Kruskal-Wallis ANOVA depending on the distribution of the EBP2Q scores (providing the Shapiro-Wilk test reveals lack of normal distribution of variables) and/or correlation coefficient significance test. We will apply Pearson or Spearman coefficients for quantitative and ordinal data, respectively, depending on the variables. The threshold for significance will be set at 0.05. The logistic regression will be applied for the identification of the factors which differentiate the importance of three main barriers to EBP implementation, indicated in the questionnaire. All data analyses will be performed using STATISTICA software, v.13.3, StatSoft, Poland.

Qualitative study (Study 2)

Background

We find it important to complement the project with a qualitative research study. Qualitative methods offer in-depth, broad and life-immersed perspectives of a phenomenon, which allows for a more comprehensive approach to a complex subject [30]. Therefore, we will expand the quantitative study with a qualitative approach in order to describe and explore the physiotherapists’ views and experiences on EBP in the most wide-ranging manner.

We aim at identifying and exploring current views, experiences, beliefs, attitudes, and opinions on EBP amongst physiotherapists in Poland. The focus will be on how physiotherapists actually understand and experience EBP in their work and life, potentially uncovering new insights and viewpoints on the matter.

We will apply the focus group methodology. We will use the inductive approach, with topics rather than questions. We plan to collect qualitative data having completed Study 1. We will use three focus groups with six to ten physiotherapists each. After the last focus group discussion, the authors will decide whether theoretical saturation is achieved. If not, additional focus groups will then be organised, until no new information or patterns emerge [31, 32]. We expect the interviews to last between 90 and 110 minutes.

After the publication of this protocol, the pilot focus group interview will be conducted first [33]. Next, we will make any necessary amendments to the interview guide, based upon the pilot interview. The focus group interviews will then be scheduled, taking into consideration specific contextual factors such as the place of the interview, the availability of the research staff and participants, allowing also for enough time after each interview for supervised data transcription and research team feedback sessions.

We will apply purposive sampling, which allows choosing individuals with specific knowledge or experience in a subject of interest [34]. Therefore, we will invite participants based on the network of physiotherapists, connected to the Department of Rehabilitation at the Faculty in Biała Podlaska of the Józef Piłsudski University of Physical Education in Warsaw. It is a rich network of physiotherapists, representing various stages of their professional careers, from graduates to very experienced individuals, working in various settings, and representing ranges of other characteristics (such as age, gender, speciality, sector, work setting). Thus, we aim to ensure intergroup heterogeneity, which will represent a broad spectrum of experiences and contexts [33]. We also want to maintain intragroup homogeneity, in order to encourage open discussions and create a non-threatening group environment. Hence, careful consideration will be given to group dynamics issues such as professional connections, roles and relationships within the focus groups. We will establish appropriate groups based on the characteristics of the participants collected prior to conducting the interviews.

As the quantitative and qualitative studies will be conducted independently, and the data will be managed and analysed separately, we will not consider it as an eligibility criterion if participants willing to take part in the qualitative study will participate in the survey study or not.

During the focus group interviews, two authors (WK and ZW) will take lead roles as dual moderators [31]. Their roles will include introducing the objectives and the topics of the study, stimulating discussion in the focus groups, and ensuring the appropriate atmosphere. Additionally, reflexive field notes will also be made during the interviews, including the potential reactions, feelings, and non-verbal elements, of both participants and researchers, to present the context of the interviews and provide a more in-depth understanding. This will be done by another research team member (WG), who will serve as an assistant. All interviews will be audiotaped and transcribed verbatim, adding the field noted conducted by the focus group assistant. WG has considerable experience in qualitative research. Additionally, we will invite another experienced qualitative researcher to ensure the rigour of the study’s conduct.

The topics will be developed drawing on existing literature on the subject, as well as the personal and professional expertise and experience of the authors. They will be introduced indirectly, in an open-ended manner and focused on the subjects related to experiencing EBP in the participants’ practice. This is meant to enable them to naturally engage in posing their own questions and identify priorities within the study’s aims and objectives [32]. The key topics will be focused around the following areas:

understanding of EBP,

opinions on EBP,

using EBP in the workplace,

experiencing EBP in daily practice.

We provide a template table, where we will record and then analyse the themes with illustrative quotes, obtained from the participants (S3 File).

Each focus group interview will begin with opening questions regarding participants’ work setting and practice. Participants will be provided with verbal and written information about the aims of the study and the data collection methods. They will also be notified that they can withdraw at any time. We will hold feedback sessions shortly after each interview.

Data analysis

We will analyse the data using the thematic analysis (TA) approach. TA is designed to identify patterns of meaning using the qualitative data, especially useful when exploring data created during focus groups discussions around a specific topic. The analysis will thus consist of data familiarisation, coding, theme development, revision, naming, and report writing [35]. We will apply a staged process of thematic analysis, through an iterative process of meetings and discussions [36]. Three authors (WG, WK, ZW) will first independently analyse the transcribed responses and read them multiple times to familiarise themselves with the content and categorise it in a meaningful way. Then, during the meetings, they will compare the codes and themes, until the shared understanding and consensus is achieved. The themes will be presented narratively, with illustrative data quotes.

Ethics

The study has received acceptance from the Ministry of Education and Science, Poland, Review Board (SONP/SP/461408/2020), and was further revised by the Ethics Committee of the Józef Piłsudski University of Physical Education in Warsaw. The study adheres to the Declaration of Helsinki.

