Original Article

J Nepal Health Res Counc 2019 Apr-Jun;17(43): 215-21

DOI https://doi.org/10.33314/jnhrc.v0i0.1711

Knowledge, Attitude and Barrier to Evidence-

based practice among Physiotherapists in selected
districts of Nepal
Shristi Bajracharya,1,2 Niraj Singh Tharu,1,2 Doly Bokalial1,3

Rehabilitation Science Department, Dhaka University Bangladesh, 2Physiotherapy Unit, Rajiv Gandhi
1

University of Health Sciences, India, 3Physiotherapy Unit, SNDT Women’s University, Maharastra, India.

ABSTRACT

Background: Evidence-based practice is considered as one of the most accepted practice all over the world.
Physiotherapists in Nepal have started evidence-based practice, but there has been no study regarding evidence-based
practice in physiotherapy in Nepal.
Methods: A cross-sectional study was carried out among 164 physiotherapists working in different clinics and
physiotherapy centers of selected districts of Nepal. A self-reported questionnaire was distributed and collected later.
Results: It was found that the physiotherapists had a positive attitude towards evidence-based practice with 95.2%
agreeing or strongly agreeing that evidence-based practice is necessary forthe practice of physical therapy and an overall
total mean score of 34.73(72.35%) out of 48 and an overall mean 2.8 out of 4. It was also found that physiotherapists
had moderate knowledge towards evidence-based practice with an overall total mean score of 19.18(68.5%) out of
28 and an overall mean of 2.74 out of 4. It was found that those having a specialization degree had two times greater
knowledge than without specialization. The major barriers to evidence-based practice were obtained insufficient time
and traditional methods of treatment.
Conclusions: Physical therapists of Nepal stated they had a positive attitude towards evidence-based practice with
the majority of the physiotherapists interested in learning more about the topic. They believed that they needed to
increase the use of evidence in practice. They thought major barrier as insufficient time hence continuous professional
development training that incorporate evidence-based practice were of greater importance.
Keywords: Attitude; barrier; evidence-based practice; knowledge.

INTRODUCTION METHODS

Evidence-based Practice (EBP) is defined as a good A cross-sectional study was conducted from December
judgment done according to one’s inner sense with no 2017 to May 2018. The districts included were Kathmandu,
confusion utilizing the best evidence for patient care.1 Bhaktapur, Lalitpur, Kavre, Gorkha, Jumla, Jiri, Kaski,
According to the Nepal Health Professional Council Rasuwa, Sarlahi, and Chitwan. Kathmandu, the capital
(NHPC) document, Evidence-based practice started city has the maximum concentration of physiotherapists
from 1990 in physiotherapy and 2010 in Nepal. There working in different clinics and rehabilitation centers of
is no research regarding the application of EBP among Nepal.
physiotherapists in Nepal. Evidence-based practice is
one of the most important aspects of any profession. It According to the data of Nepal Health Professional
is much preferred all over the world. Hence, to develop Council, there are about 1166 permanently registered
the base of EBP, it is important to know about the physiotherapists in Nepal. Among them, 111 are in
knowledge and attitude regarding EBP and also the major specialization level, 889 in level one, 104 in level two and
barriers regarding the practice of EBP. 2 EBP involves the 62 in level three. As the preference was physiotherapists
integration of the best available research evidence with who had completed a Bachelor’s degree. Hence the
clinical expertise and patient values and circumstances sample size was taken including only the physiotherapists
to make the best decision regarding patient care.3 of specialization and level one. Using the prevalence of

Correspondence: Shristi Bajracharya, Rehabilitation Science Department,

Dhaka University, Bangladesh Email: [email protected], Phone:
+9779849466561.

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 Knowledge, Attitude and Barrier to Evidence-based practice among Physiotherapists

