Attitudes, Skills and Use of Evidence-Based Practice Amongst Spanish Osteopaths: A Cross-Sectional Survey

Attitudes, Skills and Use of Evidence-Based Practice Amongst Spanish Osteopaths: A Cross-Sectional Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Attitudes, Skills and Use of Evidence-Based Practice Amongst Spanish Osteopaths: A Cross-Sectional Survey Gerard Alvarez, Cristian Justribo, Tobias Sundberg, Oliver Thomson, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-107863/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Feb, 2021 Read the published version in BMC Health Services Research → Version 1 posted 8 You are reading this latest preprint version Abstract Background: Although evidence-based practice (EBP) is largely supported across healthcare professions, its implementation in manual therapy professions such as osteopathy remains limited and debated. There is currently little knowledge of how EBP relates to osteopathy in Spain, and the attitudes, skills and utilisation of osteopaths. Objectives: The main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. A secondary aim was to identify barriers and facilitators for the adoption of EBP in the Spanish osteopathic context. Methods: National cross-sectional survey of Spanish osteopaths registered and non-registered to an osteopathic association in Spain. Eligible participants were invited by a range of recruitment strategies including email and social media campaigns to complete the Spanish-translated Evidence-Based practice Attitude and utilization Survey (EBASE) anonymously online. Results: A total of 567 osteopaths completed the survey which represents an estimated response rate of approximately 9%. Participant’s attitudes toward EBP were largely positive. Most respondents agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and professional literature and research findings were useful to their day-to-day practice (88.9%). Levels of perceived skill in EBP were reported as low to moderate with lowest levels for items related to ‘research conduct’. Except reading/reviewing professional literature and using online search engines to find practice-related literature, participant engagement in all other EBP-related activities was generally infrequent. The perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small. Main barriers to EBP uptake included a lack of clinical evidence in osteopathy and insufficient skills for applying research findings. Main facilitators of EBP uptake included access to full-text articles, internet at the workplace and online databases. Conclusions: Spanish osteopaths were largely supportive of evidence-based practice, had low to moderate skills in EBP and engaged in EBP activities infrequently. Formal regulation of the profession in Spain and the inclusion of osteopathic programs into the university sector would potentially improve EBP adhesion. Health Economics & Outcomes Research Health Policy Evidence-based practice Osteopathic medicine Cross-sectional studies Health care surveys Figures Figure 1 Background Evidence-Based Practice (EBP) has been defined as the integration of knowledge provided by the best available evidence, with a practitioner’s clinical experience and judgement, and combined with an individual patient’s values and preferences [1] . Although there is broad support for EBP across most healthcare professions, its implementation by practitioners of the manual therapy professions remains limited and contested [2–6] . One explanation for the limited uptake of EBP in this professional group is the difficulty in transferring research-based evidence into practice due to the complexity of clinical settings, including the high level of interaction between patients and practitioners [7, 8] . In fact, several healthcare disciplines [9–14] report similar issues in the implementation of EBP, including medicine [14] , physical therapy [11] and more recently, osteopathy [15, 16] . Osteopathy is considered a manual therapy discipline in which its therapeutic base has been traditionally embedded within a specific conceptual framework and principles [17–19] . However, several authors have questioned the validity, plausibility and utility of these traditional osteopathic models in the context of contemporary evidence-based healthcare [20–23] . Despite the passing of time, most of these osteopathic models have not been updated in response to the evidence, yielding to an uncritical development of the profession [23] . The lack of integration of EBP in osteopathic professional development has been explored across the world, with the subject receiving significant attention in the UK [24–27] . Osteopathy is defined by The World Health Organisation (WHO) as a first-contact patient-centred health discipline [28] . As osteopathy develops its knowledge base, the profession will need to respond and be critically reflective and move away from the prioritizing of traditional theories and anecdotes as reliable sources of evidence, and instead, pursue the generation of new knowledge through research, and ensure that clinicians and educators are able to integrate evidence into practice. Although it appears that the integration of EBP into osteopathy is largely perceived as a favourable endeavour across the osteopathy community [26, 29, 30] , recent findings suggest that osteopathy practitioner engagement with EBP activities seems to be infrequent [26, 31] . Previous research has shown that the perceived barriers to EBP implementation among UK osteopaths are lack of time, lack of evidence in the osteopathic field and lack of access to studies and databases [26] . These results are consistent with a similar previous study conducted in Australia [31] . In Spain, osteopathy is not a regulated healthcare profession [32, 33] . Consequently, osteopaths with different professional, academic and clinical profiles (e.g. qualifications, training standards and competencies) operate across Spain. At the same time, despite the existence of European standards for osteopathic education [34] , there is considerable heterogeneity across training programs [32, 33] . In this regard, the attitudes and utilisation of EBP among Spanish osteopaths remains uncertain. Therefore, the main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. We also aimed to identify the barriers and facilitators for the adoption of EBP in the Spanish osteopathic context. Methods Design National, online, cross-sectional survey. Sample and setting The survey was open to all practising osteopaths in Spain, regardless of qualification or training institution. No exclusion criteria were applied. Although there is no reliable data on the number of osteopaths practising in Spain, numbers of graduates from osteopathic educational institutions (OEIs) in Spain estimate the Spanish osteopathic workforce to be in the vicinity of 5000-6000 [33] . Based on a target population of 6000, at least 362 osteopaths were required to be surveyed in order to achieve a 5% margin of error and a 95% confidence interval for any individual item on the survey. Description of survey and variables The Evidence-Based practice Attitude and utilization Survey (EBASE) [35] is an 81-item instrument designed to assess attitudes, skills and use of evidence-based practice among health professionals. The survey is divided into seven constructs, including attitude, skills, education and training, use, barriers, enablers, and demographics. The original English EBASE instrument has demonstrated acceptable test-retest reliability (ICC = 0.578–0.986), good internal consistency (Cronbach’s alpha = 0.84), and good construct and content validity (CVI = 0.899) [35, 36] Items from three of the survey constructs are able to be generated into subscores, as follows: Attitude subscore: Sum of the first 7 items, with scores ranging from 8 (predominantly strongly disagree) to 40 (predominantly strongly agree). Skill subscore: Sum of all 13 items, with scores ranging from 13 (low level skill) to 65 (high level skill). Use subscore: Sum of the first 6 items, with scores ranging between 0 (mostly infrequent use) and 24 (mainly frequent use). Translation and adaptation of survey The questionnaire was translated from English to Spanish and adapted cross-culturally according to the forward and backward translation method recommended by the WHO [37] . Once translated, a pilot test was carried out on 20 purposely-selected Spanish osteopaths. Suggestions for improvement (e.g., provision of additional response options to some questions) were integrated into the final version of the survey. Recruitment and data collection Participation in the study was advertised between April 2020 and June 2020 using a range of recruitment strategies. First, the main osteopathic associations (n=9) and OEIs (n=7) in Spain informed their associates (academic/clinical staff and alumni) of the survey and encouraged participation. Second, the study was advertised via social media (Twitter, Facebook and Instagram) inviting osteopaths to complete the EBASE survey. All recruitment media directed participants to a dedicated project website, where participants were invited to read the study information before being redirected to the survey. Data collection was undertaken online using SurveyMonkey™ (SurveyMonkey Inc., San Mateo, California, USA). All survey items were made compulsory to mitigate the risk of missing data. Data analysis Data from the online survey were imported into IBM SPSS version 25 (Armonk, New York, IBM Corp) for data cleaning, coding and statistical analyses. Excluded from the analyses were incomplete surveys (i.e. surveys containing >20% missing data due to participant dropout) and duplicate responses (i.e. as identified using the Konstan et al. de-duplication procedure for online surveys [38] ). Categorical data were described using frequencies and percentages. Means and standard deviations were used to describe normally distributed data, and medians and the interquartile range used for non-normally distributed data. Associations between ordinal-level variables were examined using the Kendall’s Tau correlation coefficient (Ƭ), whereas relationships between nominal-level variables were assessed using Cramer’s V. Coefficients were interpreted as follows: 0.10-0.29 (weak association), 0.30-0.49 (moderate association) and 0.50-1.00 (strong association) [39] . The level of significance was set at p<0.05. Ethics The study was approved by the Ethical Committee of Sagrado Corazón Hospital, Barcelona (2019/81-CMF-HUSC). Study participation was anonymous and voluntary, and participants were able to withdraw from the survey at any time without repercussion. Informed consent was obtained from all subjects and all methods were carried out in accordance with relevant guidelines and regulations. Results The survey was commenced by 714 Spanish osteopaths. After removing duplicate entries (n=4) and incomplete responses (n=143), the adjusted sample size was 567. The reasons for participant dropout could not be examined due to the anonymous nature of the survey. It also was not possible to calculate a survey response rate as the actual reach of the survey could not be determined. However, considering a potential target population of 6000 Spanish osteopaths [33] the estimated response rate would be approximately 9% (564/6000). Characteristics of sample Participating osteopaths were predominantly male (47.1%), and aged between 30 and 49 years (62.6%); 40.7% were members of an osteopathy professional association (Table 1) . The largest proportion of participants held a Master’s degree as their highest qualification (37.9%), with 50.5% receiving this qualification within the past ten years. Two-thirds (66.0%) of participants also held a degree in physiotherapy. Most (59.5%) participants had been in osteopathic practice for six or more years, with 57.7% spending 16-45 hours/week in clinical practice, 72.3% spending up to 15 hours/week participating in research, and 50.4% working up to 15 hours/week teaching in the higher education sector. Participating osteopaths largely worked in solo practice (41.4%) in the central business district (43.4%), with most located in Cataluña (23.8%), Comunidad de Madrid (13.1%) or Comunidad Valenciana (7.6%) (Fig 1) . Table 1: Demographic characteristics of sample (n=567) Characteristic Frequency Age , n (%) <20 years 3 (0.5) 20-29 years 23 (4.1) 30-39 years 187 (33.0) 40-49 years 168 (29.6) 50-59 years 30 (5.3) 60-69 years 10 (1.8) 70+ years 1 (0.2) Missing 145 (25.6) Sex , n (%) Male 267 (47.1) Female 155 (27.3) Missing 145 (25.6) Osteopathy professional association membership , n (%) Not a