Alvarez et al. BMC Health Services Research (2021) 21:130 https://doi.org/10.1186/s12913-021-06128-6 RESEARCH ARTICLE Open Access A national cross-sectional survey of the attitudes, skills and use of evidence-based practice amongst Spanish osteopaths Gerard Alvarez1,2*, Cristian Justribo1,3, Tobias Sundberg4,5, Oliver P. Thomson6,7 and Matthew J. Leach4,8 Abstract Background: Although evidence-based practice (EBP) is largely supported across healthcare professions, its implementation in manual therapy professions such as osteopathy remains limited and debated. There is currently little knowledge of how Spanish osteopaths relate to EBP. Objectives: The main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. A secondary aim was to identify barriers and facilitators for the adoption of EBP in the Spanish osteopathic context. Methods: National cross-sectional survey of Spanish osteopaths registered and non-registered to an osteopathic association in Spain. Eligible participants were invited by a range of recruitment strategies including email and social media campaigns to complete the Spanish-translated Evidence-Based practice Attitude and utilization Survey (EBASE) anonymously online. Results: A total of 567 osteopaths completed the survey which represents an approximate response rate of 9%. Participant’s attitudes toward EBP were largely positive. Most respondents agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and that professional literature and research findings were useful to their day-to-day practice (88.9%). Levels of perceived skill in EBP were reported as low to moderate with lowest levels for items related to ‘research conduct’. Except reading/reviewing professional literature and using online search engines to find practice-related literature, participant engagement in all other EBP-related activities was generally infrequent. The perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small. Main barriers to EBP uptake included a lack of clinical evidence in osteopathy and insufficient skills for applying research findings. Main facilitators of EBP uptake included access to full-text articles, internet at the workplace and online databases. Conclusions: Spanish osteopaths were largely supportive of evidence-based practice, had low to moderate skills in EBP and engaged in EBP activities infrequently. Formal regulation of the profession in Spain and the inclusion of osteopathic programs into the university sector would potentially improve EBP skills and use. Keywords: Evidence-based practice, Osteopathic medicine, Cross-sectional studies, Health care surveys * Correspondence: gerardalv@gmail.com 1 Spain National Centre, Foundation COME Collaboration, Barcelona, Spain 2 Iberoamerican Cochrane Centre–Biomedical Research Institute Sant Pau, IIB Sant Pau, Barcelona, Spain Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Alvarez et al. BMC Health Services Research (2021) 21:130 Page 2 of 13 Background operate across Spain. At the same time, there is consid- Evidence-Based Practice (EBP) has been defined as the inte- erable heterogeneity across training programs [31, 32]. gration of knowledge provided by the best available evi- Notwithstanding, the European Committee for dence, with a practitioner’s clinical experience and Standardization (CEN) published in 2015 the Standards judgement, and combined with an individual patient’s of Osteopathic Healthcare Provision that specifies, values and preferences [1]. Although there is broad support among other requirements, an education, training and for EBP across most healthcare professions, its implementa- ethical framework for the practice of osteopathy [33]. tion by practitioners of the manual therapy professions This document highlights “Scientific rigour and remains limited and contested [2–6]. A possible explan- evidenced-informed practice as an important part of ation for the limited uptake of EBP in this professional osteopathic treatment and patient management” and in- group may be the difficulty in transferring research-based cludes the “ability to appraise medical and scientific lit- evidence into practice due to the complexity of clinical set- erature critically and the incorporation of relevant and tings, including the high level of interaction between contemporary information into practice” as essential patients and practitioners [7, 8]. In fact, several healthcare competencies for osteopathic practice [33]. In spite of disciplines [9–14] report similar issues in the implementa- these standards, Spanish osteopath’s attitudes toward, tion of EBP, including medicine [14], physical therapy [11] and utilisation of EBP remains largely unknown. After and more recently, osteopathy [15, 16]. performing a comprehensive literature search on the Osteopathy is considered a manual therapy discip- topic, only one recently published study was identified line in which its therapeutic base has been tradition- [34]. While this study provided some insight into the ally embedded within a specific conceptual framework issue in Spain, the methods and selected data extraction and principles [17–19]. However, several authors have tool do not allow direct comparisons to be made with questioned the validity, plausibility and utility of these osteopathic communities in other countries. Further traditional osteopathic models in the context of con- exploration of this issue is therefore warranted in order temporary evidence-based healthcare [20–23]. Despite to better inform the development of innovative strat- the passing of time, most of these osteopathic models egies that might assist Spanish osteopaths to embrace have not been updated in response to the evidence, EBP. Responding to this need, the main aim of this yielding to an uncritical development of the profes- study was to investigate the attitudes, skills and use of sion [23]. The lack of integration of EBP in osteo- EBP among Spanish osteopaths. We also aimed to iden- pathic professional development has been explored tify the barriers and facilitators for the adoption of EBP across the world, with the subject receiving significant in the Spanish osteopathic context. attention in the UK [24–27]. Osteopathy is defined by The World Health Organisa- Methods tion (WHO) as a first-contact patient-centred health dis- The methods conducted and reported in this present cipline [28]. As osteopathy develops its knowledge base, study closely follow those of previously published studies the profession will need to respond and be critically re- carried out by our group measuring attitudes towards flective and move away from the prioritizing of traditional EBP of osteopaths [26, 30, 35] and Chiropractors [36] theories and anecdotes as reliable sources of evidence, and instead, pursue the generation of new knowledge through Design research, and ensure that clinicians and educators are able National, online, cross-sectional survey. to integrate evidence into practice. Although it appears that the integration of EBP into osteopathy is largely per- Sample and setting ceived as a favourable endeavour across the osteopathy Due to the unregulated situation of the profession in community [15, 26, 29], recent findings suggest that oste- Spain, the survey was open to all practising osteopaths, opathy practitioner engagement with EBP activities seems regardless of qualification or training institution. There- to be infrequent [26, 30]. Previous research has shown fore, for the purpose of this study, the term “osteopath/ that the perceived barriers to EBP implementation among s” applied to any “therapist practicing osteopathy” or any UK osteopaths are lack of time, lack of evidence in the “therapist with training in osteopathy” practising in osteopathic field and lack of access to studies and data- Spain. No exclusion criteria were applied. Although bases [26]. These results are consistent with a similar pre- there is no reliable data on the number of osteopaths vious study conducted in Australia [30]. practising in Spain, numbers of graduates from osteo- In Spain, osteopathy is not a regulated healthcare pathic educational institutions (OEIs) in Spain estimate profession [31, 32]. Consequently, osteopaths with dif- the Spanish osteopathic workforce to be in the vicinity ferent professional, academic and clinical profiles (e.g. of 5000–6000 [32]. Based on a target population of 6000, qualifications, training standards and competencies) at least 362 osteopaths were required to be surveyed in Alvarez et al. BMC Health Services Research (2021) 21:130 Page 3 of 13 order to achieve a 5% margin of error and a 95% confi- integrated into the final version of the survey (Additional dence interval for any individual item on the survey. file 1). Recruitment and data collection Description of survey and variables Participation in the study was advertised between April The Evidence-Based practice Attitude and utilization 2020 and June 2020 using a range of recruitment strat- Survey (EBASE) [37] is an 80-item instrument designed to egies. First, the main osteopathic associations (n = 9) and assess attitudes, skills and use of evidence-based practice OEIs (n = 7) in Spain informed their associates (aca- among health professionals. The survey is divided into demic/clinical staff and alumni) of the survey and seven constructs, including attitude (10 items, rated using encouraged participation. Second, the study was adver- a 5-point scale, ranging from “Strongly Agree” to “Strongly tised via social media (Twitter, Facebook and Instagram) Disagree”), skills (13 items, rated using a 5-point scale, inviting osteopaths to complete the EBASE survey. All ranging from “Low” to “High”), education and training (5 recruitment media directed participants to a dedicated multiple-choice items), use (9 items, rated based on num- project website, where participants were invited to read ber of articles read/reviewed, number of times performing the study information before progressing to the survey. certain EBP-related activities, and information sources The welcome page contained information on the pur- used to inform clinical-decision making), barriers/enablers pose of the study, the survey constructs, informed con- (23 items, rated using a 4-point scale, ranging from “no sent considerations, reporting of results, storage of data, barrier / not useful” to “major barrier / very useful”), and ethics committee approval and the research team. Once demographics (19 multiple-choice items and 1 open-text the survey was accessed, participants were provided with item). The narrative interpretation of the question, “What instructions on how to complete each section. Those percentage of your practice do you estimate is based on instructions, placed in the beginning of each section, in- clinical research evidence (i.e. evidence from clinical cluded an explanation on the type of information trials)?” was based on the following grading: None (0%); required and the nature of the response options Very small proportion (1–25%); Small proportion (26– (Additional file 1). 50%); Moderate proportion (51–75%); Large proportion Data collection was undertaken online using Survey- (76–99%); or All (100%). Monkey™ (SurveyMonkey Inc., San Mateo, California, The original English EBASE instrument has demon- USA). All survey items were made compulsory to miti- strated acceptable test-retest reliability (ICC = 0.578– gate the risk of missing data. 0.986), good internal consistency (Cronbach’s alpha = 0.84), and good construct and content validity (CVI = Data analysis 0.899) [37, 38]. Data from the online survey were imported into IBM Items from three of the survey constructs can be gen- SPSS version 25 (Armonk, New York, IBM Corp) for erated into subscores, as follows: data cleaning, coding and statistical analyses. Excluded from the analyses were incomplete surveys (i.e. surveys  Attitude subscore: Sum of the first 8 items, with containing > 20% missing data due to participant drop- scores ranging from 8 (predominantly strongly out) and duplicate responses (i.e. as identified using the disagree) to 40 (predominantly strongly agree). Konstan et al. de-duplication procedure for online  Skill subscore: Sum of all 13 items, with scores surveys [40]). Categorical data were described using fre- ranging from 13 (low level skill) to 65 (high level quencies and percentages. Means and standard devia- skill). tions were used to describe normally distributed data,  Use subscore: Sum of the first 6 items, with scores and medians and the interquartile range used for non- ranging between 0 (mostly infrequent use) and 24 normally distributed data. Associations between ordinal- (mainly frequent use). level variables were examined using