0% found this document useful (0 votes)

8 views

An Evidence-Based Practice

hi student material

Uploaded by

daneilkindu

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

0% found this document useful (0 votes)

8 views

An Evidence-Based Practice

hi student material

Uploaded by

daneilkindu

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 156

Evidence-Based Practice

(EBP)

Mulugeta D

March, 2024

8 March 2024 1
▪ What is Evidence-Based Practice?

8 March 2024 2
What is Evidence-based practice/EBP?

➢ Different scholars define EBP in d/t ways

❖ A definition most agreed upon it is a problem-solving approach that

integrates the conscientious, explicit, and judicious use of current best
evidence in making decisions in combination with a clinician’s /expert’s
expertise as well as patient/ customer values and preferences.

➢ It is a three-pronged and overlapping approach, also known as the

“Triad approach”

➢ “The conscientious and judicious use of current best

evidence in conjunction with clinical expertise and patient values
to guide health [and social] care decisions” (Sackett et al. 2000: 71–72)

8 March 2024 3
▪ What is the relation ship b/n EBP and
Practice Based Evidence (PBE)?

8 March 2024 4
Evidence informed decision making
practice/EIDMP

➢ What is Evidence-informed decision-making practice/EIDMP?

▪ It is the latest definition of EBP by improving its limitations.

▪ EIDMP is using evidence to inform the decision-making, but not a

sole determinant for decision making

▪ EIDMP is one of the components required to make a decision

▪ In EIDMP, local context, personal opinions, situations, standards,
etc are taken into account to make a sound decision

▪ Evidence + local context + standards+… = EIDMP - Alan-

pearson---father of JBI
▪ It is to mean that evidence is not the only basis to make a decision.
8 March 2024 5
Key Components of Evidence-
based practice

➢ EBP has 3 key components, namely:

1. The use of validated/synthesized

evidence and

2. Clinical or professional judgment

and

3. Patient/Customer preference

8 March 2024 6
Evolution of Evidence-based Practice?

• Hence, the modern definition of EBP as per BEST

AVAILABLE
Pearson: “Decision-making that considers EVIDENCE
the Feasibility, Appropriateness,
Meaningfulness, and Effectiveness (FAME) CLIENT/
of practice.” PATIENT
CONTEXT PREFERENCE
• The best available evidence, the context
in which care is delivered, the individual
patient and the professional judgment and
PROFESSIONAL
expertise of the health professional inform JUDGMENT
this process.” =

8 March 2024 7
FAME

▪ Feasibility is the extent to which an activity is practical and

practicable. Clinical feasibility is about whether or not an activity
or intervention is physically, culturally, or financially practical or
possible within a given context. (Pearson et al., 2005)

▪ Appropriateness is the extent to which an intervention or activity

fits with or is apt in a situation. Clinical appropriateness is about
how an activity or intervention relates to the cultural or ethical
context in which care is given. (Pearson et al., 2005)

8 March 2024 8
FAME

▪ Meaningfulness refers to the meanings patients associate with an

intervention or activity as a result of their experience of it.
Meaningfulness relates to the personal experience, opinions,
values, thoughts, beliefs, and interpretations of patients or clients.
(Pearson et al., 2005)

▪ Effectiveness is the extent to which an intervention, when used

appropriately, achieves the intended effect. Clinical effectiveness
is about the relationship between an intervention and clinical or
health outcomes. (Pearson et al., 2005)

8 March 2024 9
Activity 1: Elements of EBP

Discuss with the group:

1. Do you think that one of the elements of
EBP is currently dominating in your area
of practice?

2. Do any of these areas highlight additional

responsibilities for health professionals?

3. Reflect your discussion to the room!

8 March 2024 10
JBI MODEL
• The JBI Model of EBP was initially
developed in 2005 and updated in
2016.
• The inner circle represents the pebble
of knowledge, while the inner wedges
outline JBI’s conceptualization of the
steps involved in the process of
achieving an EBP approach to clinical
decision-making.
• The outer wedges operationalize the
component parts of the Model and
articulate how they might be actioned
in a pragmatic way.
• The arrows indicate that the flow can
be bi-directional.
Overarching principles
11 Culture–Capacity–Communication-Collaboration
The JBI Pebble

• The inner circle represents EBP as per Pearson’s

concept /of modern EBP/.

• The JBI Model conceptualizes EBP as decision-

making that considers the feasibility,
appropriateness, meaningfulness, and
effectiveness of healthcare practices.

• The best available evidence, the context in which

care is delivered, the individual patient and the
professional judgment and expertise of the health
professional inform this process.

12
Global Health & Collaboration in JBI

▪ JBI believes that EBP should be driven by the

needs of global health. The achievement of
improved global health is seen as both the goal
(endpoint) & “driving force” of EBP.
▪ This may be actioned via:
• Sustainable Impact: Often evidence
implementation activities succeed in making a
change to healthcare practices.
• Engagement & collaboration (at all levels):
This is imperative to successfully address the
significant issues we face in delivering EBP.
• Knowledge need: “Gathering knowledge of
what people need, what resources are available,
and what limits constrain their choices” is vital to
EBP in healthcare (Jordan and Pearson, 2013)
13
Evidence Generation in JBI Model

• Evidence is “the basis of belief. ”

• The evidence generation wedge of the Model

identifies discourse (or narrative), experience,
and research as legitimate means of knowledge
generation.

• It recognizes that the results of well-designed

research studies grounded in any
methodological position, anecdotes, or personal
opinion and expertise are all deemed valid
methods of generating evidence to inform policy
and practice.

• Sources of evidence include Research,

Experience, Discourse,

14
Evidence Synthesis in JBI Model

• Evidence synthesis is the evaluation

or analysis and collation of research
evidence and opinion on a specific
topic to aid in decision-making in
healthcare.

• The three main components of this

wedge are systematic reviews,
evidence summaries, and Clinical
guidelines.
• All these are steps to generate evaluated
evidence for decision.

15
Evidence Transfer in JBI Model

• Fundamental to the process of

EBP is the ability of those at the
point of care to access
synthesized research evidence.

• Evidence transfer is the coactive,

participatory process to advance
access to and uptake of evidence
in local contexts.

• It incorporates active
dissemination, systems
integration, and education.

16
Evidence Implementation in JBI Model

• Evidence implementation is a purposeful and

enabling set of activities designed to engage
key stakeholders with research evidence to inform
decision-making and generate sustained
improvement in the quality of healthcare delivery.

