Primary Health Care Physicians' Attitude towards EBM

Study Setting
The present study was conducted in the center of Baghdad city, which has two directorates, Al-Karkh and Al-Rusafaa health directorates. The directorate of Al-Kharkh is served by four health sectors, while Al-Rusafaa is served by five health sectors. These health sectors provided health services through Primary Health Care Centers (PHCCs) that were distributed all over the center of Baghdad city, (39) in Al-Kharkh and (44) in Al-Rusafaa.

The total number of physicians served in these PHCCs is (620), (306) in PHCCs in Al-Kharkh and (314) in Al-Rusafaa.

For the purpose of data collection, (41) PHCCs were chosen from the total (83) PHCCs by simple random sampling as a place to carry out the present study and collect the study sample.

Study Design
To achieve the aim of the present study, a cross sectional study design was adopted, in which the center of Baghdad city was divided into two parts Al-Rusafa and Al-Kharkh health sectors.

(Peil et al., 1982) states that a cross sectional study design aims to explore a new area, or at least one about which little is known in the local context. They further report that in an exploratory study, one sets out a few preconceptions to examine a phenomenon from many point of views, looking for new ideas and insights that will not only explain what is happening but also what is hindering the acceptance of new technique. From both sectors (41) PHCCs were chosen by simple random selection.

Methods:
Sample technique. The unit of the present study was a physician who was present at the time of conducting the survey of the sampled PHCCs.

Data was obtained directly from physicians themselves through detailed questionnaire from (Appendix I) prepared and given to the physicians present in the selected PHCCs.

The questionnaire form was completed by physicians themselves during the time of work.

Preliminary Preparations:
A review of literature relevant to attitudes of physicians towards EBM was carried out .The preliminary questionnaire form was constructed.
Before applying the questionnaire form and in order to construct a final, suitable, and formative form, a pilot study was undertaken.

Pilot Study
A pilot study was carried out to set up the data collection before being finally applied to the study sample.
The main objectives of the pilot study were:

1. To indicate what kind of difficulties are likely to be met.
   
2. To examine the design of the questionnaire form, and to assess its reliability (repeatability) in order to reveal any necessary modifications.
   
3. To determine the time needed by the physicians to complete the questionnaire form, to determine how many PHCCs could be examined on average.
   
4. To test the response rate of the physicians.
   The pilot sample was collected in April, 2006. It consisted of 25 physicians selected from 4 PHCCs on a non-randomized basis. In order to assess the reliability of the information that was derived from the physicians, the pilot sample was interviewed by using a test and re-test approach in which 25 physicians were re-tested again 1 week after conducting the pilot test .

In view of the pilot study, the following points were obtained:

1. The response rate of physicians was (100%).
   
2. To evaluate the reliability of the questionnaire form, the reliability (repeatability) index was calculated (Gorid, 1996), which was the percent agreement in physician response during test and re-test occasions. The frequency distribution of positive/negative responses and results of analysis of both test and re-test interviewed physicians, were demonstrated in Table (2.1),in which the calculated reliability index was (83.3%) which indicated that the form was adequate and reliable.

Reliability =Total agreement/ total number ×100
= (20+5)/30×100
=83.3%

Sampling Frame and Technique
Sampling Size Determination:

The total population of 620 physicians enrolled in PHCCs was considered as a background.

The desired sample size for this study was 50% of the total population.

Determination of the Number of Sampled PHCCs:
The total number of PHCCs present in both parts of Baghdad City were (81) PHCCs.
As the desired sample size of this study was 50% of total population pollution, (620) served in these (83) PHCCs. So by simple random sampling, (41) PHCCs were taken from these total (83) PHCCs.

Sample Selection:
The number of physicians per PHCC varies between 5-10 physicians per PHCC.
The number of physicians needed to complete this present study was (310) physicians, 50% of the total population of (620) physicians.

As we select (41) PHCCs by simple random sampling, belong to both areas, all physicians present in these (41) PHCCs were included in this present study.