Discussion

Idea and rationale of the study

This is a protocol within a nationwide project aimed at exploring EBP profiles, as well as at identifying barriers and facilitators to the dissemination of EBP amongst physiotherapists and in the entry-level physiotherapy education in Poland [37]. In our view, there is no need to discuss in this paper the paradigm and evolution of EBP and the importance of EBP in general. The established role of EBP in various fields within and outside health care [2, 4, 8, 11], including physiotherapy practice and education [3, 6, 10, 14] are clear. The general need for this study that it is necessary to address this critical issue in terms of practice and research needs and gaps. Several barriers to the use of EBP by physicians and other healthcare professionals [12, 13], and specifically by physiotherapists [14, 15, 21], have been identified, such as an inability to understand statistical data, inadequate support from employers and colleagues, organisational and time constraints, and lack of interest. Understanding potential barriers to EBP is suggested to be the initial step to developing strategies toward successful implementation and dissemination [9, 38].

Our purpose is to explore the issues of knowledge, behaviours, experiences, and attitudes of physiotherapists in Poland towards EBP. A descriptive research study is warranted before analytical investigations and dissemination activities are conducted. More generally, we also aim at promoting and facilitating the EBP culture and use of EBP amongst physiotherapists in Poland. We believe that the most important aspect is the ethical argument within the EBP paradigm. It is unethical to provide patients with suboptimal care, to conduct unneeded research and research leading to unreliable and invalid findings and conclusions. As is wasting resources on cost-inefficient and harmful interventions as well on wasteful science [2, 5, 7, 8]. These issues correspond with the goals of our study and underpin our motivations.

Study methods and conduct

There is a great variety of tools used to assess EBP knowledge, behaviours and attitudes amongst healthcare professionals [39, 40]. Nonetheless, only the EBP2Q [20] was recently validated in Polish in a group of nurses and midwives [28, 41]. The EBP2 questionnaire presents good psychometric properties and confirmed reliability and, can be applied to self-assessment of various aspects of EBP competencies by students, lecturers and practitioners [18, 20, 35]. We find it advantageous that a validated Polish translation of this tool is available. The EBP2Q is internationally validated [42, 43] and was used to study EBP profiles of nurses in Poland [28, 41]. This will enable further comparisons.

To conduct the survey, we chose the Webankieta online survey tool as it meets all technical and legal (such as data security) requirements for the planned study, as well as it is equivalent to the SurveyMonkey platform, applied in similar studies [22, 26], while it is provided in the Polish language. It has been used by KIF for other surveys so that both the investigators and recipients are familiar with its use.

As for the qualitative part of the investigation, we decided to choose the focus group methodology. Focus groups encourage interaction and discussion between the participants, in order to enable them to express their personal, subjective, multiple and, at times, even contradictory views, generating potential new ideas and perspectives on the topic studied [30-36]. Qualitative, as well as mixed-method studies, are increasingly utilised to complement quantitative studies in investigating EBP profiles in the context of people’s voices, for richer and more in-depth exploration of EBP [33, 36, 44].

Altogether, we believe to collect a meaningful picture of how physiotherapists in Poland see, understand and use EBP.

Limitations

Potential biases

There may be bias due to the nature of the self-administered questionnaire survey. We are aware of potential non-response bias. There may be a tendency that physiotherapists are more likely to enrol if they are already familiar with the topic. This could overestimate the prevalence estimate found in our sample in the event of a significant non-response. Therefore, we will take preventive steps at the design, implementation and analysis stages of the study, such as repeating invitations to obtain late respondents, providing the accessible format of the survey, monitoring the duration of the survey throughout, as well as adjustment techniques and comparing respondents to non-respondents, if deemed necessary [45]. To achieve the standard error level not higher than 3%, we design the sample size as around 1000. Also, we take into consideration potential phenomena of conscious or unconscious misinterpretations of study findings, or spin bias, especially as we are engaged in the process of EBP and, in that context, we have our attitudes as regards the studied problem [46]. Publishing this registered report protocol is one way of minimalizing potential misreporting of methods and results, and misinterpretation. We are also aware of the potential Hawthorne effect, meaning that people could change their behaviour or answer differently when being observed. In contrast, as the study addresses the whole population of interest, and the measures will be recorded identically for all participants, we do not expect selection and ascertainment biases to occur.

Two separate studies

We plan to conduct two individual studies rather than one full mixed-methods study with integrative analyses of the quantitative and qualitative data. Nonetheless, collecting quantitative data, with the use of a recognised, comprehensive questionnaire, as well as a complementary, focus group study aimed at a deeper understanding of the problem, are in our views warranted, needed, relevant, valid, and sufficient for this pioneering study in Poland.

Dissemination

We plan dissemination activities, such as the website, social media and newsletters messages, and a webinar, to inform physiotherapists as well as to make aware and inspire policymakers and other stakeholders to advance the dissemination of EBP amongst physiotherapists. Through that process, we also aim to improve physiotherapy curricula in Poland.

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28 Sep 2021

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Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

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Reviewer #1: This study protocol describes two planned studies (one quantitative and one qualitative) investigating evidence-based practice among physiotherapists in Poland. In general, I think this is a clear, concise, and well thought out protocol. I have a few questions and suggestions that may improve the manuscript.

1. The introduction could benefit from a little more detail on the concept of evidence-based practice and examples of how this is integrated into physiotherapy.

2. The motivation for conducting these studies could be a bit better motivated. That this exact study has not been conducted in Poland is not enough.

3. The study seems very descriptive, which is ok if this is the level of information that is necessary, but perhaps the aims could be phrased as specific research questions so that it is clearer to the reader exactly what the questions these studies will try to answer.

4. It would also be useful for the authors explain how the research questions will be used. What are the goals and who will be the end users of the information gleaned from these studies?

