FEATURE ARTICLE

Factors Affecting Self-reported Implementation ofEvidence-based Practice Among a Group of Dentists

Asim Al-Ansari, BDS, MDSc, DScD, and Maha ElTantawi, BDS, MSc, PhDDepartment of Preventive Dental Sciences, College of Dentistry, University of Dammam,Dammam,Saudi Arabia

Abstract

Corresponding autedu.sa.J Evid Base Dent1532-3382/$36.00� 2014 Elsevier Inc.http://dx.doi.org/1

Objective: The study aimed at assessing the factors affecting the implemen-tation of evidence-based practice (EBP) among a group of dentists in SaudiArabia.Methods: A cross sectional study design was used where a link to an elec-tronic questionnaire was posted on the websites of the Saudi Dental Societyand a social networking site for dentists. The questionnaire was available forthree months after which responses were downloaded and analyzed. Descrip-tive statistics were calculated for various variables and logistic regression anal-ysis was used to identify factors with significant effect on the implementationof EBP.Results: Implementation of EBP was reported by 69.3% of respondents. Mostrespondents reported knowing and using MEDLINE and being able to searchfor evidence. The most frequently reported barriers were lack of time andavailability of evidence. Factors that significantly affected the implementationof EBP were 1) having some knowledge of terms related to EBP, 2) reportinglack of EBP skills as a barrier, and 3) reporting resistance to change as a barrier.Conclusions: Background knowledge related to EBP and training in its skillsare needed for the implementation of EBP whereas the presence of resistanceto change does not necessarily prevent its implementation.

Keywords: Evidence-based practice, Saudi Arabia, Barriers, Literature appraisal, Searching for evidence.

INTRODUCTION

Evidence-based practice (EBP) has been introduced toMedicine in the 1990s1 with dentistry following afterwardswith the ultimate objective of improving health care out-comes. It is defined as the ‘‘integration of the best availableevidence with clinical experience and patient preferencesinmaking clinical decisions,’’1 the stress being on the inte-gration of the different aspects rather than relying on one

hor. Tel.: +966 566064142; E-mail: aaalansari@ud.

Pract 2014;14:2-8

All rights reserved.0.1016/j.jebdp.2013.11.001

approach to clinical decision making. In dentistry, the im-plementation of EBP is reported to be progressing at aslower pace compared to medicine.2

Several studies were conducted to assess knowledge andawareness as well as attitude and perception of dentiststoward EBP.2–5 Other studies assessed barriers perceivedby dentists to prevent the implementation of EBP.6,7

Studies were also conducted to assess certain aspects ofEBP such as how dentists seek and understand newknowledge,8,9 how they acquire and utilize scientificinformation,10 the extent of research utilization amongdental hygienists11 and the frequency and type of informa-tion seeking behaviors used by dental hygiene practi-tioners and dental hygiene educators.12

A limited number of studies assessed the implementa-tion of EBP as a comprehensive process.13,14 Given the

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time since the inception of EBP, there is a noticeablescarcity of studies assessing the factors affecting theimplementation of EBP. Such studies would help in theassessment of the promoters of this implementationagainst the barriers that can potentially prevent it.Results from studies conducted in countries where EBPhas been introduced for almost two decades cannot begeneralized to settings where EBP and, to some extent,health care systems have more recent histories. Thepresent study proposes to fill this gap by identifying thefactors affecting self-reported implementation of EBPamong a group of dentists in Saudi Arabia.

MATERIALS AND METHODS

A cross sectional study design was used. Approval for thestudy was obtained from the Research Committee of theCollege of Dentistry, University of Dammam. The targetpopulation was dentists practicing in Saudi Arabia, na-tionals and expatriates.

A self-administered, anonymous questionnaire wasdeveloped based on previous studies.13,15 Thequestionnaire started with a brief introduction to thestudy purpose, stressing data confidentiality andindicating the estimated time needed to complete it. Itconsisted of five parts. The first part collected personaland practice information data including nationality,gender, age, time since graduation, type of practice(private or governmental), specialization (generaldentist or specialist/consultant) and having access to adental library and the internet at practice. The secondpart assessed EBP-related knowledge including whetherthe respondent had previously heard about EBP, whenand how, how well he/she rates his/her understandingof EBP and self-reported understanding of 13 termscommonly used in EBP. The third part of the question-naire assessed the implementation of EBP and use ofEBP-related resources. It included questions aboutwhether the respondent implemented EBP in practice,self-rated ability to perform some skills required forEBP such as formulating a PICO question, searching forevidence and critical appraisal of literature, whether therespondent used books or peer reviewed journals as sour-ces of evidence and if the respondent was aware of and/orused a number of EBP resources. The fourth part of thequestionnaire assessed the barriers the respondentsconsidered to prevent the implementation of EBP. Thefifth and last part of the questionnaire asked the respon-dent about his/her attitude and his/her level of agree-ment with whether he/she considered that EBP has thepotential to improve health care outcomes, whetherhe/she was willing to attend training sessions related toEBP and whether he/she was willing to support the imple-mentation of EBP. The questionnaire was offered in En-glish and all questions were close ended.

