A total of 101 (99%) responded to the survey. The socio-demographic characteristics of respondents are shown in Table 1 (Additional file 1).
Table 1
Socio-demographic characteristics of study participants
Participants (n = 101) | n (%) |
Age | < 30 years | 40 (39.6) |
| ≥ 30 years | 61 (60.4) |
Sex | Male | 58 (57.4) |
| Female | 43 (42.6) |
Department | Anaesthesiology | 11 (10.9) |
| Anatomic Pathology | 11 (10.9) |
| Clinical Pathology | 7 (6.9) |
| Family Medicine | 7 (6.9) |
| General Surgery | 12 (11.9) |
| Internal Medicine | 14 (13.9) |
| Imaging & Diagnostic Radiology | 13 (12.9) |
| Obstetrics & Gynaecology (OBGYN) | 12 (11.9) |
| Paediatrics & Child Health | 14 (13.9) |
Year of study | One | 30 (29.7%) |
| Two | 26 (25.7%) |
| Three | 23 (22.8%) |
| Four | 22 (21.8%) |
Table 1: Socio-demographic characteristics of study participants
Knowledge, attitude and practice of EBM: The mean scores for knowledge, attitude and practice of EBM among residents were 73.88 (SD 13.74), 66.96 (SD 6.54) and 63.19 (SD 8.43) respectively.
Knowledge about EBM
Among all the EBM resources, residents indicated that the most common resources they were aware of and used frequently were UpToDate (74.2%), PubMed (61.4%), Hinari (42.6%), Google Scholar (43,6%) and Clinical Key (43.5%) (Fig. 1) (Additional file 2).
Figure 1: Familiarity of EBM resources among residents
This is further illustrated in qualitative findings: “When you’re not on call, doing daily work, then its easy you get to Hinari, UpToDate, PubMed directly…. it is very easy for us”. (R9)
With regard to confidence in practicing the five steps of EBM, around 50% of the residents felt their level of confidence was either “good” or “very good” for four of the five steps of EBM. However, for critical appraisal, only 36.6% of the residents felt that their level of confidence was either “good” or “very good” (Fig. 2).
Figure 2: Residents’ level of confidence in EBM skills
Critical appraisal was similarly identified as the most challenging step of practicing EBM in the IDIs: “Critical appraisal – still trying to get my head around that, we haven’t been taught to really criticize things from school, the system is take this and cram it, don’t ask questions, so that’s why its hard to think critically”. (R1)
Attitude towards EBM
More than 90% of the residents agreed or strongly agreed that EBM improves patient outcomes, that it helps in clinical decision-making and should be taught to undergraduate students. Majority (> 80%) also disagreed or strongly disagreed that EBM is a mantra with no direct applicability to patients in rural settings, that it had no relevance in low resource settings and that it is suitable only for research based institutions. However, 74.3% of the residents either disagreed or strongly disagreed that the costs of EBM outweigh the benefits, indicating that EBM is cost-effective (Fig. 3).
Figure 3: Residents’ opinions about EBM
Similarly, qualitative findings showed most residents were convinced that EBM had significant impact on ensuring safer patient care: “Before I came here (AKUHN), I used to follow my consultant or MO, I didn’t know how to look for stuff myself. And I think we used to give substandard care to patients out there. When I came here, I realized, what we were doing out there was witchcraft”. (R16)
Residents believed that EBM was important in a number of ways, right from medical school to shaping future consultants. It was also vital as part of their residency as it made them competent doctors at an international level: “Important to be taught in undergraduate level because if you are taught by someone whose practicing style is the old way then you have a muted experience and you don’t know how to approach EBM. The sooner you learn, the better your approach”. (R2)
“Important for residents in order to be at par with everyone and you can practice medicine anywhere in the world and follow international treatment protocols and work in internationally accredited hospitals”. (R13)
Practice of EBM
Figure 4 depicts how often residents practiced EBM over the last month and how they managed the cases they saw over the same month. Sixty five percent of the residents said that they used EBM resources for half (or more) of the cases seen, 34.7% relied on consultants for half or more of the cases and 75.2% mostly relied on their knowledge to treat half or more of the cases.
Figure 4: Practice of EBM by residents during the last month
Despite a good understanding of and all the facilitating factors for EBM, actual application of EBM in day-to-day practice was quite low. Most residents (especially those in senior years) indicated looking up only 20–30% of patients on a daily basis, especially in senior years: “Half the time you’re doing service provision, running around, checking up on results, doing procedures, so the time to sit down and start looking through data is impossible, 30% at most”. (R18)
Barriers to the practice of EBM
The barriers faced by residents that emerged from the quantitative study were categorized into doctors’ personal barriers, organizational barriers and patient-related barriers as shown in Table 2 below.
