Factors associated with practicing evidence-based medicine among medical interns in Amhara regional state teaching hospitals, Northwest Ethiopia, 2020

Evidence-based medicine (EBM) is an essential component of modern medical practice and crucial for patient safety and high-quality healthcare services. The purpose of this study is to assess the factors associated with practicing EBM among medical interns in Amhara regional state teaching hospitals, Northwest Ethiopia. An institution based cross-sectional survey was conducted from March to April, 2020. Simple random sampling with proportional allocation was used. A total of 403 medical interns were included in the study. The data were collected using a structured self-administered questionnaire. Data were coded and entered in to Epi info 8.1 then exported to and analyzed by using SPSS 20.1. Multivariable logistic regression analysis method was used to identify the factors associated with the practice of EBM.


Results
From the total of 403 medical interns, 48.4% had good practices towards EBM. EBM knowledge, attitude towards EBM, ability to critically appraise evidence and having su cient time to search for evidence were the factors signi cantly associated with EBM practice.

Conclusion
Medical interns have limited practice of integrating scienti c evidence in to clinical practice. There is a need to setup EBM journal club, which helps to increase awareness and use of evidence, as well as assist medical interns and other clinical staffs to ensure the correct application of EBM in to clinical practice.

Background
Evidence-based medicine (EBM) is the process of systematically locating, searching, evaluating and using contemporaneous research ndings as the basis for clinical decision making [1].The practice of EBM means integrating individual clinical expertise with the best available external evidence from systematic search and client choice in clinical decision making. It involves ve steps: First, formulating a clear question based on a patient problems; second, identifying relevant studies from the literature; third, critically appraising the validity and usefulness of the identi ed studies; forth, applying the evidence to clinical practice and nally, evaluate the results of applying the evidence to patient [2]. Therefore, EBM has been considered as a cornerstone to improving the quality of healthcare services and achieving quality in patient care [3].
The world is characterized by rapid demographic and epidemiological transitions and health challenges related to new infectious, environmental and behavioral risks [4]. To meet these challenges, clinicians are increasingly expected to use evidence from various EBM sources to improve healthcare outcomes. Otherwise, it could potentially lead to increased patient morbidity [5,6]. However, most of Ethiopian physicians continue to provide healthcare services as they have done before without incorporating EBM in their clinical practices [7]. Studies conducted in different countries revealed that 30-40% of patients do not receive care according to present scienti c evidence and 20-25% of care provided is not needed [8,9]. The major barriers to the practice of EBM were inadequate knowledge and skill related to EBM, patient overload and lack of personal time [10]. Similarly, in low and middle income countries, lack of resources, poor access to information resources, lack of knowledge, lack of staff experienced in the use of EBM [11,12], insu cient administrative support and limited access to information are the most common barriers to the implementation of EBM [13][14][15]. To identify the implementation of EBM, it is critical to assess knowledge, attitude, practice and perceived barriers because it affects implementation of EBM [12].
Limited studies were conducted to assess knowledge, attitude and practice regarding EBM among Ethiopian health professionals. However, most of them included a sample populations of physicians, nurses and other healthcare professionals [7,[16][17][18], failed to include medical interns. The current study included medical interns that have not been surveyed on this topic before. Medical interns are usually at the frontline of healthcare provision in teaching hospitals; therefore they play a key role in the integration of EBM in to daily practice.
This study aimed to assess the factors associated with practicing EBM among medical interns in Amhara regional state teaching hospitals, Northwest Ethiopia. This information can help teaching hospitals in programming appropriate practical training on EBM and enables medical interns in improving their knowledge and skills regarding EBM to offer the best possible care for their patients.
In addition, information obtained from this study will helps policy makers to develop appropriate strategies for enhancing the implementation of EBM. It will also serve as baseline data for those who are interested further research on the issue.

Study area and period
This study was conducted in Amhara regional state teaching hospitals in Northwest Ethiopia, speci cally in University of Gondar and Tibebe Ghion teaching hospitals, from March-April, 2020. The Amhara region is located in Northwestern and North central parts of Ethiopia. It has 10 adminstrative zones, one special zone, 181 woredas and 78 urban centers. According to the Amhara regional health o ce report in 2019, the region has two teaching hospitals, namely the University of Gondar and Tibebe-Ghion teaching hospitals. These teaching hospitals are the training centers for undergraduate and postgraduate medical students, dentists, nurses, midwives, pharmacists and others who shoulder the responsibilities to solve the health problems of the community and the country at large.

Study design and participants
An institution-based cross-sectional study design was employed. Medical interns studying in the University of Gondar and Tibebe Ghion teaching hospitals were participants of the study. But medical interns who were on a sick leave and week off during data collection period were excluded.