• Components of evidence implementation include

a context analysis, the facilitation of practice
change, and the evaluation of process and
outcome.
• Context analysis: How ready is the organization
for change/implementation?
• Facilitation: Change or implementation projects
require a facilitator or driver of the change in an
engaged process.
• Evaluation: To determine the impact of change
and inform future activities, data on processes
and outcomes should be collected.
17
Evolution of Evidence-based practice?

Improved
health/service
Fig: Satterfield et al (2009) Toward a /performance
Transdisciplinary Model of EBP

8 March 2024 18
Components of Evidence-Based Practice?

8 March 2024 19
Components of EBP…

Old approach/EBP NEW approach

20
8 March 2024
Components of EBP with some
elaborations

8 March 2024 21
Aim / the need to have EBP
➢ Assures patients /customers receive the most up-to-date care
➢ Increase quality of care & effectiveness of programs
➢ It increases confidence in decision-making
➢ Reduce risks & possible harm/unnecessary outcomes
➢ Encourage researchers to conduct quality research
➢ Help to evaluate the quality of research findings/ literature??
➢ It is a means to translate research findings into practice
➢ It will create a teamwork/participatory research
➢ It can minimize medical errors and biased decision-making
➢ It is important to improve the quality of research, education…

8 March 2024 22
WHY we are worrying about EBP?

1. One of the reasons we do need

to focus on EBP is because of
the 60-30-10 challenge.
• Only 60% of care on average is
in line with evidence- or
consensus-based guidelines
• 30% is some form of waste or of
low value, and 10% is harm.
• 40% wastage or harm to pts!!
• The 60-30-10 challenge has
persisted for three decades.
Hence, we need to identify the
root cause and act accordingly to
avoid this much waste and harm.
WHY we are worrying about EBP?

2). Huge research implementation gaps

Research

3). High patient/customer dissatisfaction

4). High environmental competition
5). Presence of bulky and unfiltered literature, ETC
Different forms of EBP

▪ Since EBP is the use of valid evidence, expertise, values of

customers, and the context, it is applicable in all disciplines as:
• Evidence-Based Practice
• Evidence-Based Medicine
• Evidence-Based Nursing
• Evidence-Based Management
• Evidence-Based Education
• Evidence-Based Midwifery
• Evidence-Based Public Health
• Evidence –Based Education, etc

8 March 2024 25
Steps of Evidence Based Practice?

8 March 2024 26
Steps of EBP
➢ EBP has a five step model:- 5A’s

1. Formulating answerable questions (Ask)

2. Searching for the best evidence to questions (Access)

3. Critical apprising the Evidence/checking quality

(Strengths & applicability) of evidence (Appraise)

4. Synthesis /aggregate and Apply evidence (Apply)

5. Evaluating performances (Assess)

8 March 2024 27
Steps of EBP #1
Steps of EBP…

8 March 2024 29
Step1: Formulating Answerable
Questions?

8 March 2024 30
Step1: Formulating answerable
questions
• Formulating clear, specific & answerable questions is a very critical
& difficult step in EBP

• B/c if you don’t know what to be solved, your next steps will be in
poor outcome
• There are d/t types of formulating questions, where PICO is one.

• PICO (PICO_ST) is the commonest Cochrane library

✓ P – Patients/Population of interest/problem,
✓ I -- Intervention /Indicator---
✓ C -- Comparator/comparison group,
✓ O – the Outcome of interest
✓ (_ST = S --- a type of Study design, T---Time-bounded)
8 March 2024 31
Formulating answerable questions

• From PICO, d/t information is needed to formulate better

questions
• Information related to:
• Type of questions/problem/,
• Population affected by the problem,
• Interventions given &/or their frequencies,
• Possible outcomes of the interventions given…is required
• NB. It might not be a must to have comparator groups always

8 March 2024 32
• First, think about the patient and/or settings
you are dealing with

• Try to identify all of their clinical characteristics

that influence the problem

• Be as specific as possible at this stage, but you

should bear in mind that if you are too narrow
in searching you may miss important articles

8 March 2024 33
Formulating answerable questions
➢ P – It is to describe types of patients/population groups affected or got
the intervention/ eg trial intervention.
➢ P - will also include the type of comparators.
➢ Try to identify all of their clinical characteristics that influence the
problem
➢ It includes:
– Male/female?
– Elders/children?
– Men/women?
– Poor/rich?
– Rural/urban?
– Literate/illiterate etc

8 March 2024 34
Formulating answerable questions

➢ I – This will describe the following information:

• Types of intervention/s given to P & comparators.

• Time, dose, and frequencies of interventions given/planed

• A problem that needs intervention to have O

• It can be a problem for P and to bring O.

➢ I Can be: • Exposure,

• Treatment, • Counseling,
• Diagnostics, • Education,
• Referral, • Prevention, etc
8 March 2024 35
Formulating answerable questions

➢ C – This will describe the following information:

• Comparators of intervention groups; Eg. Placebo, standard Rx.

• In a clinical trial, comparator/s is/are control groups

• It is common with two population study

• In some cases, it is not a must to have a C

• Population to appreciate the outcomes on P due to I

8 March 2024 36
Formulating answerable questions

➢ O – It is the primary interest of the study that I or exposure

results
➢ If changes are +ve/-ve & larger, an I is appropriate & has a
chance of being implemented after successive evaluations.
➢ If no change (∆ =0 /very close to 0), no need of applying I
➢ This will include the following:
➢ Improvements /changes/ on P & C due to I
➢ Can be death, odds ratio, RR, mean d/ce, proportion changes…
➢ In some cases, changes/improvements might not be seen =
intervention failure /inappropriateness

8 March 2024 37
Formulating answerable questions

➢ “_ST ” – In some cases, study design used & time of

intervention might be required.

➢ The times of study and I are critical to the effectiveness of I

➢ This will include the following:
• Type of study design used: clinical trials, cohort, systematic
review & meta-analysis… are recommended/powerful.
• Information about the period of study & Intervention, etc

• Eg. For how long period I was applied? For how long time I is
recommended?

