Background Evidence-based medicine (EBM) involves the care of patients using the best available evidence from the results of good quality clinical research to guide clinical decision making 1 – 3. By incorporating the principles of Evidence-based Medicine (EBM), the family practitioner would be able to treat a patient according to the best clinical research available. This principle is implemented widely in the USA, Canada, the United Kingdom and Europe. In South Africa, however, EBM is not yet as widely incorporated into family practice. This is so despite the plethora of websites available to practitioners and the relative ease with which applicable research evidence can be found. Very few published studies are available regarding EBM or Evidence–based Practice (EBP) in the South African context. The findings of this study would thus highlight reasons and/ or barriers preventing family practitioners from implementing EBM in their respective practices. This could also lead to further research into possible methods of implementation of EBM into South African family practices. Aim: The aim of the study was to describe the perceptions, knowledge and attitudes of private practitioners regarding evidence based practice and to identify the barriers encountered in evidence based practice. Methods A questionnaire survey of general practitioners in Gauteng, South Africa, was conducted. Questionnaires were distributed to a random sample of practitioners in the Gauteng region. Two hundred and twenty one (221) practitioners participated in the survey and responded to questionnaires mailed to them. The questionnaire was mailed, faxed or e-mailed to the practitioners, which they then completed and returned for statistical analysis. Study design The study design is that of quantitative, statistical analysis (descriptive cross-sectional survey). Setting General practitioners were randomly selected from a list of practitioners in the Gauteng Province. Doing a nationwide survey would have been a mammoth undertaking. It was therefore decided to limit the research to one province and therefore it was only concentrated on practitioners practicing in the Gauteng area. Results It is interesting to note that of the two hundred and twenty one participants in this study; only 10% of the practitioners were against using EBM in their practices. This, however, stands in stark contrast to the 56% of practitioners who do not implement EBM in their practices or make use of the EBM principle at all. The major barriers preventing practitioners from implementing EBM is depicted in the following graph: Lack of time and the training in aspects of Evidence-based medicine were the main barriers preventing the full scale implementation of EBM in family practices in Gauteng. Conclusion Participating Gauteng doctors were in principle, very positive towards the implementation of EBM in their respective practices. Most of the participants agreed that EBM would benefit their patients’ care and treatment. Very few of the participants, however, make use of EBM in practice. A lack of training and time constraints were the main barriers with regards to the implementation of EBM. Proper training of medical students at undergraduate level at faculties of health sciences, would go a long way assisting prospective doctors in mastering the concept of EBM and increasing their overall awareness of EBM. Further definitive research would assist in establishing whether such awareness would be associated with improved implementation of evidence in the form of evidence based guidelines in practice.

Medical guidelines on the same medical condition differ between England and the Netherlands. These guidelines are referred to as evidence-based because they are supposedly based on a systematic searching for and appraisal of medical studies to drive recommendations for appropriate care for specific clinical circumstances. This comparative study interrogates what causes these differences and similarities between guidelines and tries to uncover the mechanisms behind the development of medical practice guidelines. Four case studies, on lower back pain and on type 2 diabetes in both countries, are used to provide a detailed empirical account of the development of medical guidelines. Interviews with guideline developers are combined with a detailed analysis of available guideline documents. The overarching finding of this thesis is that medical evidence plays a more limited and nuanced role in guideline construction than might be expected and that guidelines are manifestations of professional (self-) regulation. Importantly, the research also finds that institutions shape guidelines in a multitude of ways. This study has endeavoured to add to a more nuanced understanding of evidence within the literature: conceptualising evidence as part of a process of a social and institutional construction. This construction is used within a collaborative and communicative process aimed at creating 'objective facts'. Contrary to existing scholarship, this thesis argues that evidence merely informs the understanding of members of guideline groups while a range of economic, cultural, institutional, and political factors, that together form cognitive frames, provide the driving force behind the development of guidelines. Institutional factors have shown to be essential elements in guideline development, influencing all aspects of development through institutional cultures of practice. This study concludes that calling guidelines evidence-based is an important rhetorical instrument, which helps to conceal and legitimize some of the normative choices that are inherent in guideline making.