member of an Osteopathy professional association 185 (32.6) Registry of Osteopaths of Spain 103 (18.2) Registry of Osteopathic Physiotherapists of Spain 85 (15.0) Other Osteopathy professional association 43 (7.6) Missing 151 (26.6) Highest qualification , n (%) Diploma 82 (14.5) Bachelor degree 27 (4.8) Master’s degree 215 (37.9) PhD 46 (8.1) Other 52 (9.2) Missing 145 (25.6) Years since receiving highest qualification , n (%) < 1 year 42 (7.4) 1-5 years 150 (26.5) 6-10 years 94 (16.6) 11-15 years 59 (10.4) 16+ years 76 (13.4) Missing 146 (25.7) Other non-osteopathic qualifications , n (%) Degree in Physiotherapy 374 (66.0) Diploma/Degree in other health-related field 31 (5.5) Degree in Medicine 5 (0.9) Degree in Nursing or Podiatry 5 (0.9) Missing 152 (26.8) Years practiced in the field of osteopathy , n (%) <1 year 6 (1.1) 1-5 years 78 (13.8) 6-10 years 136 (24.0) 11-15 years 95 (16.8) 16+ years 16 (18.7) Missing 146 (25.7) Hours per week in clinical (osteopathic) practice , n (%) 0 hours 5 (0.9) 1-15 hours 47 (8.3) 16-30 hours 150 (26.5) 31-45 hours 177 (31.2) 46+ hours 42 (7.4) Missing 146 (25.7) Hours per week participating in research , n (%) 0 hours 162 (28.6) 1-15 hours 248 (43.7) 16-30 hours 9 (1.6) 31-45 hours 2 (0.4) 46+ hours 0 (0.0) Missing 146 (25.7) Hours per week working in the higher education sector , n (%) 0 hours 189 (33.3) 1-15 hours 97 (17.1) 16-30 hours 59 (10.4) 31-45 hours 29 (5.1) 46+ hours 47 (8.3) Missing 146 (25.7) Clinical setting in which osteopathy was predominantly practiced , n (%) Solo practice 235 (41.4) With a group of allied health providers 87 (15.3) With a group of complementary and allied health providers 41 (7.2) With conventional and allied health providers 37 (6.5) Within a clinical institution (e.g. hospital) 12 (2.1) Within an educational institution (e.g. university) 6 (1.1) Missing 149 (26.3) Geographical location of practice , n (%) Cataluña 135 (23.8) Comunidad de Madrid 74 (13.1) Comunidad Valenciana 43 (7.6) Andalucía 36 (6.3) Galicia 25 (4.4) Islas Baleares 17 (3.0) País Vasco 17 (3.0) Canarias 14 (2.5) Castilla-La Mancha 12 (2.1) Región de Murcia 11 (1.9) Castilla y León 8 (1.4) Extremadura 7 (1.2) Aragón 6 (1.1) Cantabria 6 (1.1) Principado de Asturias 5 (0.9) Comunidad Foral de Navarra 1 (0.2) La Rioja 1 (0.2) Missing 149 (26.3) Geographical region of practice , n (%) City (Central business district) 246 (43.4) Inner city location 88 (15.5) Rural location 43 (7.6) Outer city location 39 (6.9) Missing 151 (26.6) CAM – Complementary and alternative medicine; HVLA – high-velocity low amplitude; Use of EBP Participants reported a moderate-low level of engagement in EBP activities (median use subscore 8; IQR 5,14; range 0-24; scores ranging between 6.1 and 12.0 are indicative of a moderately-low level of use). Reading/reviewing professional literature and using online search engines to find practice-related literature were among the most frequently reported activities, with 44.6%-48.0% of participating osteopaths engaging in these activities between 1 and 10 times in the month preceding the survey (Table 2) . Participant engagement in all other EBP-related activities was generally infrequent, with 49.6%-67.2% of participating osteopaths engaging in these activities no more than 5 times in the previous month. A weak positive association was found between use subscore (categorised by quartiles) and age (Ƭ = .113, p = .007), sex (V = .155, p = .018; with higher subscores reported among male participants), highest qualification (Ƭ = .165, p < .001), years in osteopathy practice (Ƭ = .142, p < .001), number of hours in clinical practice (Ƭ = .082, p = .037), and number of hours teaching in the higher education sector (Ƭ = .225, p < .001). A moderate positive association was observed between use subscore and number of hours engaged in research work (Ƭ = .345, p < .001). Table 2. Participant engagement in evidence-based practice activities within the last month (n=567) 0 0 times n (%) 1 1-5 times n (%) 2 6-10 times n (%) 3 11-15 times n (%) 4 16+ times n (%) Missing n (%) Median (IQR) I have used an online search engine to search for practice related literature or research 65 (11.5) 157 (27.7) 96 (16.9) 51 (9.0) 117 (20.6) 81 (14.3) 3 (2,4) I have read/reviewed professional literature (i.e. professional journals & textbooks) related to my practice 65 (11.5) 184 (32.5) 88 (15.5) 46 (8.1) 107 (18.9) 77 (13.6) 2 (2,4) I have used an online database to search for practice related literature or research 107 (18.9) 174 (30.7) 66 (11.6) 36 (6.3) 103 (18.2) 81 (14.3) 2 (2,4) I have used professional literature or research findings to assist my clinical decision-making 101 (17.8) 215 (37.9) 71 (12.5) 40 (7.1) 63 (11.1) 77 (13.6) 2 (2,3) I have used professional literature or research findings to change my clinical practice 110 (19.4) 235 (41.4) 58 (10.2) 29 (5.1) 58 (10.2) 77 (13.6) 2 (2,3) I have read/reviewed clinical research findings related to my practice 125 (22.0) 193 (34.0) 62 (10.9) 35 (6.2) 75 (13.2) 77 (13.6) 2 (1,3) I have consulted a colleague or industry expert to assist my clinical decision-making 113 (19.9) 220 (38.8) 67 (11.8) 33 (5.8) 53 (9.3) 81 (14.3) 2 (2,3) I have referred to magazines, layperson / self-help books, or non-government/non-education institution websites to assist my clinical decision-making 236 (41.6) 145 (25.6) 39 (6.9) 25 (4.4) 41 (7.2) 81 (14.3) 2 (1,2) IQR – Interquartile range The perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small (comprising 1-25% of practice) by 21.5% of participants, small (26-50% of practice) by 21.7% of participants, moderate (51-75% of practice) by 26.8% of participants and large (76-99% of practice) by 12.0% of participants. Few participants reported that none (1.9% of participants) or all (1.2% of participants) of their practice was underpinned by clinical research evidence. The information sources used most frequently by participating osteopaths to inform their clinical decision-making were traditional knowledge (median rank 4; IQR 2,7) and published clinical evidence (median rank 4; IQR 2,7) (Table 3) . Published experimental/laboratory evidence was used by participants the least (median rank 8; IQR 3,10). Table 3. Sources of information used by participants to inform their clinical decision-making (in descending order of frequency)* (n=567) Information source Median (IQR) Traditional knowledge 4 (2,7) Published clinical evidence (i.e. clinical trials) 4 (2,7) Consulting fellow practitioners or experts 4 (3,6) Textbooks 5 (2,7) Personal intuition 5 (3,7) Clinical practice guidelines 6 (3,8) Personal preference 7 (4,9) Trial and error 7 (4,9) Patient preference 7 (5,9) Published experimental/laboratory evidence 8 (3,10) *Sources were ranked from 1=most frequently used, to 10=least frequently used. IQR – Interquartile range Skills and training in EBP Overall, participating osteopaths reported a low-moderate to moderate level of perceived skill in EBP (median skill subscore 39; IQR 31,48; range 13-65; scores ranging between 26.1 and 39.0 are indicative of a low-moderate to moderate skill level). Relatively higher levels of perceived skill were observed for items pertaining to ‘clinical problem identification’ (i.e. identifying answerable clinical questions [73.6% self-reported a moderate to moderate-high skill level for this item], and identifying knowledge gaps in practice [68.5% self-reported a moderate to moderate-high skill level for this item]) (Table 4) . Participants reported the lowest levels of perceived skill for items related to ‘research conduct’, with more than one-half of participating osteopaths reporting low to low-moderate skill in conducting clinical research (60.4%) and systematic reviews (50.9%). A weak positive association was found between skill subscore (categorised by quartiles) and age (Ƭ = .140, p = .001), sex (V = .256, p < .001; with higher subscores reported among male participants), highest qualification (Ƭ = .254, p < .001), years in osteopathy practice (Ƭ = .227, p < .001), number of hours in clinical practice (Ƭ = .086, p = .033), and number of hours teaching in the higher education sector (Ƭ = .265, p < .001). Skill subscore was shown to be moderately positively correlated with number of hours engaged in research work (Ƭ = .437, p < .001). Table 4. Participant’s perceived skill level in evidence-based practice (n=567) 1 Low n (%) 2 Low-moderate n (%) 3 Moderate n (%) 4 Moderate-high n (%) 5 High n (%) Missing n (%) Median (IQR) Identifying answerable clinical questions 14 (2.5) 56 (9.9) 183 (32.3) 234 (41.3) 58 (10.2) 22 (3.9) 4 (3,4) Identifying knowledge gaps in practice 25 (4.4) 84 (14.8) 222 (39.2) 166 (29.3) 48 (8.5) 22 (3.9) 3 (3,4) Locating professional literature 38 (6.7) 102 (18.0) 148 (26.1) 174 (30.7) 83 (14.6) 22 (3.9) 3 (2,4) Online database searching 44 (7.8) 101 (17.8) 143 (25.2) 155 (27.3) 102 (18.0) 22 (3.9) 3 (2,4) Retrieving evidence 46 (8.1) 112 (19.8) 158 (27.9) 145 (25.6) 84 (14.8) 22 (3.9) 3 (2,4) Critical appraisal of evidence 33 (5.8) 122 (21.5) 190 (33.5) 143 (25.2) 43 (7.6) 36 (6.3) 3 (2,4) Synthesis of research evidence 28 (4.9) 121 (21.3) 185 (32.6) 150 (26.5) 47 (8.3) 22 (3.9) 3 (2,4) Applying research evidence to patient cases 25 (4.4) 74 (13.1) 185 (32.6) 197 (34.7) 50 (8.8) 36 (6.3) 3 (3,4) Sharing evidence with colleagues 53 (9.3) 100 (17.6) 139 (24.5) 159 (28.0) 80 (14.1) 36 (6.3) 3 (2,4) Using findings from clinical research 73 (12.9) 119 (21.0) 169 (29.8) 127 (22.4) 39 (6.9) 40 (7.1) 3 (2,4) Using findings from systematic reviews 89 (15.7) 131 (23.1) 127 (22.4) 136 (24.0) 44 (7.8) 40 (7.1) 3 (2,4) Conducting systematic reviews 147 (25.9) 142 (25.0) 122 (21.5) 82 (14.5) 34 (6.0) 40 (7.1) 2 (1,3) Conducting clinical research 218 (38.4) 125 (22.0) 102 (18.0) 53 (9.3) 33 (5.8) 36 (6.3) 2 (1,3) IQR – Interquartile range The majority (>62%) of participating osteopaths had completed training in EBP, evidence application, conducting clinical research, conducting systematic reviews and critical thinking. Across all five areas, training was mostly undertaken as a minor or major component of a university course (i.e. by 24.3% to 37.7% of participants), or as a short course (i.e. by 9.2% to 17.8% of participants). Attitudes toward EBP Participants’ attitudes toward EBP were largely positive (median attitude subscore 32; IQR 28,35; range 11-40; scores ranging between 32.0 and 40.0 are indicative of a predominantly agree to strongly agree response). At least 4 out of 5 participating osteopaths agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and professional literature and research findings were useful to their day-to-day practice (88.9%), with a similar proportion expressing an interest in learning or improving the skills necessary to incorporate EBP into their practice (88.9%) (Table 5) . On the other hand, a large proportion (43.5%) of participants disagreed or strongly disagreed that EBP placed an unreasonable demand on their practice. The attitude subscore (categorised by quartiles) was found to be weakly positively associated with participant sex (V = .162, p = .011; with more favourable attitudes reported among male participants), number of hours teaching in the higher education sector (Ƭ = .104, p = .013), and number of hours engaged in research work (Ƭ = .133, p = .003). Table 5. Participant attitudes toward evidence-based practice (n=567) 1 Strongly Disagree n (%) 2 Disagree n (%) 3 Neutral n (%) 4 Agree n (%) 5 Strongly Agree n (%) Median (IQR) I am interested in learning or improving the skills necessary to incorporate EBP into my practice 12 (2.1) 16 (2.8) 35 (6.2) 202 (35.6) 302 (53.3) 5 (4,5) EBP is necessary in the practice of osteopathy 14 (2.5) 17 (3.0) 28 (4.9) 225 (39.7) 283 (49.9) 4 (4,5) Professional literature (i.e. journals & textbooks) and research findings are useful in my day-to-day practice 10 (1.8) 13 (2.3) 40 (7.1) 288 (50.8) 216 (38.1) 4 (4,5) EBP improves the quality of my patient’s care 17 (3.0) 27 (4.8) 56 (9.9) 234 (41.3) 233 (41.1) 4 (4,5) EBP assists me in making decisions about patient care 12 (2.1) 30 (5.3) 63 (11.1) 260 (45.9) 202 (35.6) 4 (4,5) Prioritizing EBP within osteopathic practice is fundamental to the advancement of the profession 21 (3.7) 48 (8.5) 63 (11.1) 211 (37.2) 224 (39.5) 4 (4,5) EBP takes into account my clinical experience when making clinical decisions 21 (3.7) 73 (12.9) 98 (17.3) 214 (37.7) 161 (28.4) 4 (3,5) EBP takes into account a patient’s preference for treatment 36 (6.3) 143 (25.2) 116 (20.5) 173 (30.5) 99 (17.5) 3 (2,4) There is a lack of evidence from clinical trials to support most of the treatments I use in my practice 41 (7.2) 138 (24.3) 