the Kendall’s Tau correlation coefficient (Ƭ), whereas relationships between Translation and adaptation of the survey nominal-level variables were assessed using Cramer’s V. The questionnaire was translated from English to Coefficients were interpreted as follows: 0.10–0.29 (weak Spanish and adapted cross-culturally according to the association), 0.30–0.49 (moderate association) and 0.50– forward and backward translation method recommended 1.00 (strong association) [41]. The level of significance by the WHO [39]. Once translated, a pilot test was car- was set at p < 0.05. All correlations were determined a ried out on 20 purposely-selected Spanish osteopaths. priori (based on analyses reported for other studies using Suggestions for improvement (e.g., provision of EBASE). To ensure comparability across studies using additional response options to some questions mainly EBASE, analyses were not corrected for multiple related to the Spanish educational system) were comparisons. Alvarez et al. BMC Health Services Research (2021) 21:130 Page 4 of 13 Ethics engagement in all other EBP-related activities was gener- The study was approved by the Ethical Committee of ally infrequent, with 49.6–67.2% of participating osteo- Sagrado Corazón Hospital, Barcelona (2019/81-CMF- paths engaging in these activities no more than 5 times in HUSC). Study participation was anonymous and volun- the previous month. tary, and participants were able to withdraw from the A weak positive association was found between use sub- survey at any time without repercussion. Informed con- score (categorised by quartiles) and age (Ƭ = .113, p = .007), sent was obtained online from all subjects and all sex (V = .155, p = .018; with higher subscores reported methods were carried out in accordance with relevant among male participants), highest qualification (Ƭ = .165, guidelines and regulations. p < .001), years in osteopathy practice (Ƭ = .142, p < .001), number of hours in clinical practice (Ƭ = .082, p = .037), Results and number of hours teaching in the higher education sec- The survey was commenced by 714 Spanish osteopaths. tor (Ƭ = .225, p < .001). A moderate positive association was After removing duplicate entries (n = 4) and incomplete observed between use subscore and number of hours responses (n = 143), the adjusted sample size was 567. engaged in research work (Ƭ = .345, p < .001). The reasons for participant dropout could not be exam- The perceived proportion of clinical practice that was ined due to the anonymous nature of the survey. It also based on clinical research evidence was reported to be was not possible to calculate a survey response rate as very small by 21.5% of participants, small by 21.7% of the actual reach of the survey could not be determined. participants, moderate by 26.8% of participants and large However, considering a potential target population of by 12.0% of participants. Few participants reported that 6000 Spanish osteopaths [32] the estimated response none or all of their practice was underpinned by clinical rate would be approximately 9% (564/6000). research evidence. The information sources used most frequently by par- Characteristics of sample ticipating osteopaths to inform their clinical decision- Participating osteopaths were predominantly male making were traditional knowledge (median rank 4; IQR (47.1%), and aged between 30 and 49 years (62.6%); 2,7) and published clinical evidence (median rank 4; IQR 40.7% were members of an osteopathy professional asso- 2,7) (Table 3: ranked from 1 = most frequently used, to ciation (Table 1). The largest proportion of participants 10 = least frequently used). Published experimental/la- held a Master’s degree as their highest qualification boratory evidence was used by participants the least (37.9%), with 50.5% receiving this qualification within (median rank 8; IQR 3,10). the past 10 years. Two-thirds (66.0%) of participants also held a degree in physiotherapy. Most (59.5%) partici- Skills and training in EBP pants had been in osteopathic practice for six or more Overall, participating osteopaths reported a low- years, with 57.7% spending 16–45 h/week in clinical moderate to moderate level of perceived skill in EBP practice, 72.3% spending up to 15 h/week participating (median skill subscore 39; IQR 31,48; range 13–65; in research, and 50.4% working up to 15 h/week teaching scores ranging between 26.1 and 39.0 are indicative of a in the higher education sector. Participating osteopaths low-moderate to moderate skill level). Relatively higher largely worked in solo practice (41.4%) in the central levels of perceived skill were observed for items pertain- business district (43.4%), with most located in Cataluña ing to ‘clinical problem identification’ (i.e. identifying an- (23.8%), Comunidad de Madrid (13.1%) or Comunidad swerable clinical questions [73.6% self-reported a Valenciana (7.6%) (Fig. 1). The missing values reported moderate to moderate-high skill level for this item], and in the results represent participants that did not answer identifying knowledge gaps in practice [68.5% self- the question as they had withdrawn from the survey at reported a moderate to moderate-high skill level for this that point. item]) (Table 4). Participants reported the lowest levels of perceived skill for items related to ‘research conduct’, Use of EBP with more than one-half of participating osteopaths Participants reported a moderate-low level of engagement reporting low to low-moderate skill in conducting clin- in EBP activities (median use subscore 8; IQR 5,14; range ical research (60.4%) and systematic reviews (50.9%). 