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The questionnaire was pilot tested on 9 teaching staffmembers at the College of Dentistry, University ofDammam to assess clarity of questions, face and contentvalidity as well as ease of using the electronic format ofthe questionnaire. Minor modifications in questionsphrasing were performed accordingly. The modifiedquestionnaire was uploaded to online survey website(www.fluidsurveys.com/; Bridgewater, New Jersey, UnitedStates) and a link to the survey was posted on the SaudiDental Society website (www.sds.org.sa/) and a socialnetworking site for dentists (www.saudident.com/). Areminder to respond to the survey was posted on eachwebsite three times over a period of three months. Thelatest estimate of the number of members of the SaudiDental Society stands at 3000, although it is not knownhow many of them access the website regularly enoughto notice the survey. In other polls posted on www.saudident.com/, the number of dentists responding tosurveys ranged from 45 to 180. Hypothetically, a degreeof overlap could have existed between the users of bothsites since each website targeted dentists practicing inSaudi Arabia although the degree of overlap in the num-ber of users cannot be known. It is unlikely that any user/dentist would have answered the questionnaire twicegiven its length.

An Excel file of the responses to the questionnaire wasdownloaded at the end of three months. The file wascleaned of personal identifiers to maintain confidentialityand imported to SPSS version 17.0 (SPSS Inc., Chicago,IL, USA) for statistical analysis. Descriptive statisticswere calculated as frequencies and percents of responsesto questions. A knowledge score of EBP terms was calcu-lated by summing responses indicating understandingand ability to explain each of the 13 terms. Cronbachalpha of this knowledge score was calculated to assess itsinternal consistency. The EBP terms knowledge scorewas dichotomized into 0, no knowledge of any of theterms and >0, some knowledge of terms. The relation be-tween applying EBP and various factors was assessed usingchi-square (or Fisher exact test as indicated). Variableswith statistically significant association at the 5% levelwere entered into logistic regression analysis to identifyfactors that affected the implementation of EBP andodds ratios calculated to assess strength of association.Bar charts were used for graphical presentation.

RESULTS

Responses were received from 201 dentists. Half of the re-sponding dentists were Saudi, in the age group 24–35 andgraduated in the last 10 years (54.5%, 52% and 48.7%respectively). Most respondents were male, working ingovernmental positions and general dentists (61.7%,72.7% and 58.5% respectively). Most of them had accessto a dental library and internet in their practices (59.2%and 79.6% respectively).

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Figure 1. Self reported knowledge of some termsused in EBP.

Figure 2. Knowledge and use of some EBP resources.

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The majority of respondents heard about EBP (78.6%)and did so within the last five years (54%). They heardabout EBP from lectures (50%), articles (23.8%), work-shops (6.7%), books (5.5%) or other sources (14%).Most of them (69.3%) reported they implemented EBPin their professional lives.

Figure 1 shows the self-reported knowledge of respon-dents as regards some terms commonly used in EBP.The greatest number of dentists reported they under-stood and could explain terms as ‘‘randomization,’’ ‘‘sys-tematic reviews’’ and ‘‘blinding’’ (71.2%, 68.6% and60.9% respectively). Dentists were least familiar withterms such as ‘‘meta analysis,’’ ‘‘confidence interval’’and ‘‘likelihood ratio’’ where 44.2%, 38.5% and 27.6%respectively reported understanding and being able touse these terms. Dentists’ responses indicating levels ofunderstanding of these 13 terms showed consistency(Cronbach alpha for internal consistency of EBP termsknowledge score ¼ 0.92).

Most respondents reported using journals as a sourceof evidence (68.6%), whereas 22.4% reported usingbooks and 9% reported using a combination of differentsources. Figure 2 shows the levels of knowledge and use ofsome EBP resources. MEDLINE (www.ncbi.nlm.nih.gov/pubmed) – a primary source of evidence – was the mostwidely known and used (78.7%). Among the secondarysources of evidence, the Evidence Based Dentistry Journal(www.nature.com/ebd) and the Journal of EvidenceBased Dental Practice (www.jebdp.com/) were the mostknown and used (41.9% and 37.4% respectively) whereasinternet-based, freely-accessible resources such as TheDental Elf (www.thedentalelf.net/) and TRIP (www.tripdatabase.com/) were not known by two thirds of therespondents (63.2% and 63% respectively). Respondentswere split about the Cochrane database where 34.8% re-

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ported knowing about and using it and 38.1% reportednot knowing about it.