Studien syftade till att belysa arbetet med missbruksvården i Bosnien-Hercegovina. Det som har studerats är hur de yrkesverksamma ser på forskning, egen erfarenhet samt klientens erfarenheter och önskemål i valet av behandling. Den metodologiska utgångspunkten var en hermeneutisk kvalitativ ansats, där semistrukturerade intervjuer har genomförts och sedan studerats. Dessa intervjuer utfördes på ett behandlingshem i Bosnien-Hercegovinas huvudstad Sarajevo och antalet intervjupersoner var fem personer. Resultatet visade hur de arbetar på behandlingshem i Bosnien-Hercegovina. Resultatet visade även att Bosnien-Hercegovina använder sig utav evidensbaserad praktik. Vikten ligger i att få en trygg och verksam vård. Evidensbaserad praktik används utifrån tre olika källor, dessa är klientens erfarenhet, behov och önskemål, den professionellas erfarenhet och förmåga samt vetenskaplig kunskap. BosnienHercegovina tillämpar dessa tre olika källor i sitt behandlingsarbete.

Background: This research was designed to understand factors influencing Motor Vehicle Crashes (MVCs) on or near the Hualapai Tribe’s reservation in northwestern Arizona. The goal is to enable the Tribe to develop and implement a locally relevant MVC intervention program. The specific aims were to: i) compile and analyze 2010-2016 MVC data from Hualapai and federal sources to assess distributions of frequency, rates, high risk-locales, causes, days, times, age and sex of the drivers, in addition to assessing related conditions; ii) document local perceptions of environmental, social, and behavioral barriers to safe driving practices, and knowledge of MVC risk factors and existing tribal laws; and iii) provide evidence-based recommendations using the results from quantitative and qualitative data analyses. Approach/Methods: The research process applied a Community-Based Participatory Research approach and mixed methods using: a) secondary data analyses of records from six tribal programs and Indian Health Service (IHS), and b) qualitative analyses of data from two focus groups and field documents. Sensitivity analyses were conducted of IHS and Tribal Driving Under the Influence (DUI) data, using the 2010 U.S. Census as the denominator after adjusting for an undercount of up to 25%. Descriptive statistics, Fisher’s Exact Test, and linear and logistic regressions were used to examine significance. MVCs per 10 miles per year were estimated for State Route 66 and Diamond Bar Road/Grand Canyon West on or near the reservation due to higher numbers of crashes. Statistical process control charts, especially g-charts monitoring time between events, were plotted to examine the stability in the number of MVCs over time for each road. NVivo11Pro© was used to code and analyze the focus group data, guided by both inductive and deductive theories. Results: Driver’s seatbelt use in the Hualapai community increased from 2010 to 2012 (p < .0005), and reported DUIs decreased from 2010 to 2016 (p = .027). Similarly, car/booster seat use improved from 2014 to 2015 (p < .0005). Two hundred and fifty (N = 250) MVC-related injuries were registered at IHS facilities for Hualapai community members between 2006 and 2015. The highest rate, 22.4%, was observed in 15- to 24-year-olds, followed by 21.6% in 55- to 64-year-olds. For several combinations of numerators and denominators, sensitivity analysis of the IHS data shows a clear disparity between the Tribe’s MVC rate compared to the 2008 U.S. rate of 771.4 nonfatal injuries per 100,000 persons and the national goal for Healthy People 2020 (694.3 nonfatal injuries/100,000 persons). The major themes emerged from qualitative analyses of the focus groups were: i) unsafe traffic infrastructures, ii) DUI, iii) repeated DUI offenders driving on the reservation, and iv) a perception of lenient tribal traffic laws and enforcement on the reservation. Using study results, five Public Service Announcements were co-developed to inspire community-members to continue the trends noted from 2010-2016 and be aware of continued risks. Conclusions: MVCs are a multidimensional issue needing communitywide awareness of the range of risk factors. An intervention that addresses human and structural risks requires an alliance of tribal programs and external partners (e.g., IHS, university, federal, and state). Recommendations: Local recommendations include providing school- and institution-based education about alcohol/alcoholism and DUI consequences, and ongoing culturally and locally relevant communitywide education through the local newsletter and radio station.