151 (26.6) 178 (31.4) 59 (10.4) 3 (2,4) The adoption of EBP places an unreasonable demand on my practice 50 (8.8) 197 (34.7) 148 (26.1) 141 (24.9) 31 (5.5) 3 (2,4) EBP – Evidence-based practice; IQR – Interquartile range A secondary analysis was performed to assess the relationship between membership of a professional association and attitude, skill and use subscores. Our results showed a weak positive association between professional association membership and skill subscore (V = .130, p = .031; i.e. higher perceived skill subscore among those reporting membership of a professional association) and use subscore (V = .170, p = .003; i.e. higher use subscore among those reporting membership of a professional association). In a further analysis between associations, we found a weak positive association between professional association affiliation and skill subscore (V = .213, p < .001; i.e. higher perceived skill subscore among those reporting membership of ROFE) and use subscore (V = .168, p = .002; i.e. higher use subscore among those reporting membership of ROFE). Barriers and enablers of EBP use Of the 13 listed barriers to EBP uptake, participants identified 8 as being minor to moderate barriers, including lack of clinical evidence in osteopathy (51.3%), insufficient skills for applying research findings (50.8%), lack of time (49.9%), insufficient skills for appraising research (48.8%), insufficient skills for interpreting research (47.1%), insufficient skills for locating research (46.0%), lack of industry support for EBP (45.1%), and lack of incentive to participate in EBP (44.4%). The remaining 5 barriers (i.e. lack of resources, interest, relevance, colleague support, and patient preference) were considered by many (49.2% to 63.1%) participants as not being a barrier or only a minor barrier to EBP uptake. Most participating osteopaths indicated that the 10 listed enablers of EBP uptake were either moderately or very useful. These enablers included improving access to: full-text journal articles (63.8% rated this strategy as moderately or very useful), internet in the workplace (63.3%), free online databases (63.0%), online EBP education materials (62.8%), critical reviews of research evidence relating to osteopathy (61.0%), research rating tools (58.2%), online tools that facilitate practitioner appraisal of the evidence (58.0%), databases requiring licence fees (57.3%), critically appraised topics relating to osteopathy (57.3%), and critical appraisal tools (56.3%). Discussion This study aimed to assess the attitudes, skills and utilisation of EBP, as well as the barriers and enablers of EBP use, among Spanish osteopaths. Overall, our results showed that Spanish osteopaths hold positive views towards EBP but their utilization/implementation is still poor. Positive responses about EBP training and utilisation were modest and, in general, the perceived level of EBP-related skill was very low. Despite these low levels of skill in relation to the utilization of EBP , several barriers to the use of EBP were perceived as not important by participants. Although it was not possible to calculate the mean response and the number of withdrawals from the survey, the final number of participants that completed the survey was around 9% of the target population, which is similar to the survey response rate reported for osteopaths in a similar UK study [26] Our study sample had a high proportion of male participants and those aged between 30 and 49 years, which was similar to that reported in another recent survey of Spanish osteopaths [33] . Previous studies in the UK and Australia have also reported comparable gender distributions [26, 31] although in Sweden this distribution was more balanced [40] . In our survey, 73% of osteopaths had a previous degree in a healthcare profession regulated in Spain. This is consistent with other surveys conducted in Spain [33] , where the majority of osteopaths have reported a previous degree in physiotherapy and postgraduate training in osteopathy. EBP attitudes Most participating Spanish osteopaths agreed that EBP is necessary in the practice of osteopathy, with the majority interested in learning or improving the skills necessary to incorporate EBP into their practice. Overall, attitudes toward EBP were positive. In fact, this favourable view of EBP is in accordance with other healthcare professions, such as nursing [41, 42] , physiotherapy [11, 43, 44] , dentistry [45] and chiropractic [12] , as well as osteopaths in other countries [26, 31, 40] . Although attitudes towards EBP were generally positive, a considerable number of respondents (30%) believed that EBP placed an unreasonable demand on their practice. This item was much less reported by Australian (17%) [31] , UK (16%) [26] and Swedish osteopaths (17%) [40] . This suggests that almost one-third of our sample may be experiencing difficulties in integrating EBP into their daily practice. Therefore, further efforts are required to enhance the competence, skills and efficiency of implementing the components of EBP amongst osteopaths in Spain. A possible explanation for these contrasting findings could be the lack of professional regulation in Spain, even compared to osteopathy in Sweden, where like Spain, osteopathy is also an emerging profession. However, in Sweden, there are far fewer OEIs (currently just one), and just a single osteopathic association of which the majority of osteopaths are members of [40] . The relatively higher number of OEIs in Spain and the diversity of educational focus (such as time spent on EBP) may explain the burden that Spanish osteopaths perceive in enacting EBP. Research from nursing and physical therapy has found the level of professional education to be predictive of the propensity to adopt EBP; although, other factors were also influential, such as desire to learn, practicality (i.e. non-interference with productivity or patient flow) and beliefs about EBP [46, 47] . Indeed, there was some indication in our study that participating osteopaths had a misconstrued understanding of the EBP paradigm, with a large proportion of participants believing that EBP did not take into consideration the patient's perspective. Other studies have also indicated that osteopaths view EBP as a threat to the professional identity of the profession [24, 25, 48] . This suggests that Spanish osteopaths might benefit from revisiting the fundamental purposes of contemporary EBP which seeks to prioritise ethical care, is relationship-based, advocates shared decision-making and relates the evidence to the individual patient’s context and situation [7] . EBP skills Participating Spanish osteopaths perceived their EBP skill level to be low to moderate, which is relatively lower than that reported among osteopaths in other countries [26, 31, 40] , chiropractors [12] and physiotherapists [43] . A notable insecurity among participants related to the conduct of clinical studies or systematic reviews. This finding was somewhat expected as these advanced research activities are not typically taught within undergraduate clinical programs. Another self-reported skill-deficit related to the implementation of research findings, that is, the process of applying research evidence into clinical practice. This coincides with the perceived barriers of EBP uptake reported by participants, of which half of our sample identified insufficient skills in applying research findings as a barrier to EBP utilisation. In fact, this is a problem affecting many healthcare professions, where considerable ‘research-practice gaps’ exist [49–51] . However, these research-practice gaps can be attributed to more than just insufficient knowledge and skills; organizational factors, and social and attitudinal behaviours are also important contributors [49] . We argue that all of these factors are likely to be responsible for the limited application of research evidence in Spanish osteopathic practice given the historical lack of research culture within the profession in both the clinical and academic domain. The impact of research culture on EBP use was supported to some extent by the association between EBP use and number of hours engaged in research work and teaching in the higher education sector. When this finding is compared against surveys of Australian [31] or UK [26] osteopaths, there are similarities in the number of hours dedicated to research activities (i.e. 0-15 hours/week; Spain=72%, Australia=84%, UK=72%), though Spanish osteopaths did seem to dedicate more hours to teaching in the higher education sector (i.e. 1-30 hours/week; Spain=28%, Australia=15%, UK=18%). Hence, one might expect Spanish osteopaths to have a higher perceived level of EBP-related skill, although this was not the case. This raises questions about the integration of EBP and research into Spanish osteopathic curricula. Use EBP A moderately-low level of engagement in EBP activities was reported in our sample. An interesting finding was that around 1 in 5 participants had not searched an online database or used scientific literature to change their clinical practice in the month preceding the survey. This behaviour can be partially explained by the types of information sources used by our sample. The main source of information used by participants to inform their clinical decision-making was traditional knowledge, followed by published clinical evidence and peer opinion or textbooks. These results highlight the importance of traditional knowledge to Spanish osteopaths; a finding that also can be extended to osteopaths in Australia [31] , UK [26] and Sweden [40] , who also report traditional knowledge as the primary source of information used to inform clinical decision-making. However, while Australian and UK osteopaths cited clinical guidelines as their second most frequently used information source, in the present study, Spanish osteopaths rated these guidelines as their sixth most frequently used source of information and in comparison, it was reported in ninth position by Swedish osteopaths [40] . Given that clinical guidelines typically represent the best available evidence in a field, a considerable research-practice gap may be evident in Spanish and Swedish osteopathic practice. Notwithstanding, there appear to be few differences in EBP use between these countries. Similar to our sample, the use of EBP among osteopaths in Australia, UK and Sweden is reported to be generally low [26, 31, 40] , as it is among US and Canadian chiropractors [9, 52] . Existing evidence suggests physical therapists have a relatively greater level of engagement with EBP [43, 53] . Interestingly, two-thirds of our sample held a qualification in physiotherapy, which is common among osteopaths in Spain [32, 33] . This result raises the question as to why participating osteopaths engage with EBP to a lesser extent than physiotherapists. One explanation is that to date, we have no data on Spanish physiotherapist engagement in EBP activities, which possibly could be different from other countries. Further, almost half of our sample received their highest qualification at least six years before the survey, and in Spain, EBP has been only recently integrated into physiotherapy curricular [54] . Osteopathy also has been traditionally embedded in clinical models and frameworks conceived by a small number of individuals from when the discipline was attempting to establish itself, leading to an uncritical development of the profession [23] . An examination of the comparative uptake of EBP among different health disciplines in Spain may shed some further light on this issue. In terms of potential solutions to improving EBP uptake, education about EBP alone may not be sufficient [55] . Findings from a recent scoping review suggest education programs aimed at improving local barriers may be a more effective method of improving EBP engagement [56] . Within osteopathy, these barriers to EBP uptake are not entirely clear. Indeed, in the case of our respondents, most did not perceive there to be any major barriers. Barriers and enablers for EBP Previous surveys of osteopaths [26, 31, 40] have reported lack of clinical evidence in osteopathy (Australia=60%; UK=69%; Sweden=53%) and lack of time (Australia=53%; UK=57%) as major barriers to EBP uptake. Although none of the thirteen listed factors in the survey were identified as major barriers to EBP uptake among Spanish participants, lack of clinical evidence in osteopathy and lack of time were still considered the most notable issues of concern, with at least one-half of respondents reporting these as minor to moderate barriers. Other