Data Collection Tool:
A combination of questions from two published questionnaires was used to determine attitudes, knowledge, engagement and barriers towards EBM (Fritsche et al., 2002; and McColl et al., 1998b) were used to construct the questionnaire used in this study. The validity and reliability of the questionnaire developed by Fritsche et al is documented, while McColl et al used literature and previous focus
: Primary Health Care Physicians' Attitude towards EBM

Study Population:
During the study period, 334 questionnaire forms were distributed in (41) PHCCs in both parts of Baghdad City. Table (3.1)

Demographic Determinants of the Study Population:
Table (3.2) reveals that among 296 physicians who completed the questionnaire form, 181 were male and 115 female, M/F ratio was 1.3:1.

The age of study subjects were: 11 physicians less than 30 years, 93 physicians between 30-39 years, 149 physicians between 40-49 years, 37 physicians between 50-59 years, and 6 physicians more or equal to 60 years; also among study subjects 0% had a doctorate, 4% a master degree, 8% a diploma, and 88% had M.B.Ch.B.

Table (3.2):

Attitude towards EBM:

Physicians' Attitude towards the Current Promotion of EBM.
Table (3.3) illustrates physician's attitude towards the current promotion of EBM, (3%) extremely welcoming, (65%) welcoming, (17%) neutral (neither welcoming nor unwelcoming), (13%) unwelcoming, and (2%) extremely unwelcoming.

Physician Use of EBM in Practice:
Table (3.4) illustrates the percentage of physicians who feel that clinical practice is currently EBM, 0% of physicians is 100% use of EBM in practice, 0% is 75% use of EBM in practice, 0% of physicians is 50% use of EBM in practice, 11.5% of physicians is 25% use of EBM in practice, and 88.5% of physicians is 0% use of EBM in practice.

Practicing EBM Improves Patient Care
Table (3.5) illustrates the attitude of physicians that practicing EBM improves patient care, (6.4%) of physicians strongly agreed that

EBM is of Limited Value in General Practice because much of Primary Care Lacks a Scientific Base:
Table (3.6) illustrates the physician's attitude towards this statement (28.4%) strongly agreed with it (40.2%) agreed with it, (23.6%) neutral, (7.8%) disagreed with it, (0%) strongly disagreed.

Usefulness of Research Findings in Day-to-Day Management of Patient:
Table (3.7) illustrates the physician's attitude towards the usefulness of research findings in day-to-day management of patients; (1.7%) were extremely useful, (61.8%) were useful, (23.6%) were neutral, (11.8%) were useless, and (1%) were totally useless.


The Way for Moving from Opinion Based Practice towards EBM:
Table (3.8) illustrates the three different ways for moving from opinion-based medicine towards EBM,

1. By learning the skills of EBM i.e. to identify and appraise primary literature or systematic review on self;
   
2. By seeking and applying evidence-based summaries which give the clinical ''bottom line''; such summaries may be obtained from abstracting journals;
   
3. By using evidence-based practice guidelines developed by expert colleagues for use by others.

The answer of the question, which one of these methods you are using, please tick one or more ways. The answer for way (a) was 19, for way (b) was 24, for way (c) was 15.(Table 3.8)

The answer of the question which one of these methods you would be interested in using in the future, please tick one or more boxes, the answers were: For method (a) 53, for method (b) 246, for method (c) 167.(Table 3.8)

The answer of the question which one of these methods do you think is the most appropriate in General Practice, tick one box. The answers were: 15 for method (a), 153 for method (b), 128 for method (c). (Table 3.8)

Major barriers to practicing EBM in General Practice:
Table ( 3.9) illustrates the perceived major barriers to practicing EBM in general practice reported by 296 physicians; 215 responses were the lack of personal time and work overload, 167 responses for the physician's misconception about EBM; 134 responses for the resources barrier, 96 responses for evidence itself, 76 responses for patient related factors, and 43 responses for organization barrier.

Figure (3.1) shows the distribution of these barriers according to their frequencies.

Awareness and Perceived Usefulness of Relevant Information Source:
Table (3.10) shows that the physicians had low level of awareness of extracting journals, review publications and databases relevant to EBM. Only 12.2% of respondents were aware of the Cochrane Database of Systematic Review, 19.8% of Bandolier, and 25.6% Evidence-Based Medicine (BMJ publishing group). Less than 1% used any of these resources in clinical decision-making.

