Background
Recent decades have witnessed a gradual movement towards clinical care informed by research evidence [
1]. This concept of evidence-based medicine - more inclusively termed evidence-based practice (EBP) - is described as the integration of best available research evidence with clinical expertise and patient values [
2], and is now considered a common-sense approach to modern healthcare provision [
3]. Despite widespread support for EBP, its integration into healthcare policy and practice has been ad hoc across professions and jurisdictions [
4‐
11]. This may be partly due to a criticism of EBP in housing reliance on algorithm-driven decision-making; challenges in translating research evidence into patient-centred care and difficulties applying EBP to complex clinical presentations may present as additional barriers to EBP uptake [
12,
13]. These concerns have been highlighted by various disciplines, including healthcare philosophy [
14,
15], medicine [
12,
16‐
19], physiotherapy [
20‐
22], and more recently, osteopathy [
23‐
25].
Osteopathy is a health profession originating in the United States in the late 1800s, where its providers, osteopathic physicians, are licenced to practice in all areas of medicine; yet, although the majority (56%) practice in primary care specialities [
26]
, few (1–2%) specialize in osteopathic manipulative treatment [
27]. This is in contrast to osteopathic practitioners, or osteopaths, trained outside the US, where manual therapy treatment may be considered the main scope of osteopathic practice [
28]. In the UK, osteopaths are autonomous primary care practitioners primarily trained to manage musculoskeletal conditions, of which spinal pain is the most common, and whom typically provide manual therapy treatment, exercise and self-management recommendations [
29,
30].
Osteopathic practice and clinical decision-making is embedded within traditional concepts and principles [
31,
32], many of which are drawn from interpretations and observations by prominent individuals made early in the history of the profession. Contemporary research has led some authors to question the validity and usefulness of such models [
33‐
35]. Certainly, there is insufficient research evidence to support all aspects of osteopathy practice and the need for a broader research agenda has been proposed [
36,
37]. Although the role of research evidence in osteopathy has been debated, there is agreement that EBP needs to be integrated into the osteopathic approach [
23,
38‐
41]. Nonetheless, potential barriers to the acceptance of EBP by UK osteopaths remain with some for example concerned that implementing EBP may fail to preserve traditional osteopathic principles [
13,
42]. Research in physiotherapy points to other factors that may act as barriers to implementing EBP, such as financial and time constraints, and the possible conflict of evidence with patients’ treatment preferences and expectations [
43,
44]. Whether these barriers also apply to osteopathy is largely unknown given the relative paucity of EBP research in osteopathy. The aim of the study presented in this paper was to investigate UK osteopaths’ attitudes, skills and utilisation of research evidence in practice, their training in EBP, as well as the barriers to, and facilitators of EBP adoption.
Methods
Design and ethics
National cross-sectional survey in the UK. The Research Ethics Committee of the University College of Osteopathy (London, UK) approved the study. No identifying data were collected and results were only reported as aggregate data, thus maintaining participant anonymity. Study participation was voluntary with the option to withdraw/drop-out at any time.
Setting and participants
All osteopaths registered with the General Osteopathic Council in the UK by June 2017 were eligible and sampled.
Description of questionnaire and variables
The Evidence-Based practice Attitude and utilization SurvEy (EBASE) is an 84-item instrument evaluating the attitudes, perceived skills and use of EBP amongst healthcare providers [
47]. The questionnaire has been previously administered to different health provider groups [
4,
5,
8,
9,
47,
48], and psychometric evaluation shows good internal consistency, content validity, construct validity, and acceptable test-retest reliability [
47,
49].
EBASE is divided into seven parts: attitude (Part A), skill (Part B), education and training (Part C), use (Part D), barriers to EBP (Part E), and enablers of EBP (Part F). The final section, Part G, gathers information on participant demographics. Parts A, B and D of EBASE generate three subscores: attitude subscore, range from 8 (predominantly strongly disagree) to 40 (predominantly strongly agree); skill subscore, range from 13 (primarily low-level skill) to 65 (primarily high-level skill); and use subscore, range from 0 (mainly infrequent use) to 24 (mainly frequent use). For this study, several survey items were modified for the target population (e.g., the term ‘osteopathy’ was substituted for complementary medicine ‘CAM’). Several response options in Part G (demographics) also underwent change to ensure suitability for a UK audience. These changes did not alter item meaning, and thus, did not affect the validity or reliability of the instrument. The survey was administered electronically (hosted by SurveyMonkey™), with all questions made compulsory to minimise missing data.