50% and a precision of 7% the sample size was calculated Table 1. Characteristics of respondents (n=164).
164.
Characteristics Frequency Percentage
The survey tool was the adaptation from self-reported Gender of Male 78 47.6
questionnaire adapted by Jette et.al in 2003 which was
Physiotherapists Female 86 52.4
originally used to study attitudes of physician and general
practitioner towards evidence-based medicine and the 20-30 129 78.7
structured questionnaire used by Yahui & Swami Nathan Age of 31-40 27 16.5
in 2017 regarding Knowledge, attitude, and barriers
Physiotherapists 41-50 3 1.8
to evidence-based practice among physiotherapists in
Malaysia. >50 5 3
<2 65 39.6
Number of years
The final structured questionnaire was prepared that 2-5 55 33.5
consisted of 2 sections. First, the demographic part and working as a
the second section that consisted of questions regarding 6-10 30 18.3
Physiotherapist
knowledge, attitude and, barriers to evidence-based >10 14 8.5
practice. Responses to most of the items concerning <20 6 3.7
attitudes and beliefs and knowledge and skills related Number of hours 20-30 11 6.7
to evidence-based Practice were addressed using 5 point
worked per week 31-40 36 22
Linkert Scale with “strongly disagree” and “strongly
agree” as the anchors >40 111 67
<5 14 8.5
Number of
The questionnaires were distributed to the respective 5-10 67 40.9
hospitals and rehabilitation centers in Kathmandu and patients seen in
11-15 44 26.8
outside Kathmandu, a representative from NEPTA- a day
>15 39 23.8
Nepal (Nepal Physiotherapy Association) distributed
the questionnaire. Two week time was given to fill No of <5 65 39.6
up the form following which they were collected and Physiotherapist 5-10 64 39
checked for completion and entered in Excel sheet. 11-15 22 13.4
working in area
The respective representative from outside Kathmandu
collected the questionnaire and scanned them back to of practice >15 13 7.9
the researcher, and some sent it back with people coming
to Kathmandu. They too were entered in Excel and were An attitude of physiotherapists regarding evidence-
imported in SPSS to analyze using SPSS version 16 for based practice was measured by respondents’ indicating
Microsoft Windows. Data were analyzed considering 95% their level of agreement to statements in 5 point
confidence interval and 5% level of significance. Ethical Linkert scale.(0=strongly disagree;4=strongly agree).
approval was taken from the Nepal Health Research Responses are summarized in table 2. Positive attitudes
Council. (Reg no: 517/2017)Consent forms were filled by were reflected by the overall mean score of 2.89 with
all the physiotherapists participating in the study. the majority of the respondents agreeing or strongly
agreeing to positive questions and the majority of the
RESULTS respondents disagreeing or strongly disagreeing to
negative questions. The average score was obtained
The study was carried out among 164 physiotherapists 34.73 out of 48 with a percentage of 73.25%. Respondents
working in various districts of Nepal. Table 1 show that showed they generally had a positive attitude towards
almost half a percentage of both male (47.6%) and evidence-based practice with majority of them sticking
female(52.4%) have been included in the study. Maximum to agree or strongly agree in the statements, application
percentage that is around 78.7% are around 20-30 years of EBP is necessary for the practice of physical therapy
of age. Maximum of 40.9% see around 5-10 patients in a (95.7%), literature and research are useful in day to day
day.39.6% patients see around less than 5 patients in a practice (93.9%), EBP improves quality of patient care
day. Maximum number of physiotherapist around 54.3% (92.7%), EBP helps to make decision about patient care
are appointed in acute care hospitals. Majority of the (89.6%).
patient treated that is 47.5% are orthopedic cases.

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 Knowledge, Attitude and Barrier to Evidence-based practice among Physiotherapists

Table 2. Measure of attitude and belief towards EBP.

Strongly Strongly
Statement Disagree Neutral Agree Mean (SD)
disagree agree
(N/%) (N/%) (N/%) (N/%) (N/%)
Application of EBP is necessary in the
5 (3) 1 (0.6) 1 (0.6) 61 (37.2) 96 (58.5) 3.48 0.81
practice of Physical Therapy
Literature and research are useful in day
4 (2.4) 1 (0.6) 5 (3) 82 (50) 72 (43.9) 3.32 0.7
to day practice
EBP places unreasonable demand on
12 (7.3) 29 (17.7) 40 (24.4) 59 (36) 24 (14.6) 2.33 1.14
Physical Therapists
I am interested in learning or
improving the skills necessary to 4 (2.4) 1 (0.6) 11 (6.7) 100 (61) 48 (21.3) 3.14 0.76
Incorporate EBP in my practice.
EBP improves quality of patient care 6 (3.7) 0(0) 6 (3.7) 88 (53.7) 64 (39) 3.24 0.83
EBP helps me make decision about
2 (1.2) 2 (1.2) 13 (7.9) 96 (58.5) 51 (31.1) 3.17 0.72
patient care
EBP does not take into account patient
4 (2.4) 32 (19.5) 60 (36.6) 58 (35.4) 10 (6.1) 2.23 0.91
preferences
I need to increase use of Evidence in my
3 (1.8) 2 (1.2) 14 (8.5) 110 (67.1) 35 (21.3) 3.05 0.71
daily practice
Literature and research findings help
1 (0.6) 1 (0.6) 6 (3.7) 91 (55.5) 65 (39.6) 3.33 0.63
improve patient care.
I am interested in attending courses
1 (0.6) 1 (0.6) 11 (6.7) 91 (55.5) 60 (36.6) 3.27 0.66
related to EBP.
Mean(SD) 2.89 0.56