8 March 2024 38
Types/Categories of Questions

▪ Generally, scientific questions that need evidence from different

sources are two types:
• Background questions:
o Are general questions/information that can be collected by
referring to textbooks, documents, records, etc
o Are questions that do not need critical questions and reviewing
databases
• Foreground questions:
o Are questions that need detailed & specific evidence from d/t
sources
o Has 4 components: PICO_st?

8 March 2024 39
Types /Categories of questions
• Formulated questions can be d/t in its type
• Study design can determine the type of evidence to be searched &
reviewed. Questions by their type can be grouped as:
Question Description of information Study designs to answer
type questions
Therapy Information about the Effectiveness RCTs, Meta analysis
and/or risk of a specific treatment
Diagnosis Information about the Accuracy or RCTs, Cohort study
usefulness of a diagnostic tool/test
Etiology/ Information on cause or risk factors RCTs, meta analysis, cohort
Harm for a disease or condition study
Prognosis Information on probable outcome, Cohort study > case control
progression or survivability study
Meaning Detail understanding of Concepts, Qualitative study, systematic
phenomena,… review of qualitative study
40
Typology for question building

Step2: Finding the Best Evidence?

8 March 2024 41
Temple for asking answerable questions

▪ Things that we need to consider to search and also to summarize

the concepts/contents of evidence after searching.

8 March 2024 42
▪ Example1:
▪ Do the campus smoking ban decrease the amount that
students smoke?
• P = Smoking campus students
• I = Smoking ban
• C = No smoking ban
• O = Students smoke less or no smoking

8 March 2024 43
• Eg: Regional Health Bureau head needs consultation from senior
leadership trainers. He asked trainers as he needs to see if short-term in-
service leadership training can improve the commitment and
accountability of position-holder staff at offices and health facilities.
• P = Position holder staff at office & facility
• I = Short-term in-service leadership training
• C = position holder staff who do not get training
• O = Improved commitment and accountability of staff

• PICO question: Can short-term in-service leadership training improve

the commitment and accountability of position-holder staff at offices and
health facilities for better engagement and performance of the health
system?
8 March 2024 45
Eg4: Aster comes to your antenatal clinic to consider a water birth. But
she wants to know if being born underwater, compared with being born
on ‘dry land’, would present any additional risks to her baby.
▪ Hence, identify PICO that can be helpful to design questions for giving
precise answers or information to her, so that she can decide.
Population (P) Newborn babies Press to reveal
Intervention (I) Waterbirth Press to reveal
Comparison (C) 'Land' birth Press to reveal
Outcomes (O) Neonatal morbidity or mortality

• PICO Question: In newborn babies, does a waterbirth (compared with being

born ‘on dry land’), increase the risk of morbidity or mortality?

8 March 2024 46
• Activity 2: home-based individual assignment
1. Think of ideas for PICO formulation: Areas could be clinical
practice, leadership/management, education, etc
2. Practice identification of four PICOs from your ideas.
3. Formulate four PICO questions based on your PICOS.
4. Also indicate the techniques for how you will search for
literature from potential sources for your PICO questions.

8 March 2024 47
Step 2: Finding the Best Evidence?

8 March 2024 48
Step2: Finding the Best Evidence

▪ Searching for the best external evidence is very critical to

answer the formulated question
▪ A good search is characterized by the following points,
but not limited to:
▪ Clear research question ̴ PICO_ST
▪ Comprehensive search
o All domains, no language restriction, unpublished and
published literature, up-to-date
▪ Document the search (replicability)

8 March 2024 49
Step2: Finding Evidence…

▪ To search for adequate and valid evidence, we need to ask

and answer the following critical questions:
✓ What Evidence is required?
✓ From where it will be searched?
✓ How it will be searched?
✓ Who will search it?
✓ When it will be searched?
✓ Are all evidence important to our question?
✓ If not, how can we evaluate & select these sources?
▪ Note! Researches need to have an evidence search plan

50
Sources of EBP…
➢ EBP needs evidence from defined sources

➢ In general sources of Evidence can be:

1. Published article in peer-reviewed journals

2. Grey literature;
– Office reports
– Government reports Online search & in
– Unpublished research person collection

– Preceding, Briefs
– Expertise opinion
8 March 2024 51
Sources of EBP…
▪ The inclusion of unpublished & grey literature may minimize
the potential effects of publication bias.

▪ Publication bias occurs when the outcome of an experiment

or research study influences the decision about whether—or
how quickly—the manuscript may be published.

52
Sources of EBP…

➢ Based on availability, sources of EBP can be:

▪ Online sources/websites & Databases: the following are

common data bases in health.
• Google Scholar, PubMed,
• EMBASE, HENARI,
• Scopus Web of Science
• Medline, NIH library,
• Cochrane library, Research4life (health +agriculture) Etc

▪ Non online sources:

▪ Grey literature are under this category
53
Google Scholar

▪ Owned by Google company (USA)

▪ Contains only research outputs
▪ Not specific, includes predator articles
▪ The search output gives:
• # of articles found
• Time period option
• Title & its format (Pdf, HTML)
• Options: Save, cite, cited by, etc
▪ When click on “Cite” option, you will get options of reference
management software (EndNote, Zotero, Mendeley…) and
Reference styles (APA, Vancouver, Harvard, etc)

8 March 2024 54
Google Scholar…

• Contains only research outputs

• Not specific, includes predator articles
• The search output gives:

8 March 2024 E-mail: [email protected] Website: www.bdu.edu.et/cmhs 55

Researc4 life

▪ Research4Life is the collective name for five programs –

HINARI, AGORA OARE, ARDI, GOALI.

▪ It provides developing countries with free or low-cost access

to academic and professional peer-reviewed content online.

▪ It is a huge literature database for health, agriculture,..

▪ It has higher geographic coverage

8 March 2024 56
• Online portal to access information on health and related social
sciences

• Coordinated by WHO and Yale University

• Offering up to 13,500 journals / 60,000 books / 110 other information

resources / 150 publishers' content included [June 2018]

• It is with subscription / Individual or Institutional

• Discount or waiver will be given to developing countries, students,…

• It is through a login using the user ID given

• Its address is = https://www.who.int/hinari

8 March 2024 57
• Click on the Hinari logo to open the program.
• All the programs your institution is registered for are listed. Login to any of the
other programs by returning to this page (use the R4L Portal – Applications tab
at the top of the web browser).
• To open another program, click on the specific logo.
• Your Hinari username and password will grant access to the other programs
(and ditto for your institution’s AGORA, ARDI GOALI or OARE logins).