Recruitment and data collection procedures
A pilot study was performed on a convenience sample of five osteopaths associated with the University College of Osteopathy (London, UK), each with varying clinical and academic experience. The purpose of the pilot was to ensure the survey items were clear and appropriate to osteopaths. Some minor terminological changes were made as a result, primarily to enhance clarity. Estimated completion time was 10–15 min.
For the subsequent full study, potential participants were invited to voluntarily participate in the survey through emails sent by the General Osteopathic Council (GOsC), the Institute of Osteopathy (iO) and the National Council for Osteopathic Research (NCOR) in the UK. These agencies also promoted the survey via electronic/paper media. The emails and posts contained a link to EBASE and a participant information sheet, which explained the study, its relevance to the osteopathic profession and what participation would involve. Interested participants had to provide informed consent by responding to a screening question at the beginning of the questionnaire hosted by SurveyMonkey™. A follow-up email was sent two weeks after the initial invitations to remind participants to participate in the study. Data collection was undertaken between the months of June and August 2017. The online survey tool automatically restricted attempts to respond to the survey more than once by the use of cookies per device.
Statistical methods
The sample size calculation, based on a target population of 5200 osteopaths (March 31, 2017) [
45], and a response distribution of 50%, indicated that at least 358 osteopaths would need to complete the EBASE questionnaire to attain a 5% margin of error with a confidence level of 95% for each survey item [
46]. Survey responses were exported from SurveyMonkey™ into SPSS (v.24.0) for coding and statistical analysis. Partially-completed surveys, due to drop-out, were excluded from the analysis if more than 20% of all items were incomplete [
10]. Any missing data were reported as missing values. Categorical data were described using frequency distributions and percentages. Measures of central tendency and variability were used for normally distributed descriptive data (including continuous [i.e. EBASE subscore] and categorical [i.e. Likert scale] data), while medians and the interquartile range were used to describe non-normally distributed data. Associations between ordinal-level variables were examined using Kendall’s Tau correlation coefficient (Ƭ), and relationships between nominal-level variables assessed using Cramer’s V, with coefficients between 0.10–0.29 representing a weak association, 0.30–0.49 a moderate association, and 0.50 and above a strong correlation. The tests of association were informed by previous research using EBASE [
4‐
6,
8‐
10]. The level of significance was set at
p < 0.05.
Results
A total of 517 (9.9%), out of 5200 UK-registered osteopaths [
45] responded to invitations to participate. Excluding 142 responses that were > 20% incomplete, the final response rate was 7.2% (375/5200), which exceeded the minimum required sample size.
Description of the sample
Participants were largely ≥40 years of age (53.9%), and held an honours degree or higher (54.2%) (Table
1). Participant gender was equal, most had practiced osteopathy for at least 6 years (65.8%), and half worked in southern UK (50.4%). For further demographic data, see Table
1.