Table 3. Measure of skills and knowledge required for Evidence Based Practice.
Strongly Strongly
Statement Disagree Neutral Agree Mean (SD)
disagree agree
(N/%) (N/%) (N/%) (N/%) (N/%)
I am able toconductsearch to answer
1 (0.6) 2 (1.2) 27 (16.5) 107 (65.2) 26 (15.9) 2.95 0.65
my clinical questions confidently
I am confident in my ability to critically
3 (1.8) 8 (4.9) 41 (25) 98 (59.8) 14 (8.5) 2.68 0.73
review professional literature
I use practice guidelines in my Practice 1 (0.6) 5 (3) 62 (37.8) 85 (51.8) 11 (6.7) 2.61 0.68
I am able to incorporate patient
1 (0.6) 7 (4.3) 58 (35.4) 90 (54.9) 8 (4.9) 2.59 0.68
preferences with practice guidelines
I learnt foundations for EBP in My
3 (1.8) 13 (7.9) 20 (12.2) 80 (48.8) 48 (29.3) 2.96 0.94
academic years
I received formal training in search
Strategies for finding research relevant 4 (2.4) 44 (26.8) 33 (20.1) 66 (40.2) 17 (10.4) 2.29 1.05
to my practice
I am familiarwith the medical
Search engines e.g PEDro, PubMed 4 (2.4) 8 (4.9) 14 (8.5) 79 (48.2) 59 (36) 3.1 0.92
Mean (SD) 2.74 0.27

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 Knowledge, Attitude and Barrier to Evidence-based practice among Physiotherapists

The measure of knowledge and skills for EBP were carried and skill that is physiotherapists ability to search to
out by asking respondents to answer the questions in a answer clinical questions confidently and Gender was
Linkert Scale of 0 to 4. In table 3, the mean score of 2.74 found statistically significant. It was found that male
indicated moderate skills among the physiotherapists respondents thought they were able to search to answer
to acquire evidence-based practice. The standard clinical questions confidently two times more than
deviation was obtained 0.27 which is lesser than the female.
mean score indicating the significance. The average
score of the total was obtained 19.18 out of 28 with a Figure 1 depicts the picture of barriers towards evidence-
mean percentage of 68.5. based practice. The maximum number of participants
that is 67.06% indicated that insufficient time was one of
In the question mentioning the learning of evidence- the top three barriers to evidence-based practice.62.8%
based practice during the academic years 78% agreed of the respondents stated lack of research skills to be
that they did learn EBP in their academic years.48.8% among the top three barriers to evidence-based Practice
agreed and 29.3% strongly agreed that they learned followed by inability to apply research findings in patient
evidence-based practice during their academic population where 61.6% of the respondents marked it as
years.68.3% agreed or strongly agreed that they are the top 3 barriers to evidence-based practice. Limited
confident in the ability to critically review professional access to search engines was considered to be the top
literature. 81.1% responded that they agreed or strongly 3 barriers to evidence-based practice by around 53.04%
agreed that they can search to answer clinical questions of the respondents. Around 34.1% of the respondents
confidently. ranked lack of support from colleagues as the top three
barriers to evidence-based practice. Lack of interest
Binary logistic regression analysis was carried out between has been stated as the top 3 barriers to evidence-based
the variable of attitude and the factors associated with Practice by only 23.8% of the respondents which is
the respondents. In table 4, physiotherapists having the minimum percentage among the 6 options. In the
specialization level thought it was necessary to increase open-ended question with additional barriers patient’s
the use of evidence in daily practice five times more belief towards a traditional method of treatment was
than those having no specialization (p =.035, 95% CI: considered another major barrier for evidence-based
1.12-22.69). Physiotherapists who worked in an acute practice.
care hospital felt literature and research findings help
improve patient ninth times than those of others. (p= Figure 2 shows that physiotherapists had a good
.04, 95% CI: 1.088-75.39) understanding of the research terms meta-analysis,
systematic review, absolute risk, and relative risk.
Also, Table 4 shows the results of binary logistic The research terms that the physiotherapists had less
regression between knowledge and skills and the factors understanding were heterogeneity, confidence interval
associated with the respondents. Variable of knowledge and odds ratio.