8 March 2024 58
• Online portal to access information on health and related social
sciences

• Coordinated by WHO and Yale University

• Offering up to 13,500 journals / 60,000 books / 110 other information

resources / 150 publishers' content included [June 2018]

• It is with subscription / Individual or Institutional

• Discount or waiver will be given to developing countries, students,…

• Its address is = https://www.who.int/hinari

8 March 2024 E-mail: [email protected] Website: www.bdu.edu.et/cmhs 59

PubMed

• Owned by the National Library of Medicine /NIH/

• PubMed has space “Advanced search” space for searching

• It has Mesh

• Is a free-access database through login

• Contains only peer-reviewed articles

• It gives PubMed ID for each published article

• Its address: https://pubmed.ncbi.nlm.nih.gov/

8 March 2024
60
PubMed
❑ Medical Subject Headings (MeSH)
➢ It is a controlled vocabulary produced by the National Library of
Medicine
• used for indexing
• Cataloging
• Searching for biomedical and health-related information and
documents
• Searching with MeSH-controlled vocabulary give you more precise
search results

• Has a user guide

➢ To search for literature, use advanced search space

8 March 2024
61
• To access the MeSH Database from the PubMed
homepage, click on the link from the right column
of the PubMed home page.
• A second way to access MeSH is to open the
Databases drop down menu and then to click on
MeSH.
PubMed: Advanced Search Space

8 March 2024 63
PubMed: Searching outputs

• Has a user guide

• PubMed gives us citation/title & address for each
• Abstract
• Full article
• options: save, email, send to for search outputs
• Shows us search outputs/total & list of each/
• Tells us the time period given,

• etc

8 March 2024 64
PubMed: Advanced Search Space

8 March 2024 E-mail: [email protected] Website: www.bdu.edu.et/cmhs 65

PubMed: Advanced Search Space

o After getting appropriate references from data bases,

o You can choose either all or some from the list of literature
o You can also Click either on save or send buttons
o If click on send button, choose to whom:
✓ Email?
✓ Reference manager software?
✓ Folder?
o If reference manger, to which?
EndNote? RefMe?
Mendeley? SciRef?
Zotero? RefWork? etc

8 March 2024 66
Sources of EBP…

▪ Based on accessibility, online evidence sources can be:

a. Open sources
Eg. PubMed, Web of Science, Google Scholar, …

b. With subscription,
Eg. HENARI, Scopus,

C. Protected /secured
Eg. Medline, EMBASE, Cochrane library?

67
Sources of EBP…
➢ It is best if we have systematic review and Meta-analysis evidence
than single research; why? b/c

1. It increases the power of study/evidence = ability to detect the

exact /existing/ true estimate of a test/method

2. Provides better estimate with narrower CI due to relatively

larger sample size and lowered bias by various mechanisms

8 March 2024 68
Searching for best evidence…

How can we get evidence?

▪ We can get evidence by searching from all possible sources

▪ For non-online sources, we can collect hard/soft copies in person

▪ For electronic sources, we will use d/t searching strategies:

▪ Symbols, keywords, Mesh terms, phrases, synonyms (truncation/wild

cards), browser, internet, database, etc are crucial & need to be
included in the searching for evidence plan.

▪ Define time, geography/place/, study design, etc = important to

narrow search outputs

8 March 2024 69
Searching for best evidence…

8 March 2024 70
How can we searching for best evidence…

➢ Identify terms that you would want to include in your search:

➢ Question: In patients who have had a heart attack, does simvastatin

reduce mortality?

8 March 2024 71
How can we searching for best evidence…

8 March 2024 72
How can we searching for best evidence…

8 March 2024 73
How can we searching for best evidence…

➢ Boolean (Search) Operators

• Connect terms and locate records containing matching terms
• Inserted in a search box – AND , OR , NOT
• Must be in UPPERCASE when used

➢ AND Operator
• The AND operator is used to combine two
concepts e.g. hip AND fracture.
• In the shaded area; retrieves items
containing all the search terms

8 March 2024 74
How can we searching for best evidence…

OR operator NOT operator

▪ Renal OR kidney – in the shaded area with ▪ pig NOT guinea – in the
the overlap in the middle having both search shaded area; eliminates items
terms; retrieves items containing either
in 2nd term (guinea) terms
search term or both search terms

8 March 2024 75
Using truncation and wild cards

▪ Are searching technique used to find variations and plurals of a

word, using a common stem or root word.
▪ It is a technique used where a word ending is replaced by a symbol.

▪ Commonly used symbols are asterisk (*), question mark (?),

hashtag (#), exclamation point (!), dollar sign ($)
▪ Using phrase or proximity searching: “…”
• Allows you to search for an exact phrase. E.g. “Information literacy”

▪ Eg1. If the truncation symbol is , then the truncated word, prevent,

will search for prevention, preventive, preventable, etc

▪ Eg2. contamina$ will give literature such as contamination, contaminants,

contaminated, contaminate, contaminates

▪ Eg3. Wom?n for Woman or Women

76
Sensitivity and Specificity of
evidence review

▪ To increase sensitivity; ▪To increase specificity:

• Expand your search using (broader
• Use a thesaurus to identify more
terms) in the thesaurus. specific headings
• Use a text word search of the database
• Use more specific terms in the
• Use truncation and wildcards to catch text word search
spelling variants.
• Use Boolean AND to represent
• Use Boolean OR to make sure you have other aspects of the question
included all alternatives for the terms you • Limit the search by publication
are after (myocardial AND infarction) OR type, year of publication, etc.
(heart AND attack))

8 March 2024 77
How can we get evidence?

• Literature noted the types of literature review as follows:

1. Narrative (traditional) searching
2. Descriptive or Mapping Reviews
3. Scoping Reviews
4. Systematic Review and Meta-analysis
5. Critical Reviews
6. Realistic Review
7. Umbrella Review

8 March 2024 78
Searching for best evidence…
1. Narrative/traditional review
▪ Is simply putting a narrative review to summarize or synthesize
what has been written on a particular topic but does not seek
generalization or cumulative knowledge from what is
reviewed
▪ Is skewed towards a qualitative interpretation of prior knowledge

▪ Here, research questions are broader, not narrow & specific

▪ Uses informal, unsystematic & subjective methods to collect,
interpret, and summarize information.
o Searching, quality appraisal & data synthesis are often not
documented & auditable.
o Greater risk of author and selection bias
8 March 2024 79
Searching for best evidence…

2. Descriptive or Mapping Reviews

• The primary goal is to determine the extent to which a body of
knowledge in a particular research topic reveals any interpretable
pattern or trend with respect to pre-existing propositions, theories,
methodologies or findings.