3.1.7 Access to the Relevant Databases and the World Wide Web WWW:
Only 14.8 % (42/296) of physicians had access to Medline or other Bibliographic databases, and only 10.4 % (31/296) had some kind of access to the world wide web. In the previous year, 4.4 % (13/296) had consulted Medline or another database for literature searching. Of the respondents, 11.8 %( 35/296) reported having training in literature searching, 4.7 % (14/296) attended a course on practicing EBM and only 2.3 % (7/296) attended courses on critical appraisal. On the positive side, almost all of them, 95% (281/296), would like to attend courses relevant to practicing EBM.

Understanding of Technical Terms Used in EBM:
Table (3.11) shows that relative risk, absolute risk, odd ratio, and systematic review were the most technical items that the respondents can understand and explain to others.

Absolute risk, relative risk, systematic review, Meta analysis are the most technical items that the respondent can understand but cannot explain to others.

Respondents show high percent desirability to understand all the technical terms, while low percentage of respondents show that these technical terms would not be helpful to them to understand.

Figure (3.3) shows the percentage of PHCPs that are able to understand and explain technical terms to others. Relative risk, absolute risk, odd ratio, and systematic review are the most term they are able to understand and can explain to others by PHCPs 14%, 13.4%, 12.8%, and 11.1% respectively.

Systematic Review of Randomized controlled Trials of Strategies to Promote Adherence to Tuberculosis Treatment

Study selection
The literature search identified 14 studies of strategies that promoted adherence to TB treatment and were found through electronic database search. The 14 trials were screened according to the criteria mentioned in method section.

Only 5 of the trials met the inclusion criteria. Details of the 5 studies and data extracted for appraisal are shown in (Table 3.12).

Interventions Studied
Interventions examined were patient reminder cards (Paramasivan et al., 1993), patient education (Sanmarti et al., 1993), and an incentive for patients (Pilote et al., 1996), help from peer group through community health workers (Pilote et al., 1996), a combination of patient education and incentive (Morisky et al., 1990), and incentive staff supervision (Jin et al., 1993).

Data Synthesis and Critical Appraisal
The number of participants in each trial ranged from 200 to 1300 patients, who had active tuberculosis (Paramasivan et al., 1993; Morisky et al., 1990; Jin et al., 1993) were contacts of patients with tuberculosis and required prophylaxis (Morisky et al., 1990; Sanmarti et al., 1993) or were contacts of patients with tuberculosis awaiting evaluation for active treatment or prophylaxis (Pilote et al., 1996).

Participants in three of the five studies were disadvantaged - namely, illiterate patients in Madras (Paramasivan et al., 1993), homeless people (mostly men) living in San Francisco, many of whom had a history of drug and alcohol misuse (Pilote et al., 1996); and patients with low income in Los Angeles, most of whom did not have English as their first language (Morisky et al., 1990). Interventions were not always directed as those who were receiving treatment. One study tested interventions on the mothers of children from state and private schools in Barcelona Province who had tested positive for tuberculin (Sanmarti et al., 1993). While another evaluated an intervention directed at the staff of tuberculosis clinics in Korea (Jin et al., 1993).

The commonest measure of adherence was completion of treatment (case holding). However, two trials assessed adherence to appointment keeping (Morisky et al., 1990; Pilote et al., 1996) and two examined the use of drugs (Morisky et al., 1990; Sanmarti et al., 1993). Only one study considered the outcome of treatment.

And this was assessed as the rate of bacteriological conversion in those who initially had positive results on sputum microscopy or culture (Jin et al., 1993).
In one trial, allocation was by case record number and was therefore not concealed Morisky et al., 1990). For the remaining trials, adequacy of concealment could not be determined and information was also not available on the method used for generation of allocation sequence, with the exception of one study, in which 43 subjects (13.5%) could not be accounted for (Sanmarti et al., 1993).

Loss to follow up was not reported to have occurred. All the studies used an intention to treat analysis. None reported whether those assessing outcome were blinded to the intervention to which patients had been assigned.

