Impact of Research Educational Intervention on Knowledge, Attitudes, Perceptions, and Pharmacy Practices Towards Evidence-based Medicine Among Junior Pharmacists

Background Establishing evidence-based medicine (EBM) is important for pharmaceutical care services to be effective and for adding value to patient care. Increasing examples are illustrating that health professionals hold positive attitudes toward EBM. Nevertheless, their knowledge and skills are relatively insufficient. The objective of this study was to assess the impact of research educational intervention on knowledge, attitudes, perceptions, and pharmacy practices towards evidence-based medicine among junior pharmacists. Methods A one group pre-test/post-test quasi-experimental design was conducted on postgraduate junior pharmacy staff working or training at one of the three randomly selected tertiary care settings in Riyadh, Saudi Arabia. This study consisted of two phases. During the first phase, a structured questionnaire assessing the knowledge, perceptions, and attitudes of the participants regarding EBM, as well as basic biostatistics, epidemiology and the utilization of EBM, was administered. The second phase was scheduled to begin four weeks after the distribution of the educational materials, whereby the same questionnaire was redistributed among the same participants. Results Sixty-seven pharmacists participated in this study. The overall percentage mean score of correct responses of the study participants' knowledge was 37.0% in the pre-test compared to 44.4% in the post-test. The percentage mean score of correct responses for biostatistics and epidemiology and study design sections significantly increased after the study intervention (p < 0.001), (p = 0.02), respectively. Regarding the study participants' attitudes towards EBM, only one item, "Willingness to support the promotion of EBM implementation,” was statistically significantly higher in the post-test (61, 93.8%) participants compared to participants (53, 80.3%) in the pre-test, while "Possessing sufficient skills to implement EBM principles" was the only statistically significant item for the study participants' perceptions towards EBM in the pre-test compared to the post-test, (82.1%, 92.4%), respectively. Moreover, our results showed that 74.6% of the respondents were practicing EBM before the study intervention versus 81.5% after the intervention. Conclusion The results of this study reveal that comprehensive educational intervention might improve the knowledge, attitudes, and perceptions of EBM among pharmacists and encourage them to incorporate this into their everyday clinical practice.


Introduction
Evidence-based medicine (EBM) is "the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions" [1]. The concept of EBM, more broadly, marks a shift among healthcare professionals from a traditional emphasis on actions based on the opinions of authorities to guide clinical practice to an emphasis on databased, clinically relevant studies and research.
The practice of EBM involves four primary steps: formulating a clear question based on a patient problem, identifying relevant studies from the literature, critically appraising the validity and usefulness of the identified studies, and applying the findings in clinical practice [2]. Despite enthusiasm in the educational and research communities for EBM, the attitudes of practicing general internists about EBM have not been systematically investigated. Although EBM encourages the use of primary research studies, evidence-based clinical practice guidelines, and systematic overviews to inform treatment decisions, recent surveys have suggested that most physicians still rely heavily on the opinion of colleagues or consultants when making decisions [3][4][5].
The pharmacy profession has improved to include the provision of cognitive services, in addition to the traditional role of medication dispensing. Establishing EBM is important for pharmaceutical care services to be effective and for adding value to patient care. Pharmacists must accept and actively participate in the research needed to establish the required evidencebased pharmaceutical care. In a survey of pharmacists, the majority held a positive attitude towards evidence-based practices, which reflects the awareness of the pharmacists towards their profession in EBM [2].
Acknowledgment of EBM and the study of design, including understanding methods of evaluating, interpreting, and criticizing primary literature, is indeed not new among junior pharmacists but it is still gaining traction. Many studies have evaluated the perceptions of EBM among health care professionals [6][7]. Others have ascertained the knowledge on adverse effects associated with complementary medicines, as well as evaluating awareness of pharmacovigilance among pharmacists and other healthcare providers.
There are examples illustrating that health professionals hold positive attitudes toward EBM [8][9][10][11]. Nevertheless, their knowledge and skills about the implementation of EBM are relatively insufficient [11][12][13][14]. Moreover, measuring perception, knowledge, and the ability to evaluate, interpret, and criticize literature among junior pharmacists is still lacking [15]. The objective of this study was to assess the impact of educational intervention on the research knowledge, attitudes, perceptions, and practices towards EBM among junior and intern pharmacists.

Study design
A one group pretest-posttest quasi-experimental design was conducted from January 2017 to December 2017 at three tertiary care settings: King Fahad Medical City, King Faisal Specialist Hospital and Research Center and Prince Sultan Cardiac Center, Riyadh-Saudi Arabia.

