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E-learning of Evidence-Based Health Care (EBHC) to increase EBHC competencies in healthcare professionals: A systematic review
Rohwer A1, Rehfuess E2, Young T1
1Centre for Evidence-based Health Care ,Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa2Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-University of Munich, Germany
SURMEPIStellenbosch University Rural Medical Education Partnership Initiative
Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa www.sun.ac.za/cebhc email: [email protected] Tel: +27-21-9389886 www.facebook.com/cebhc
Study ID Country Sample size (n) Study design Participants Intervention Comparison Main outcomes Main results
E-learning vs. No intervention
Bergold 2013 Germany 120 RCT Junior doctors
Online EBM course consisting of presentations and
exercises. EBM tutor was available for questions on
content and technology
No learning (waiting list)
• EBM knowledge
• EBM skills
• Usefulness of EBM course
Improved knowledge and skills scores improved significantly after
the course.
Course was seen as very useful
Forsetlund
2003Norway 148 RCT
Public health
physicians
EBM workshop with access to databases and
participation in asynchronous discussion list
Access to databases for one year (no
learning)
• EBP behaviour
• EBP attitudes
• EBP knowledge
• Pre- and post-test
No difference in EBP behaviour between groups.
Significant difference for knowledge scores between groups.
Kok 2013 Netherlands132 (54
clusters)Cluster RCT Physicians
Blended learning: introductory, interactive e-learning
course on EBM workshop with didactic and interactive
sessions
No learning
• EBM behaviour
• EBM knowledge
• EBM skills
• Self-efficacy
• Pre- and post-test
Significant absolute difference in EBM behaviour between groups.
Significant difference in improvement in knowledge and skills
scores between groups.
Attitudes similar in both groups.
Shilling 2006 USA 134 RCTUndergraduate
medical students
Web-based modules on searching and selecting best
evidence and calculating NNT within Family Medicine
clerkship
Traditionally structured Family
Medicine clerkship, no modules on
EBM
• Searching skills
• Attitude
• Pre- and post-test
Web-based EBM module group performed more effective
literature searches and selected higher quality articles than
control group.
Change in attitude was significantly more in web-based EBM
module group.
E-learning vs. Face-to-face lecture or workshop
Bradley 2005 Norway 175 RCTUndergraduate
medical studentsComputer-assisted (CD-ROM) on five steps of EBM Workshop on five steps of EBM
• EBM knowledge
• EBM skills
• EBM attitudes
• Post-test only
No difference between groups in EBM knowledge, skills or
attitude scores
Brettle 2013 UK 77 RCT
Nurses (pre-
registration
diploma)
Online tutorial on searching within the “Foundations in
Nursing” module
Lecture on searching (same content
as online tutorial) within the
“Foundations in Nursing” module
• Searching skills
• pre- and post-test
Searching skills improved for both groups.
No difference in improvement between groups
Davis 2007 UK 55 RCTPostgraduate
medical studentsShort, computer-based session on EBM (CD-ROM)
Lecture on EBM with similar content
structure and duration as
intervention
• EBM knowledge
• EBM attitude
• Pre- and post-test
Both groups significantly improved their scores after intervention.
No difference in improvement between groups
Davis 2008 UK 229 RCTUndergraduate
medical studentsShort, computer-based session on EBM (CD-ROM)
Lecture on EBM with similar content
structure and duration as
intervention
• EBM knowledge
• EBM attitude
• Pre- and post-test
Both groups significantly improved their scores after intervention.
No difference in improvement between groups
Hadley 2010 UK 237 (7 clusters) Cluster RCT Medical interns
Clinically integrated teaching of EBM: Three modules on
EBM (asking questions, accessing literature, appraising
literature). Unlimited access for six weeks
Standalone, three hour face-to-face
lecture (same content as
intervention)
• EBM knowledge
• EBM skills
• Pre-and post-test
Post-intervention knowledge scores improved in both groups.
No difference in the amount of improvement between groups
Horiuchi
2009Japan 93 RCT Nurses
E-learning of EBM divided into four parts, distributed
according to individual progress
EBM teaching divided into one
evening lecture per week (for one
month)
• EBM knowledge
• pre- and post-test
• Satisfaction with learning
No difference in post-intervention knowledge scores. Significant
change between pre-and post-intervention scores in web-based
group, but not in face-to-face group.
Kamin 2001 USA 27 RCT
Undergraduate
physician
assistants
EBM course with computer-mediated communication
using asynchronous discussion software
EBM course with face-to-face
discussions in mentor groups
• EBM knowledge
• Pre-and post-test
Both groups improved scores after intervention.
No difference in post-intervention score between groups.
Significant attitudinal differences between groups
Kulier 2009 UK, Netherlands 61 (6 clusters) Cluster RCT
Obstetrics and
gynaecology
residents
Clinically integrated EBM course with self-directed e-
learning components and clinically relevant activities
Lectures on EBM, using PowerPoint
slides (same as in e-learning).