• May not systematically review all of the literature, but present studies
that are representative of most works published in a particular area &
they consider a specific time frame to be mapped.

• Unlike narrative review, it follows a systematic & transparent

procedure, including searching, screening & classifying studies

• Questions are generic & relate to publication patterns, trends over a

certain period.
8 March 2024 80
Searching for best evidence…

3. Scoping Reviews
• Attempts to provide an initial indication of the potential size &
nature of the extant literature on an emergent topic
• Also conducted to examine the extent, range and nature of
research activities in a particular area,
• Determines the value of undertaking a full systematic review, or
identify research gaps in the extant literature
• It usually concludes with the presentation of a detailed
research agenda for future works along with potential
implications for both practice and research
• Unlike former reviews, the aim of scoping the field is to be as
comprehensive as possible, including grey literature.

8 March 2024 81
4. Aggregative Reviews/
Systematic Review

▪ A review of the evidence on a clearly formulated question that uses systematic

and explicit methods to identify, select and critically appraise relevant primary
research, and to extract & analyze data from the studies that are included in the
review.

▪ It uses transparent procedures to find, evaluate & synthesize the results of

independent studies to minimize bias.

▪ A systematic review must have:

1. Registration
2. Reporting standard---usually a PRISMA statement /checklist/ & diagram
3. Clearly defined objective /question
4. Clear inclusion and exclusion criteria
5. Explicit search strategy
6. Systematic coding & analysis of included studies
7. Meta-analysis (where possible)
Searching for best evidence…

▪ Difference systematic review & traditional review?

▪ Narrative ▪ Systematic review
(Traditional review)
• Objective
• Subjective • Narrow question
• Broad question • Methods clearly defined
• Studies appraised
• Methods unclear
• Has clear searching steps
• Studies not appraised and strategies

• Searching steps & strategies • Each strategy is auditable

and replicable
are not clearly defined

8 March 2024 83
Searching for best evidence…

▪ Why are systematic reviews

important?
• Identify gaps in current research
• The need to filter and use unfiltered
bulky information/information overload
• EBP requires valid evidence
• Presence of information hierarchy
• To select quality& applicable information
• To minimize information bias & increase
power of evidence
• Is replicable
84
Searching for best evidence…

❑ The steps /key elements of a systematic review:

1. Formulate the question---PICO
2. Plan the review
3. Comprehensive search
4. Unbiased selection and abstraction process
5. Critical appraisal of data
6. Synthesis of data (may include meta-analysis)
7. Interpretation and report of results

8 March 2024 85
Searching for best evidence…

Meta-analysis
• Is a quantitative approach for systematically combining results of
previous research to arrive at conclusions about the body of
research.

• Is a statistical method to combine the results of independent studies

into a single new quantitative estimate or pulled value or
summary effect size along with Confidence interval (CI)

• Meaning: generating new knowledge by combining existing

evidence.

• The summary effect size is a value that reflects the average magnitude
of the intervention effect for a particular outcome of interest.
Searching for best evidence…

Meta-analysis
• Though meta-analysis is a powerful tools for deriving meaningful
conclusions, it might not always be feasible to run it due to:
• Clinical, Methodological and Statistical heterogeneities of the
included studies.
• In these cases, it is recommended to conduct the following analysis:
1. Do not do meta analysis
2. Exclude studies (outlying studies)
3. Use qualitative synthesis for each
4. Subgroup analysis based on heterogeneity variable
5. Meta-Regression Analysis

• For example, qualitative synthesis includes vote counting, content

analysis, classification schemes & tabulations.
87
What is meta-regression analysis?

• Meta-regression is a meta-analysis that uses regression

analysis to combine, compare, and synthesize research
findings from multiple studies while adjusting for the effects
of available covariates on a response variable.

• Is a quantitative study design used to systematically assess

previous research studies to derive conclusions about
that body of research.

• Is used to investigate differences for categorical

explanatory variables as done in subgroup analyses.

8 March 2024 88
Meta-Analysis…

• Meta-analysis will use fixed or random-effects models to combine

the results of reviewed studies, assess heterogeneity, and calculate
a weighted average effect estimate from different studies.

• The fixed-effects model assumes that: 1). The true effect of

treatment is the same for every study, and 2). There is low
heterogeneity. But in reality, it might not be always true.

• Thus, using a fixed model is not recommended in meta-analysis

• Random-effects model whereas assumes that:
1. The true effect estimate for each study varies,
2. There is high heterogeneity,
3. It provides larger CI.
Heterogeneity Assessment
in Meta-analysis

▪ Heterogeneity is estimated by:

1. Forest plot (I2) with values ranging from 0-100%.= Value by
heterogeneity, not by chance

▪ Heterogeneity: Low if I2 <25%, medium if I2 is 25 -74% &

high if I2 is > 75%.

▪ Systematic review will not end with meta analysis if I2 is high.

2. Using Cochrane Q statistic: the weighted sum of squared

differences b/n individual study effects and the pooled effect across
studies. P-value will decide the heterogeneity.

3. Using CI: heterogeneity has wider CI -- indicative of errors

Risk of bias in systematic review

• English-language bias - occurs when reviewers exclude papers

published in languages other than English

• Citation bias - occurs when studies with significant or positive results

are referenced in other publications, compared with studies with
inconclusive or negative findings

• Inclusion / exclusion bias: excluding important or including less

important

• Publication Bias - arises when trials with statistically significant results

are more likely to be published in high reputable journals and cited most.

• Publication bias will be indicated by Funnel plot

8 March 2024 91
Funnel plot
• A funnel plot is a simple scatter plot of the intervention effect estimates
(OR, logOR) from individual studies against some measure of each study’s
size or precision.

8 March 2024 92
Searching for best evidence…

5). Realistic Reviews

▪ Are theory-driven interpretative reviews developed to inform,
enhance, or supplement conventional systematic reviews by
making sense of heterogeneous evidence about “complex
interventions” applied in diverse contexts to inform policymakers

▪ It usually starts by articulating likely underlying mechanisms &

then examines available evidence to find out whether and where
these mechanisms are applicable.
▪ Are important to generate evidence when generating
pooled value is impossible due to:
o Heterogeneity, and nature of variables (qualitative)
▪ Is mostly applicable in social science, and also in Medicine.