0–24; scores ranging between 6.1 and 12.0 are indicative A weak positive association was found between skill of a moderately-low level of use). Reading/reviewing pro- subscore (categorised by quartiles) and age (Ƭ = .140, fessional literature and using online search engines to find p = .001), sex (V = .256, p < .001; with higher subscores practice-related literature were among the most frequently reported among male participants), highest qualification reported activities, with 44.6–48.0% of participating osteo- (Ƭ = .254, p < .001), years in osteopathy practice (Ƭ = paths engaging in these activities between 1 and 10 times .227, p < .001), number of hours in clinical practice (Ƭ = in the month preceding the survey (Table 2). Participant .086, p = .033), and number of hours teaching in the Alvarez et al. BMC Health Services Research (2021) 21:130 Page 5 of 13 Table 1 Demographic characteristics of sample (n = 567) Table 1 Demographic characteristics of sample (n = 567) Characteristic Frequency, n (Continued) (%) Characteristic Frequency, n Age, n (%) (%) 18–20 years 3 (0.5) 11–15 years 95 (16.8) 20–29 years 23 (4.1) 16+ years 16 (18.7) 30–39 years 187 (33.0) Missing 146 (25.7) 40–49 years 168 (29.6) Hours per week in clinical (osteopathic) practice, n (%) 50–59 years 30 (5.3) 0h 5 (0.9) 60–69 years 10 (1.8) 1–15 h 47 (8.3) 70+ years 1 (0.2) 16–30 h 150 (26.5) Missing 145 (25.6) 31–45 h 177 (31.2) Sex, n (%) 46+ hours 42 (7.4) Male 267 (47.1) Missing 146 (25.7) Female 155 (27.3) Hours per week participating in research, n (%) Missing 145 (25.6) 0h 162 (28.6) Osteopathy professional association membership, n (%) 1–15 h 248 (43.7) Not a member of an Osteopathy professional 185 (32.6) 16–30 h 9 (1.6) association 31–45 h 2 (0.4) Registry of Osteopaths of Spain 103 (18.2) 46+ hours 0 (0.0) Registry of Osteopathic Physiotherapists of Spain 85 (15.0) Missing 146 (25.7) Other Osteopathy professional association 43 (7.6) Hours per week working in the higher education sector, n (%) Missing 151 (26.6) 0h 189 (33.3) Highest qualification, n (%) 1–15 h 97 (17.1) Diploma 82 (14.5) 16–30 h 59 (10.4) Bachelor degree 27 (4.8) 31–45 h 29 (5.1) Master’s degree 215 (37.9) 46+ hours 47 (8.3) PhD 46 (8.1) Missing 146 (25.7) Other 52 (9.2) Clinical setting in which osteopathy was predominantly practiced, Missing 145 (25.6) n (%) Years since receiving highest qualification, n (%) Solo practice 235 (41.4) < 1 year 42 (7.4) With a group of allied health providers 87 (15.3) 1–5 years 150 (26.5) With a group of complementary and allied health 41 (7.2) providers 6–10 years 94 (16.6) With conventional and allied health providers 37 (6.5) 11–15 years 59 (10.4) Within a clinical institution (e.g. hospital) 12 (2.1) 16+ years 76 (13.4) Within an educational institution (e.g. university) 6 (1.1) Missing 146 (25.7) Missing 149 (26.3) Other non-osteopathic qualifications, n (%) Geographical region of practice, n (%) Degree in Physiotherapy 374 (66.0) City (Central business district) 246 (43.4) Diploma/Degree in other health-related field 31 (5.5) Inner city location 88 (15.5) Degree in Medicine 5 (0.9) Rural location 43 (7.6) Degree in Nursing or Podiatry 5 (0.9) Outer city location 39 (6.9) Missing 152 (26.8) Missing 151 (26.6) Years practiced in the field of osteopathy, n (%) CAM Complementary and alternative medicine < 1 year 6 (1.1) 1–5 years 78 (13.8) 6–10 years 136 (24.0) Alvarez et al. BMC Health Services Research (2021) 21:130 Page 6 of 13 Fig. 1 Geographical location of practice, n (%) higher education sector (Ƭ = .265, p < .001). Skill sub- .013), and number of hours engaged in research work score was shown to be moderately positively correlated (Ƭ = .133, p = .003). with number of hours engaged in research work (Ƭ = A secondary analysis was performed to assess the .437, p < .001). relationship between membership of a professional as- The majority (> 62%) of participating osteopaths had sociation and attitude, skill and use subscores. Our completed training in EBP, evidence application, con- results showed a weak positive association between ducting clinical research, conducting systematic reviews professional association membership and skill sub- and critical thinking. Across all five areas, training was score (V = .130, p = .031; i.e. higher perceived skill mostly undertaken as a minor or major component of a subscore among those reporting membership of a university course (i.e. by 24.3 to 37.7% of participants), professional association) and use subscore (V = .170, or as a short course (i.e. by 9.2 to 17.8% of participants). p = .003; i.e. higher use subscore among those report- ing membership of a professional association). In a Attitudes toward EBP further analysis between associations, we found a Participants’ attitudes toward EBP were largely positive weak positive association between professional associ- (median attitude subscore 32; IQR 28,35; range 11–40; ation affiliation and skill subscore (V = .213, p < .001; scores ranging between 32.0 and 40.0 are indicative of a i.e. higher perceived skill subscore among those predominantly agree to strongly agree response). At least reporting membership of ROFE) and use subscore 4 out of 5 participating osteopaths agreed or strongly (V = .168, p = .002; i.e. higher use subscore among agreed that EBP was necessary in the practice of osteop- those reporting membership of ROFE). athy (89.6%) and professional literature and research findings were useful to their day-to-day practice (88.9%), Barriers and enablers of EBP use with a similar proportion expressing an interest in learn- Of the 13 listed barriers to EBP uptake, participants ing or improving the skills necessary to incorporate EBP identified 8 as being minor to moderate barriers, into their practice (88.9%) (Table 5). On the other hand, including lack of clinical evidence in osteopathy a large proportion (43.5%) of participants disagreed or (51.3%), insufficient skills for applying research find- strongly disagreed that EBP placed an unreasonable ings (50.8%), lack of time (49.9%), insufficient skills demand on their practice. for appraising research (48.8%), insufficient skills for The attitude subscore (categorised by quartiles) was interpreting research (47.1%), insufficient skills for lo- found to be weakly positively associated with participant cating research (46.0%), lack of industry support for sex (V = .162, p = .011; with more favourable attitudes EBP (45.1%), and lack of incentive to participate in reported among male participants), number of hours EBP (44.4%). The remaining 5 barriers (i.e. lack of re- teaching in the higher education sector (Ƭ = .104, p = sources, interest, relevance, colleague support, and Alvarez et al. BMC Health Services Research (2021) 21:130 Page 7 of 13 Table 2 Participant engagement in evidence-based practice activities within the last month (n = 567) 0 1 2 3 4 Missing Median 0 1–5 6–10 11–15 16+ n (%) (IQR) times times times times times n (%) n (%) n (%) n (%) n (%) I have used an online search engine to search for practice related literature or 65 157 96 51 (9.0) 117 