Six different strategies to promote adherence were tested in the trials included in this review (Table 3.12). Up to two reminder letters sent to patients with tuberculosis soon after they had defaulted on clinic attendance produced good results. Of the 29 patients who defaulted in the intervention group, 17 (58.6%) returned, compared with 4 out of 31 (12.9%) in the control group. Even among illiterate patients, rates of return were high (Paramasivan et al., 1993).

A monetary incentive ($5 (3)) was highly effective in promoting adherence to an initial appointment for evaluation of tuberculosis among homeless people with positive results on tuberculin testing (Pilote et al., 1996). In the same study, recruits from the homeless community (so called peer health advisers) were paid to help patients keep their appointments, and this intervention was also effective compared with the control group. There was no statistical difference detected between the financial incentive and the peer adviser (Table 3.12).

Health education given to mothers every two months improved compliance with chemoprophylaxis among children positive for tuberculin (Sanmarti et al., 1993). Each of three health education strategies was compared with no health education.

Estimates of the effectiveness of the interventions in promoting attendance at the last clinic visit were better when the nurse visited or telephoned the patients at home than when health education was provided by a doctor at the clinic. The summary relative risk for the health education approaches compared with standard care (leaflet only) was 1.2 (95% confidence interval 1.1 to 1.4). Recent drug use assessed by the presence of a drug metabolite in a urine sample at the last clinic visit was significantly higher in each of the intervention groups compared with the controls.

One study compared a monetary incentive and health education with routine care (Morisky et al., 1990). The proportion completing treatment differed significantly between the intervention and control groups for patients receiving prophylaxis against tuberculosis but not for patients with the clinical disease. As the confidence intervals overlapped substantially, however, no real difference might exist between the two odds ratios. Benefits were also found in terms of the average proportion of appointments kept and the mean proportion of drugs taken in this study.

Finally, an intervention directed at staff in tuberculosis clinics rather than patients, was studied (Jin et al., 1993). Patients with tuberculosis attending health centers with intense supervision of staff were more likely to complete treatment than those attending health canters with routine supervision of staff. The effect of the intervention on bacteriological conversion (cure) rate was also favorable (relative risk 1.7 (1.4 to 1.9)).

Experts Opinions about the Ability of Applying the Strategies that Promote Adherence to Tuberculosis Treatment in our Practice

Survey Result A
This page shows the number of participants who scored each box for each question in both the first and second round questionnaires. Those in the row above are the numbers from the first round while those in the row below are the numbers from the second round. This enables you to see where knowledge of other participants scoring may have influenced participants to change their scoring of some questions between the first and second rounds.

Item One
Up to two reminder letters sent to patients with tuberculosis soon after they had defaulted on clinic attendance produced good results.

Item Two
A monetary incentive was highly effective in promoting adherence to an initial appointment for the evaluation of tuberculosis among homeless people with positive results on tuberculin testing.

Item Three
Health education given to mothers every 2 months improved compliance with therapy among children positive for tuberculin.

Item Four
Health education in promoting attendance at last clinic visit was better when the nurse visited or telephoned the patients at home than when health education was provided by the doctor at the clinic.

Item Five
Patients with tuberculosis attending health centers with intense supervision of staff were more likely than those attending health centers with routine supervision of staff, to complete treatment.

Item Six
Recruits from community to advise homeless people with positive results on tuberculin testing in promoting adherence to an initial appointment for evaluation of TB.

Survey Result B
This page shows the percentage of participants who scored each box for the questions in the second round questionnaire. They were these percentages that were examined to ascertain where there was or wasn't a consensus of opinion.

Item One
Up to two reminder letters sent to patients with tuberculosis soon after they had defaulted on clinic attendance produced good results.

Item Two
A monetary incentive was highly effective in promoting adherence to an initial appointment for the evaluation of tuberculosis among homeless people with positive results on tuberculin testing.

Item Three
Health education given to mothers every 2 months improved compliance with therapy among children positive for tuberculin.

Item Four
Health education in promoting attendance at last clinic visit was better when the nurse visited or telephoned the patients at home than when health education was provided by doctor at the clinic.

Item Five
Patients with tuberculosis attending health centers with intense supervision of staff were more likely than those attending health centers with routine supervision of staff to complete treatment.