Interaction with tutor during lectures
• EBM knowledge
• EBM attitude
• Pre- and post-test
Post-test scores improved in both groups. No difference in EBM
attitudes
McLeod 2010 USA441 (12
clusters)Cluster RCT Surgical residents
Online journal club made up of 8 packages emailed to
participants, each package containing one clinical and
one methodological article. Asynchronous discussions on
list serv, moderated by facilitator. Clinical scenarios
included in discussions
Monthly face-to-face journal club
using same articles, led by general
surgical faculty member.
• Critical appraisal skills
• Post-test only
Significant difference between skills scores.
Face-to-face group had better scores.
E-learning vs. Other types of e-learning
Brouwers
2011Canada 87 RCT
Healthcare
professionals,
Clinicians,
methodologists,
policy makers and
trainees
1) Online tutorial on AGREE II tool
2) Online tutorial on AGREE II tool plus practice
feedback
Participants were given the AGREE II
manual
• EBM skills (appraising a
guideline)
• Satisfaction with learning
• Self-efficacy
• Attitudes
• Post-test only
No difference between groups for any of the outcomes
Fernandez
2014Australia 187 Non-RCT
Postgraduate
nursing students
Evidence-based practice (EBP) DVD: demonstrations of
EBP skills provided on a DVD
1) Standard distance method
2) Computer Lab teaching method
(on campus) – practical
interactive computer-based
training with immediate
feedback
3) Face to face didactic classroom
teaching method – classroom
teaching
• EBP knowledge
• EBP skills
• Post-test only
Group receiving DVD scored higher for developing question,
identifying level of evidence, and critical appraisal than other
groups. No difference in searching the literature
Kulier 2012
Argentina, Brazil,
Democratic
Republic of
Congo, India,
Philippines, South
Africa, Thailand
204 (60
clusters)Cluster RCT
Obstetrics and
gynaecology
residents
Clinically integrated EBM e-learning course containing
recorded presentations but incorporating learning
activities, assignments and assessments in clinical
practice. Clinical trainer involved in face-to-face teaching.
Self-directed EBM teaching package
containing recorded presentations.
Access to facilitator that could be
consulted on demand.
• EBM knowledge
• EBM skills
• EBM attitudes
• Educational environment
• Pre- and post-test
Significant difference in post-test knowledge and skills scores
between groups.
Clinically integrated e-learning group had better scores.
No effect on educational environment.
MacRae 2004 Canada 81 RCT Surgeons
Online journal club made up of 8 packages emailed to
participants, each package containing one clinical and
one methodological article. Asynchronous discussions on
list serv, moderated by facilitator.
Participants also received 8 packages
per email and were given access to
main medical and surgical journals.
• Critical appraisal skills
• Post-test only
Significant difference in critical appraisal skills between groups.
Online group plus asynchronous discussions had better scores.
BackgroundSystematic reviews show that teaching EBHC to students and healthcare professionals leads to increased EBHC knowledge and skills. Thequestion is therefore no longer whether we should be teaching EBHC, but rather how we should be teaching it. We assessed theeffectiveness of EBHC e-learning on EBHC competencies in healthcare professionals.
MethodsWe considered randomised and non-randomised controlled trials, interrupted time series and controlled before-and-after studies thatcompared EBHC e-learning or blended learning to no learning, face-to-face, blended or e-learning for healthcare professionals. Wesearched MEDLINE, EMBASE, CENTRAL, CINHAL, ERIC, SCOPUS, PsychInfo and Web of Knowledge. Two authors independently screenedsearch outputs, selected studies for inclusion, extracted data and made risk of bias judgements. Discrepancies were resolved throughdiscussion. We synthesised results in a meta-analysis where possible and narratively synthesised results of outcomes where meta-analysis was not possible.
Preliminary resultsThe search yielded 3770 references after removal of duplicates. After title andabstract screening, we identified 32 potentially eligible studies, of which 17 metour inclusion criteria (Figure 1). Included studies were individually and clusterRCTs and controlled trials. Participants included undergraduate and postgraduatestudents as well as practicing clinicians. Most studies compared EBHC e-learningto lectures or no learning, while some compared blended learning to lectures orno learning. Overall, studies were of moderate quality, but 10 of the studies werejudged as having high risk of attrition bias, due to large loss to follow-up (Figure2). Due to heterogeneous interventions and outcome measurements, we werenot able to perform meta-analysis and reported results narratively (Table 1).Knowledge scores improved after e-learning interventions when compared to nolearning. When comparing e-learning to face-to-face interventions, knowledgescores improved in both groups and there was generally no difference in theimprovement. One study that compared a clinically integrated e-learning moduleto a pure online module showed significantly more improvement in knowledgescores in the clinically integrated e-learning group.
ConclusionE-learning of EBHC is effective in increasing EBHC knowledge and skills but should be integrated into clinical modules for maximum benefit and relevance.
Figure 1: Flow diagram of included studies
Figure 2: Summary graph of risk of biasTable 1: Characteristics and results of included studies
+
-
?
Low risk of bias
High risk of bias
Unclear risk of bias