Study participants
All postgraduate junior pharmacy staff who were working or training at one of the three randomly selected tertiary care settings were eligible to participate in this study. The junior pharmacist represents those pharmacists who have been in practice for no more than one year or are still undergoing on-the-job training during the defined study period.

Recruitment
The study participants were randomly approached and invited to take part in this study by a trained research coordinator over a six-month period to reach the needed sample size.

Intervention and data collection procedure
This study consisted of two phases. During the first phase, a structured questionnaire assessing the knowledge, perceptions, and attitudes of the participants regarding EBM as well as basic biostatistics, epidemiology and the utilization of EBM was administered (pretest). Upon completion, the study results were interpreted. After that, the participants were provided with educational material. The content of the educational material was based on a review of the literature, covering the core element of EBM which is training in research related skills and study design [16,17]. The curriculum covered (i) basic biostatistics and (ii) basic epidemiology and study design. To facilitating learning, the participants were provided with hard copies of educational materials and asked to read the materials daily. Moreover, participants had received reminder twice a week to read the educational materials.
The second phase was scheduled to begin four weeks after the distribution of the educational materials, whereby the same questionnaire was re-distributed among the same participants (posttest). The questionnaire was developed based on the content of the educational materials that were provided to the participants and according to Downing's recommendations for effective test development [18]. The questionnaire encompassed 4 sections. The first section is the knowledge section which included 19 multiple-choice question about basic biostatistics and basic epidemiology and study designs. The biostatistics part incorporated questions related to hypothesis testing and other questions related to descriptive and inferential statistics. Whereas, epidemiology and study designs part included questions to recognizing the appropriate study design and other questions related to basic epidemiology measurements, randomization, bias and confounding factors. To calculate the participants' knowledge score, correct answers were given a score of 1 whereas, incorrect answers or unanswered question were given a score of 0. The total score of the correct answers reflected the participants' knowledge level. The second section included 4 questions to identify the study participants' attitudes towards EBM. The attitudes questions were assessing their interest in learning or improving the skills necessary to incorporate EBM into practice, willingness to support the promotion of EBM implementation, decisions about patient care and need to increase the use of evidence in daily practice. The third section included 9 questions to identify the participants' perceptions towards EBM. A 5-point Likert scale was used for the attitudes' and perceptions' questions (strongly agree, agree, uncertain, disagree, and strongly disagree). The last section was asking participants about practicing EBM. Moreover, demographic characteristics encompassed gender, age and educational background (Pharm-D holders have mandatory clinical training for nine months before graduation while pharmacy degree holders only undergo four months of clinical training). Total years of clinical experience were also collected from the study participants.
The questionnaire was piloted and evaluated for its face validity by a panel of experts including physicians, researchers, and senior pharmacists. Some modifications in the questions were made after discussions with the panel of experts. Moreover, a pilot study was performed on 10 subjects to enhance the clarity of the questionnaire and was revised as per their comments.

Ethical consideration
The study was approved by the institutional review board of King Fahad Medical City. Participants who met the inclusion criteria and agreed to participate were asked to sign a consent form which informs participants about the purpose of the study and ensures that their personal information will be kept confidential.

Sample size calculation
The sample size was calculated by the Raosoft® sample size software calculator (Raosoft, Inc., Seattle, WA) with presumed 50% having knowledge of EBM among the study participants, a 95% confidence interval, and a 5% margin of error. This allowed us to calculate the required sample size of 67 participants.

Statistical analysis
All the contemporaneous research findings for EBM were based on clinical decisions. Thereby, the studied variables were of ordinal or nominal order which was presented in frequencies and percentages. Cronbach's alpha test was applied to assess the internal consistency of EBM, scores, and another scale of measurement. The assessment questionnaire had Cronbach's alpha = 0.96. Ordinal scale data was represented as a binary outcome, and a paired t-test analyzed the respective pooled Relationship Assessment Scores (RAS). All the inferences were drawn at 95% confidence interval (CI). The responses of the Likert scale were joined into combinations of (I) "strongly agree" and "agree" and (II) "uncertain", "disagree", and "strongly disagree". Microsoft Excel® (Microsoft Corp., Redmond, WA) and the Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY), version 22 software, were used for data analysis.

Results
Sociodemographic characteristics of the study participants are presented in Table 1. The majority of participants were female (85.1%) and had less than one year of clinical experience (71.6%). Moreover, each the study participants had no previous formal training in EBM.