5. The protocol could benefit from another language/grammatical reading. One example is the last sentence of the first paragraph: “It is unethical to deliver suboptimal, ineffective or dangerous, or cost-ineffective interventions to patients and clients, as unethical is waste in unneeded and flawed research.” To me, this sentence is unclear and difficult to follow.

Reviewer #2: Manuscript Number: PONE-D-21-25941

Title: Knowledge, behaviours and attitudes towards Evidence-Based Practice amongst physiotherapists in Poland. A nationwide cross-sectional survey and focus group study protocol

Comment 1: this is research proposal why don’t you consider its publication after study was conducted?

Comment 2: on page 2 at the end of first paragraph of your abstract you have mentioned as this title/issue was addressed in other parts of the world. So why don’t you use already existed evidences or why not consider doing systematic review and meta- analysis from these evidences.

Comment 3: on page 2 under methods of abstract you have planned to use online survey. One big problem of this method was respondent may update him/her self before responding and may discuss with others. So how you will overcome these problems? You also mentioned use of purposive sampling. Did you think purposive sampling can help in assuring representativeness? Why don’t you consider sampling methods like stratified sampling techniques?

Comment 4: on page 3 just above objectives you have said there is no same study in Poland. Why did you take this as justification to repeat the study? Is there any difference you have found between Poland and other countries physiotherapists?. Add more strong justification to repeat the study.

Comment5: on page 5 under sample size you just plan to take 1000 participants. but you better show clear procedure on how you calculate your sample size. So it help future researcher in replication of the study.

Comment 6: on page 6 under Data management and analysis you have planned to run descriptive statistics. But you should specify what types of descriptive statistics for groups of variables (Example for continuous data and for categorical data).

Comment 7: on page 8 under discussion you wrote a lot of evidence regarding evidence based practice. Did you think you will find different results despite you didn’t mention weakness of previous studies.

Comment 8: on page 9 under limitation you put anticipated limitation. But in reality what you think may not come problematic. Please consider writing limitation after completion of the study.

Comment: 9 on page 10 under author contribution you write some contribution which will expect if study was already conducted (e.g Formal analysis: Maciej Płaszewski, Weronika Grantham, Joanna Trębska). Please revise.

Reviewer: Ahmednur Adem Aliyi

Email: ahmedhariro@gmail.com

Reviewer #3: This research protocol is well design outlying the planning of the authors’ study. It will require minor revision as attached.

Reviewer #4: This is an interesting study and the authors have collected a unique dataset using cutting edge methodology. The paper is generally well written and structured. Overall, this is a clear, concise, and well-written manuscript. The introduction is relevant. Sufficient information about the previous study findings is presented for readers to follow the present study rationale and procedures. The methods are generally appropriate. Overall, the results are clear

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Reviewer #1: No

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Reviewer #3: No

Reviewer #4: Yes: MAHMOUD AL-MASAEED

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Submitted filename: review of PLOS ONE manuscript.docx

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Submitted filename: PLOS ONE paper review 4.docx

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9 Nov 2021

Dear Reviewers,

Dear Academic Editor,

We are grateful for taking the time to support us with expert feedback and valuable input to our manuscript. We are thankful for giving us this opportunity to improve our submission. As part of the submission process, we have provided detailed responses both to the Academic Editor’s and each of the Reviewers’ comments.

Response to the Academic Editor

Dear Academic Editor,

We greatly appreciate your assistance and contribution to our report. We amended the manuscript in accordance with your suggestions.

Academic Editor’s comment:

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Our response:

Thank you for this suggestion. We have prepared the manuscript accordingly.

Academic Editor’s comment:

We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

Our response:

We carefully checked the grant award numbers in the ‘Financial disclosure’ and ‘Funding Information’ sections and we confirmed that the grant numbers match; however, as there are some wording differences (‘award’ and ‘grant’), we now provide the same text in the manuscript and the online submission form.

Academic Editor’s comment:

3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

Our response:

We have included the ethics statement in the Methods section (as a separate subsection, at the end of the section, so that the statement corresponds to both the quantitative and qualitative parts of the study). We have changed the ‘Ethics and dissemination’ section to the ‘Dissemination’ section. We have moved the subsection to the end part of the ‘Discussion’ section so that it is a part of the main manuscript. And we have added a more in-depth explanation regarding planned dissemination activities, following the suggestions of Reviewer 1.

Once again, we would like to thank you for your support.

Response to the Reviewer #1:

Reviewer’s comment:

The introduction could benefit from a little more detail on the concept of evidence-based practice and examples of how this is integrated into physiotherapy.

Our response:

We thank the Reviewer for this suggestion. We have followed this suggestion, along with the Reviewer’s 3 corresponding advice. We have improved the ‘Introduction’ section accordingly. Please see the revised manuscript, especially the version with tracked changes.

Reviewer’s comment:

The motivation for conducting these studies could be a bit better motivated. That this exact study has not been conducted in Poland is not enough.

Our response:

We thank the Reviewer for this suggestion. We have added a more detailed motivation and justification for the study at the end of the ‘Introduction’ section. It also follows a corresponding remark from Reviewer 3. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

The study seems very descriptive, which is ok if this is the level of information that is necessary, but perhaps the aims could be phrased as specific research questions so that it is clearer to the reader exactly what the questions these studies will try to answer.

Our response:

Following this important remark, we have listed specific objectives of our study and addressed them in the revised manuscript, especially in the ‘Discussion’ and ‘Introduction’ sections. The manuscript is supplemented with a study questionnaire file (in Polish), and the original, English version of the questionnaire is also available. We believe that these enhancements, along with the qualitative study key topics, listed in the qualitative study part ‘Methods’ section, give more in-depth insights as regards the specific study questions. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

It would also be useful for the authors explain how the research questions will be used. What are the goals and who will be the end users of the information gleaned from these studies?