Table 1
Demographic characteristics of sample (n = 375)
Age, n (%) | < 20 years | 1 (0.3) |
20–29 years | 19 (5.1) |
30–39 years | 55 (14.7) |
40–49 years | 85 (22.7) |
50–59 years | 92 (24.5) |
60–69 years | 21 (5.6) |
70+ years | 4 (1.1) |
Missing | 98 (26.1) |
Sex, n (%) | Female | 146 (38.9) |
Male | 130 (34.7) |
Missing | 98 (26.1) |
Highest qualification, n (%) | Certificate | 1 (0.3) |
Diploma/Advanced Diploma | 34 (9.1) |
Bachelor degree | 39 (10.4) |
Honours degree | 76 (20.3) |
Graduate Certificate/Diploma | 29 (7.7) |
Master’s degree | 91 (24.3) |
PhD/Professional doctorate | 7 (1.9) |
Missing | 98 (26.1) |
Years since receiving highest qualification, n (%) | < 1 year | 15 (4.0) |
1–5 years | 42 (11.2) |
6–10 years | 79 (21.1) |
11–15 years | 41 (10.9) |
16+ years | 100 (26.7) |
Missing | 98 (26.1) |
Years practiced in the field of osteopathy, n (%) | < 1 year | 7 (1.9) |
1–5 years | 23 (6.1) |
6–10 years | 68 (18.1) |
11–15 years | 56 (14.9) |
16+ years | 123 (32.8) |
Missing | 98 (26.1) |
Hours per week in clinical (osteopathic) practice, n (%) | 0 h | 1 (0.3) |
1–15 h | 40 (10.7) |
16–30 h | 129 (34.4) |
31–45 h | 90 (24.0) |
46+ hours | 17 (4.5) |
Missing | 98 (26.1) |
Hours per week participating in research, n (%) | 0 h | 136 (36.3) |
1–15 h | 132 (35.2) |
16–30 h | 7 (1.9) |
31–45 h | 2 (0.5) |
46+ hours | 0 (0.0) |
Missing | 98 (26.1) |
Hours per week teaching in the higher education sector, n (%) | 0 h | 208 (55.5) |
1–15 h | 60 (16.0) |
16–30 h | 9 (2.4) |
31–45 h | 0 (0.0) |
46+ hours | 0 (0.0) |
Missing | 98 (26.1) |
Treatments typically provided in first osteopathic consultation, n (%) | Articulation | 255 (68.0) |
Soft tissue therapy | 234 (62.4) |
Exercise | 226 (60.3) |
HVLA thrust | 182 (48.5) |
Muscle energy therapy | 179 (47.7) |
General osteopathic treatment | 150 (40.0) |
Functional technique | 128 (34.1) |
Myofascial release | 122 (32.5) |
Relaxation advice | 112 (29.9) |
Cranial technique | 108 (28.8) |
Ice/cold treatment | 83 (22.1) |
Strain-counterstrain | 65 (17.3) |
Acupuncture/acupressure | 62 (16.5) |
Other | 49 (13.1) |
Visceral therapy | 43 (11.5) |
Electrotherapy | 24 (6.4) |
Orthotics | 15 (4.0) |
Steroid injection | 1 (0.3) |
Clinical setting in which osteopathy is predominantly practiced, n (%) | With a group of CAM providers | 113 (30.1) |
Solo practice | 95 (25.3) |
With CAM & conventional providers | 31 (8.3) |
With a group of conventional providers | 24 (6.4) |
Within an educational institution | 5 (1.3) |
Within a clinical institution | 3 (0.8) |
Missing | 104 (27.7) |
Geographical location, n (%) | London | 75 (20.0) |
Southeast UK | 69 (18.4) |
Southwest UK | 45 (12.0) |
Midlands (UK) | 20 (5.3) |
Scotland | 16 (4.3) |
East Anglia | 15 (4.0) |
Northeast UK | 14 (3.7) |
Northwest UK | 7 (1.9) |
Wales | 4 (1.1) |
Other | 4 (1.1) |
Northern Ireland | 2 (0.5) |
Missing | 104 (27.5) |
Osteopathy professional association membership, n (%) | Institute of Osteopathy | 200 (53.3) |
Not a member of an osteopathy association | 45 (12.0) |
Sutherland Cranial College of Osteopathy | 39 (10.4) |
Other | 26 (6.9) |
Sutherland Society | 23 (6.1) |
Foundation for Paediatric Osteopathy | 18 (4.8) |
Molinari Institute of Health | 8 (2.1) |
Rollin E Becker Institute | 8 (2.1) |
Institute of Classical Osteopathy | 7 (1.9) |
Geographical region, n (%) | Outer city suburbs | 94 (25.1) |
Rural/remote region | 70 (18.7) |
City (Central business district) | 59 (15.7) |
Inner city suburbs | 46 (12.3) |
Missing | 106 (28.3) |
Attitudes toward EBP
Participants reported generally positive attitudes toward EBP, with a median subscore of 30 (IQR 26,33; range 11–40; with a median score ranging between 24.1 and 31.9 defined as a predominantly neutral to agree response). The majority (82.6%) agreed that professional literature and research findings are useful for practice, EBP assists in clinical decision making (80.8%), and EBP is necessary in the practice of osteopathy (76.5%) (Table
2). Most (80.8%) also reported an interest in learning or improving the skills necessary to incorporate EBP into practice.
