Awareness, knowledge, use, and attitudes toward evidence based medicine in a developing country: survey of physicians in a canton in Bosnia and Herzegovina

Aim To assess awareness, knowledge, use, and attitudes toward evidence-based medicine (EBM) and The Cochrane Library (CL) among physicians from Zenica-Doboj Canton (ZDC), Bosnia and Herzegovina. Methods In this cross-sectional study, a self-administered anonymous questionnaire was sent by post to all state owned health institutions (2 hospitals and 11 Primary Health Care Institutions) in ZDC. The main outcome measures were physicians’ awareness of the Cochrane, awareness and use of CL, access to EBM databases, and access to internet at work. 358 of 559 physicians responded (63.69%). Results 23.18% of respondents stated they had access to EBM databases, but only 3.91% named the actual EBM databases they used. The question on the highest level of evidence in EBM was correctly answered by 35.7% respondents, 34.64% heard about Cochrane and 32.68% heard about CL. They obtained information about CL mostly on the internet and from colleagues, whereas the information about EBM was obtained mainly during continuous medical education. Conclusion Although the attitudes toward EBM are positive, there is a low awareness of EBM among physicians in ZDC. Open access to the CL should be used more. Educational interventions in popularizing EBM and Cochrane are needed to raise awareness both among students and practicing physicians, and finally among lay audience.

Evidence based medicine (EBM) is described as an integration of individual clinical expertise, the best available external clinical evidence from systematic research, and individual patients' predicaments, rights, and preferences, in making clinical decisions about their care (1,2). However in many settings there are still barriers to its implementation (3)(4)(5)(6).
Systematic reviews with or without meta-analysis produced by The Cochrane Library (CL) are considered as the "gold standard" in EBM (15)(16)(17)(18). Cochrane systematic reviews (CSRs) can raise the quality of health care, especially in developing countries with scarce resources. For example, CSRs have been shown to provide invaluable evidence in creating national reimbursement lists (19).
A nation-wide study among physicians in Croatia concluded that there was low awareness about EBM and the CL (30%), and additional educational interventions were required (6). Unlike Croatia, Bosnia and Herzegovina (BH) has no organized Cochrane activity yet (20). Our study aimed to assess the awareness, knowledge, use, and attitudes toward EBM and the CL (as the only available EBM database in BH with unrestricted access) among physicians in Zenica-Doboj Canton (ZDC), to help in the implementation of educational activities that would improve the use of EBM and the CL.

Study design and settings
This is a cross-sectional survey of all physicians working in primary and secondary health care institutions in ZDC. ZDC has a population of 385 067 (21)

Survey instrument
We used a 30-item self-administered questionnaire, modified from a similar study by Novak et al (6), provided by courtesy of and approved by Livia Puljak, Split School of Medicine, Croatia. The questionnaire was modified so that the questions specifically related to Croatia were left out.
Physicians were asked about the average number of patients seen per day, physicians' need for help in making medical decisions, internet usage and access to EBM databases, attitudes, awareness, knowledge, and use of EBM, Cochrane, and the CL, their professional status, scientific degree, and age. The questionnaire was distributed to 559 physicians together with a short letter explaining the aim of the study and stating that participation in the study was voluntary and anonymous.

Statistical analysis
Data were analyzed by Microsoft Excel 2007 and SPSS, version 13.0 (SPSS Inc., Chicago, IL, USA). Normality of distribution of continuous variables was tested using Kolmogorov-Smirnov test. Normally distributed variables are presented as frequencies and relative frequencies. Difference in distribution frequency was tested with χ 2 test. Continuous variables with non-normal distribution are presented using median and interquartile range (IQR). Histogram was created, and when bimodal distribution was observed, it was divided empirically (23), using 50 percentile as a cutoff point. Normality of these two distributions was then tested using Kolmogorov-Smirnov test. Distributions were presented by mode, median, and IQR. P values ≤0.050 were considered statistically significant. Bimodal age distribution was stratified according to variables that were indicative as a cause of bimodality. All questions with binary variables were tested in relation to the first and second modal age distributions by calculating odds ratios (OR) and 95% confidence interval (CI).