Our response:

We elaborate on these issues in the ‘Discussion’ section, specifically under the ‘Idea and rationale of the study’ section. Also, there is a separate ‘Dissemination’ section at the end of the manuscript. However, to make our arguments more clear and accessible to the reader, we rearranged and improved both sections, according to this significant comment. We moved the ‘Dissemination’ part to the end of the ‘Discussion’ section so that the manuscript is now, we hope, more concise. We also address the goals of the study in the improved ‘Introduction’ section, following the Reviewer’s suggestions. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

The protocol could benefit from another language/grammatical reading. One example is the last sentence of the first paragraph: “It is unethical to deliver suboptimal, ineffective or dangerous, or cost-ineffective interventions to patients and clients, as unethical is waste in unneeded and flawed research.” To me, this sentence is unclear and difficult to follow.

Our response:

We have rewritten the indicated sentence. We also checked the whole manuscript for English language quality, with help from a native English speaker, knowledgeable of scientific writing.

Reviewer’s answer to the review question 4:

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer’s answer: no

Our response:

We supplemented the original data availability statement provided in the manuscript with the information regarding the anticipated availability of data from the completed study. It now matches, in the ‘Data availability statement’ section of the online submission form, as it has been included in the original submission.

We would like to thank the Reviewer for analysing our paper and for very helpful and constructive comments and suggestions. We hope that our responses and the revised manuscript are complete and sound.

Response to the Reviewer #2:

Reviewer’s comment:

Comment 1: this is research proposal why don’t you consider its publication after study was conducted?

Our response:

We took the advantage of the PLoS policy of open science and the opportunity for publishing full reports of study protocols (the Registered Report Protocol type of study, https://journals.plos.org/plosone/s/what-we-publish#loc-registered-reports) so that the investigation is transparent, and we follow the rule of presenting the protocol openly to ensure scientific rigour and fairness of the final report. Publishing study protocols is encouraged for a number of reasons (please see the PLoS ONE, https://journals.plos.org/plosone/s/submission-guidelines#loc-registered-reports, or BMJ, https://authors.bmj.com/before-you-submit/how-to-write-a-study-protocol/).

To us, the added value of it is the opportunity to have the study rationale and methods peer-reviewed so that both the study conduct and reporting will gain on quality.

Reviewer’s comment:

Comment 2: on page 2 at the end of first paragraph of your abstract you have mentioned as this title/issue was addressed in other parts of the world. So why don’t you use already existed evidences or why not consider doing systematic review and meta- analysis from these evidences.

Our response:

One of the main goals of our project is to translate knowledge and to disseminate Evidence-based physiotherapy practice in Poland, among a specific group of people, within specific circumstances. Both undergraduate physiotherapy education, and organisational and policy issues of practice, among other contextual factors, are in Poland very different from many other countries. The data from, and findings of this study, are needed for that process. We first need to conduct descriptive studies in this particular population. The contextual factors are crucial so that we cannot rely on indirect evidence from other contexts.

The idea of a research synthesis study is interesting. In our view, it needs a thorough consideration of which research synthesis study method would be accurate for such heterogeneous data, with studies conducted in very much varying Evidence-based cultures, settings, and with different study methods and designs. Also, cross-sectional and qualitative study designs are not typically eligible for systematic reviews, especially as regards meta-analyses. Perhaps a scoping review study could be a good starting point for mapping the evidence of that issue. It could help to project the findings of our study in a more systematic perspective.

Reviewer’s comment:

Comment 3: on page 2 under methods of abstract you have planned to use online survey. One big problem of this method was respondent may update him/her self before responding and may discuss with others. So how you will overcome these problems? You also mentioned use of purposive sampling. Did you think purposive sampling can help in assuring representativeness? Why don’t you consider sampling methods like stratified sampling techniques?

Our response:

We agree that a survey method may be vulnerable to recall bias, or Hawthorne effect, among other potential biases, connected to this type of study. Therefore, we address these issues in the ‘Limitations’ part of the study, which is improved according to the Reviewers’ suggestions and advice. Nonetheless, both the survey designs and the online methods of questionnaire distribution and data collection are standard. We are taking advantage of the EBP2 questionnaire, with its good scientific properties, with the availability of Polish validated translation. We are not able to control the fidelity of the responses. Nonetheless, it could not have been checked even if the survey would have been conducted in-person, with the investigator. There are no open questions such as an explanation of a term or definition in the questionnaire.

As regards purposive sampling, we chose this method for the focus group, qualitative study part of our endeavour, as standard in this type of study (Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Thousand Oaks, CA: SAGE Publications; 2017). We elaborate on this issue in the ‘Methods’ section of Study 2 (‘A focus group approach will be applied for Study 2, with purposive sampling to achieve a representative picture of physiotherapists with respect to the setting, specialty, seniority, educational degrees, and age’), as well as we indicate it in the ‘Abstract’.

Reviewer’s comment:

Comment 4: on page 3 just above objectives you have said there is no same study in Poland. Why did you take this as justification to repeat the study? Is there any difference you have found between Poland and other countries physiotherapists?. Add more strong justification to repeat the study.

Our response:

Please see our explanation to your first comment. The Evidence-based culture in Poland, on many – individual, organisational, educational, policy levels, is specific and different, in many ways, from other countries and cultures. There is no one, uniform standard of physiotherapy education and conduct. Our study is not a repetition of any other studies (this is one of the reasons why we would like to publish the protocol of our study). The issues of knowledge translation and dissemination of Evidence-based practice are crucial and most important in terms of overcoming the knowledge-to-practice gaps, and it must be tailored to local contexts. Please see e.g. the World EBHC Day 2021 initiative (https://worldebhcday.org/) on how infodemic is being fought throughout the world, in different countries, cultures and settings, to different people, and how Evidence-based health care is important in this subject matter, with the very importance of local, regional and national initiatives. We cannot just rely on earlier studies and data collected in various settings.