More dentists reported being able to search for evi-dence and critically appraise it than those reporting beingable to formulate a PICO question (87.8%, 59.6% and36.5% respectively). Only 0.6% of respondents reportedthey were unable to search for evidence.

The most commonly reported barriers against imple-menting EBP were lack of EBP skills, unavailability of ev-idence, lack of time and resistance to change (69.2%,60.3%, 59.6% and 50% respectively). The least frequentlyreported barriers were financial constraints, not havingaccess to the internet and poor understanding of English(45.5%, 33.5% and 28.2% respectively).

Almost all respondents agreed that EBP has the poten-tial to improve health care (95.5%) and the majority indi-cated they were willing to attend EBP workshops andtraining events and support the implementation of EBPin their professional life (84.6% and 92.3% respectively).

No significant association existed between implement-ing EBP and each of nationality, gender, age, graduationand type of practice dentists work in (P ¼ 0.31, 0.51, 0.13,0.32 and 0.10 respectively). In addition, no significant as-sociation was observed with having barriers as financialconstraints, not having access to the internet, poor under-standing of English or unavailability of evidence(P ¼ 0.93, 0.14, 0.24 and 0.94 respectively).

Table 1 shows the variables that were significantlyrelated to implementing EBP in bivariate analysis andthose that still had significant association in the multivar-iate logistic regression model. In bivariate analysis, somevariables increased the odds of implementing EBDincluding having a library close to practice, havinginternet access in practice, rating oneself as havinggood understanding of EBD concept, having some knowl-edge of EBD terms, being able to formulate a PICO

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TABLE 1. Relation between factors affecting the implementation of EBP using bivariate and multivariate analysis.

Factors

Bivariate relation Multivariate relation

OR 95% CI OR 95% CI

General dentist vs specialist 0.23* 0.11, 0.46 0.42 0.13, 1.35Library close to practice: presence vs absence 4.66* 2.30, 9.42 2.10 0.69, 6.36Internet access in practice: presence vs absence 2.83* 1.28, 6.25 1.05 0.27, 4.08Heard about EBD: #5 years vs >5 years 0.27* 0.13, 0.57 0.47 0.14, 1.56Self rating of understanding of EBD concept: good vs fair or

poor16.16* 4.75, 54.93 3.07 0.62, 15.11

EBD terms knowledge: some vs none 11.72* 4.33, 31.72 6.18* 1.19, 32.01Primary source of evidence: books vs peer reviewed journals 0.31* 0.14, 0.69 0.79 0.26, 2.44Formulate a PICO question: yes vs no 8.39* 2.81, 25.07 2.63 0.58, 11.84Search for evidence: yes vs no 3.61* 1.35, 9.66 1.38 0.31, 6.19Appraise literature: yes vs no 8.85* 3.89, 20.18 1.13 0.33, 3.83Lack of time: yes vs no 0.43* 0.20, 0.94 0.41 0.13, 1.26Lack of EBD skills: yes vs no 0.22* 0.08, 0.60 0.19* 0.05, 0.79Resistance to change: yes vs no 2.61* 1.24, 5.48 3.42* 1.15, 10.22

OR: odds ratio, CI: confidence interval.*Statistically significant at P # 0.05.

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question, being able to search for evidence, being able toappraise literature and experiencing resistance to changeas a barrier (OR¼ 4.66, 2.83, 16.16, 11.72, 8.39, 3.61, 8.85and 2.61 respectively). Other factors decreased the oddsof implementing EBD including being a general dentistcompared to being a specialist, hearing about EBDrecently within the last 5 years, using books as a primarysource of evidence, reporting lack of time as a barrierand reporting lack of EBD skills as a barrier (OR ¼0.23, 0.27, 0.31, 0.43 and 0.22 respectively).

Three factors significantly affected the implementationof EBP in multivariate analysis: 1) having some vs noknowledge of terms commonly used in EBP, 2) reportinglack of EBP skills as a barrier, and 3) reporting resistanceto change as a barrier. Having some understanding ofterms used in EBP increased the odds of implementingEBP 6 times (OR ¼ 6.18, CI ¼ 1.19, 32.01). Lack of EBPskills decreased the odds of implementing EBP to thefifth (OR ¼ 0.19, CI ¼ 0.05, 0.79). On the other hand,resistance to change increased the odds of implementingEBP almost three and half times (OR ¼ 3.42, CI ¼ 1.15,10.22).