RESultS
Out of 559 questionnaires, 358 were completed and returned: 217 from hospitals and 141 from primary health care institutions. The total response rate was 63.69%, 69.97% in hospitals and 55.29% in primary health care. The sample included 55.03% (197/358) of women and 43.57% (156/358) of men (5 questionnaires had missing data) (Table 1). Median age was 42 years (IQR, 34-53 years). The data on age had a bimodal distribution ( Figure 1). Median age of the first mode distribution was 34 (IQR 29-37) years, while median age of the second mode distribution was 54 (IQR 49-57) years (Table 1). Hospital physicians had a median of 20 (IQR 15-30) patients daily and primary health care physicians had 40 (IQR 30-50). The majority of physicians graduated from the Sarajevo University. Among hospital physicians, one fifth held a master's degree and/or a PhD, which is more than among primary health physicians. 189 (52.79%) physicians assessed their knowledge of English as good or excellent and 231 (64.52%) physicians assessed their computer knowledge as good or excellent. Almost all physicians, 354 (98.88%), stated that continuous medical education (CME) was needed.
Significantly more hospital physicians than primary care physicians indicated that they needed help in making medical decisions ( Hospital physicians were more aware that they had access to specialized EBM databases (P < 0.001), although just 6 (2.76%) of them listed the CL as a specialized EBM database ( The majority of participants got information on EBM through CME (

DiSCuSSioN
Our study showed that the awareness, knowledge, and use of EBM and CL in ZDC was low despite the fact that the most participants had positive attitude toward EBM and many of them were interested to learn about the methodology of making CSRs. The awareness of EBM in our setting (23%) was lower than that in Croatia (6) (54%), while the awareness of CL was similar to that in Croatia, where one third of participants heard of Cochrane (6), and about half of the participants were unaware of the CL (11).
The research methods used in this study have some limitations. The response rate was similar to that in the study by Novak et al (6), but our sample was not representative of the population of physicians from the entire country, since it included physicians only from one canton. Another limitation was the use of a self-administered questionnaire, which yielded a lot of missing data, compared to the study by Novak et al, which used a telephone survey.
The bimodal age distribution found in our study, unusual for other settings, indicates that there are very few middle generation physicians. This finding can be explained by emigration of physicians during the war in BH (1992)(1993)(1994)(1995)(1996), and a smaller number of physicians graduating during the war years. This means that future educational activities have to be targeted at two different groups of physicians: those who graduated before the war and those who graduated after the war.
Major barriers to practicing EBM were insufficient knowledge on EBM and insufficient internet availability. In our setting, internet availability at work was 71.79%, better than in Jordan (11) -53.70%, but worse than in Croatia (6) -99.1% in hospital setting and 83.4% in primary health care setting.
To be able to practice EBM, physicians need to get acquainted with EBM, Cochrane, and the CL and its use in daily practice, which is why a mandatory, vertically integrated course in research methodology should be introduced into the medical curriculum (24).
Fortunately, Wiley provides free access for middle and low income countries, which includes BH. Also, thanks to the Croatian Cochrane Branch, BH physicians have a free access to summaries translated into Croatian (cochrane.org/ hr/evidence, croatia.cochrane.org/hr), which is one of the official languages in BH and is understood by the speakers of the Bosnian and Serbian language.
We are glad that even this study was an act of promotion of the CL, since we were repeatedly asked by the physicians about the details of the CL usage. Some of the respondents stated that this questionnaire was the first time they heard about the CL. Additionally, following the footsteps of the neighboring Croatia, we started publishing articles on Cochrane in the official journal of BH Academy of Sciences (20).
Knowledge and practice of EBM among physicians in ZDC were not very high, but the attitudes toward EBM were relatively positive. There is a need for specifically designed educational interventions that would encourage physicians to use open access to the CL, as well as experiences and materials from Cochrane Croatia. Improving internet accessibility at work is needed, especially in primary health care setting. Special attention should be paid to pregraduate and postgraduate students of medicine and physicians younger than 42, who tend to use web based resources more frequently. Integrating EBM longitudinally and vertically throughout the academic curriculum would be beneficial for promotion and application of clinical knowledge in daily practice in order to improve community health.