81 3 (2,4) research (11.5) (27.7) (16.9) (20.6) (14.3) I have read/reviewed professional literature (i.e. professional journals & 65 184 88 46 (8.1) 107 77 2 (2,4) textbooks) related to my practice (11.5) (32.5) (15.5) (18.9) (13.6) I have used an online database to search for practice related literature or 107 174 66 36 (6.3) 103 81 2 (2,4) research (18.9) (30.7) (11.6) (18.2) (14.3) I have used professional literature or research findings to assist my clinical 101 215 71 40 (7.1) 63 77 2 (2,3) decision-making (17.8) (37.9) (12.5) (11.1) (13.6) I have used professional literature or research findings to change my clinical 110 235 58 29 (5.1) 58 77 2 (2,3) practice (19.4) (41.4) (10.2) (10.2) (13.6) I have read/reviewed clinical research findings related to my practice 125 193 62 35 (6.2) 75 77 2 (1,3) (22.0) (34.0) (10.9) (13.2) (13.6) I have consulted a colleague or industry expert to assist my clinical decision- 113 220 67 33 (5.8) 53 81 2 (2,3) making (19.9) (38.8) (11.8) (9.3) (14.3) I have referred to magazines, layperson / self-help books, or non-government/ 236 145 39 25 (4.4) 41 81 2 (1,2) non-education institution websites to assist my clinical decision-making (41.6) (25.6) (6.9) (7.2) (14.3) IQR Interquartile range patient preference) were considered by many (49.2 to licence fees (57.3%), critically appraised topics relating to 63.1%) participants as not being a barrier or only a osteopathy (57.3%), and critical appraisal tools (56.3%). minor barrier to EBP uptake. Most participating osteopaths indicated that the 10 Discussion listed enablers of EBP uptake were either moderately or This study aimed to assess the attitudes, skills and util- very useful. These enablers included improving access isation of EBP, as well as the barriers and enablers of to: full-text journal articles (63.8% rated this strategy as EBP use, among Spanish osteopaths. Overall, our results moderately or very useful), internet in the workplace showed that Spanish osteopaths hold positive views to- (63.3%), free online databases (63.0%), online EBP educa- wards EBP but their utilization/implementation is still tion materials (62.8%), critical reviews of research evi- poor. Positive responses about EBP training and utilisa- dence relating to osteopathy (61.0%), research rating tion were modest and, in general, the perceived level of tools (58.2%), online tools that facilitate practitioner EBP-related skill was very low. Despite these low levels appraisal of the evidence (58.0%), databases requiring of skill in relation to the utilization of EBP, several bar- riers to the use of EBP were perceived as not important by participants. Although it was not possible to calculate Table 3 Sources of information used by participants to inform the mean response and the number of withdrawals from their clinical decision-making (in descending order of frequency) the survey, the final number of participants that com- (n=567) pleted the survey was around 9% of the target popula- Information source Median (IQR) tion, which is similar to the survey response rate Traditional knowledge 4 (2,7) reported for osteopaths in a similar UK study [26] Our study sample had a high proportion of male par- Published clinical evidence (i.e. clinical trials) 4 (2,7) ticipants and those aged between 30 and 49 years, which Consulting fellow practitioners or experts 4 (3,6) was similar to that reported in another recent survey of Textbooks 5 (2,7) Spanish osteopaths [32]. Previous studies in the UK and Personal intuition 5 (3,7) Australia have also reported comparable gender distribu- Clinical practice guidelines 6 (3,8) tions [26, 30] although in Sweden this distribution was Personal preference 7 (4,9) more balanced [35]. In our survey, 73% of osteopaths had a previous degree in a healthcare profession regu- Trial and error 7 (4,9) lated in Spain. This is consistent with other surveys con- Patient preference 7 (5,9) ducted in Spain [32], where the majority of osteopaths Published experimental/laboratory evidence 8 (3,10) have reported a previous degree in physiotherapy and IQR Interquartile range postgraduate training in osteopathy. Alvarez et al. BMC Health Services Research (2021) 21:130 Page 8 of 13 Table 4 Participant’s perceived skill level in evidence-based practice (n = 567) 1 2 3 4 5 Missing Median Low Low-moderate Moderate Moderate-high High n (%) (IQR) n (%) n (%) n (%) n (%) n (%) Identifying answerable clinical questions 14 (2.5) 56 (9.9) 183 (32.3) 234 (41.3) 58 (10.2) 22 (3.9) 4 (3,4) Identifying knowledge gaps in practice 25 (4.4) 84 (14.8) 222 (39.2) 166 (29.3) 48 (8.5) 22 (3.9) 3 (3,4) Locating professional literature 38 (6.7) 102 (18.0) 148 (26.1) 174 (30.7) 83 (14.6) 22 (3.9) 3 (2,4) Online database searching 44 (7.8) 101 (17.8) 143 (25.2) 155 (27.3) 102 (18.0) 22 (3.9) 3 (2,4) Retrieving evidence 46 (8.1) 112 (19.8) 158 (27.9) 145 (25.6) 84 (14.8) 22 (3.9) 3 (2,4) Critical appraisal of evidence 33 (5.8) 122 (21.5) 190 (33.5) 143 (25.2) 43 (7.6) 36 (6.3) 3 (2,4) Synthesis of research evidence 28 (4.9) 121 (21.3) 185 (32.6) 150 (26.5) 47 (8.3) 22 (3.9) 3 (2,4) Applying research evidence to patient cases 25 (4.4) 74 (13.1) 185 (32.6) 197 (34.7) 50 (8.8) 36 (6.3) 3 (3,4) Sharing evidence with colleagues 53 (9.3) 100 (17.6) 139 (24.5) 159 (28.0) 80 (14.1) 36 (6.3) 3 (2,4) Using findings from clinical research 73 (12.9) 119 (21.0) 169 (29.8) 127 (22.4) 39 (6.9) 40 (7.1) 3 (2,4) Using findings from systematic reviews 89 (15.7) 131 (23.1) 127 (22.4) 136 (24.0) 44 (7.8) 40 (7.1) 3 (2,4) Conducting systematic reviews 147 (25.9) 142 (25.0) 122 (21.5) 82 (14.5) 34 (6.0) 40 (7.1) 2 (1,3) Conducting clinical research 218 (38.4) 125 (22.0) 102 (18.0) 53 (9.3) 33 (5.8) 36 (6.3) 2 (1,3) IQR Interquartile range EBP attitudes favourable view of EBP has been also reported in other Most participating Spanish osteopaths agreed that EBP is healthcare professions, such as nursing [42, 43], physio- necessary in the practice of osteopathy, with the majority therapy [11, 44, 45], dentistry [46] and chiropractic [12], interested in learning or improving the skills necessary to as well as osteopaths in other countries [26, 30, 35]. incorporate EBP into their practice. Overall, attitudes Although attitudes towards EBP were generally posi- toward EBP were positive which is in accordance with a tive, a considerable number of respondents (30%) recent study also conducted in Spain [34]. In fact, this believed that EBP placed an unreasonable demand on Table 5 Participant attitudes toward evidence-based practice (n = 567) 1 2 3 4 5 Median Strongly Disagree Neutral Agree Strongly (IQR) Disagree n (%) n (%) n (%) Agree n (%) n (%) I am interested in learning or improving the skills necessary to 12 (2.1) 16 (2.8) 35 (6.2) 202 302 (53.3) 5 (4,5) incorporate EBP into my practice (35.6) EBP is necessary in the practice of osteopathy 14 (2.5) 17 (3.0) 28 (4.9) 225 283 (49.9) 4 (4,5) (39.7) Professional literature (i.e. journals & textbooks) and research findings are 10 (1.8) 13 (2.3) 40 (7.1) 288 216 (38.1) 4 (4,5) useful in my day-to-day practice (50.8) EBP improves the quality of my patient’s care 17 (3.0) 27 (4.8) 56 (9.9) 234 233 (41.1) 4 (4,5) (41.3) EBP assists me in making decisions about patient care 12 (2.1) 30 (5.3) 63 260 202 (35.6) 4 (4,5) (11.1) (45.9) Prioritizing EBP within osteopathic practice is fundamental to the 21 (3.7) 48 (8.5) 63 211 224 (39.5) 4 (4,5) advancement of the profession (11.1) (37.2) EBP takes into account my clinical experience when making clinical 21 (3.7) 73 (12.9) 98 214 161 (28.4) 4 (3,5) decisions (17.3) (37.7) EBP takes into account a patient’s preference for treatment 36 (6.3) 143 116 173 99 (17.5) 3 (2,4) (25.2) (20.5) (30.5) There is a lack of evidence from clinical trials to support most of the 41 (7.2) 138 151 178 59 (10.4) 3 (2,4) treatments I use in my practice (24.3) (26.6) (31.4) The adoption of EBP places an unreasonable demand on my practice 50 (8.8) 197 148 141 31 (5.5) 3 (2,4) (34.7) (26.1) (24.9) EBP Evidence-based practice, IQR Interquartile range Alvarez et al. BMC Health Services Research (2021) 21:130 Page 9 of 13 their practice. This item was much less reported by affecting many healthcare professions, where consider- Australian (17%) [30], UK (16%) [26] and Swedish osteo- able ‘research-practice gaps’ exist [50–52]. However, paths (17%) [35]. This suggests that almost one-third of these research-practice gaps can be attributed to more our sample may be experiencing difficulties in integrat- than just insufficient knowledge and skills; organizational ing EBP into their daily practice. Therefore, further ef- factors, and social and attitudinal behaviours are also forts are required to enhance the competence, skills and important contributors [50]. We argue that all of these efficiency of implementing the components of EBP factors may be in part responsible for the limited applica- amongst osteopaths in Spain. A possible explanation for tion of research evidence in Spanish osteopathic practice these contrasting findings could be the lack of profes- given the historical lack of research culture within the pro- sional regulation in Spain, even compared to osteopathy fession in both the clinical and academic domain. in Sweden, where like Spain, osteopathy is also an emer- The impact of research culture on EBP use was sup- ging profession. However, in Sweden, there are far fewer ported to some extent by the association between EBP OEIs (currently just one), and just a single osteopathic use and number of hours engaged in research work and association of which the majority of osteopaths are teaching in the higher education sector. Although this members of [35]. The relatively higher number of OEIs association has been already reported amongst Spanish in Spain and the diversity of educational focus (such as osteopaths [34], when this finding is compared against time spent on EBP) may explain the burden that Spanish surveys of Australian [30] or UK [26] osteopaths, there osteopaths perceive in enacting EBP. are similarities in the number of hours dedicated to Research from nursing and physical therapy has found research activities (i.e. 0–15 h/week; Spain = 72%, the level of professional education to be predictive of the Australia = 84%, UK = 72%), though Spanish osteopaths propensity to adopt EBP; although, other factors were did seem to dedicate more hours to teaching in the also influential, such as desire to learn, practicality (i.e. higher education sector (i.e. 1–30 h/week; Spain = 28%, non-interference with productivity or patient flow) and Australia = 15%, UK = 18%). Hence, one might expect beliefs about EBP [47, 48]. Indeed, there was some indi- Spanish osteopaths to have a higher perceived level of cation in our study that participating osteopaths had a EBP-related skill, although this was not the case. This misconstrued understanding of the EBP paradigm, with raises questions about the integration of EBP and a large proportion of participants believing that EBP did research into Spanish osteopathic curricula. not take into consideration the patient’s perspective. Other studies have also indicated that osteopaths view EBP as a threat to the professional identity of the profes- Use of EBP sion [24, 25, 49]. This suggests that Spanish osteopaths A moderately-low level of engagement in EBP activities might benefit from revisiting the fundamental purposes was reported in our sample. An interesting finding was of contemporary EBP which seeks to prioritise ethical the relatively high proportion of participants that had care, is relationship-based, advocates shared decision- not searched an online database (18.9%) or used scien- making and relates the evidence to the individual tific literature to change their clinical practice (19,4%) in patient’s context and situation [7]. the month preceding the survey. This behaviour can be partially explained by the types of information sources EBP skills used by our sample. The main source of information Participating Spanish osteopaths perceived their EBP used by participants to inform their clinical decision- skill level to be low to moderate, which is relatively making was traditional knowledge, followed by published lower than that reported among osteopaths in other clinical evidence and peer opinion or textbooks. These countries [26, 30, 35], chiropractors [12] and physiother- results highlight the importance of traditional knowledge apists [44]. A notable insecurity among participants to Spanish osteopaths; a finding that also can be related to the conduct of clinical studies or systematic extended to osteopaths in Australia [30], UK [26] and reviews. This finding was somewhat expected as these Sweden [35], who