The core justification for our study is the need for data collection and for researching the Evidence-based culture amongst physiotherapists in Poland to facilitate further developments such as EBP dissemination and knowledge translation activities. We indicate it in the paper – both in the introduction and in the discussion. In the ‘Objectives’ subsection, we provide the general and specific aims of the study and the whole project. We indicate that ‘The overall aim of the project is to improve and facilitate the process of the dissemination of EBP in Polish physiotherapy’. In the ‘Discussion’ section, we formulate a general justification for the study, where the lack of such study data for Poland is one issue, while the other, regarding the need for study findings, is the issue of critical practice and research gaps: ‘The general need for this study is that no such study was so far conducted in Poland and that it is necessary to address this critical issue in terms of practice and research needs and gaps’.

Reviewer’s comment:

Comment 5: on page 5 under sample size you just plan to take 1000 participants. but you better show clear procedure on how you calculate your sample size. So it help future researcher in replication of the study.

Our response:

The procedure consists of applying the standard formula for the minimum sample size (n) with an assumed level of estimation error (here 3%) and a confidence level (here 95%):

(70052 (〖1.96〗^2∙0,25))/(70052∙〖0.03〗^2+〖1.96〗^2∙0.25)≈1000

1.96 is the value of the normal distribution for the cumulative distribution of 1-(1-0.95)/2 ; 0.25 is the constant in the case of an unknown level of a fraction in the population.

We included this explanation in the revised paper. Please also see our response to a corresponding question of Reviewer 3. We hope that we have sufficiently addressed these questions. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Comment 6: on page 6 under Data management and analysis you have planned to run descriptive statistics. But you should specify what types of descriptive statistics for groups of variables (Example for continuous data and for categorical data).

Our response:

The use of specific descriptive statistics depends, among others, on the type of a variable and the measurement scale in which the observation results are recorded (in this case, responses to the questionnaire). The most commonly used structure indicators can be calculated for all kinds of variables, both qualitative and quantitative (all measurement scales). The same applies to the dominant (but only for the variables that make up the unimodal series). For ordinal variables (all responses with 5-point Likert scale) the best measure of the average level is the median, but it is allowed to use the arithmetic mean for comparative purposes (e.g. verification of the hypothesis that the level of education is a feature differentiating the answer to a specific question). The selection of dependency measures also depends on the type of the variable: the Pearson coefficient is used for quantitative variables, the Spearman coefficient for ordinal variables, and for nominal features measures based on chi-square statistics.

Reviewer’s comment:

Comment 7: on page 8 under discussion you wrote a lot of evidence regarding evidence based practice. Did you think you will find different results despite you didn’t mention weakness of previous studies.

Our response:

The individual studies from various countries and settings provide differing findings. Our aim is to conduct a study relevant to the Polish context. An evidence synthesis or critical appraisal of other studies is not our aim in this investigation.

Reviewer’s comment:

Comment 8: on page 9 under limitation you put anticipated limitation. But in reality what you think may not come problematic. Please consider writing limitation after completion of the study.

Our response:

We will discuss the limitations in our report of the completed study. Here we discussed limitations to ensure the soundness and clarity of the protocol. We concentrated on the study design limitations and potential (anticipated) study conduct limitations, not on the limitations of the study findings (which we will address in the study report). Especially, we indicated potential biases which we are aware of. As this is a methods report, we concentrated on those issues. This part of the paper is also amended, following the suggestions of the Reviewers. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Comment: 9 on page 10 under author contribution you write some contribution which will expect if study was already conducted (e.g Formal analysis: Maciej Płaszewski, Weronika Grantham, Joanna Trębska). Please revise.

Our response:

We followed the definitions of the study contributor roles as provided by the Journal (https://journals.plos.org/plosone/s/authorship#loc-author-contributions), and considered all current and future roles in the conduct of the study and preparation of the reports. Therefore, we indicated the subsequent roles. The ‘Formal analysis’ role is defined as ‘Application of statistical, mathematical, computational, or other formal techniques to analyze or synthesize study data’. Therefore, we listed those of us who have contributed to the data analysis methods conceptualisation and reporting (which is done in the submitted manuscript under its relevant sections. For the same reasons, we indicated those of us who contribute within the ‘Investigation’ and ‘Data curation’ roles. We acknowledge the Journal’s policy regarding authorship. We consulted other registered report protocols, published at PLoS One, and some of them also indicate authors’ roles for the whole study process (e.g. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253950), while others not (e.g. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257223). Therefore, we would like to leave the role descriptions as stated. The responses to the reviewers will be published alongside the paper, providing it is accepted, so that the full information and transparency will be ensured (https://journals.plos.org/plosone/s/revising-your-manuscript).

We are grateful to the Reviewer for taking his time for a thorough analysis of our paper, and for sharing with us his considerations. We hope that our replies are clear and informative.

Response to the Reviewer #3:

Reviewer’s comment:

Abstract: conclusions should be rewritten to explain the proposed or expected outcome rather than repeating the purpose and objectives of the study under conclusions.