Item Six
Recruits from community to advise homeless people with positive results on tuberculin testing in promoting adherence to an initial appointment for evaluation of TB.

A Consensus (agreement) was reached among items five (83.2%) and six (83.2%). This means that strategy 5 (intense staff supervision) and strategy six (peer health advisers) are accepted by experts and their implementations in our general practice to promote adherence to TB treatment are feasible. Also consensus (disagreement) was reached among items one (83.3%), two (83.3%), three (83.3%), and four (83.3%). This means that strategies 1, 2, 3, and 4 are not accepted by experts and their implementations are unfeasible in general practice.

4.1 Part One: Primary Health Care Physician's Attitude towards EBM

Background
In an environment with an increasing focus on both the accountability of health expenditure and identification and measurement of health outcomes for all health interventions, it would be hazardous to ignore EBM by primary care physicians (Sackett and Rosenberg, 1995; Bannett and Glaziou, 1997; Silagy and Haines, 1998; Rosenberg and Donald, 1995; Nash, 1999).

The present study was conducted to describe the attitude towards, knowledge of, engagement in, and barriers to practicing EBM amongst PHC physicians in the center of Baghdad city.

Methodological Issues:
To achieve the aim of the present study, a cross sectional study design was carried out with advantages carefully balanced against the disadvantages. Among the well known advantages of cross sectional study are:

1. The study describes the distribution of items under study.
   
2. The study is useful in determining association between variables of interest and thereby gives a hint in formulating a hypothesis for the causation of such behavior.

The present study is the first study to examine attitudes towards, knowledge of, engagement in, and barriers to practicing EBM among primary health care physicians in the country as a whole.

The present study uses a self-report questionnaire form. Therefore, it is important to have confidence in the reliability and validity of the present survey data collection i.e. questionnaire. The reliability was assessed using test and re-test approach. Nearly all of the items in the survey questionnaire have moderate to high acceptance.

Reliability with overall reliability was 83.3 % among the pilot sample with no significant difference found between male and female physicians.

The response rate was 88.6% .Our subjects were physicians rather than health care teams; our narrow focus was partly due to the availability of an inadequate sampling frame.

Interpretation of Findings

Attitude towards EBM
The welcoming attitude of primary health care physicians are similar to those of British (McColl et al., 1998b) and Australian general practitioners (Mayer and Piterman,1999). The median value for estimated percentage of the respondents' clinical practice that was EB was 15%. This is lower than the figure of 50% reported by McColl et al. It is a subjective estimate, however, which has its limitations.

Awareness of Relevant Information Source
The past few years have witnessed a worldwide plethora of books, workshops and courses on how to practice and teach EBM. The Cochrane library has an increasing number of systematic reviews relevant to primary care. Evidence-Based Medicine and the American College of physicians Journal Club, as well as other online summaries of scientifically sound and clinically relevant articles are becoming increasingly available for primary health care physicians (Sackett et al., 1996).

The PHCPs in Baghdad, however, had a low level of awareness of well-known resources of EBM and, even if they were aware, did not make use of them in clinical decision-making. The classical definition of EBM put forward by Sackett et al involves integrating individual clinical expertise with the best available external research evidence (Ramsey et al., 1991). Without using current best evidence, the practice of PHCPs possibly is at risk of becoming out of date, to the detriment of patients (Sackett et al., 2000). This is very probably because it has been shown that a significant negative correlation exists between our knowledge of up-to-date care and the years that have elapsed since graduation from medical schools (Ramsey et al., 1991)

Access to Relevant Database and World Wide Web:
Only 14.1% and 10.4 % of the PHCPs had access to Medline and to the world wide web, respectively. The past couple of years, however, have witnessed a widespread governmental and private uptake and utilization of the Internet; consequently, the corresponding figures may now be higher. Although it has been shown recently that the printed Index Medicus is still the most effective literature retrieval method for GP (Verhoeven et al., 2000), there is a need to train PHCPs in electronic literature retrieval methods. The Internet fosters the practice of EBM by facilitating the generation, synthesis, dissemination and exchange of research evidence (Jaded et al., 2000). It enhances the role of EB decision-making by giving PHCPs cheap, fast and efficient access to up-to-date, valid and relevant knowledge at the right place, and in the right amount and format (Pickering, 1997).