Table 2
The mean scores for each of the barriers faced by AKUHN residents
Barriers | Total score (n/N) | Mean score | Standard Deviation |
Lack of familiarity with EBM | 267/505 | 2.64 | 1.18 |
EBM practice devalues clinical experience | 194/505 | 1.92 | 0.74 |
Impracticality of EBM for everyday use | 248/505 | 2.46 | 1.03 |
EBM removes the ‘art’ of medicine | 200/505 | 1.98 | 0.77 |
EBM de-emphasizes history taking and physical examination skills | 195/505 | 1.93 | 0.78 |
Lack of time to access EBM sources | 338/505 | 3.35 | 1.18 |
Insufficiency of basic EBM skills | 300/505 | 2.97 | 1.14 |
Skepticism over the quality of evidence | 274/505 | 2.71 | 1.10 |
Patients’ unawareness about EBM and preference of traditional approach | 286/505 | 2.83 | 1.09 |
Table 2: The mean scores for each of the barriers faced by AKUHN residents
The most important organizational barrier faced by residents was lack of time to access EBM resources due to heavy workload, with mean score of 3.35 (SD 1.18). This was also reflected in the qualitative findings as illustrated by the following quotes: “Number one barrier is large number of patients- so you do just bare minimum for each and just move on”. (R12)
“There is a turn around time, if I end up spending few more minutes reading about a patient, during work hours, you neglect radiographs and there is a constant need for validating reports before certain time”. (R13)
The barrier with the second highest mean was a personal barrier – “insufficiency of basic EBM skills” with a mean score of 2.97 (SD 1.14) (Table 2). Doctors struggle to practice EBM in their daily practice because of lack of awareness and ability to think critically, because they have never been taught to question or think broadly since undergraduate education: “Searching because it takes up the most time because you have to make sure you get right thing, people have to be taught technique for searching, there is a systematic way”. (R5)
“Kenyan education makes us just follow orders, we are not taught to think outside the box. So we continue doing things a certain way without asking questions”. (R5)
Many residents felt that “Patients’ unawareness about EBM and preferences of traditional approach” was a major barrier to practice of EBM with a mean score of 2.83 (SD 1.09) (Table 2).
Conversely, the major concern from the qualitative findings was not lack of patients’ awareness about EBM but patients having too much access to health information. However most residents found this to be a motivator to read more but not a challenge. They felt that access to health information by patients had a positive influence on their practice of EBM and acted as a facilitator instead of a barrier. They generally believed that “an informed patient was a good patient”. (R15) Another resident said “It stops you from slacking so I take it as positive and motivates me to up my game”. (R13)
Relationship between knowledge, attitude, practice and barriers of EBM and socio-demographic factors
There were no significant variations in knowledge and attitudes towards EBM across the four participant characteristics (Table 3). However, the practice of EBM varied across department and year of study. Each unit increase in year led to a corresponding 1.48 increase in the mean score for practice of EBM (p-value = 0.01) and each unit increase in department led to a corresponding 2.20 decrease in the mean score of practice of EBM (p-value = 0.00).
Table 3
Relationship between level of knowledge, attitude and practice and socio-demographic factors.
| Linear Regression Coefficient (95% CI) | P-value | Multiple Linear Regression Coefficient (95% CI) | P-value |
Knowledge | Sex | -3.50 (-8.97-1.98) | 0.21 | -3.16 (-8.62-2.31) | 0.25 |
Age | 0.75 (-2.27-1.72) | 0.13 | 0.53 (-0.52-1.59) | 0.32 |
Dept. | -0.02 (-1.13-1.09) | 0.97 | | |
Year | 1.89 (-0.51-4.29) | 0.12 | 1.26 (-1.34-3.87) | 0.34 |
Attitude | Sex | 1.50 (-1.11-4.10) | 0.26 | | |
Age | -0.16 (-0.63-0.31) | 0.50 | | |
Dept. | 0.24 (-0.29-0.77) | 0.37 | | |
Year | 0.11 (-1.04-1.27) | 0.85 | | |
Practice | Sex | 1.10 (-2.27-4.48) | 0.52 | | |
Age | -1.03 (-4.21-2.16) | 0.52 | | |
Dept. | -2.15 (-2.64- -1.67) | 0.00 | -2.20 (-2.67- -1.72) | 0.00 |
Year | 1.13 (-0.34-2.60) | 0.13 | 1.48 (0.40–2.57) | 0.01 |
Table 3: Relationship between level of knowledge, attitude and practice and socio-demographic factors.