important barriers related to lack of skills (applying research, research appraisal and interpreting research), showing the necessity to improve these abilities in order to encourage EBP uptake among new osteopaths. While education is important, there also needs to be a change in mindset, triggered by a comprehensive reflection that considers osteopathy as a healthcare profession that embraces science as a way to evolve and self-assess [48] . Exactly how EBP and research culture should be promoted among healthcare practitioners remains controversial. Several recent scoping reviews in the field of physiotherapy suggests some ideas [56, 57] . The first consideration is that any strategy aimed at improving EBP uptake should be tailored to the local scenario to contextualize the training program. The second consideration is that multifaceted strategies (containing at least five elements) are more likely to be associated with significant changes in learning outcomes. Stander et al. (2018) also highlights the need for EBP training programmes to be underpinned by behaviour change models, learning theories and a concrete theoretical framework [56] . A recent systematic review and Delphi survey proposes a set of 68 core competencies as a possible framework to inform the development of EBP curricula for health professionals [58] Regarding enablers, around 63% of participants considered free access to scientific evidence, access to the internet at work, access to free databases and online EBP education materials to be very useful enablers. This was in line with osteopath’s reports in other countries [26, 31, 40] . In the case of Spain, we argue that the national unification of osteopathic curricula and the inclusion of these programmes in universities are also necessary enablers to improving EBP uptake. These actions will potentially improve the consistency of programmes, ensure course content represents best practice, and help nurture a stronger research and EBP culture within the profession. While these actions might be difficult to accomplish in Spain without national professional regulation, results from Sweden (where osteopathy is also an unlicensed health profession) demonstrate that extensive exposure to EBP training (91% of Swedish osteopaths vs. 62% of Spanish osteopaths) correlates with higher perceived skills in EBP [40] . Limitations Although the survey response rate exceeded the minimum sample size required, we noticed a high percentage of missing responses. As all responses were compulsory, this meant many respondents dropped out of the survey early, possibly due to survey fatigue. This was also an issue reported in a UK study of osteopaths [26] . Nonetheless, as the original English version of EBASE has demonstrated good internal consistency and acceptable test-retest reliability [35, 36] , and the fact that survey fatigue was not detected during pilot testing, it was not considered appropriate to modify the number of survey items. While the process of translating the questionnaire strictly followed standard methods reported by WHO [37] , including a pilot study, the psychometric properties of the Spanish version of the questionnaire was not formally assessed, which could have impacted the validity and reliability of findings. As has occurred in other osteopathic surveys conducted in Spain [32, 33] , a large proportion of responses came from two geographical regions (Cataluña and Madrid). These results likely reflect the geographical distribution of osteopaths in Spain. Notwithstanding, there were a number of regions that were not well represented, whose views might potentially differ from the more well-represented regions. Recall bias and selection bias are other intrinsic limitations of the study design. Conclusions This study furthers our understanding of Spanish osteopaths’ attitudes, skills and use of EBP. Our results showed that participant’s attitudes toward EBP were largely positive. At least four out of five participating osteopaths agreed that EBP was necessary in the practice of osteopathy and professional literature and research findings were useful to their day-to-day practice. However, the perceived skills, use and engagement in EBP activities was reported as moderate to low. Fortunately, there was general interest in learning and improving the skills necessary to incorporate EBP into clinical practice. Our findings, therefore, suggest that appropriate educational initiatives and wider inclusion of osteopathic educational programmes into university environments would be helpful in assisting Spanish osteopaths to embrace EBP. Although, as discussed in this paper, the absence of osteopathy regulation in Spain could continue to curtail efforts to improve EBP uptake in this professional group. List of Abbreviations EBP - Evidenced-based practice WHO - World Health Organization OEIs - Osteopathic Educational Institutions EBASE – Evidence-Based practice Attitude and Utilization Survey Declarations Ethics approval and consent to participate The study was approved by the Ethical Committee of Sagrado Corazón Hospital, Barcelona (2019/81-CMF-HUSC). Study participation was anonymous and voluntary, and participants were able to withdraw from the survey at any time without repercussion. Informed consent was obtained from all subjects and all methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding The study did not receive any financial support from any sponsor Authors' contributions GA and CJ translated and adapted the questionnaire and established local recruitment strategies. GA and CJ drafted the first manuscript in collaboration with TS and OT. ML conducted the statistical analysis and drafted the results. GA, CJ, TS, OT and ML critically interpreted the data, edited the manuscript and reviewed and approved the final manuscript. References Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71–2. doi:10.1136/bmj.312.7023.71. Innes SI, Leboeuf-Yde C, Walker BF. How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years. Chiropr Man Therap. 2018;26:8. Rabey M, Hall T, Hebron C, Palsson TS, Christensen SW, Moloney N. 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Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey. JAMA Netw Open. 2018;1:e180281. Cite Share Download PDF Status: Published Journal Publication published 10 Feb, 2021 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 07 Dec, 2020 Reviews received at journal 06 Dec, 2020 Reviewers agreed at journal 22 Nov, 2020 Reviewers invited by journal 20 Nov, 2020 Editor assigned by journal 19 Nov, 2020 Editor invited by journal 19 Nov, 2020 Submission checks completed at journal 18 Nov, 2020 First submitted to journal 12 Nov, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-107863","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":4956656,"identity":"68381930-3eb7-4635-96af-171ba26d7bae","order_by":0,"name":"Gerard Alvarez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYNACNgYZBvYGIMPAgngtPAw8B0BaJEjRIpEAYhGhRd699+HnijI7HoObz69u+FEgwcDf3p2AV4vhmePGkmfOJfMY3M4pu9kDdJjEmbMb8GuZkcYg2djGzCM5OyftBg9Qi4FELgEt858x/2xsq+eRnHkm7eYfYrTIS7CxAW05zMMvwX7sNlG2GPCksVk2nDvOw8+Tw3ZbxkCCh6Bf5NuPMd9sKKuWY2M//uzmmz82cvztvQRsOQBn8hiASbzKwbY0wJnsDwiqHgWjYBSMgpEJAFopQbSVCdYrAAAAAElFTkSuQmCC","orcid":"","institution":"Spain National Centre, Foundation COME Collaboration, Barcelona, Spain","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Gerard","middleName":"","lastName":"Alvarez","suffix":""},{"id":4956657,"identity":"1fbba8ef-19fc-491e-8b5f-7cb878a2b596","order_by":1,"name":"Cristian Justribo","email":"","orcid":"","institution":"Hospital Sagrado Corazón de Barcelona","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cristian","middleName":"","lastName":"Justribo","suffix":""},{"id":4956658,"identity":"337b99d7-6364-4033-a98b-0c0517c3aa41","order_by":2,"name":"Tobias Sundberg","email":"","orcid":"","institution":"University of Technology Sydney","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Sundberg","suffix":""},{"id":4956659,"identity":"b263d327-f2c5-405e-88c7-b4ab062522fd","order_by":3,"name":"Oliver Thomson","email":"","orcid":"","institution":"University College of Osteopathy","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Oliver","middleName":"","lastName":"Thomson","suffix":""},{"id":4956660,"identity":"13519848-1cdc-4872-8759-151201ac5c73","order_by":4,"name":"Matthew Leach","email":"","orcid":"","institution":"Southern Cross University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Leach","suffix":""}],"badges":[],"createdAt":"2020-11-13 16:51:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-107863/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-107863/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-021-06128-6","type":"published","date":"2021-02-10T15:00:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3795453,"identity":"46664a2f-2ec3-4a6b-8e1c-2c2d1e3eab2b","added_by":"auto","created_at":"2020-11-24 15:46:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63548,"visible":true,"origin":"","legend":"Geographical location of practice, n (%)\nNote: The designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of Research Square concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. This map has been provided by the authors.","description":"","filename":"Fig1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-107863/v1/d91eb6f182a964b1e7bd0070.JPG"},{"id":13620496,"identity":"c3ed3ad6-811f-4958-a0c8-8a1e0635c135","added_by":"auto","created_at":"2021-09-17 07:05:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1168692,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-107863/v1/548ac831-2a53-400e-9962-551ff6f3ac06.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eAttitudes, Skills and Use of Evidence-Based Practice Amongst Spanish Osteopaths: A Cross-Sectional Survey\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eEvidence-Based Practice (EBP) has been defined as the integration of knowledge provided by the best available evidence, with a practitioner\u0026rsquo;s clinical experience and judgement, and combined with an individual patient\u0026rsquo;s values and preferences \u003ca href=\"https://paperpile.com/c/AFaecu/HLNj3\"\u003e[1]\u003c/a\u003e. Although there is broad support for EBP across most healthcare professions, its implementation by practitioners of the manual therapy professions remains limited and contested \u003ca href=\"https://paperpile.com/c/AFaecu/BRBsz+G4OOa+EuoP6+FLzLb+DG2T8\"\u003e[2\u0026ndash;6]\u003c/a\u003e. One explanation for the limited uptake of EBP in this professional group is the difficulty in transferring research-based evidence into practice due to the complexity of clinical settings, including the high level of interaction between patients and practitioners \u003ca href=\"https://paperpile.com/c/AFaecu/lbrSh+oBRh9\"\u003e[7, 8]\u003c/a\u003e. In fact, several healthcare disciplines \u003ca href=\"https://paperpile.com/c/AFaecu/18b1T+ciZoh+1SZqR+3vDPY+taSNj+hvPJi\"\u003e[9\u0026ndash;14]\u003c/a\u003e report similar issues in the implementation of EBP, including medicine \u003ca href=\"https://paperpile.com/c/AFaecu/hvPJi\"\u003e[14]\u003c/a\u003e, physical therapy \u003ca href=\"https://paperpile.com/c/AFaecu/1SZqR\"\u003e[11]\u003c/a\u003e and more recently, osteopathy \u003ca href=\"https://paperpile.com/c/AFaecu/dSx0Y+9tyxE\"\u003e[15, 16]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003eOsteopathy is considered a manual therapy discipline in which its therapeutic base has been traditionally embedded within a specific conceptual framework and principles \u003ca href=\"https://paperpile.com/c/AFaecu/jlEBd+EvWdP+6ug0V\"\u003e[17\u0026ndash;19]\u003c/a\u003e. However, several authors have questioned the validity, plausibility and utility of these traditional osteopathic models in the context of contemporary evidence-based healthcare \u003ca href=\"https://paperpile.com/c/AFaecu/c8lVw+SmNlc+d0YOs+h9fnd\"\u003e[20\u0026ndash;23]\u003c/a\u003e. Despite the passing of time, most of these osteopathic models have not been updated in response to the evidence, yielding to an uncritical development of the profession \u003ca href=\"https://paperpile.com/c/AFaecu/h9fnd\"\u003e[23]\u003c/a\u003e. The lack of integration of EBP in osteopathic professional development has been explored across the world, with the subject receiving significant attention in the UK \u003ca href=\"https://paperpile.com/c/AFaecu/QcqH4+hdrfa+1btJv+8sHiE\"\u003e[24\u0026ndash;27]\u003c/a\u003e\u003cu\u003e.