8 March 2024 93
Searching for best evidence…

6). Critical Reviews

▪ Aim to provide a critical evaluation & interpretive analysis of
existing literature to reveal weaknesses, contradictions, strengths,
controversies, inconsistencies, and/or other issues with respect to
theories, hypotheses, research methods or results.

▪ Unlike other review types, this attempts to take a reflective account of the
research, and assess its credibility by using appraisal instruments.

▪ Also attempts to constructively inform other scholars about the

weaknesses of prior research and indicate focusing directions for
further improvement.

▪ It can also be termed as ‘article critique’ or ‘Journal club.’

8 March 2024 94
How to conduct article critique?

❖Article critique report needs to include the following:

1. Name(s) of the author(s) 7. Objectives,

2. Title of article 8. Approach or methods,
3. Title of journal, volume number, date, 9. Findings,
month and page numbers
10. Discussion, and
4. Statement of the problem/issue discussed
11. Conclusion
5. The author’s purpose,
12. Recommendation
6. Hypothesis/research questions,

NB: The critique review needs also to contain some introduction

and conclusion about the review process & reviewed article. 95
How to conduct article critique…

❖ The bulk of your critique, however, should consist of your qualified

opinion of the article.
❖ Read the article to get an overview. Then read it again, critically.
❖ Key steps of your critique review:
• Have the source to be critique at hand
• Read, reread and understand the message of an article
• Take notes on each section of an article
• Evaluate each section is appropriate or not as per the title,
research questions, and study objectives.
• Put your evaluation in the report format or frame work you
developed

8 March 2024 96
How to conduct article critique…

▪ Some questions you want to address in your critique are:

1. Is the title of the article appropriate and clear?
2. Is the abstract specific, representative of the article, and in the
correct form?
3. Is the purpose of the study are described clearly in the introduction
section?
4. Are the author’s statements clear and able to show the relevance of
the study to the readers?
5. Are research questions/hypothesis/ and study objectives clearly
stated and have linked to the title of the article?

8 March 2024 97
How to conduct article critique…

6. Is the study design clearly stated and appropriate to the title?

7. Are methods clear, detailed and appropriate to the title?
8. Are data collection, measurements and processing steps stated clearly and
accepted to answer the study objectives?
9. Are the experimental methods described adequately?
10. Are statistical analysis are stated step by step clearly and appropriate to
the title and study objectives?
11. What statistical models and analysis software used?
12. Are results stated clearly as per the study objectives?
13. Did the author answer study objectives/research questions?
14. Did the author use appropriate data presentation techniques eg. Tables,
figures, charts?
8 March 2024 98
How to conduct article critique…

15. Did the author discuss findings appropriately using right literature,
policy implications and possible justifications?
16. Is discussion from local to global and clear in language?
17. Do you find errors of fact and interpretation in the discussion?
18. Did the author use appropriate, up-to-date and adequate literature and
citation?
19. Had any ideas been overemphasized/underemphasized?
20. How do you evaluate an article in terms of scientific misconduct
(plagiarism, falsification, fabrication, authorship…)?
21. Did the author follow appropriate ethical procedures?
22. Do you find language: punctuation, tense agreement, clarity, idea flow ,
etc errors?

8 March 2024 99
How to conduct article critique…

23. Did the authors put limitations of the article?

24. Are conclusions appropriate (answer objectives) and based on the study findings?
25. Did the author forward specific, targeted and feasible recommendations?
26. Are recommendations only based on study findings of generic?
27. What are the areas that you find with major or minor errors?
28. What is your conclusion on the article:
Strengths: ----------
Limitations: ------------
29. What is your over all recommendation to be a literature source or not? --------------------------------
o Name of evaluator _____________
o Signature __________________
o Date and year ______________________

8 March 2024 100

7. Umbrella Review?

• An umbrella review is a review of systematic reviews or

meta-analyses.
• Is a systematic review that only considers other systematic
reviews as an eligible study type for inclusion.
• Also named as overviews of reviews, reviews of reviews,
summaries of systematic reviews, or syntheses of reviews.
• Is a new systematic review method to get valid evidence

• Are among the highest levels of evidence currently

available in medicine.

8 March 2024 101

Data management & Referencing

➢ What is data management?

➢ Data management is the practice of collecting, keeping,
processing, using, securing & storing an organization’s /researchers’
data, where it is then utilized for strategic decision-making to improve
business /research outcomes.

➢ The goal of data mgt is to help people, organizations, researchers and

connected things optimize the use of data within the bounds of policy and
regulation so that they can make decisions and take actions that
maximize the benefit to the organization /answer research questions.

➢ The data mgt includes a combination of d/t functions that collectively aim
to make sure that the data in corporate systems is accurate, relevant,
available & accessible.

8 March 2024 102

Fundamentals of data management

▪ Good data management is fundamental for:

• Research excellence • Prevent data loss

• High quality data
• Propper communication
• Data sharing, replication
and reuse • Prevent unethical data access & use
• Sustainability • It is a crucial asset for a corporate,
• Long-term sustainability researchers,…
and accessibility
• Important as an auditory tool for
• Data security researchers, corporates,
• Reputational benefit
103
Data management & Referencing

➢ Key components of Data mgt include:

• Data gathering /generating
• Data handling/storage
• Data processing
• Data governance,
• Data security
• Data accessibility
• Data sharing policy and Ethics
• Intellectual property/ownership

8 March 2024 104

Data management & Referencing

8 March 2024 105

Data management & Referencing

▪ Data mgt needs a clear data mgt plan

▪ Data mgt plan needs to consider the following:

• Your institution's and funding agency's expectations & policies
• Whether you collect new data or reuse existing data
• The type of data collected and its format
• The quality assurance methods and data quality status
• Storage, archive, backup policy and implementation
• Form/format of your data
• Storage and archiving options and requirements
• Organizing and describing or labeling the data
• Data access and sharing
• Privacy, consent, intellectual property, and security issues
• Budgeting for data management
106
Data management & Referencing

Managing research data is usually

an integral part of the research
process, so you probably already
do it.