Table 4. Binary logistic regression analysis for attitude/knowledge and factors associated with the respondent.
Attitude or Belief Factor Level n Odds ratio(95% CI) P N
Ineedto increase use of Specialization 56 5.044 (1.12-22.69) .035 164
Specialization
Evidence in my daily
Level No specialization 108 Reference
Practice
Literature and Facility at which Acute care
89 9.05 (1.088-75.39) .042 164
research findings help Physiotherapists hospital
improvepatient care work Others 75 Reference
Knowledge Factor Level n Odds ratio (95% CI) P N
I am able to conduct Female 86 Reference .04 163
searchto answer myclinical Gender
questions confidently Male 77 2.44 (1.042-5.721)

I am confident in my Specialization 56 2.5 (1.1-5.3) .01 163

ability to critically review Specialization Level
professional literature No specialization 108 Reference

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 Knowledge, Attitude and Barrier to Evidence-based practice among Physiotherapists

Figure1. Barriers towards Evidence Based Practice.

80
70
60
50
40 Do not understand
30 Understand some what
20
10
Understaand completely
0

Figure 2.Self-reported Knowledge of research terms.

DISCUSSION physiotherapists worked less than 20 hours per week and

62% of the physiotherapists worked more than 40 hours
In the demographic section, total male respondents per week compared to the study,8 where 32.4% worked
were 47.6% and the female respondents were 52.4%. more than 40 hours per week. But, a study,4 had similar
This percentage varied from the two other studies, results where 59.2% worked more than 40 hours per
4, 5
wherethe total male respondents were 32.8% and week.This shows the increased load of the patients to
female respondents were 67.2% and where the total be seen by the physiotherapists in Nepal.
male percentage was 25.5% and the female percentage
was 73.5%. The results obtained suggested that physiotherapists
had a generally positive attitude towards evidence-
Maximum percentage of respondents were in the age Based Practice. Majority of the physical therapists
group 21-30 years and similar was found in the study, had thought the application of EBP was necessary for
5
where the maximum number that is 85.3% of the the practice of physical therapy and literature and
respondents lay in the age group 25 to 34. However, research was useful in day to day practice. Also, they
another study,6 found the maximum number of believed evidence-based practice improved the quality
Physiotherapists between 30 to 39 years of age that is of patient care. A similar survey in Nigeria, 6 reported
58%. that a maximum of 99% agreed or strongly agreed EBP
is necessary. Literature is useful to practice (98%), EBP
A study,7 showed that number of physiotherapists improves quality of patient care (98%), and they need
working less than 20 hours per week was 10.7% and to increase the use of evidence in their daily practice.
another study,4 showed the number of physiotherapists (99%), and evidence helps in decision-making (88%).
who worked less than 20 hours per week was 7.2%.
The researcher’s study showed that only 3.7% of the

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 Knowledge, Attitude and Barrier to Evidence-based practice among Physiotherapists

In a study among nurses,8 regarding the attitude towards CONCLUSIONS

evidence-based practice the mean score of 3.6 was
considered as positive attitudes towards evidence-based Physical therapists of Nepal had a positive attitude
where the score was from 1 to 5. In the researcher’s and moderate knowledge towards evidence-based
study, the mean score of 2.89 was obtained for a score practice. There was a significant association between
from 0 to 4 which indicated apositive attitude in our study the variable of attitude and specialization level and
as well.8 The mean score of 2.74 was obtained for score facility at which the physiotherapists worked and with
measuring from (0 to 4) as compared to the knowledge specialization level, age and number of years working
and skill scores of nurses that was 4.1 measuring from (1 as a physiotherapists and knowledge and skill variables.
to 6). The knowledge regarding physiotherapists could The major barrier to evidence-based practice measured
be considered moderate with a mean percentage of was insufficient time. As the major barrier had been
68.5%. considered time, continuous professional development
workshops and training could be beneficial to the
Another study,4 discussed those having bachelor’s degree physiotherapists
as their highest certificate, were less likely to have the
skills or training required for evidence-based practice ACKNOWLEDGEMENTS
compared to those with a master’s degree. Similarly,
in our study, those having a specialization degree were We would like to thank Centre for Rehabilitation of
more confident in their ability to critically review Paralyzed, Bangladesh for supervising us throughout the
professional literature. study. We also would like to thank all the physiotherapists
who gave their precious time in filling up the form
Also, the understanding of certain research terms without any hesitation. Finally, we would like to thank
was associated with the highest degree obtained. As representative physiotherapists outside Kathmandu who
obtained in the study, 4 respondents with baccalaureate helped in distribution of the forms as well as collecting
degrees had less knowledge of the research terms and returning them back.
compared to those having masters’ degree. Similar
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