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOsteopathy is defined by The World Health Organisation (WHO) as a first-contact patient-centred health discipline \u003ca href=\"https://paperpile.com/c/AFaecu/awPuV\"\u003e[28]\u003c/a\u003e. As osteopathy develops its knowledge base, the profession will need to respond and be critically reflective and move away from the prioritizing of traditional theories and anecdotes as reliable sources of evidence, and instead, pursue the generation of new knowledge through research, and ensure that clinicians and educators are able to integrate evidence into practice. Although it appears that the integration of EBP into osteopathy is largely perceived as a favourable endeavour across the osteopathy community \u003ca href=\"https://paperpile.com/c/AFaecu/vENwn+1aIpN+1btJv\"\u003e[26, 29, 30]\u003c/a\u003e, recent findings suggest that osteopathy practitioner engagement with EBP activities seems to be infrequent \u003ca href=\"https://paperpile.com/c/AFaecu/VwU0w+1btJv\"\u003e[26, 31]\u003c/a\u003e. Previous research has shown that the perceived barriers to EBP implementation among UK osteopaths are lack of time, lack of evidence in the osteopathic field and lack of access to studies and databases \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv\"\u003e[26]\u003c/a\u003e. These results are consistent with a similar previous study conducted in Australia \u003ca href=\"https://paperpile.com/c/AFaecu/VwU0w\"\u003e[31]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003eIn Spain, osteopathy is not a regulated healthcare profession \u003ca href=\"https://paperpile.com/c/AFaecu/I6K0X+qfI1G\"\u003e[32, 33]\u003c/a\u003e. Consequently, osteopaths with different professional, academic and clinical profiles (e.g. qualifications, training standards and competencies) operate across Spain. At the same time, despite the existence of European standards for osteopathic education \u003ca href=\"https://paperpile.com/c/AFaecu/MkXPn\"\u003e[34]\u003c/a\u003e, there is considerable heterogeneity across training programs \u003ca href=\"https://paperpile.com/c/AFaecu/I6K0X+qfI1G\"\u003e[32, 33]\u003c/a\u003e. In this regard, the attitudes and utilisation of EBP among Spanish osteopaths remains uncertain. Therefore, the main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. We also aimed to identify the barriers and facilitators for the adoption of EBP in the Spanish osteopathic context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNational, online, cross-sectional survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey was open to all practising osteopaths in Spain, regardless of qualification or training institution. No exclusion criteria were applied. Although there is no reliable data on the number of osteopaths practising in Spain, numbers of graduates from osteopathic educational institutions (OEIs) in Spain estimate the Spanish osteopathic workforce to be in the vicinity of 5000-6000 \u003ca href=\"https://paperpile.com/c/AFaecu/qfI1G\"\u003e[33]\u003c/a\u003e. Based on a target population of 6000, at least 362 osteopaths were required to be surveyed in order to achieve a 5% margin of error and a 95% confidence interval for any individual item on the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of survey and variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Evidence-Based practice Attitude and utilization Survey (EBASE) \u003ca href=\"https://paperpile.com/c/AFaecu/q2Bon\"\u003e[35]\u003c/a\u003e is an 81-item instrument designed to assess attitudes, skills and use of evidence-based practice among health professionals. The survey is divided into seven constructs, including attitude, skills, education and training, use, barriers, enablers, and demographics. The original English EBASE instrument has demonstrated acceptable test-retest reliability (ICC = 0.578\u0026ndash;0.986), good internal consistency (Cronbach\u0026rsquo;s alpha = 0.84), and good construct and content validity (CVI = 0.899) \u003ca href=\"https://paperpile.com/c/AFaecu/q2Bon+BIXGx\"\u003e[35, 36]\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eItems from three of the survey constructs are able to be generated into subscores, as follows:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eAttitude subscore: Sum of the first 7 items, with scores ranging from 8 (predominantly strongly disagree) to 40 (predominantly strongly agree).\u003c/li\u003e\n\u003cli\u003eSkill subscore: Sum of all 13 items, with scores ranging from 13 (low level skill) to 65 (high level skill).\u003c/li\u003e\n\u003cli\u003eUse subscore: Sum of the first 6 items, with scores ranging between 0 (mostly infrequent use) and 24 (mainly frequent use).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTranslation and adaptation of survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire was translated from English to Spanish and adapted cross-culturally according to the forward and backward translation method recommended by the WHO \u003ca href=\"https://paperpile.com/c/AFaecu/BqwzO\"\u003e[37]\u003c/a\u003e. Once translated, a pilot test was carried out on 20 purposely-selected Spanish osteopaths. Suggestions for improvement (e.g., provision of additional response options to some questions) were integrated into the final version of the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipation in the study was advertised between April 2020 and June 2020 using a range of recruitment strategies. First, the main osteopathic associations (n=9) and OEIs (n=7) in Spain informed their associates (academic/clinical staff and alumni) of the survey and encouraged participation. Second, the study was advertised via social media (Twitter, Facebook and Instagram) inviting osteopaths to complete the EBASE survey. All recruitment media directed participants to a dedicated project website, where participants were invited to read the study information before being redirected to the survey.\u003c/p\u003e\n\u003cp\u003eData collection was undertaken online using SurveyMonkey\u0026trade; (SurveyMonkey Inc., San Mateo, California, USA). All survey items were made compulsory to mitigate the risk of missing data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the online survey were imported into IBM SPSS version 25 (Armonk, New York, IBM Corp) for data cleaning, coding and statistical analyses. Excluded from the analyses were incomplete surveys (i.e. surveys containing \u0026gt;20% missing data due to participant dropout) and duplicate responses (i.e. as identified using the Konstan et al. de-duplication procedure for online surveys \u003ca href=\"https://paperpile.com/c/AFaecu/IsTsW\"\u003e[38]\u003c/a\u003e). Categorical data were described using frequencies and percentages. Means and standard deviations were used to describe normally distributed data, and medians and the interquartile range used for non-normally distributed data. Associations between ordinal-level variables were examined using the Kendall\u0026rsquo;s Tau correlation coefficient (Ƭ), whereas relationships between nominal-level variables were assessed using Cramer\u0026rsquo;s V. Coefficients were interpreted as follows: 0.10-0.29 (weak association), 0.30-0.49 (moderate association) and 0.50-1.00 (strong association) \u003ca href=\"https://paperpile.com/c/AFaecu/d8Awy\"\u003e[39]\u003c/a\u003e. The level of significance was set at p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Committee of Sagrado Coraz\u0026oacute;n Hospital, Barcelona (2019/81-CMF-HUSC). Study participation was anonymous and voluntary, and participants were able to withdraw from the survey at any time without repercussion. Informed consent was obtained from all subjects and all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey was commenced by 714 Spanish osteopaths. After removing duplicate entries (n=4) and incomplete responses (n=143), the adjusted sample size was 567. The reasons for participant dropout could not be examined due to the anonymous nature of the survey. It also was not possible to calculate a survey response rate as the actual reach of the survey could not be determined. However, considering a potential target population of 6000 Spanish osteopaths \u003ca href=\"https://paperpile.com/c/AFaecu/qfI1G\"\u003e[33]\u003c/a\u003e the estimated response rate would be approximately 9% (564/6000).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipating osteopaths were predominantly male (47.1%), and aged between 30 and 49 years (62.6%); 40.7% were members of an osteopathy professional association \u003cstrong\u003e(Table 1)\u003c/strong\u003e. The largest proportion of participants held a Master\u0026rsquo;s degree as their highest qualification (37.9%), with 50.5% receiving this qualification within the past ten years. Two-thirds (66.0%) of participants also held a degree in physiotherapy. Most (59.5%) participants had been in osteopathic practice for six or more years, with 57.7% spending 16-45 hours/week in clinical practice, 72.3% spending up to 15 hours/week participating in research, and 50.4% working up to 15 hours/week teaching in the higher education sector. Participating osteopaths largely worked in solo practice (41.4%) in the central business district (43.4%), with most located in Catalu\u0026ntilde;a (23.8%), Comunidad de Madrid (13.1%) or Comunidad Valenciana (7.6%) \u003cstrong\u003e(Fig 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e \u003cstrong\u003eDemographic characteristics of sample (n=567)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Frequency\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026lt;20 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e3\u0026nbsp;\u0026nbsp; (0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e20-29 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e23\u0026nbsp;\u0026nbsp; (4.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e30-39 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e187 (33.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e40-49 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e168 (29.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e50-59 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e30\u0026nbsp;\u0026nbsp; (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e60-69 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e10\u0026nbsp;\u0026nbsp; (1.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e70+ years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e1\u0026nbsp;\u0026nbsp; (0.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e145 (25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e267 (47.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e155 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e145 (25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOsteopathy professional association membership\u003c/strong\u003e,\u003cem\u003e n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eNot a member of an Osteopathy professional association\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e185 (32.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eRegistry of Osteopaths of Spain\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e103 (18.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eRegistry of Osteopathic Physiotherapists of Spain\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e85 (15.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eOther Osteopathy professional association\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e43\u0026nbsp;\u0026nbsp; (7.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e151 (26.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eHighest qualification\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eDiploma\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e82 (14.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eBachelor degree\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e27\u0026nbsp;\u0026nbsp; (4.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMaster\u0026rsquo;s degree\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e215 (37.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003ePhD\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e46\u0026nbsp;\u0026nbsp; (8.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e52\u0026nbsp;\u0026nbsp; (9.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e145 (25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eYears since receiving highest qualification\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026lt; 1 year\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e42\u0026nbsp;\u0026nbsp; (7.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e1-5 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e150 (26.