Participants' knowledge of the basic biostatistics, epidemiology, and study design
After calculating the knowledge score for every single section before and after the study intervention, our results showed that the overall percentage mean score of correct responses by the study participants was 37.0% in the pre-test compared to 44.4% in the post-test.
The percentage mean score of correct responses for the biostatistics section was 33.9% in the pre-test versus 43.5% in the post-test (p < 0.001). In epidemiology and study design section, the percentage mean score of correct responses significantly increased after the study intervention (p = 0.02) ( Table 2).   All items in the questionnaire were studied to assess the association between the sociodemographic characteristics, research knowledge, attitudes, perceptions, and practices among the participants before and after the study intervention. Only the RAS pre-test EBM percentage mean score was significantly higher among Pharm-D (pharmacy degree) holders 85.5 ± 19.1 compared to 73 ± 29.1 among bachelor pharmacy degree holders (

Discussion
Educational intervention is a common way to spread EBM [19][20][21][22]. In our study, although the overall research knowledge score of the study participants has improved significantly after the study intervention, the percentage mean score of correct responses was low. This might be explained by the fact that research training is not required for pharmacists in Saudi Arabia and most staff continue to practice based on what they learned in school and their practice experiences.
Our results provide important evidence in the plan for spreading the knowledge and implementation of EBM as it encourages self-based learning. Previous studies reported that cooperative tasks enhance our ability to learn more than individual teaching [23][24]. Our results revealed that establishing comprehensive educational intervention can enhance knowledge and EBM practices among the study participants.
Previous studies reported that health professionals have positive attitudes towards EBM [8,12]. A study conducted on pharmacists showed that 90% have positive attitudes towards EBM and 84% thought research findings were an important daily practice; these results reflect the awareness of the pharmacists towards their profession in EBM [2]. Likewise, regarding the participants' attitudes and perceptions, our results showed that the study participants were more willing to support the promotion of EBM implementation and perceived that they possessed sufficient skills to implement EBM principles after the intervention. Leaders can power this attitude by providing chances for practices, which in turn might positively enhance the knowledge towards EBM.
Moreover, our results showed that the research knowledge among participants holding Pharm-D degrees was significantly higher compared to bachelor pharmacy degree holders. This might be explained by the fact that Pharm-D holders have mandatory clinical training for nine months before graduation, while pharmacy degree holders have clinical training for only four months.
The results of this study provide leaders and educators guidance to promote knowledgeable attitudes, perceptions, and practices related to EBM. Attaining baseline information about EBM among the staff permits an organization to develop educational activities and process modifications to fruitfully include EBM into daily practice, as the staff's knowledge, attitudes, perceptions, and practices affect the achievement of any initiatives to implement EBM.
The strengths of this study are that the study was conducted in tertiary care settings and the study participants in pre-testing and post-testing were the same subjects. However, the study had some limitations as it is a self-report survey, not an audit of actual practice and did not include a control group. Furthermore, our study explored the short-term effects of the intervention on the study participants' research knowledge, attitudes, and practices of EBM.
Despite the limitation, this study aims to stimulate more research on this critical issue, especially long-term follow-up and controlled studies of EBM educational intervention on the study participants' knowledge, attitudes, and practices.

Conclusions
In conclusion, the results of this study reveal that comprehensive research educational intervention might improve the knowledge, attitudes, and perceptions of EBM among pharmacists and encourage them to incorporate this into their everyday clinical practice.  A 39-year-old man presents with a mild sore throat, fever, malaise, and headache is treated with penicillin for the presumed streptococcal infection. He returned after a week with hypertension, fever, rash, and abdominal pain. He responded favorably to Chloramphenicol after a diagnosis of Rocky Mountain spotted fever is made. Select the study design that is most appropriately illustrated above.

Case-Control Study
Clinical Trial

Cohort Study
Case Report The inability to link exposure to disease in particular individuals and the inability to control for confounding variables are two limitations of which study design?
Case-Control Studies Controlling for selection bias A case-control study is performed to judge whether a drug is associated with an increased incidence of early miscarriage. The final analysis showed that the odds ratios (OR) for miscarriage with drug exposure is 1.3 (95% confidence interval (CI) = 0.9 -1.7). Which one of the following provides a correct description of the result?
The drug increases the risk of miscarriage by 70%.
The drug increases the risk of miscarriage by 30%.
The drug decreases the risk of miscarriage by 10%.
The drug is not associated with an increased risk of miscarriage Cohort studies are thought to provide better information than case-control studies with regard to the causal association between an exposure and a disease because: Non-differential misclassification bias does not affect cohort studies