Understanding of Technical Terms:
Our respondents showed a low level understanding of the technical terms used in evidence-based medicine. Interpretation of evidence was a key element in practicing EBM, and this low level understanding could hinder interpretation and make cascading of evidence to other members of the primary care team more difficult.
The respondents in McCool's study apparently were more familiar with technical terms commonly used in EBM, but one should keep in mind that only 7 doctors (2.3 %) in Baghdad City have attended courses on critical appraisal in contrast to (39 %) in UK (McColl et al., 1998b)

Views on Major Barriers to Practicing EBM:
The major perceived barriers to practicing EBM in primary care were patient overload and lack of personal time (72.4 %). In McCool's study, lack of personal time was also the main perceived barrier to practicing EBM (71 %).''General physicians must come to grips with 19 original articles per day, 365 days per year, if they want to keep abreast to their field'' (Davidoff et al., 1995).

In McCool's study, the attitude of the patient was perceived as a barrier in 18% of the responses. The corresponding figure in our study was (25.6 %). Research has shown that patients' attitude should not be ignored, as they may present a major impediment to most primary prevention programmes (Fitzgerald and Pillipov, 2000).

Views on How Best to Move to EBM:
The largest proportion of PHCPs (51.8 %) thought that the best way to move from opinion based medicine to EBM was by learning the skills of EBM, while (43.2 %) thought it should be using EBM guidelines. In contrast, most of respondents in McCool's study (57%) thought that the most appropriate way was by using EBM guidelines, while (37%) thought that it should be by seeking and applying EBM summaries, and only (5%) by identifying and appraising the primary literature or systematic review (McColl et al., 1998b). This is an interesting contrast.

It has been suggested that practicing five steps of EBM is needed for the conditions that we encounter every day in order to be 'up to the minute' and very sure about what we are doing(Yamey, 2000). This probably explains why a large proportion of respondents was interested in learning the skills of EBM. It has been found, however, that operating in the 'appraising' model is time consuming and not suitable for busy overloaded practitioners (Guyatt et al., 2000), and the emphasis now, is shifting towards "information mastery" rather than traditional EBM (Shaughnessy et al., 1994).
On a much deeper level, to put evidence into action, the evidence needs to be relevant to the recipient in the sense that it should answer questions that PHCPs really want answers to and not simply cover topics that are interesting or researchable (Backer and Gilbert, 2000). Furthermore, selecting the most appropriate strategy should relate to how PHCP is most likely to react to new information about the effectiveness of clinical strategies that may affect many of their patients (Wyszewainski and Green, 2000). With more prospective trials being carried out, changing behaviors would be better understood and more effective.

Systematic Review of Randomized Controlled Trials of Strategies to Promote Adherence to Tuberculosis Treatment
Systematic reviews of randomized trials of interventions to improve adherence to prescribed drug treatment (Haynes et al., 1996) and compliance with appointment keeping (Macharia et al., 1992) have recently been published. Our review differs from these in several ways.

Firstly, it concerns a single infectious disease and aims to find out which strategies are successful in promoting adherence to the comparatively long course of treatment required. Neither of the two recent reviews includes studies of adherence to tuberculosis treatment as these fail to meet the selection criteria.
Secondly, adherence is defined broadly to cover all aspects of patient conformity to medical advice, including clinic attendance and taking drugs.

Thirdly, we included trials that measured adherence even when they did not measure the impact of the measure, such as on cure. Although, in general, Haynes et al are correct in stating that the ultimate purpose of improving adherence is to ensure clinical benefits (Haynes et al., 1996). In tuberculosis it seems reasonable to assume that patients who complete their treatment enjoy better health.