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e6-10 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e94 (16.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e11-15 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e59 (10.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e16+ years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e76 (13.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e146 (25.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOther non-osteopathic qualifications\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eDegree in Physiotherapy\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e374 (66.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eDiploma/Degree in other health-related field\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e31\u0026nbsp;\u0026nbsp; (5.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eDegree in Medicine\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e5\u0026nbsp;\u0026nbsp; (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eDegree in Nursing or Podiatry\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e5\u0026nbsp;\u0026nbsp; (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e152 (26.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eYears practiced in the field of osteopathy\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026lt;1 year\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e6\u0026nbsp;\u0026nbsp; (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e1-5 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e78 (13.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e6-10 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e136 (24.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e11-15 years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e95 (16.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e16+ years\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e16 (18.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e146 (25.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eHours per week in clinical (osteopathic) practice\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e0 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e5\u0026nbsp;\u0026nbsp; (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e1-15 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e47\u0026nbsp;\u0026nbsp; (8.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e16-30 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e150 (26.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e31-45 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e177 (31.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e46+ hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e42\u0026nbsp;\u0026nbsp; (7.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e146 (25.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eHours per week participating in research\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e0 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e162 (28.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e1-15 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e248 (43.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e16-30 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e9\u0026nbsp;\u0026nbsp; (1.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e31-45 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e2\u0026nbsp;\u0026nbsp; (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e46+ hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e0\u0026nbsp;\u0026nbsp; (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e146 (25.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eHours per week working in the higher education sector\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e0 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e189 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e1-15 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e97 (17.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e16-30 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e59 (10.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e31-45 hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e29\u0026nbsp;\u0026nbsp; (5.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003e46+ hours\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e47\u0026nbsp;\u0026nbsp; (8.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e146 (25.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"100%\"\u003e\n\u003cp\u003e\u003cstrong\u003eClinical setting in which osteopathy was predominantly practiced\u003c/strong\u003e,\u003cem\u003e n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eSolo practice\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e235 (41.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eWith a group of allied health providers\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e87 (15.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eWith a group of complementary and allied health providers\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e41\u0026nbsp;\u0026nbsp; (7.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eWith conventional and allied health providers\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e37\u0026nbsp;\u0026nbsp; (6.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eWithin a clinical institution (e.g. hospital)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e12\u0026nbsp;\u0026nbsp; (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eWithin an educational institution (e.g. university)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e6\u0026nbsp;\u0026nbsp; (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e149 (26.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eGeographical location of practice\u003c/strong\u003e,\u003cem\u003e n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eCatalu\u0026ntilde;a\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e135 (23.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eComunidad de Madrid\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e74 (13.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eComunidad Valenciana\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e43\u0026nbsp;\u0026nbsp; (7.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eAndaluc\u0026iacute;a\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e36\u0026nbsp;\u0026nbsp; (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eGalicia\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e25\u0026nbsp;\u0026nbsp; (4.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eIslas Baleares\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e17\u0026nbsp;\u0026nbsp; (3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003ePa\u0026iacute;s Vasco\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e17\u0026nbsp;\u0026nbsp; (3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eCanarias\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e14\u0026nbsp;\u0026nbsp; (2.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eCastilla-La Mancha\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e12\u0026nbsp;\u0026nbsp; (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eRegi\u0026oacute;n de Murcia\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e11\u0026nbsp;\u0026nbsp; (1.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eCastilla y Le\u0026oacute;n\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e8\u0026nbsp;\u0026nbsp; (1.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eExtremadura\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e7\u0026nbsp;\u0026nbsp; (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eArag\u0026oacute;n\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e6\u0026nbsp;\u0026nbsp; (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eCantabria\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e6\u0026nbsp;\u0026nbsp; (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003ePrincipado de Asturias\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e5\u0026nbsp;\u0026nbsp; (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eComunidad Foral de Navarra\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e1\u0026nbsp;\u0026nbsp; (0.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eLa Rioja\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e1\u0026nbsp;\u0026nbsp; (0.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e149 (26.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cstrong\u003eGeographical region of practice\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eCity (Central business district)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e246 (43.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eInner city location\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e88 (15.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eRural location\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e43\u0026nbsp;\u0026nbsp; (7.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eOuter city location\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e39\u0026nbsp;\u0026nbsp; (6.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78%\"\u003e\n\u003cp\u003e\u003cem\u003eMissing\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e151 (26.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCAM \u0026ndash; Complementary and alternative medicine; HVLA \u0026ndash; high-velocity low amplitude;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of EBP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported a moderate-low level of engagement in EBP activities (median use subscore 8; IQR 5,14; range 0-24; scores ranging between 6.1 and 12.0 are indicative of a moderately-low level of use). Reading/reviewing professional literature and using online search engines to find practice-related literature were among the most frequently reported activities, with 44.6%-48.0% of participating osteopaths engaging in these activities between 1 and 10 times in the month preceding the survey \u003cstrong\u003e(Table 2)\u003c/strong\u003e. Participant engagement in all other EBP-related activities was generally infrequent, with 49.6%-67.2% of participating osteopaths engaging in these activities no more than 5 times in the previous month.\u003c/p\u003e\n\u003cp\u003eA weak positive association was found between use subscore (categorised by quartiles) and age (Ƭ = .113, p = .007), sex (V = .155, p = .018; with higher subscores reported among male participants), highest qualification (Ƭ = .165, p \u0026lt; .001), years in osteopathy practice (Ƭ = .142, p \u0026lt; .001), number of hours in clinical practice (Ƭ = .082, p = .037), and number of hours teaching in the higher education sector (Ƭ = .225, p \u0026lt; .001). A moderate positive association was observed between use subscore and number of hours engaged in research work (Ƭ = .345, p \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Participant engagement in evidence-based practice activities within the last month (n=567)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e0\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003etimes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1-5\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003etimes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6-10 times\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e11-15 times\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e16+\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003etimes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have used an online search engine to search for practice related literature or research\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e65 (11.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e157 (27.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e96 (16.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e51 (9.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e117 (20.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e81 (14.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have read/reviewed professional literature (i.e. professional journals \u0026amp; textbooks) related to my practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e65 (11.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e184 (32.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e88 (15.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e46 (8.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e107 (18.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e77 (13.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have used an online database to search for practice related literature or research\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e107 (18.