Sample size determination and sampling technique
The sample size was determined using single population proportion formula n= (Zα/2) 2 (p (1-p)/d 2 ; where n= the required sample size, level of con dence taken to be 95%, Zα/2 (1.96), a 5% margin of error (d=0.05), 50% proportion of EBM practice and n= the required sample size. The calculated sample size was 384 with 10% non-response rate, nal sample size was 423.
A strati ed random sampling technique was used to select participants from the University of Gondar and Tibebe Ghion teaching hospitals. By taking the list of medical interns from the human resource of each hospitals, we determine the proportionate sample to be taken, to proportionate number of study subjects for each hospital, the formula = (n) x (nf) / N was used where n = number of medical interns in each hospital, nf = total sample size and N = the total number of medical interns in the two hospitals. Then, considering their proportion of the population, simple random sampling method was applied.

Measurements and data collection techniques
Data was collected using self-administered questionnaire which had ve sections; socio-demographic, EBM knowledge, attitude toward EBM, EBM practice and perceived barriers for practicing EBM. The questionnaire was adapted from previous published studies because these prior works have already been validated and can be used for an international comparison [6,19]. Data was collected by a total of six health informatics students (BSc). The attitude of respondents was measured by 11 questions with ve point Likert's scale. All individual answers to attitudinal questions was computed to obtain total scores; then, mean score was calculated to categorize as having favorable attitude (if participants scored >=mean score) or unfavorable attitude (if Participants scored < mean score). In addition, respondents level of knowledge was measured by calculating the mean score of the 14 items and categorized as knowledgeable (if participants scored >=mean score of the correctly answered questions) or not knowledgeable (if participants scored <mean score of the correctly answered questions). The respondent's level of practice was measured by 10 questions with ve point Likert's scale. All individual answers to practice questions was computed to obtain total mean scores and categorized as good practice (if participants scored >= mean score) or poor practice (if participants scored < mean score).

Data quality assurance and management
The data collectors and supervisors were trained prior to the actual data collection about the purpose of the study, sampling procedure, methods of data collection and ethical issues. Continuous follow-up and supervision were done by the supervisors and principal investigator throughout the data collection period. The data were checked daily for completeness and consistency.
The questionnaire was pretested on 5% of the similar population at Tikur Anbessa specialized hospital for consistency of response and validity of the questionnaire. Some adjustments were made while adapting to the Ethiopian context. Using the data obtained from the pre-test, the questionnaire was checked for reliability (internal consistency) using the Cronbach alpha test. The reliability for knowledge questions had a Cronbach's alpha value of 0.839; attitude had a Cronbach's alpha value of 0.764 and practice (Cronbach's alpha 0.750). These values indicate that the questionnaire has very good reliability.

Data processing and analysis
The collected data were checked manually for comprehensiveness and uniformity of responses. Data were coded and entered in to Epi info 8.1 then exported to and analyzed by using SPSS 20.1. The descriptive statistical analysis was applied to compute the mean, standard deviation, frequency and percentages of the study variables. Bivariate analyses; Spearman's rank correlation coe cient test was used to examine the bivariate correlations between the dependent and the independent variables. Selection of variables to be included in the nal model was done by examining multi-collinearity among independent variables, with the purpose of excluding variables with strong correlation (rho-values >0.85). Finally, multivariable logistic regression analysis was done to control potential confounders and to identify the factors associated with practicing EBM. The variables which had signi cant association were identi ed on the basis of adjusted Odds Ratio (AOR), with 95% con dence interval (CI) and p-value ≤ 0.05.