Our response:

Thank you for this comment and the suggestion. We formulated the conclusions to address the protocol report so that we did not address the outcomes. Also, we had some difficulty in formulating conclusions in a study protocol. There are protocol reports of corresponding investigations with no conclusions in the abstract as well as in the full text (e.g. Mariano AS, Souza NM, Cavaco A, et al. Healthcare professionals’ behavior, skills, knowledge and attitudes on evidence-based health practice: a protocol of cross-sectional study. BMJ Open 2018;8:e018400). On the other hand, others address study rationale as conclusions (e.g. Kapitza C, Lüdtke K, Tampin B, Ballenberger N (2020) Application and utility of a clinical framework for spinally referred neck-arm pain: A cross-sectional and longitudinal study protocol. PLoS ONE 15(12): e0244137).

Considering your comment, the fact that we have no ‘Conclusions’ section in the full text of our paper, and taking the unclear and unstandardised place of ‘Conclusions’ sections of protocol reports, we decided to delete the ‘Conclusions’ section of the abstract. We believe that this corresponds with your remarks. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Introduction: should be rewritten. The authors quoted 40 references under introduction with only four short paragraphs.

Our response:

We reconsidered the reference list and deleted a few unnecessary citations. We especially reconsidered refs. 24-29, regarding EBP in physiotherapy ‘….across countries and contexts…’ and refs. 33-40, regarding also EBP studies ‘amongst physiotherapists worldwide’, which were overlapping. We left representative examples and the most current reports so that our statements remain supported with sufficient and informative, but not excessive referencing. We added one reference addressing the definition of EBP. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Start with the definition of EBP and the introduction will benefit from detailed explanation.

Our response:

This, and the former, correspond with the comments of Reviewer 1. We thank the Reviewer for the suggestions We supplemented the introduction accordingly, adding one most relevant and current definition of EBP. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

The authors mentioned at the end of introduction “In contrast, no such research was completed in Poland. This is the first study to address EBP profiles of physiotherapists practicing in Poland”. This is a strong statement and cannot be granted as the authors unaware of unpublished work in this field. I suggest deleting this statement.

Our response:

Thank you for this advice. Indeed, we did not conduct any formal study to support this statement. Nonetheless, as we have a thorough recognition of the subject matter, and the argument is crucial, we will leave a more careful and legitimate communication, adding the ‘to the best of our knowledge’ account. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Objectives: under specific objectives please add “ To formulate recommendations based on the findings of the study”

Our response:

Thank you for this suggestion. We improved the text accordingly, inserting a corresponding statement, and including an additional explanation regarding the aims of the study. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Methods:

Quantitative study: The validity of questionnaire should be obtained from reference 42 and their Cronbach’s alpha and reliability scores should be reported after data collection.

Our response:

Thank you for this suggestion. We will report the Cronbach’s alpha and reliability scores of the questionnaire in our final report.

Reviewer’s comment:

Explain in more details’ inclusion and exclusion criteria of the participants.

Our response:

In the quantitative part of the study (Study 1), all physiotherapists registered in Poland will be eligible. We described this criterion in detail in the ‘Setting and participants’ section, with explanations regarding such potentially disturbing issues as level of education or nationality.

As regards the qualitative part (Study 2), we applied the same layout of the manuscript, so that the ‘Setting and participants’ section of Study 2 includes details on focus group interview eligibility criteria.

Under that section, we also address the issue of the eligibility of participants who would be willing to participate in both studies.

Reviewer’s comment:

What is the proposed or estimated response rate among the participants?

Our response:

The study assumed the minimum sample size of 1000, without estimating the response rate. Please see our reply to your question regarding sample size calculation. Based on surveys previously conducted by our institution in the same population, using the same communication methods and procedures, we do not expect a response below 1000. We will conduct specific actions to ensure a response, as we have described in the 'Conduct of the survey' section.

Reviewer’s comment:

Under setting and participants, second paragraph: the statement “ A small number of physiotherapists ……” How many? Need reference to support it.

Our response:

Thank you for this suggestion. We deleted the phrase ‘A small number of…’ as it is vague and is not relevant in terms of eligibility criteria. Registered physiotherapists, who had completed their vocational training before 2015, are eligible (providing they meet the remaining criteria), regardless of their number.

Reviewer’s comment:

Table 1: outline the presence of many confounding factors with focus on work experience and highest qualifications which are related to outcome of KAP.

Our response:

We have included these remarks in the ‘Discussion’ section, under the limitations of the study. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Under sample size: How the data will be extracted? What will be the sampling technique? What is the sampling equation to calculate sample size? How did the authors come up with around 1000?

Our response:

The procedure consists of applying the standard formula for the minimum sample size (n) with an assumed level of estimation error (here 3%) and a confidence level (here 95%):

(70052 (〖1.96〗^2∙0,25))/(70052∙〖0.03〗^2+〖1.96〗^2∙0.25)≈1000

1.96 is the value of the normal distribution for the cumulative distribution of 1-(1-0.95)/2 ; 0.25 is the constant in the case of an unknown level of a fraction in the population.

Please also see our response to a corresponding question of Reviewer 2. We hope that we have sufficiently addressed these questions. Please see the revised manuscript, specifically the version with the track changes.

Reviewer’s comment:

Under data collection: what are the dependent and independents variables?

Our response:

Independent variables are all demographic and professional characteristics listed in Table 1, and dependent variables are the responses to the EBP2 questionnaire (Table 2).

Reviewer’s comment:

I have a concern with 5-point Likert scale as it has too many available categories which may obscure rather than define the purpose of the respondent. Therefore, I suggest collapsing into 3 categories across response which may improve the outcome of the analysis (Reference: Grimbeek P., Bryer F., Beamish W., D’Netto M. Stimulating the’Action’ as Participants in Participatory Research. Volume 2. Griffith University; Brisbane, Australia: 2005. Use of data collapsing strategies to identify latent variables in CHP questionnaire data; p. 125.).