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e174 (30.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e66 (11.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e36 (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e103 (18.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e81 (14.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have used professional literature or research findings to assist my clinical decision-making\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e101 (17.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e215 (37.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e71 (12.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e40 (7.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e63 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e77 (13.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (2,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have used professional literature or research findings to change my clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e110 (19.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e235 (41.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e58 (10.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e29 (5.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e58 (10.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e77 (13.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (2,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have read/reviewed clinical research findings related to my practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e125 (22.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e193 (34.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e62 (10.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e35 (6.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e75 (13.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e77 (13.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (1,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have consulted a colleague or industry expert to assist my clinical decision-making\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e113 (19.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e220 (38.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e67 (11.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e33 (5.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e53 (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e81 (14.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (2,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have referred to magazines, layperson / self-help books, or non-government/non-education institution websites to assist my clinical decision-making\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e236 (41.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e145 (25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e39 (6.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"63\"\u003e\n\u003cp\u003e25 (4.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e41 (7.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e81 (14.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e2 (1,2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR \u0026ndash; Interquartile range\u003c/p\u003e\n\u003cp\u003eThe perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small (comprising 1-25% of practice) by 21.5% of participants, small (26-50% of practice) by 21.7% of participants, moderate (51-75% of practice) by 26.8% of participants and large (76-99% of practice) by 12.0% of participants. Few participants reported that none (1.9% of participants) or all (1.2% of participants) of their practice was underpinned by clinical research evidence.\u003c/p\u003e\n\u003cp\u003eThe information sources used most frequently by participating osteopaths to inform their clinical decision-making were traditional knowledge (median rank 4; IQR 2,7) and published clinical evidence (median rank 4; IQR 2,7) \u003cstrong\u003e(Table 3)\u003c/strong\u003e. Published experimental/laboratory evidence was used by participants the least (median rank 8; IQR 3,10).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Sources of information used by participants to inform their clinical decision-making (in descending order of frequency)* (n=567) \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003e\u003cstrong\u003eInformation source\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Median (IQR)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003eTraditional knowledge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e4\u0026nbsp;\u0026nbsp; (2,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003ePublished clinical evidence (i.e. clinical trials)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e4\u0026nbsp;\u0026nbsp; (2,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003eConsulting fellow practitioners or experts\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e4\u0026nbsp;\u0026nbsp; (3,6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003eTextbooks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e5\u0026nbsp;\u0026nbsp; (2,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003ePersonal intuition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e5\u0026nbsp;\u0026nbsp; (3,7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003eClinical practice guidelines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e6\u0026nbsp;\u0026nbsp; (3,8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003ePersonal preference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e7\u0026nbsp;\u0026nbsp; (4,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003eTrial and error\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e7\u0026nbsp;\u0026nbsp; (4,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003ePatient preference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e7\u0026nbsp;\u0026nbsp; (5,9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"425\"\u003e\n\u003cp\u003ePublished experimental/laboratory evidence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"169\"\u003e\n\u003cp\u003e8 (3,10)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Sources were ranked from 1=most frequently used, to 10=least frequently used.\u003c/p\u003e\n\u003cp\u003eIQR \u0026ndash; Interquartile range\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSkills and training in EBP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, participating osteopaths reported a low-moderate to moderate level of perceived skill in EBP (median skill subscore 39; IQR 31,48; range 13-65; scores ranging between 26.1 and 39.0 are indicative of a low-moderate to moderate skill level). Relatively higher levels of perceived skill were observed for items pertaining to \u0026lsquo;clinical problem identification\u0026rsquo; (i.e. identifying answerable clinical questions [73.6% self-reported a moderate to moderate-high skill level for this item], and identifying knowledge gaps in practice [68.5% self-reported a moderate to moderate-high skill level for this item]) \u003cstrong\u003e(Table 4)\u003c/strong\u003e. Participants reported the lowest levels of perceived skill for items related to \u0026lsquo;research conduct\u0026rsquo;, with more than one-half of participating osteopaths reporting low to low-moderate skill in conducting clinical research (60.4%) and systematic reviews (50.9%).\u003c/p\u003e\n\u003cp\u003eA weak positive association was found between skill subscore (categorised by quartiles) and age (Ƭ = .140, p = .001), sex (V = .256, p \u0026lt; .001; with higher subscores reported among male participants), highest qualification (Ƭ = .254, p \u0026lt; .001), years in osteopathy practice (Ƭ = .227, p \u0026lt; .001), number of hours in clinical practice (Ƭ = .086, p = .033), and number of hours teaching in the higher education sector (Ƭ = .265, p \u0026lt; .001). Skill subscore was shown to be moderately positively correlated with number of hours engaged in research work (Ƭ = .437, p \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Participant\u0026rsquo;s perceived skill level in evidence-based practice (n=567)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLow-moderate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModerate-high\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(IQR)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eIdentifying answerable clinical questions\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e14\u0026nbsp;\u0026nbsp; (2.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e56\u0026nbsp;\u0026nbsp; (9.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e183 (32.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e234 (41.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e58 (10.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e4 (3,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eIdentifying knowledge gaps in practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e25\u0026nbsp;\u0026nbsp; (4.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e84 (14.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e222 (39.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e166 (29.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e48\u0026nbsp;\u0026nbsp; (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (3,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eLocating professional literature\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e38\u0026nbsp; (6.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e102 (18.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e148 (26.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e174 (30.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e83 (14.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eOnline database searching\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e44\u0026nbsp;\u0026nbsp; (7.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e101 (17.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e143 (25.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e155 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e102 (18.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eRetrieving evidence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e46\u0026nbsp;\u0026nbsp; (8.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e112 (19.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e158 (27.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e145 (25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e84 (14.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eCritical appraisal of evidence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e33\u0026nbsp;\u0026nbsp; (5.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e122 (21.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e190 (33.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e143 (25.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e43\u0026nbsp;\u0026nbsp; (7.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e36 (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eSynthesis of research evidence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e28\u0026nbsp;\u0026nbsp; (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e121 (21.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e185 (32.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e150 (26.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e47\u0026nbsp;\u0026nbsp; (8.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eApplying research evidence to patient cases\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e25\u0026nbsp;\u0026nbsp; (4.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e74 (13.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e185 (32.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e197 (34.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e50\u0026nbsp;\u0026nbsp; (8.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e36 (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (3,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eSharing evidence with colleagues\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e53\u0026nbsp;\u0026nbsp; (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e100 (17.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e139 (24.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e159 (28.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e80 (14.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e36 (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsing findings from clinical research\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e73 (12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e119 (21.