DISCUSSION

The study was conducted to assess the factors affectingthe implementation of EBP among a group of dentists.Distributing the questionnaire through a link posted onthe two websites returned responses from 201 dentists.This method was the most logistically feasible to reachdentists in different regions of the country. Other studiesusing mailed or electronic surveys sent to health profes-

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sionals reported low response rates2,6,14,16 raising theconcern that response rates of health professionals tosurveys are decreasing.17 Among the limitations of thestudy is that it relied on self-reported implementation ofEBP where the participants may give responses that are so-cially acceptable (such as implementing EBP) even if thisis not true.18 It is difficult however to use other definitionsof the study outcome since it is mostly a decision makingprocess that is not associated with more tangible evi-dence.

The percentage of dentists in this study reporting theimplementation of EBP was higher than that of Kuwaitidentists reporting it in another study (69.3% and 60%respectively).13 It is lower than the 88% of American den-tists reporting practicing EBP in another study.6 However,those American dentists were reported by the authors ofthe study to be early adopters of EBP who volunteeredto join their study from a group of dentists attending anevent to promote EBP.

Participants in the present study reported better knowl-edge of EBP terms related to methodological issues(randomization, blinding, publication bias.) than termsexpressing statistical measures and concepts (absoluterisk, confidence interval, likelihood ratio,.). For ex-ample, they reported understanding ‘‘systematic reviews’’better than ‘‘meta analysis’’ although both are relatedwith mostly the inclusion of statistical procedures differ-entiating the latter from the former. Terms describingmethodological concepts were also reported to be knownand/or understood by >50% of respondents in differentstudies2,4,5 whereas statistical terms were comparativelyusually less understood.2,13,15,19

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In the present study, three times as many respondentsreported using journals as sources of evidence as thosereporting using books for the same purpose (68.6% and22.4% respectively). This greater reliance on journalsand electronic resources was also reported in otherstudies.2,10 Studies conducted a few years earlier reportedgreater use of textbooks and traditional resourcescompared to journals and electronic databases.4,8,20

Using textbooks is problematic due to the duration thatusually elapses between publication of research findingsand their incorporation in textbooks. They remain,however, a source for background information that manypractitioners prefer.10

The greatest majority of respondents reported knowingand using MEDLINE whereas secondary sources of evi-dence as CATs, TRIP database and Dental Elf were knownby a minority. Evidence-based journals and the Cochranedatabase occupied a middle position between MEDLINEand other secondary sources of evidence. Although MED-LINE and the CochraneCollaboration and its OralHealthGroup were established at around the same time,21,22

practitioners report more knowledge and use of theformer than the latter.2,23 Several studies reportedmodest knowledge and/or use of the Cochrane Reviewsthat is increasing slowly with time.4,5,19 Using secondarysources of evidence such as the Cochrane library andother databases can save the time required to search forevidence11 and thus reduce the impact of lack of time asa barrier.24 However, it is reported that the number of sys-tematic reviews in dentistry is less compared to their coun-terparts in medicine which stresses the importance ofprimary sources of evidence and the associated skills ofappraising evidence retrieved from them.4,25

In the present study, only 0.6% reported being unableto search for evidence. This percentage is similar to thesmall percentage of Iowa dentists reporting in a previousstudy that their search for information was never efficientor effective.10 Although lower percentage of respondentsin the present study reported being able to formulate aPICO question and appraise literature than to searchfor evidence, these percentages were higher than thosein other studies.2,5

In the present study, lack of EBP skills, unavailabilityof evidence and lack of time were the most importantbarriers cited by respondents against the implementationof EBP. Subject related barriers such as lack of EBPskills were also reported by other studies to varying de-grees4,13 and so was time constraint.2,4,5 Barriers relatedto the concept of EBP itself – such as unavailabilityof evidence – were also reported in other studies.2,3

Financial constraints were cited in other studies.4,5,19 Inthe present study, the effect of limited access to theinternet on the implementation of EBP seemed lesscritical than in other studies.13,19 Half the respondentsindicated that resistance to change is a barrier to theimplementation of EBP, similar to other studies.6,7 In

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contrast, a study conducted among a group of primaryhealth care physicians in Riyadh region indicated thatrespondents thought their colleagues’ attitude towardEBP was welcoming.15

It is interesting that almost 70% of respondents re-ported that lack of EBP skills was a barrier to its imple-mentation and 85% indicated they were willing toattend EBP training workshops although about 70% re-ported they implemented EBP. This can be explainedby respondents feeling justified to claim they imple-mented EBP when they might have been using scientificevidence in their practice to various degrees without actu-ally implementing EBP as a complete process. On theother hand, they may have been just referring to barriersfacing others and expressing willingness to get additionalEBP training.