Results
Socio demographic characteristics  Table 4 Barriers to the practice of EBM The most frequently reported barriers among medical interns were lack of access to electronic data bases 241(59.8%), lack of time to apply research evidences 288 (71.5%), lack of documents that guide the practice of EBM 262 (65.0%), and lack of institutional support for practicing EBM 320 (79.4%). Table 5 Factors associated with the practice of EBM In the bivariate analysis, access to research article in workplace, access to electronic data base in work place, patient preference to EBM, patient believe in scienti c evidence, having su cient time to search for research evidence, having su cient time to read research paper, reward for practicing EBM, supervisor support for practicing EBM, ability to access evidence, ability to critically appraise evidence, , ability to apply evidence, EBM knowledge, attitude towards EBM shows signi cant association with EBM practice at 0.01 level of signi cance.
In the multivariable analysis, ability to critically appraise research evidence, EBM knowledge, attitude towards EBM and having enough time to search for research evidence were factors signi cantly associated with the practice of EBM.  Table 6 Discussion This study was aimed to assess the factors associated with practicing EBM among medical interns in Amhara regional state teaching hospitals. The result of this study indicated that medical interns have limited knowledge of key concepts of EBM, but a relatively positive attitude towards the concepts and limited practice of integrating scienti c evidence in to clinical practice.Majority of medical inters had never received any training related to EBM. The output from the multivariable analysis identi es EBM knowledge, attitude towards EBM, ability to critically appraise evidence and having su cient time to search for research evidence was the factors positively associated with the practice of EBM.
In this study, 57.1% participants had good knowledge about EBM. More than half (55.1%) of respondents answered correctly as critical appraisal skills are needed to ensure the quality of the research papers and 52.6% of them answered correctly as the practice of evidence based medicine requires the appropriate identi cation and formulation of clinical questions. Which is consistent with a study conducted in Switzerland on EBM among medical students [20].
In contrast, a study conducted on knowledge, attitude and behavior towards EBP of occupational therapy students in Ireland showed that almost all (97%) of participants aware that critical appraisal skills are needed to ensure the quality of all the research papers. Majority (94%) of them aware that the practice of EBM requires the appropriate identi cation and formulation of clinical question [21]. This difference may be due to different teaching methods, content or delivery of EBM within the curricula and lack of formal EBM training in Teaching hospitals included in the current study. An experimental evidence of EBM educational intervention from Mexico, suggested that formal medical students training in EBM improve medical student's knowledge and skill about EBM [22].
The current study also showed 68.0% of medical interns had favorable attitude towards EBM. This nding was consistent with evidence from the other studies [23,24]. This might be a rst step in motivating and was a good sign for promoting the teaching of EBM in medical students' curriculum. Similarly, a study conducted on awareness, attitude and knowledge of evidence based medicine among Jordanian physicians indicated that 63.5% of participants were positive towards EBM [25]. In contrast, a study that was conducted among medical students reported a weak positive attitude toward EBM [26]. In the current study, 91.3% of medical interns agreed that practicing EBM improve patient care. Similarly, the study conducted on Knowledge, attitudes and practice of physicians in University Hospitals in Japan indicated that 90% of participants believed that EBM would improve patient outcomes [27]. Another study conducted on Knowledge and Attitudes of Physicians Towards EBM in Iran also indicated that 92.6% of physicians believed that practicing EBM improves patients' management [28], but was higher than a study conducted on attitudes, knowledge, and perceived barriers on the practice of evidence based medicine among Japanese residents, in which 65% of participants said that EBM improve patient care [29]. Furthermore, this study demonstrated that 94.3% of participants believed that the practice of EBM is helpful tool for clinical decision making. This was higher than a study done on knowledge and attitude of evidence based practice in which 80% of participants believed that EBM is helpful in clinical decision-making [30].
Medical interns had a good practice (48.4%) towards EBM. Similar result were found on awareness, attitude and knowledge of EBM among physicians in Jordan, in which 50% of participants were practicing EBM [25]. Another study done in Saudi Arabia also showed that 43.1% of the physicians are practicing EBM in their clinical practice [31]. Only 1.1% of residence doctors practice EBM in their clinical practice in Sudan [8], which is lower than the current study. In contrast, 70% of physicians in Canada were applying EBM in their clinical practice [32]. Evidence from China also revealed that 76.0% of physicians applied EBM in routine daily practice [33]. The difference could be due to the level and experience of the respondents included in the studies. Professionals with higher level of quali cation are better equipped with knowledge and skills to retrieve, appraise and utilize the available evidence.
In this study the most commonly identi ed barriers to the practice of EBM were lack of time to apply evidence in clinical practice (71.5%), lack of access to electronic database (59.8%), lack of institutional support (79.4%), lack of critical appraisal skill (56.8%), lack of skill to apply EBM (35.7%), lack of reward for practicing EBM (76.2%) and lack of patient preference to practice EBM (67.0%). Similarly, a study conducted in Gaza reported that the main factors affecting the practice of EBM were lack of knowledge needed to practice EBM (35%), negative attitude among senior colleagues (25%), lack of relevant resources (23%), work overload (20%) and lack of institutional support (18%) [34].
Lack of time to apply research evidence was the main barrier reported in the current study. Several studies also found that lack of personal time was the main perceived barriers [35,36]. A study conducted to assess knowledge, attitudes and practices of EBM among physicians in Egypt reported that the rst barrier to practicing EBM for most physicians was patient overload (82.67%), followed by lack of critical appraisal skills (82%), lack of time (80.67%), lack of skills (72.67%), insu cient resources (67.33%), shortage of nancial gain (64.67%), and limited access to information (63.09%) [37]. A study conducted to assess Knowledge, attitudes and practices of primary health care physicians towards EBM in Qatar revealed that the major perceived barriers to practicing EBM were lack of free time (75.3%), limited resources and facilities (62.6%), no library in the location and lack of training workshops and courses (61%) [35]. Another study conducted to assess EBM knowledge, attitude and practice among doctors in Sri Lanka also indicated the following barriers: insu cient resources (77.7%), patient overload (66.6%), lack of skills to apply EBM (65.8%), lack of personal time (64.8%) and lack of endorsement by health authorities (59%) [23] Conclusions The result of this study indicated that medical interns have limited knowledge of key concepts of EBM, but a relatively positive attitude towards the concepts and limited practice of integrating scienti c evidence in to clinical practice.
EBM knowledge, attitude towards EBM, ability to critically appraise evidence and having su cient time to search for evidence were the factors signi cantly associated with EBM practice. Insu cient time to apply research evidence, lack of access to electronic database and lack of institutional support were the most important barriers for practicing EBM.
Teaching hospitals in Ethiopia needs to setup EBM journal club, which helps to increase awareness and use of evidence, as well as assist medical interns and other clinical staffs to ensure the correct application of EBM in to clinical practice. Further studies are required to assess the level of knowledge, attitude and practice of medical interns regarding EBM in Ethiopian medical universities.