also report traditional knowledge as advanced research activities are not typically taught the primary source of information used to inform clin- within undergraduate clinical programs. ical decision-making. However, while Australian and UK Another self-reported skill-deficit related to the imple- osteopaths cited clinical guidelines as their second most mentation of research findings, that is, the process of frequently used information source, in the present study, applying research evidence into clinical practice. This Spanish osteopaths rated these guidelines as their sixth coincides with the perceived barriers of EBP uptake most frequently used source of information and in com- reported by participants, of which half of our sample parison, it was reported in ninth position by Swedish os- identified insufficient skills in applying research findings teopaths [35]. Given that clinical guidelines typically as a barrier to EBP utilisation. In fact, this is a problem represent the best available evidence in a field, a Alvarez et al. BMC Health Services Research (2021) 21:130 Page 10 of 13 considerable research-practice gap may be evident in scenario could explain the time constraints to be Spanish and Swedish osteopathic practice. involved in research activities. Notwithstanding, there appear to be few differences in Other important barriers related to lack of skills EBP use between these countries. Similar to our sample, (applying research, research appraisal and interpreting the use of EBP among osteopaths in Australia, UK and research), showing the necessity to improve these abil- Sweden is reported to be generally low [26, 30, 35], as it ities in order to encourage EBP uptake among new oste- is among US and Canadian chiropractors [9, 53]. Exist- opaths. While education is important, there also needs ing evidence suggests physical therapists have a relatively to be a change in mindset, triggered by a comprehensive greater level of engagement with EBP [44, 54]. Interest- reflection that considers osteopathy as a healthcare pro- ingly, two-thirds of our sample held a qualification in fession that embraces science as a way to evolve and physiotherapy, which is common among osteopaths in self-assess [49]. Spain [31, 32]. This result raises the question as to why Exactly how EBP and research culture should be pro- participating osteopaths engage with EBP to a lesser moted among healthcare practitioners remains contro- extent than physiotherapists. One explanation is that to versial. Several recent scoping reviews in the field of date, we have no data on Spanish physiotherapist en- physiotherapy suggests some ideas [57, 58]. The first gagement in EBP activities, which possibly could be dif- consideration is that any strategy aimed at improving ferent from other countries. Further, almost half of our EBP uptake should be tailored to the local scenario to sample received their highest qualification at least 6 contextualize the training program. The second consid- years before the survey, and in Spain, EBP has been only eration is that multifaceted strategies (containing at least recently integrated into physiotherapy curricular [55]. five elements) are more likely to be associated with sig- Osteopathy also has been traditionally embedded in nificant changes in learning outcomes. Stander et al. [57] clinical models and frameworks conceived by a small also highlights the need for EBP training programmes to number of individuals from when the discipline was be underpinned by behaviour change models, learning attempting to establish itself, leading to an uncritical theories and a concrete theoretical framework. A recent development of the profession [23]. An examination systematic review and Delphi survey proposes a set of 68 of the comparative uptake of EBP among different core competencies as a possible framework to inform health disciplines in Spain may shed some further the development of EBP curricula for health profes- light on this issue. sionals [59]. In terms of potential solutions to improving EBP up- Regarding enablers, around 63% of participants take, education about EBP alone may not be sufficient considered free access to scientific evidence, access to [56]. Findings from a recent scoping review suggest edu- the internet at work, access to free databases and online cation programs aimed at improving local barriers may EBP education materials to be very useful enablers. This be a more effective method of improving EBP engage- was in line with osteopath’s reports in other countries ment [57]. Within osteopathy, these barriers to EBP up- [26, 30, 35]. In the case of Spain, we hypothesize that take are not entirely clear. Indeed, in the case of our the national unification of osteopathic curricula and the respondents, most did not perceive there to be any inclusion of these programmes in universities may also major barriers. contribute to improvements in EBP skills and uptake. In fact, a higher academic degree has been shown to be as- Barriers and enablers for EBP sociated with a higher propensity to adopt EBP and this Previous surveys of osteopaths [26, 30, 35] have reported has also been observed in Spanish osteopaths [34]. Fur- lack of clinical evidence in osteopathy (Australia = 60%; thermore, educational programmes and their associated UK = 69%; Sweden = 53%) and lack of time (Australia = curricula can act as a key driver for shaping healthcare 53%; UK = 57%) as major barriers to EBP uptake. professionals’ knowledge, skills and attitudes towards Although none of the thirteen listed factors in the survey activities associated with EBP [60]. Not surprisingly, were identified as major barriers to EBP uptake among integrating EBP into the curricula of academic pro- Spanish participants, lack of clinical evidence in osteop- grams has become an essential requirement for aca- athy and lack of time were still considered the most not- demic institutions providing training for healthcare able issues of concern, with at least one-half of professions [61–63]. respondents reporting these as minor to moderate bar- But above all, we consider that it is necessary to riers. Despite the rather high proportion of academics change the way EBP is taught within osteopathic educa- noticed in our sample and in another study conducted tional programs in Spain. Currently, for many OEIs, EBP