Table 2
Participant attitudes toward evidence-based practice (n = 375)
Professional literature (i.e. journals & textbooks) and research findings are useful in my day-to-day practice | 2 (0.5) | 28 (7.5) | 35 (9.3) |
224 (59.7)
| 86 (22.9) | 4 (4,4) |
EBP assists me in making decisions about patient care | 8 (2.1) | 28 (7.5) | 36 (9.6) |
208 (55.5)
| 95 (25.3) | 4 (4,5) |
I am interested in learning or improving the skills necessary to incorporate EBP into my practice | 3 (0.8) | 29 (7.7) | 40 (10.7) |
199 (53.1)
| 104 (27.7) | 4 (4,5) |
EBP is necessary in the practice of osteopathy | 8 (2.1) | 36 (9.6) | 44 (11.7) |
183 (48.8)
| 104 (27.7) | 4 (4,5) |
EBP improves the quality of my patient’s care | 8 (2.1) | 47 (12.5) | 60 (16.0) |
176 (46.9)
| 84 (22.4) | 4 (3,4) |
There is a lack of evidence from clinical trials to support most of the treatments I use in my practice | 4 (1.1) | 60 (16.0) | 67 (17.9) |
176 (46.9)
| 68 (18.1) | 4 (3,4) |
Prioritizing EBP within osteopathic practice is fundamental to the advancement of the profession | 33 (8.8) | 59 (15.7) | 73 (19.5) |
136 (36.3)
| 74 (19.7) | 4 (3,4) |
EBP takes into account my clinical experience when making clinical decisions | 11 (2.9) | 108 (28.8) | 84 (22.4) |
125 (33.3)
| 47 (12.5) | 3 (2,4) |
EBP takes into account a patient’s preference for treatment | 20 (5.3) | 139 (37.1) | 90 (24.0) | 85 (22.7) | 41 (10.9) | 3 (2,4) |
The adoption of EBP places an unreasonable demand on my practice | 35 (9.3) |
181 (48.3)
| 99 (26.4) | 49 (13.1) | 11 (2.9) | 2 (2,3) |
There was no significant association between attitude subscore and most demographic characteristics. There was a weak association between attitude and gender (with higher attitude scores reported in males; V = 0.294, p < 0.001) and geographical region (with higher attitude scores reported among osteopaths working in the city and inner city suburbs; V = − 0.246, p < 0.001). There was also a weak negative correlation between attitude and years since receiving highest qualification (Ƭ = − 0.130, p = 0.01) and a weak positive correlation between attitude and hours/week participating in research (Ƭ = 0.242, p < 0.001).
Skills in EBP
Participants reported moderate levels of perceived skill in EBP, with a median subscore of 39 (IQR 32,45; range 13–65; with a median score ranging between 26.1 and 39.0 defined as a predominantly low-moderate to moderate skill level). The highest levels of perceived skill in EBP were reported for items relating to clinical problem identification (Table
3). The lowest levels of perceived skill were reported for the conduct of systematic reviews (74.6%) and clinical research (80.5%).