Reasons to retain and manage

research data are to ensure
reproducibility, facilitate online
sharing & create creditability
/witness.

8 March 2024 107

Research data management …

➢ Data mgt is required by institutions: owners, funders,

researchers, supervisors, etc

➢ Five common funder requirements from data mgt are:

1. Detail description of data to be collected/created
2. Data quality strategies/status
3. Standards/methodologies for data collection & management
4. Ethics and Intellectual Property
5. Plans for data sharing and access
6. Strategy for long-term preservation

8 March 2024 108

Research data security

▪ Control access to computers:

• Use passwords and lock your machine when away from it
• Run up-to-date anti-virus and firewall protection
• Restrict access to sensitive materials = privacy
• Avoid personal identifies
• Use codes
▪ Control physical access to buildings, rooms, filing cabinets…
▪ Proper dispose of data & equipment once the project is finished
▪ Use data back up system

8 March 2024 109

Data storage

▪ It needs to include the following, but not limited to:

• Format (excel, spss, stata, etc)
• Name
• Data type : secondary, primary
• Data size
• Data collection techniques
• Data quality activities
• Data codebooks
• Data owner
• Conflict of interest,. etc

8 March 2024 110

Data sharing
Data use
• To whom
• Research
• How
• Decision making
• By which format
• Confirmation
• For what purpose
• Report • For howling period
• Business • Path: in person or email sharing
• Education • With fee or free
• Trainings • With what restriction
• Etc • Etc
8 March 2024 111
Referencing

• It is a standardized method of acknowledging sources of

information & ideas that you have used in your assignment
or research in a way that uniquely identifies their source.

• Texts (direct quotation), facts and figures, as well as ideas

and theories, from both published and unpublished works,
must be referenced.

• Reference list: a list of sources that you have quoted

from or cited in your text.

8 March 2024 112

Referencing…

▪ How can we take message from literature & cite?

a. Read literature & write the message using your own words.

b. Summarize/paraphrase a paragraph you read & cite it.

c. In rare cases, you may do direct copy paste using quotation

that followed by citation if no other better option to
summarize & pass the message of that paragraph = Not
recommended!!

d. If you use literature other than these steps, you may

face to plagiarism

8 March 2024 113

Referencing…

• The purpose of proper citation is to prevent plagiarism.

• Plagiarism: Close imitation or publication of another author's

language, thoughts, ideas, or expressions, and the representation
of them as one's own original work without summarization,
paraphrasing, quotation & citation.

• Plagiarism can be self plagiarism or others’ plagiarism.

• Self plagiarism: using/ redoing own former ideas, publications,

methods, procedures,…for later research work without citation. =
It is most commonly practiced by assuming it is not plagiarism

8 March 2024 114

Referencing…

• Literature can be managed by reference software

• Some of the commonly used software include:
– EndNote
– Mendeley
– Zotero
– RefMe
– SciRef
– RefWork
– etc.
8 March 2024 115
Referencing…

• There are different types of referencing styles

• The choice for referencing style is d/t across d/t institutions.

• The most commonly applied styles are:

• Vancouver (number delegation) .

• Harvard - (author, year).

• APA (American Psychological Association: it follows

Author, year, page, line #) style.

8 March 2024 116

Referencing: Harvard style

• The Harvard referencing system is commonly used in most

journals and in many disciplines.

• Its format of citation is (author, year)

• Is mostly used in social science research

• The reference list will be based on alphabetical

order, not based on order of citation.

• Example:

8 March 2024 117

Referencing: Harvard style…

How to cite /practice it in the document?

▪ One author
• Tilahun (1971) suggested that Abyssinians will be the leading East
Africans by 2030.
• Incidence of AIDS cases is unexpected in Gondar (Mulat, 1990)
▪ Two to six authors
• Aster and Tadesse (1900) reported malaria outbreak in Burie town.
▪ More than six authors;
• Mesay et al. (2011) recommended that thinking malaria prevention
mechanisms is vital parallel to irrigation practices.

8 March 2024 118

Referencing: Harvard style…

• The Harvard referencing system is commonly used in most

journals and in many disciplines.

• Its format of citation is (author, year)

• Is mostly used in social science research

• The reference list will be based on alphabetical order, not

based on order of citation.

• Example:

8 March 2024 119

Referencing: Vancouver style

• This type of system is most often seen in journals.

• The majority of health science literatures use this style.
• The numeric system uses numbers rather than the author's
name in the document citation.
• The reference list is arranged in numerical NOT alphabetical
order.
• Each reference in the document is tagged with a number
according to the order of its citation.
• The reference manager software gives hyperlink to each
reference in the document.

8 March 2024 120

Referencing: Vancouver…

▪ Example. TB has been recognized as a major public health problem in

Ethiopia [1]. The country has been adopting different strategies for TB
control [2].The first 2011 national TB prevalence survey revealed smear
positive PTB prevalence of 108/100,000 [2-4].

▪ Eg. Sample list of references in Vancouver style

1. Andualem M. Transmission and pathogenesis of TB. Clin Chest Med . 2020;

64(2):17-20.
2. EMoH. TB prevention and control guideline 2005. 16 edn. USA: McGraw-Hill
companies Medical publishing division; 2005.
3. Abebe K, Firew T, Aster M, Abate H, Balew Z, Almaz G., et.al. Epidemiology of TB
and ist risk factors in Amhara Region, Ethiopia. BMC Pulmonology. 2012; 320: 12.

121
Referencing: Important!

• Put each citation close to the information you wish to acknowledge.

• E.g. Data collection for the magnitude and risk factors of malaria in
Bahir Dar City was done both in the lab (5 -8) and the field (8, 9).

• Do not put all references of a paragraph together at the end of

the paragraph, which is non specific. = Commonly practiced error!

• Don’t overuse certain citations!

• Use UpToDate and relevant/matching/ literature to your purpose.

• Acknowledge each, even a word, which is not yours.

• Reference you cited must be listed in the reference list.