In general, the findings of the existing trials are encouraging as most strategies seem to improve adherence. We cannot find unpublished trials, and we cannot rule out the possibility of publication bias resulting in an overoptimistic view of the effects of the interventions (Dickerson et al., 1995). Simple measures such as reminder letters sent to patients who defaulted are efficacious, even among illiterate patients (Paramasivan et al., 1993). A previous review also concluded that reminder letters were consistently useful in reducing broken appointments in several settings (Macharia et al., 1992).
Another strategy that holds promise is the use of peer help. The only trial that assessed the impact of lay health workers looked exclusively at adherence to a first appointment (Pilote et al., 1996). Further research is therefore needed to determine the full potential of this intervention. The use of money as an inducement to comply with medical advice might work in the short term but is problematic (Morisky et al., 1990; Pilote et al., 1996). The global burden of tuberculosis is in poor countries where this strategy would be expensive and set precedents that could harm the work of health services in providing effective care for a range of conditions.

The independent effect of health education on adherence is difficult to determine from existing trials. In one study, patients receiving health education were contacted or seen every two months while those in the control group were not (Sanmarti et al., 1993). The relative contributions of health education and increased attention are therefore hard to separate. Furthermore, in the study by Morisky et al, health education was linked with a monetary incentive. So the independent roles of the interventions cannot be separated (Morisky et al., 1990). Lack of information in the study of intensive staff supervision (Jin et al., 1993) makes it difficult to determine the practicality of this strategy in other settings.

The measures of adherence to treatment used in most of the studies in this review were appointment keeping or completion of treatment (drug collection up to the end of the treatment course). The extent to which these intermediate outcomes correlate with actual drug taking was unknown. While two trials found good correspondence between clinic attendance and evidence of drug metabolites in the urine (Morisky et al., 1990; Sanmarti et al., 1993),''these measures are poor surrogates for regular drug taking'' (Haynes et al., 1980). The only study measuring treatment outcome did, however, show better clinic attendance and a higher cure rate in patients in the group in which staff were intensely supervised compared with those in the control group (Jin et al., 1993).

Directly Observed Treatment
One compliance enhancing strategy that is conspicuous by its absence among the trials we reviewed, is directly observed treatment. In this scheme, the patient takes the drugs in the presence of a health care provider or other designated person. We have recently become aware of two trials of this intervention. Self-administered treatment with monthly follow up is currently being compared with treatment directly observed by a relative and by a peripheral worker in a study in Pakistan. In South Africa, a trial has recently been completed comparing self-administered treatment and treatment supervised in the community and at the specialist clinic. These and any other trials will be incorporated in subsequent editions of this review as they become available to us, provided that they meet the inclusion criteria.

Directly observed treatment has been successfully implemented in several settings and found to be associated with substantial improvements in rates of adherence and drug resistance (Sbarbaro and Sbarbaro 1994; Alwood et al., 1994; Weis et al., 1994; Wilkinson, 1994; Neher et al., 1996).

However, it has usually been introduced as part of a comprehensive effort to improve tuberculosis services. The most common accompanying interventions are improved accessibility of services, increased availability of drugs, changes in drug regimens, patient incentives, tracing of patients who default, and outreach efforts (Garner and Volmink, 1997). Directly observed treatment may, therefore, simply be a marker for a more serious commitment to tuberculosis control. Carefully designed randomized trials evaluating the independent effects of directly observed treatment are awaited.
Experts' Opinions about the Ability of Applying the Strategies that Promote Adherence to Tuberculosis Treatment in our Practice

Delphi method is a structured facilitation technique that explores consensus among groups of experts by synthesizing opinions. Group judgment is preferable to individual judgments, which are prone to personal bias (Lawrence and Olesen, 1997; Naylor, 1995). Via this technique we were able to reach a consensus among experts in National TB Control Programme about strategies that promoted adherence to TB treatment which were achieved through systematic review of primary research findings. In two of six strategies, consensus was reached with the ability of applying them in our practice; these were (i) intensive staff supervision, and (ii) peer health advisers. In the other four strategies, consensus was reached with the inability of applying them in our practice.

Stability of response has been suggested as an indicator of consensus in Delphi survey (Crisp et al., 1997). There was a surprisingly little change in the scoring from the first round to second round of the survey. When completing the second, participants were aware of how others had scored in the previous round, but this appeared to have little influence upon their opinions.