In the present study, neither age of respondents nortime since graduation significantly affected implement-ing EBP. Another study11 and a systematic review26

confirmed that age did not affect research utilization.Some studies reported better outcomes for younger prac-titioners as regards knowledge of EBP terms2,13 whereasanother study9 reported that older dentists used peer re-viewed resources more than others.

In the present study, twice as many specialists reportedimplementing EBP as general dentists. Several studies re-ported associations between different aspects of EBP andincreasing duration of education whether through post-graduate studies and specialization8,14,23 or by longerduration of undergraduate programs.11 This differencemay be attributed to better opportunities for training,application of research methods and development of crit-ical thinking skills.10,12,23

In the present study, the presence of enabling re-sources such as a dental library and access to the internetwere positively associated with implementing EBP.Although having a dental library at practice was less prev-alent than having access to the internet (59.25% and79.6% respectively), having a library had the greaterodds of affecting the implementation of EBP (OR ¼2.10 and 1.05 for library and internet availability respec-tively). In both cases, the effect was not statistically signif-icant. This may indicate a greater reliance on printjournals than electronic resources similar to what was re-ported by others.10 In a study conducted among primaryhealth care physicians in Riyadh region in 2002, only10.2% reported having access to the internet15; a muchlower percent than that in the current study possiblydue to the high cost of high speed internet in Saudi Ara-bia at that time. As time passes and internet access be-comes more common place in different countries, morereliance on electronic resources would be expected andinternet accessibility issues will affect EBP implementa-tion even less.

Understanding terms associated with EBP was signi-ficantly related to the actual implementation of EBP

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in bivariate and multivariate analysis whereas overallself-rated understanding of EBP concept lost statisticalsignificance in multivariate analysis. Only when the prac-titioner understands EBP-related terms would he/she beable to appraise the evidence and then decide whether toapply it to the patient. This is real understanding of EBPas needed in practical life. It differs from the overallperceived understanding of EBP that some practitionersmay think they have.

The three EBP skills; formulating a PICO question,searching for evidence and literature appraisal weresignificantly associated with implementing EBP in bivar-iate analysis but lost this significance in multivariateanalysis. All of them were significantly associated withand logically included when participants reported lackof EBP skills as a barrier to its implementation. Theeffect of the latter barrier on the implementation ofEBP remained statistically significant in multivariateanalysis and markedly reduced the odds of this imple-mentation.

Rather than being a deterrent, resistance to changeincreased the odds of implementation of EBP about threeand half times when all other factors were considered.This was the only one among all studied factors whose ef-fect intensified in multivariate analysis (in this case,increased the odds of implementing EBP). This relationis difficult to interpret because of the cross sectional na-ture of the study so that it cannot be known whetherthe presence of resistance to change motivated the re-spondents to conquer this resistance and thus implementEBP or if the implementation of EBP by respondents intheir different organizations triggered various forms ofresistance to change, and consequently the resistancewas the effect of the implementation rather than thecause. A third explanation could be that dentists – facedin their organizations by resistance to change currentpractices and reluctance to adopt modern techniques –had to resort to hard evidence based on scientific findingsand thus implemented EBP because of this. Whatever thetruth behind this situation is, it shows that the presence ofresistance is not by itself associated with the nonimple-mentation of EBP. At the very least, it is not an effectivebarrier.

CONCLUSION

The present study attempted to identify factors affectingimplementing EBP among a group of dentists. Afteralmost two decades of introducing EBP into health care,it may be appropriate to focus on the actual implementa-tion of EBP after many studies have assessed the aware-ness, knowledge and attitude of practitioners to EBP aswell as barriers to its implementation. The main pointsto be concluded from the present study are that back-ground knowledge in researchmethods as well as training

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in EBP-specific skills are major determinants affecting theimplementation of EBP. The presence of barriers per sedoes not preclude the implementation of EBP. However,more research is required to understand the interactionbetween practitioner professional attributes and trainingand the environment in which he/she practices on onehand and their effect on the implementation of EBP onthe other hand. It would be interesting also to assess thefactors affecting the implementation of EBP from the pa-tient’s perspective.

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