122
Referencing: EndNote

• Is developed by Thomson Reuters Corporation, but now is

owned by Clarivate Analytics

• It is a software that:
1. Searches literatures from web libraries

2. Stores and organizes references from d/t sources

3. Inserts citations into a Word document

4. Automatically format & update your references

according to a predefined citation style

8 March 2024 123

Referencing: Flows in using EndNote

8 March 2024 124

Referencing: EndNote…

➢ Five steps you follow to import citations into your document:

a. Install EndNote on your PC/Laptop

b. Create an EndNote Library

c. Collect References and Import into EndNote

d. Insert (Cite) the References in MS word

e. Change Reference (Citation) Style

8 March 2024 125

Referencing: Installation of EndNote

1. Open the folder EndNote X9

2. Double click the EndNote X9.exe
3. Click Next and select I would like to evaluate EndNote X9
4. Click Next until finish
5. In the ‘EndNote X9’ folder, copy EndNote.exe
6. Paste it to the installation directory

8 March 2024 E-mail: [email protected] Website: www.bdu.edu.et/cmhs 126

Referencing: EndNote

Step 2: Create an EndNote Library

a. Click on file button

b. Click on new button

c. Specify place/file location to save the file,

d. Give file name to the reference library

e. Click on save button to finish creating process

f. Then, click on file to open and enter reference either

manually or online technique

8 March 2024 127

Referencing: EndNote

Step3: Collect references/ Method 1: Search in databases

Citations &export citations (PubMed)

▪ In this step, we have three a. Perform search in PubMed

methods to apply
b. Mark references to be saved
a. Method 1: Search in databases
and export citations (PubMed) c. From the Send to drop-down
menu, select Endnote.
b. Method 2: Search PubMed
directly in EndNote d. From the send to drop down
menu select Vancouver format
c. Method 3: Manually enter a
Reference e. Save the file

8 March 2024 128

Referencing: EndNote

Step3: Method 1: Import into EndNote

a. Open an EndNote library previously created.
b. To import references, click on . A dialogue box

“Import” appears:
i. Import data file: Browse for the saved file from PubMed
ii. Import option : Click Other filters. Look for the database
name PubMed (NLM). Click Choose.

a. Click Import. The references will appear in your active

EndNote Library.

8 March 2024 129

Referencing: EndNote

Step3: Method 2: Search PubMed directly in

EndNote
• Valid only for Freely Available Databases
• This Method is good for Known Citations
a. In an EndNote Library, under Online Search on the left,
click on PubMed (NLM).
b. Enter keyword in search box
c. Retrieved records from 1 through XX. Enter the
desired number for XX.
d. All records (relevant?) will be saved into EndNote
8 March 2024 130
Referencing: EndNote

Step3: Method 3: Manually create a Reference

• Useful for literatures which are not found in databases
a. In an EndNote Library, at the top, click on References→New
Reference
b. Under Reference Type, click on the drop-down menu and
select accordingly (eg. Web Page)
c. Enter information such as author, year, title
d. Simply click on inner X (reference entry window) and the
reference will be saved

8 March 2024 131

EndNote: other features

a. Remove Duplicates
i. In an EndNote Library, click References on the menu bar→ Find
Duplicates
b. Organize References into Groups (or folders)
i. Highlight a reference in EndNote Library
ii. Right – Click→ Add References To → Create Custom Group…
iii. Type a group name. Enter.
c. Auto-Filtering with Smart Groups
d. Compress a Library and Email to Colleague

e. Direct Links to Web of Science via Library Proxy

8 March 2024 132

Step4: Insert reference in word
(Cite While You Write)

a. Open your EndNote library

b. Highlight a reference/s you want to cite
c. In word doc, indicate the place you want to insert by cursor
d. Click on insert citation button to finish it Or use short
cut as Click on “alt” and “2” buttons
e. Now, the reference is inserted.
Step5: Change the reference style
• From EndNote menu, click on style option and select the one from the
options that you want to apply

8 March 2024 133

Formats of references in
Vancouver style

• The style had d/t formats for articles, books, etc.

• For article, the order is: authors’ name. Title of article. journal name
in italic. Year of publication; volume: number, page number. Idol, URL.

• Eg1. Asemahagn MA. Burden of anemia among pregnant women in

Amhara Region. PLoS ONE. 2020; 15:6, 1-12.
https://doi.org/10.1371/journal.pone.0234822.

• For books, Authors’ name. Title of the book. place of publication:

publisher, year of publication, edition of the book.

• Eg2. Andualem M. The Ethiopian Health Information System. England:

Biomedical Central, 2016, 1st edition.

134
Step3. Critical Apprising the Evidence
/Checking quality?

8 March 2024 135

Step3. Apprising the Evidence/
checking quality

▪ Critical appraisal is reviewing the evidence to determine whether a

research article is trustworthy, relevant, impactful, and with
minimal bias.

▪ Is a process of carefully & systematically examining research to

judge its methods, validity, reliability, & relevance/usefulness to
a particular context.

▪ Why Critical Appraisal? B/c 1). we have bulky and unfiltered

literature!! 2). We need valid evidence for practice

▪ How Critical appraisal will be done??

▪ Start with a hierarchy (or levels) of evidence

8 March 2024 136

Hierarchy of Scientific Evidence Strength
Strongest
Umbrella
Review
SR and
Metanalysis
of RCTs

Critically appraised
literature, EBP guidelines

Randomized Clinical Trials

/RCTs

Systematic review and metanalysis

of nonrandomized clinical trials

Non randomized Clinical trials

A systematic review of the cohort, case-
control studies

Cohort studies, case-control studies

Systematic review & metanalysis of descriptive,

cross-sectional, case or case series studies
Weakest Descriptive studies, cross-sectional studies, Case studies,
or case series
Background information, expert opinion, non-EBP guidelines
Step3. Apprising the Evidence
/checking quality…

• Level I: evidence from a systematic review, randomized control

trials (RCTs), or evidence-based reviews
• Level II: evidence from one well-designed RCT
• Level III: evidence from well-designed studies without
randomization = cohort study
• Level IV: evidence from other types of studies including case-control
and cohort studies
• Level V: evidence from systematic reviews of descriptive and
qualitative studies
• Level VI: evidence from one descriptive or qualitative study
• Level VII: evidence from the opinion of authorities and/ or reports
of expert committees
8 March 2024 138
Step3. Apprising the Evidence
/checking quality…

How can we do appraisal?

• Evaluating articles by observing their structure: if they include
AIMRDCR?
• Evaluating articles by asking sorts of questions
• Critically evaluating the match of Title vs Objective vs Study
Design vs Method?
• Evaluate by type of study design: interventional vs non-
interventional; Randomized vs nonrandomized; cohort vs cross-
sectional, etc
• Study period; recent vs outdated