Conclusions & Recommendations
Recent attempts to improve clinical decision-making and practices through the use of best available evidence have led to the widespread use of the term EBM among health care professions including PHC. The practice of EBM constitutes five systematic steps that include searching for, critically appraising, and consequently applying the evidence to the patients as appropriate, and evaluating the impact.
Primary health care physicians need to have knowledge and skills as a tool that enables them to implement EBM. This study investigates for the first time in the country, the primary health care physicians their attitude towards, knowledge of, engagement in, and barriers to EBM. The results indicate that the majority of respondents in this study have positive attitudes towards the concept of EBM. In addition, the results indicate that the majority of respondents have little knowledge of EBM. Also the majority of respondents, in this study, consider their practice not as evidence-based, the results indicate that the majority is not engaging in activities related to EBM, that include searching and reading of literature.

This study further establishes several barriers that hinder respondents from practicing EBM. The barriers include lack of time, misconceptions about EBM, resources barriers, inability to access and appraise the evidence, patient related barriers, and organization related barriers.

This study establishes no statistically significant relationship between demographic variables (age, gender, professional qualification) and attitude towards EBM.
This study identifies certain strategies achieved through the process of systematic review of primary literatures that promote adherence to TB treatment. These include (i) monetary incentive (ii) health education (iii) peer community advisers (iv) health education plus monetary incentive (v) intensive staff supervision.

We have found evidence for the effectiveness of several specific interventions to improve adherence to tuberculosis treatment. These should be implemented by health care providers when appropriate to local circumstances. Even simple interventions, such as reminder letters, are useful for helping to ensure that patients finish their treatment.

Many innovations for improving adherence to tuberculosis treatment exist, but only a few have been tested in randomised trials. To ensure relevance of interventions to settings in which most of the tuberculosis caseload occurs, studies in low income countries are a priority. Further research should measure adherence as well as clinical outcomes. Two of six of these strategies, are accepted by group of experts in National TB Control Programme.

1. Addressing key policy and awareness in this arena (EBM) could substantially enhance the quality of primary health care with the integrative efforts of:

• Medical Education System
  
• Ministry of Health
  
• Medical Syndicate
  
• Health Research Organizations

2. A comprehensive Anti-TB Evidence Based Excellence Model that suits the current Iraqi/Arab needs should be developed. Such a framework model should emphasize the following issues:

• The mission of primary health care.
  
• The role of policy makers in problem-solving and capacity building
  
• The coordination efforts of researchers, evidence finders and appraisers, and clinical practitioners.
  
• The strategic problem-solving solutions for the actual practical obstacles.

3. The results of this study are expected to help post-graduate tutors, Ministry of Health and health authorities, university departments of Community Medicine and local research centers in designing local strategies for encouraging the implementation of EBM guidelines and summaries.

4. Teaching all PHCHs skills of practicing EBM by feasible and friendly methods should be also encouraged, however, these skills of appraising EBM should be introduced in training programmes of medical schools.

5. Strategies for encouraging changes among PHCHs and overcoming the barriers should be part of the decision makers' vision. Some recommended strategies:

I) Continuing medical education approaches

• Educational materials:
  This can achieved by distribution of published or printed recommendations for clinical care, including papers, books and video or electronic materials.
  
• Conferences: Participation of health care providers in conferences, lectures and workshops.

II) Quality assurance approaches

• Audit and feed back;
  Review of performance of health care provider over a particular period of time and provision of this information to the providers.
  
• Reminders;
  Systems designed to remind clinicians or patients of information and/or desired actions. These may be manual or computerized.

III) Social influence approaches

• Local consensus processes
  Development of local guidelines or practice protocols through participation and round table discussion.
  
• Use of influential individuals who may change the attitudes and behaviors of others by personal example and influences.
  

IV) Targeted approaches

• a) Academic detailing
  An educational outreach approach to providing information to practitioners, similar to activities by pharmaceutical industry sales representatives to market drugs.
  
• b) Tailored interventions
  Use of group discussion (focus group), personal interviews, observation of surveys of targeted providers to identify and address barriers to change their behavior.
  

6. It is probably time to establish an EBM center that will help to implant the principles, methods and practicing among the PHC teams members throughout Iraq.

7. Lastly, patient values and expectations as well as ethical issues should play a role in determining whether and which interventions should be implemented.

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Figure 3.1

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Figure 3.3

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