in Spain [34], the main osteopathic profile in this coun- is incorporated within the curriculum by teaching spe- try is clinical-based with the 60% of osteopaths dedicat- cific research techniques, methods and statistics in the ing 5 days per week to clinical practice [32]. This final years of training. Instead, we propose that the Alvarez et al. BMC Health Services Research (2021) 21:130 Page 11 of 13 philosophy of EBP should be promoted from the begin- Conclusions ning and embedded along the whole programme. Such This study furthers our understanding of Spanish osteo- integration should be facilitated by the explicit inclusion paths’ attitudes, skills and use of EBP. Our results of EBP as a core competency within professional stan- showed that participant’s attitudes toward EBP were dards and requirements in addition to accreditation pro- largely positive. At least four out of five participating os- cesses [60]. OEIs directors should commit to design teopaths agreed that EBP was necessary in the practice their programmes according to this perspective and of osteopathy and professional literature and research teachers should present their contents always balancing findings were useful to their day-to-day practice. How- the knowledge acquired from tradition and experience ever, the perceived skills, use and engagement in EBP ac- with the knowledge obtained from research literature tivities was reported as moderate to low. Fortunately, and adequate appraisal. In summary, we argue that a there was general interest in learning and improving the better professional qualification of osteopaths is neces- skills necessary to incorporate EBP into clinical practice. sary in Spain and that this process must be based on a Our findings, therefore, suggest that wider inclusion of pedagogical shift from the mere delivery of contents to osteopathic educational programmes into university the promotion of critical thinking and reflective practice. environments along with a pedagogical shift towards the These actions will potentially improve the consistency of promotion of critical thinking and reflective practice programmes, ensure course content represents best prac- may be helpful in assisting Spanish osteopaths to tice, and help nurture a stronger research and EBP culture embrace EBP. Although, as discussed in this paper, the within the profession. While these actions might be difficult absence of osteopathy regulation in Spain could poten- to accomplish in Spain without national professional regu- tially continue to curtail efforts to improve EBP uptake lation, results from Sweden (where osteopathy is also an in this professional group. unlicensed health profession) demonstrate that extensive exposure to EBP training (91% of Swedish osteopaths vs. Supplementary Information 62% of Spanish osteopaths) correlates with higher perceived The online version contains supplementary material available at https://doi. org/10.1186/s12913-021-06128-6. skills in EBP [35]. Additional file 1. Limitations Although the survey response rate exceeded the mini- Abbreviations mum sample size required, we noticed a high percentage EBP: Evidence-Based Practice; WHO : World Health Organization; of missing responses. As all responses were compulsory, OEIs: Osteopathic Educational Institutions; EBASE: Evidence-Based practice this meant many respondents dropped out of the survey Attitude and Utilization Survey; CAM: Complementary and Alternative Medicine early, possibly due to survey fatigue. This was also a limitation that was discussed in a UK study of osteo- Acknowledgements paths [26]. Nonetheless, as the original English version The authors wish to acknowledge in first place all the surveyed participants. of EBASE has demonstrated good internal consistency Secondly, the following Research Collaborative Partners: Registro de los Osteópatas de España (ROE), Federación de Osteópatas de España (FOE), and acceptable test-retest reliability [37, 38], and the fact Sociedad Europea de Medicina Osteopática (SEMO), Asociación de that survey fatigue was not detected during pilot testing, Profesionales de Osteopatía (APREO), Unió Osteopàtica Catalana (UNOCAT), it was not considered appropriate to modify the number Registro de Osteópatas titulados en Fisioterapia de España (ROFE), Escola d’Osteopatia de Barcelona (EOB), Instituto Español de Osteopatía Clásica of survey items. (IEOC), Formación Belga Española de Osteopatía (FBEO), European While the process of translating the questionnaire Osteopathy and Research Academy (EORA), Instituto de Osteopatía de strictly followed standard methods reported by WHO Valencia (INOVA), Escuela de Osteopatía de A Coruña (EOC), Escuela de Osteopatía y Técnicas para la Salud (EOTS), Organización Colegial de [39], including a pilot study, the psychometric properties Osteópatas de España (OCOE), Fundación Terapias Naturales (FTN) and of the Spanish version of the questionnaire was not for- Osteópatas sin Fronteras (SFRON). mally assessed, which could have impacted the validity Authors’ contributions and reliability of findings. As has occurred in other GA and CJ translated and adapted the questionnaire and established local osteopathic surveys conducted in Spain [31, 32], a large recruitment strategies. GA and CJ drafted the first manuscript in proportion of responses came from two geographical collaboration with TS and OT. ML conducted the statistical analysis and drafted the results. GA, CJ, TS, OT and ML critically interpreted the data, regions (Cataluña and Madrid). These results likely edited the manuscript and reviewed and approved the final manuscript. reflect the geographical distribution of osteopaths in Spain. Notwithstanding, there were a number of regions Funding that were not well represented, whose views might The study did not receive any financial support from any sponsor. potentially differ from the more well-represented Availability of data and materials regions. Recall bias and selection bias are other intrinsic The datasets used and/or analysed during the current study are available limitations of the study design. from the corresponding author on reasonable request. Alvarez et al. BMC Health Services Research (2021) 21:130 Page 12 of 13 Ethics approval and consent to participate 13. Snow JE, Leach MJ, Clare BA. 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