Cultural factors affecting the development of an evidence-based information service in a third sector provider of complementary cancer care Matthew Breckons Introduction Many people with cancer access complementary and alternative medicine (CAM) and a need for high quality information was emphasised in reports by the House of Lords and the National Institute for Health and Clinical Excellence. Organisational culture, incorporating people’s underlying assumptions, values and actions, has been highlighted as an important factor when attempting to introduce evidence-based practices. Opinion is divided over the relevance of evidence to CAM practice, although the influence that this has on the cultural context of a CAM organisation is not understood. Aims To identify cultural factors affecting the introduction of an evidence-based information service in a third-sector CAM organisation and, in light of factors identified, to suggest feasible innovations to achieve a more evidenced-based approach. Methods Access to the charity was gained through a Knowledge Transfer Partnership. Soft Systems Methodology, a form of action research, was used to carry out four ‘learning cycles’ in which data was collected and fed back to staff at the organisation to prompt discussion on what could be improved. Learning cycles focused on improving the quality of web-based and printed information and gaining an understanding of how the information service could be improved from staff and service-user perspectives. Results Results suggested that a lack of time and emphasis on marketing values led to difficulties feeding back results and making changes that were perceived to reduce demand for the charity’s services. A lack of management support and a reluctance to implement rules made introducing any form of information policy problematic. Additionally, structural factors such as a large team of part-time staff and a lack of financial resources led to communication difficulties as well as limiting the opportunity for staff development. Conclusions This is the first study to document systematic attempts to make evidence-based changes in a third sector CAM organisation. As such, this study has generated results demonstrating how cultural and structural constraints in this type of organisation may influence attempts to make evidence-based changes. Introduction of an initiative such as the Information Accreditation Scheme (IAS) may provide benefits to an organisation of this type by guiding the development of information production systems at the same time as raising the profile of the organisation. The findings of this study strongly suggest that, despite demands from policy makers for the provision of evidence-based CAM information, there may be systematic difficulties experienced by organisations responsible for the production of this information. Further research is needed to understand how producers of CAM information can be supported in providing high quality, evidence-based materials.

As one of the most recommended strategies in decision making of contemporary medicine, evidence-based medicine (EBM) is attracting more and more attention. For EBM, the scientific evidences are obtained mainly from the randomized controlled trials (RCTs), systematic review and meta-analysis. In particular, meta-analysis can help researchers statistically combine several independent studies for a same clinical problem. In meta-analysis, Cohen's d and Hedges' g are among the most commonly used effect size measurements for continuous data. To compute these mean difference criteria, the sample mean and standard deviation are two conventional statistics reported in the literature. However, some other clinical studies may instead report the median, minimum and maximum values, and/or sample quartiles. Such a situation requires researchers to estimate the sample mean and standard deviation from these reported summary statistics. We note, however, that most existing estimators in the literature have some serious limitations. For this, we propose to improve the existing methods and extend them to three frequently encountered scenarios. In this thesis, we developed the optimal sample mean estimators, the normality test statistics and the updated Cohen's d mean difference criterion for three commonly encountered scenarios in meta-analysis. In Chapter 1, we gave a brief introduction on evidence-based medicine, meta-analysis and the summary data. In Chapter 2, we introduced our optimal estimators of the sample mean under the three scenarios, respectively. In Chapter 3, we proposed several methods for testing the normality of the underlying data. And in Chapter 4, we proposed to improve the famous Cohen's d and its relevant parameters. To assess the practical performance of our newly proposed methods, we also chose a few real data at the end of each chapter as illustrating examples. Numerical results of those studies indicated that our proposed methods have satisfactory performance both in theory and in practice. Following our new methodology, we also recommended an improved procedure for medical researchers to conduct meta-analysis. For illustration, we chose a meta-analysis in Chapter 5 on the effect of phytosterols to plasma CRP level (Rocha et al., 2016) to compare the results obtained from our recommended procedure and from the original methods. The results showed that our recommended procedure may lead to distinctly different results for a same clinical problem. To conclude the thesis, we expect that our newly proposed methods can be regarded as "rules of thumb" and will soon be widely applied in meta-analysis and evidence-based medicine.