Table 3
Participant self-reported skills in evidence-based practice (n = 375)
Identifying precise clinical questions | 10 (2.7) | 38 (10.1) |
138 (36.8)
| 134 (35.7) | 55 (14.7) | 0 (0.0) | 4 (3,4) |
Identifying knowledge gaps in practice | 7 (1.9) | 20 (5.3) | 144 (38.4) |
162 (43.2)
| 42 (11.2) | 0 (0.0) | 4 (3,4) |
Locating professional literature | 16 (4.3) | 58 (15.5) | 104 (27.7) |
123 (32.8)
| 74 (19.7) | 0 (0.0) | 4 (3,4) |
Online database searching | 29 (7.7) | 81 (21.6) | 95 (25.3) |
106 (28.3)
| 64 (17.1) | 0 (0.0) | 3 (2,4) |
Retrieving evidence | 26 (6.9) | 75 (20.0) |
122 (32.5)
| 99 (26.4) | 53 (14.1) | 0 (0.0) | 3 (2,4) |
Critical appraisal of evidence | 24 (6.4) | 71 (18.9) |
126 (33.6)
| 118 (31.5) | 36 (9.6) | 0 (0.0) | 3 (2,4) |
Synthesis of research evidence | 40 (10.7) | 90 (24.0) |
125 (33.3)
| 90 (24.0) | 30 (8.0) | 0 (0.0) | 3 (2,4) |
Applying research evidence to patient cases | 21 (5.6) | 67 (17.9) |
130 (34.7)
| 127 (33.9) | 30 (8.0) | 0 (0.0) | 3 (3,4) |
Sharing evidence with colleagues | 25 (6.7) | 91 (24.3) |
114 (30.4)
| 100 (26.7) | 45 (12.0) | 0 (0.0) | 3 (2,4) |
Using findings from clinical research | 24 (6.4) | 69 (18.4) |
131 (34.9)
| 119 (31.7) | 27 (7.2) | 5 (1.3) | 3 (2,4) |
Using findings from systematic reviews | 63 (16.8) | 83 (22.1) |
120 (32.0)
| 82 (21.9) | 22 (5.9) | 5 (1.3) | 3 (2,4) |
Conducting systematic reviews |
182 (48.5)
| 98 (26.1) | 63 (16.8) | 15 (4.0) | 12 (3.2) | 5 (1.3) | 2 (1,2) |
Conducting clinical research |
213 (56.8)
| 89 (23.7) | 43 (11.5) | 21 (5.6) | 9 (2.4) | 0 (0.0) | 1 (1,2) |
There was a weak positive correlation between skill subscore (categorised by quartiles) and highest qualification (Ƭ = 0.240, p < 0.001) and hours per week teaching in the higher education sector (Ƭ = 0.212, p < 0.001), and a weak negative correlation between skill subscore and years since receiving highest qualification (Ƭ = − 0.204, p < 0.001). A moderate positive correlation between skill subscore and hours per week participating in research (Ƭ = 0.382, p < 0.001) was also observed.
Use of EBP
Participants engaged in EBP activities at a moderately-low level in the month preceding the survey, with a median subscore of 12 (IQR 11,15; range 6–30; with a median score ranging between 6.1 and 12.0 defined as a predominantly moderately-low level of use). Most (> 65%) participants partook in the first five EBP-related activities no more than five times in the preceding month (Table
4). A similar level of activity was also reported for consultation with a colleague/industry expert (77.1%) or use of the lay literature (80.6%) to assist clinical decision-making. The only exception to this was the use of online search engines to pursue practice related literature or research, which was performed by 68% of participants, between 1 and 10 times in the month prior.
Table 4
Participant use of evidence-based practice (i.e. number of times each activity was performed over the last month) (n = 375)
I have read/reviewed professional literature (i.e. professional journals & textbooks) related to my practice | 31 (8.3) |
214 (57.1)
| 56 (14.9) | 23 (6.1) | 32 (8.5) | 19 (5.1) | 2 (2,3) |
I have read/reviewed clinical research findings related to my practice | 90 (24.0) |
188 (50.1)
| 38 (10.1) | 13 (3.5) | 27 (7.2) | 19 (5.1) | 2 (1,2) |
I have used professional literature or research findings to assist my clinical decision-making | 57 (15.2) |
198 (52.8)
| 51 (13.6) | 14 (3.7) | 36 (9.6) | 19 (5.1) | 2 (2,3) |
I have used an online database to search for practice related literature or research | 140 (37.3) |
142 (37.9)
| 35 (9.3) | 16 (4.3) | 17 (4.5) | 25 (6.7) | 2 (1,2) |
I have used professional literature or research findings to change my clinical practice | 91 (24.3) |
213 (56.8)
| 28 (7.5) | 6 (1.6) | 18 (4.8) | 19 (5.1) | 2 (1,2) |
I have used an online search engine to search for practice related literature or research | 22 (5.9) |
158 (42.1)
| 97 (25.9) | 32 (8.5) | 41 (10.9) | 25 (6.7) | 2 (2,3) |
I have consulted a colleague or industry expert to assist my clinical decision-making | 81 (21.6) |
208 (55.5)
| 40 (10.7) | 6 (1.6) | 15 (4.0) | 25 (6.7) | 2 (2,2) |
I have referred to magazines, layperson/self-help books, or non-government/non-education institution websites to assist my clinical decision-making | 91 (24.3) |
211 (56.3)
| 32 (8.5) | 5 (1.3) | 11 (2.9) | 25 (6.7) | 2 (1,2) |
There was a moderate positive correlation between use subscore (categorised by quartiles) and hours per week participating in research (Ƭ = 0.300, p < 0.001). There was a weak positive correlation between use subscore and highest qualification (Ƭ = 0.226, p < 0.001), hours per week teaching in the higher education sector (Ƭ = 0.120, p = 0.032) and geographical region (i.e. higher use scores amongst osteopaths working in the city and inner city suburbs; V = 0.174, p = 0.005). A weak negative correlation was observed between use subscore and years since receiving highest qualification (Ƭ = − 0.235, p < 0.001) and years practicing osteopathy (Ƭ = − 0.133, p = 0.013).