Furthermore, each response in the scale should be assigned a numerical value so that parametric statistics can be used for Likert data. Higher score indicates positive response.

Our response:

We will consider your suggestions in the analysis. However, in the EBP2Q, with the procedure which we will need to follow, the questions have the replies ranged in a 5-point Likert scale, some of them reverse-coded. We, therefore, address this issue in the ‘Data collection’ part of the paper, including in Table 2. The variables resulting from the answers provided in the questionnaire will be treated as quazi-measurable / quazi-quantitative (assigning the answers with numerical values, as indicated in Table 2, and in the ‘Data management and analysis’ section). Nonetheless, in the statistical analysis, it may turn out that some of the responses will be aggregated to a 3-point scale. It is better, however, that we have the possibility to reduce the number of variants.

Reviewer’s comment:

Qualitative study: this will definitely complement the quantitative study; however, it may be a problematic during COVID-19 pandemic. If this is the case, those conducting the interview should implement physical distance restrictions and wear face mask during the interview to overcome this problem.

Our response:

We will conduct the interview in a responsible way. We acknowledge, implement and promote all safety restrictions and responsible behaviours as regards COVID-19 risks.

Reviewer’s comment:

What is the duration of the interview? When will it take place? Over span of how long?

Our response:

The duration of the interview is described in the ‘Design’ part of the ‘Methods’ section of Study 2. Following your suggestion, we added the information about when and over span of how long the interviews will take place. Please see the revised manuscript.

Reviewer’s comment:

The one conducting interview should have experience in qualitative research.

Experts in qualitative research should supervised data collection and hold feedback sessions shortly after the interview.

Our response:

WG, one of the co-authors, has considerable experience in qualitative research. Additionally, we will invite another experienced qualitative researcher to ensure the rigour of the study conduct. We added such information in the manuscript.

Reviewer’s comment:

All interviews should be recorded and transcribed in full to verify the accuracy of responses.

Our response:

This procedure is described in the ‘Data collection’ part of the ‘Methods’ section of Study 2.

Reviewer’s comment:

Two members of the research team independently should analyze the transcribed responses and read them on multiple times to familiarize self with the contents and categorize it in a meaningful way.

All these points should be explained and incorporated under the design of qualitative study.

Our response:

This issue is described under the ‘Data analysis’ section. Nonetheless, to improve accuracy, we included additional information and explanations addressing these important methods issues. Thank you for your suggestions.

Reviewer’s comment:

Limitations of the study: should explain in details and logical ways. Personal, recall, misinterpretation biases are possibilities in this study.

Our response:

We added two subheadings (‘Potential biases’ and ‘Two separate studies’), to clarify to the readers the two potential areas of study limitations – potential biases connected to these study designs and their conduct, as well as separate conducting of the quantitative and qualitative studies.

We improved the discussion of potential biases with a more specific addressing to potential biases and potential misinterpretation. As we are researching current EBP profiles of our participants, and this is not a retrospective cohort or case-control study, we will refrain from discussing recall bias as it is defined by the CEBM Oxford [Catalogue of Bias Collaboration, Spencer EA, Brassey J, Mahtani K. Recall bias. In: Catalogue of Bias 2017. https://www.catalogueofbiases.org/biases/recall-bias].

Reviewer’s comment:

References: The manuscript presents several references which are outdated (1 and 44), and some are irrelevant. The references should be revised, updated, and only used if it is relevant to the study. It also should follow the guidelines of the journal.

Our response:

We followed the Reviewer’s suggestions. As the reference 1, however, is the first full text, classical paper defining the paradigm of EBM, and is needed for our introduction – ‘It is now thirty years since the Evidence-Based Medicine Working Group coined the term (…)’, we would like to leave this reference as it is. However, we deleted ref. 3, as its content is halfway refs 1 and 2, and factually does not support any additional statements in the paper. Please, see also our reply to the comment regarding the ‘Introduction’ section, which also addresses the reference list.

We are grateful for taking your time to support us with your in-depth, expert feedback which did help us to improve our manuscript.

Response to the Reviewer #4:

Reviewer’s comment:

This is an interesting study and the authors have collected a unique dataset using cutting edge methodology. The paper is generally well written and structured. Overall, this is a clear, concise, and well-written manuscript. The introduction is relevant. Sufficient information about the previous study findings is presented for readers to follow the present study rationale and procedures. The methods are generally appropriate. Overall, the results are clear.

Our response:

We would like to thank the Reviewer for taking their time and effort and analysing our manuscript. We appreciate the positive and encouraging comments.

Submitted filename: Response to Reviewers.docx

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4 Dec 2021

Submitted filename: re 2 for EBP.docx

Click here for additional data file.

10 Dec 2021

Dear Academic Editor,

Dear Reviewers,

We would like to thank you for the analysis of our revised manuscript and for your valuable feedback. Please find below our responses to your comments.

Response to the Reviewer #1:

Reviewer’s comment:

The authors have done a good job responding to the reviewers and editing the study protocol accordingly. I only have a few final suggestions.

While the author’s have partially addressed the motivation behind the study beyond that it is the first of its kind in Poland, I still think the manuscript could benefit from a little bit stronger motivation. For example, on page 3 in the statement “to the best of our knowledge, no such research was completed in Poland” could be enhanced with something like “and there are unique factors of this context which may be important” etc. Also, the abstract still lists the study being in Poland as the only real motivation.

Our response:

We thank the Reviewer for this suggestion. We added a more detailed justification to the sentence you indicated. We also added an explanatory statement in the abstract, in the ‘Objectives’ section.

Reviewer’s comment:

There are still some grammatical mistakes and sentences which could be edited.