Class of 2015 Abstract / Objectives: The study aimed to increase EPS risk factor assessment when prescribers order prophylactic anticholinergics with antipsychotics. An evidence-based pharmacist checklist card was developed to aid in this decision making process. Methods: A retrospective chart review of patients admitted to the acute inpatient psychiatry units at an academic medical center was conducted to determine baseline prophylactic anticholinergic prescribing habits over a two-month period. Charts were included if the patient was at least 18 years old and ordered at least one scheduled antipsychotic during the admission. An educational intervention session introduced the pharmacist checklist card and shared baseline findings. Post-intervention data was collected during a two-month period following the intervention. The percentage of prophylactic anticholinergic orders based upon pharmacist checklist card parameters pre and post-intervention was analyzed using chi-square test. Results: There was a significant decrease in the total percentage of orders for prophylactic anticholinergics from 72.7% in the pre-intervention period to 50.8% in the post-intervention period (p<0.001). Significant changes in the percentage of orders for prophylactic anticholinergics were also found for patients at no-to-low risk for EPS (56.4% versus 31.8%, p=0.014) and at low-to-moderate risk for EPS (79.6% versus 50.8%, p=0.003). There were no significant changes observed in the percentage of orders for prophylactic anticholinergics for patients at moderate-to-high risk for EPS. A lower percentage of patients prescribed a prophylactic anticholinergic experienced adverse effects in the post versus the pre-intervention period (52.31% versus 75.27%, p=0.003). Conclusions: Significant differences were found between pre and post-intervention anticholinergic medication prescribing habits. This suggests that increased patient risk factor assessment in the form of a pharmacist checklist card is effective in decreasing orders for prophylactic anticholinergic medications not clinically indicated and reducing the incidence of adverse effects.

Magister Scientiae Dentium - MSc(Dent) / This was a cross-sectional study done in Lagos, Nigeria on 114 dentists. The aim of the study was to describe the knowledge and attitudes of dentists towards the concept of evidence-based dentistry (EBD). This study also attempted to create an awareness of this concept in the minds of previously uninformed dentists as well as demonstrate its need in continuous professional education via seminars, updates, lectures and short-term courses in Lagos, Nigeria. / South Africa

Evidence based practice (EBP) is a worldwide phenomena defined as the “conscientious explicit and judicious use of current best evidence in making decisions about the patient’s care”. The evidence based practice concept’s aim is to effectively guide health care professionals to build knowledge that will be supported by evidence. Evidence based practice must be supported by evidence based teaching. Nurse educators must be up to date with evidence based teaching as well as the latest evidence based teaching strategies, in order to teach the new millennial nursing students and for the new qualifications structure. Teaching the concept of evidence based practice by implementing evidence based teaching to nursing students will enable them to transform the future of healthcare by delivering high quality care practice. A paucity of evidence is available on evidence based teaching and teaching strategies in the South African context. Therefore the researcher used a systematic review methodology to explore and describe the best available evidence based teaching strategies and to develop a guideline on evidence based teaching strategies for nurse educators. The data bases searched included: MEDLINE, CINAHL, PubMed and Google Scholar. Manual searches were done and completed with the assistance of librarians. A total number of n=50 studies were identified as potentially relevant to the study. The number or articles included for critical appraisal were 20. On completion of the critical appraisal n=17 articles were identified for the review. The included studies for the review were n=7 Level 1, systematic reviews and n=10 Level 2, quasi-experimental studies. Three studies were excluded after critical appraisal from two reviewers, appraisal was done independently, and consensuses were reached between the two reviewers. The Joanna Briggs Institutes critical appraisal and data extraction instruments were used for the study. The descriptive data synthesis was done of the included studies as well as a comparison of teaching strategies to determine which one to better than the other one. Although n = 4 of the teaching strategies (concept mapping, internet-based learning, evidence based interactive strategy and cultural competence) significantly increased knowledge, the overall results found that a variety of teaching strategies to be implemented to increase the knowledge outcomes of the nursing students. The different teaching strategies found were: e-learning, concept mapping, internet-based learning, web-based learning, gaming, problem-based learning, and case studies, evidence based learning and cultural competence. However, more research is needed to investigate the best use of the different teaching strategies and compare the impact of a variety of teaching strategies on increasing knowledge of the nursing student.

Over the last three decades there has been a greater need for health care practitioners to base their decision on the best available in order to optimise quality and cost-effective patient care. Evidence-based practice necessitates guideline development, education and review in order to achieve improved patient outcomes. However, initiatives that endeavour to disseminate and implement evidence-based practice have faced barriers and opposition. Barriers that might hamper the implementation of evidence-based practice include characteristics of the evidence itself, personal, institutional or organizational factors. The research study explored and described the barriers to implementation of evidence-based practices in a critical care unit. Based on the data analysis, recommendations were made to enhance the implementation of evidence-based practices in the critical care unit. A quantitative, explorative, descriptive and contextual research design was used to operationalize the research objectives. The target population comprised professional nurses in the critical care unit. Non-probability sampling was used to obtain data by means of a structured self-administered questionnaire. Descriptive data analysis was applied, using a statistical programme and the aid of a statistician. The results are graphically displayed using bar graphs and tables. Recommendations for nursing practice, education and research were made. Ethical principles have been maintained throughout the study.