Almost one-third (30.7%) of participants reported that no more than 25% of their clinical practice was informed by clinical trial evidence; 20.5% reported clinical evidence informed 26–50% and 51–75% of practice, and 6.4% indicated clinical evidence informed 76–99% of practice. The information source most frequently used by participants to inform their clinical decision-making was traditional knowledge (median rank 3; IQR 1,5), followed by clinical practice guidelines (median rank 4; IQR 2,7) and personal intuition (median rank 5; IQR 2,7) (Table
5).
Table 5
Sources of information used to inform clinical decision-making (ranked by most frequent to least frequently used source)a (n = 375)
Traditional knowledge | 3 (1,5) |
Clinical practice guidelines | 4 (2,7) |
Personal intuition | 5 (2,7) |
Consulting fellow practitioners or experts | 5 (3,7) |
Patient preference | 5 (3,7) |
Personal preference | 5 (3,7) |
Published clinical evidence (i.e. clinical trials) | 6 (3,8) |
Textbooks | 6 (4,7) |
Trial and error | 8 (6,9) |
Published experimental/laboratory evidence | 10 (7,10) |
Training in EBP
Most participants reported some level of training in evidence-based practice/osteopathy (81.3%), evidence application (71.5%), critical thinking/analysis (72.3%), and clinical research (57.1%). Participants mainly received this training as a component of a study program (38.7–46.7%), and to a lesser extent, via a seminar or short course (9.6–25.1%). Over half (52.3%) of respondents had received no training in the conduct of systematic reviews and meta-analyses.
Barriers to and enablers of EBP uptake
The only factors perceived by most participants as being moderate to major barriers to EBP uptake were a lack of clinical evidence in osteopathy (69.1%), and lack of time (56.6%). Most participants perceived other factors to be minor barriers or no barrier to EBP uptake.
Most participants reported that internet in the workplace (70.5%), ability to download full-text articles (60.1%), access to free online databases (55.9%) and online EBP education materials (55.9%) were ‘very useful’ enablers of EBP implementation. Factors considered ‘moderately to very useful’ included access to critical reviews (80.1%), databases requiring licence fees (73.3%), and critically appraised topics relating to osteopathy (67.5%). Very few participants rated the listed enablers of EBP uptake as not useful.
Conclusions
Our study contributes towards an increased understanding of UK osteopaths’ attitudes, skills and use of EBP. The findings suggest that responding UK osteopaths have a generally positive attitude toward EBP, self-report moderate-level skills in EBP, and typically engage in EBP-related activities at a moderately-low level. Encouragingly, most respondents wanted to improve their skills to facilitate the uptake of EBP into osteopathic practice. Additionally, the findings highlight the need for further research; in particular, the need to (i) investigate the meaning that osteopaths ascribe to EBP, (ii) establish the skill level of osteopaths in implementing EBP in clinical practice, (iii) determine a reasonable and clinically feasible level of EBP-related activity for osteopaths, and (iv) develop suitable interventions and strategies that support osteopaths to effectively improve the uptake of EBP.
Acknowledgements
The authors would like to thank Dr. Michael Ford for his valuable assistance with survey administration, and the University College of Osteopathy (formerly the British School of Osteopathy), General Osteopathic Council, Institute of Osteopathy and National Council for Osteopathic Research, for promoting the survey and distributing invitations to their respective members.
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