Our response:

The manuscript was double-checked by our native English colleague. He still found some inaccuracies and they are now rewritten. Thank you for this remark.

Reviewer’s comment:

The authors bring up the Hawthorne effect in the limitations section. It could be useful to the reader to briefly explain what this is (that is, that people change their behavior or answer differently when being observed).

Our response:

Thank you for this suggestion. We have added a short explanation, following the Hawthorne effect mention.

Reviewer’s comment:

Finally, the abstract now only consists of objectives and methods, I understand this because it is a protocol, but would it be possible to just have an unstructured abstract instead?

Our response:

Thank you for this suggestion, but we would like to leave the structured layout of the protocol, as standard fot PLoS ONE, including registered report protocols, such as Spitzer L, Mueller S (2021) Registered Report Protocol: Survey on attitudes and experiences regarding preregistration in psychological research. PLoS ONE 16(7):e0253950 and Adams D, Malone S, Simpson K, Tucker M, Rapee RM, Rodgers J, et al. (2021) Protocol for a longitudinal study investigating the role of anxiety on academic outcomes in children on the autism spectrum. PLoS ONE 16(9): e0257223, which also have no ‘Conclusions’ sections.

Response to the Reviewer #2:

Reviewer’s comment:

Dear author of this study,

I will not pass every effort you made in responding to comments and correction you made in your documents.

But I believe you should modify your last objective which say “to identify the facilitators and barriers in the implementation of EBP they experience in their everyday practice” . Because you planned to use crossectional study (survey) which can’t tell us direction of relationships. I recommend you to modify like “ to identify factors associated with EBP among physiotherapist”

Our response:

We thank the Reviewer for this remark. We have rewritten the objective so that it is now not suggesting an explanatory, rather than a descriptive study.

We would like to thank the Reviewer 3 and the Reviewer 4 for analysing our revised manuscript and for their replies.

We are grateful to the Reviewers and to the Academic Editor for their valuable input to our manuscript. Once again, we do appreciate your expert support. Our paper, and our study, have considerably improved through this peer-review process.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

4 Jan 2022

7 Feb 2022

Dear Reviewers,

Thank you for your final analysis of our manuscript. We are thankful for your valuable input to this paper and to this project. Thank you.

Dear Academic Editor,

Thank you for your points you have raised to our revised manuscript. And thank you for the time and effort you have given to the whole process of scientific editing of our submission.

Please find below our elaboration on how we addressed your suggestions in the amended manuscript.

Editor comment:

Editing the abstract: deleting duplications of methods in the online version, and adding something on the results (i.e. how they will be presented) and discussion (i.e. limitations).

Our response:

Based on your suggestions, we have made the following changes:

�  Both the online, and paper, versions, are now identical.

�  The Abstract, especially the issue of whether to include Results and Discussion/Conclusions sections in the Abstract had been previously raised by two of the Reviewers and we have already changed the abstract, especially the sections under discussion. Therefore, while preparing this revision, we took into our considerations those comments and suggestions of the Reviewers. Nonetheless, we think that your suggestion is final and decisive in this matter, especially in terms of the Journal’s requirements, so that we have added the Results and Discussion as you have indicated.

The word count for Abstract is 300 in the revised manuscript.

Editor comment:

Making presentation plan consistent for the survey and the qualitative study (i.e. objective, methods, results); please note, I believe that it’s easier for the reader to see the plan for the analysis and results presentation (e.g. empty tables) separately, as it would be in a research article.

Our response:

Thank you for this suggestion. We have analysed the paper again in the context of the separate presentation of the two legs of our study (the survey, Study 1, and the focus group study, Study 2) and we have decided as follows:

�  we believe the layout of the paper, as it is already provided, is clear and understandable in terms of the separate description of the objectives and methods of Study 1 and Study 2: we provide separate sections (i.e. QUANTITATIVE STUDY (Study 1); QUALITATIVE STUDY (Study 2)) and subsections to both sections (such as Objectives, Methods, Study design, Data collection and analysis); but, we are aware that reporting two planned studies in one paper is challenging and we do understand your concern, so that we have decided to add to the manuscript a supplementary file – the flow chart of the study, with a graphic presentation of the planned study conduct, with its quantitative and qualitative part; we have added a corresponding statement in the paper, at the beginning of the Methods section, before the description of Study 1 and Study 2; we believe it will serve as additional guide for the readers;

�  as regards the results and planned analyses, we have provided an additional table – also as a supplementary file – a template table which will be used during the focus group meetings for data (narratives) collection and then for analyses of the qualitative part (Study 2); we have added (in the Data collection section) a relevant statement in the paper – leading to the supplementary file (Supplementary File 3);

as regards the survey part (Study 1) the manuscript includes a demographics table and a EBP2Q structure and content table, which, when used with the template survey (supplementary file – already included, now Supplementary File 2), provides in our view a sufficient guide for the readers if how the data will be collected and then how the results will be presented.

Again, thank you very much for your support and guidance. We believe that the provided improvements will meet the requirements of the Journal. For a technical pip from the Journal, please see below our reply.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

14 Feb 2022

Knowledge, behaviours and attitudes towards Evidence-Based Practice amongst physiotherapists in Poland.  A nationwide cross-sectional survey and focus group study protocol

PONE-D-21-25941R3

Dear Dr. Płaszewski,

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Kind regards,

Ramune Jacobsen

Academic Editor

PLOS ONE

21 Feb 2022

PONE-D-21-25941R3

Knowledge, behaviours and attitudes towards Evidence-Based Practice amongst physiotherapists in Poland.  A nationwide cross-sectional survey and focus group study protocol

Dear Dr. Płaszewski:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ramune Jacobsen

Academic Editor

PLOS ONE