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e169 (29.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e127 (22.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e39\u0026nbsp;\u0026nbsp; (6.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e40 (7.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eUsing findings from systematic reviews\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e89 (15.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e131 (23.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e127 (22.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e136 (24.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e44\u0026nbsp;\u0026nbsp; (7.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e40 (7.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eConducting systematic reviews\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e147 (25.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e142 (25.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e122 (21.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e82 (14.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e34\u0026nbsp;\u0026nbsp; (6.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e40 (7.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e2 (1,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"127\"\u003e\n\u003cp\u003e\u003cstrong\u003eConducting clinical research\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e218 (38.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e125 (22.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e102 (18.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e53\u0026nbsp;\u0026nbsp; (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e33\u0026nbsp;\u0026nbsp; (5.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e36 (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e2 (1,3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR \u0026ndash; Interquartile range\u003c/p\u003e\n\u003cp\u003eThe majority (\u0026gt;62%) of participating osteopaths had completed training in EBP, evidence application, conducting clinical research, conducting systematic reviews and critical thinking. Across all five areas, training was mostly undertaken as a minor or major component of a university course (i.e. by 24.3% to 37.7% of participants), or as a short course (i.e. by 9.2% to 17.8% of participants).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitudes toward EBP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; attitudes toward EBP were largely positive (median attitude subscore 32; IQR 28,35; range 11-40; scores ranging between 32.0 and 40.0 are indicative of a predominantly agree to strongly agree response). At least 4 out of 5 participating osteopaths agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and professional literature and research findings were useful to their day-to-day practice (88.9%), with a similar proportion expressing an interest in learning or improving the skills necessary to incorporate EBP into their practice (88.9%) \u003cstrong\u003e(Table 5)\u003c/strong\u003e. On the other hand, a large proportion (43.5%) of participants disagreed or strongly disagreed that EBP placed an unreasonable demand on their practice.\u003c/p\u003e\n\u003cp\u003eThe attitude subscore (categorised by quartiles) was found to be weakly positively associated with participant sex (V = .162, p = .011; with more favourable attitudes reported among male participants), number of hours teaching in the higher education sector (Ƭ = .104, p = .013), and number of hours engaged in research work (Ƭ = .133, p = .003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Participant attitudes toward evidence-based practice (n=567)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeutral\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eI am interested in learning or improving the skills necessary to incorporate EBP into my practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e12 (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e16 (2.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e35 (6.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e202 (35.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e302 (53.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e5 (4,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eEBP is necessary in the practice of osteopathy\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e14 (2.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e17 (3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e28 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e225 (39.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e283 (49.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e4 (4,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eProfessional literature (i.e. journals \u0026amp; textbooks) and research findings are useful in my day-to-day practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e10 (1.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e13 (2.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e40 (7.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e288 (50.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e216 (38.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e4 (4,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eEBP improves the quality of my patient\u0026rsquo;s care\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e17 (3.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e27 (4.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e56 (9.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e234 (41.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e233 (41.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e4 (4,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eEBP assists me in making decisions about patient care\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e12 (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e30 (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e63 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e260 (45.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e202 (35.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e4 (4,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrioritizing EBP within osteopathic practice is fundamental to the advancement of the profession\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e21 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e48 (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e63 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e211 (37.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e224 (39.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e4 (4,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eEBP takes into account my clinical experience when making clinical decisions\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e21 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e73 (12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e98 (17.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e214 (37.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e161 (28.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e4 (3,5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eEBP takes into account a patient\u0026rsquo;s preference for treatment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e36 (6.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e143 (25.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e116 (20.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e173 (30.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e99 (17.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eThere is a lack of evidence from clinical trials to support most of the treatments I use in my practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e41 (7.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e138 (24.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e151 (26.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e178 (31.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e59 (10.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"182\"\u003e\n\u003cp\u003e\u003cstrong\u003eThe adoption of EBP places an unreasonable demand on my practice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e50 (8.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e197 (34.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003e148 (26.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"74\"\u003e\n\u003cp\u003e141 (24.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e31 (5.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e3 (2,4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eEBP \u0026ndash; Evidence-based practice; IQR \u0026ndash; Interquartile range\u003c/p\u003e\n\u003cp\u003eA secondary analysis was performed to assess the relationship between membership of a professional association and attitude, skill and use subscores. Our results showed a weak positive association between professional association membership and skill subscore (V = .130, p = .031; i.e. higher perceived skill subscore among those reporting membership of a professional association) and use subscore (V = .170, p = .003; i.e. higher use subscore among those reporting membership of a professional association). In a further analysis between associations, we found a weak positive association between professional association affiliation and skill subscore (V = .213, p \u0026lt; .001; i.e. higher perceived skill subscore among those reporting membership of ROFE) and use subscore (V = .168, p = .002; i.e. higher use subscore among those reporting membership of ROFE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers and enablers of EBP use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 13 listed barriers to EBP uptake, participants identified 8 as being minor to moderate barriers, including lack of clinical evidence in osteopathy (51.3%), insufficient skills for applying research findings (50.8%), lack of time (49.9%), insufficient skills for appraising research (48.8%), insufficient skills for interpreting research (47.1%), insufficient skills for locating research (46.0%), lack of industry support for EBP (45.1%), and lack of incentive to participate in EBP (44.4%). The remaining 5 barriers (i.e. lack of resources, interest, relevance, colleague support, and patient preference) were considered by many (49.2% to 63.1%) participants as not being a barrier or only a minor barrier to EBP uptake.\u003c/p\u003e\n\u003cp\u003eMost participating osteopaths indicated that the 10 listed enablers of EBP uptake were either moderately or very useful. These enablers included improving access to: full-text journal articles (63.8% rated this strategy as moderately or very useful), internet in the workplace (63.3%), free online databases (63.0%), online EBP education materials (62.8%), critical reviews of research evidence relating to osteopathy (61.0%), research rating tools (58.2%), online tools that facilitate practitioner appraisal of the evidence (58.0%), databases requiring licence fees (57.3%), critically appraised topics relating to osteopathy (57.3%), and critical appraisal tools (56.3%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to assess the attitudes, skills and utilisation of EBP, as well as the barriers and enablers of EBP use, among Spanish osteopaths. Overall, our results showed that Spanish osteopaths hold positive views towards EBP but their utilization/implementation is still poor. Positive responses about EBP training and utilisation were modest and, in general, the perceived level of EBP-related skill was very low. Despite these low levels of skill in relation to the utilization of EBP , several barriers to the use of EBP were perceived as not important by participants. Although it was not possible to calculate the mean response and the number of withdrawals from the survey, the final number of participants that completed the survey was around 9% of the target population, which is similar to the survey response rate reported for osteopaths in a similar UK study \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv\"\u003e[26]\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eOur study sample had a high proportion of male participants and those aged between 30 and 49 years, which was similar to that reported in another recent survey of Spanish osteopaths \u003ca href=\"https://paperpile.com/c/AFaecu/qfI1G\"\u003e[33]\u003c/a\u003e. Previous studies in the UK and Australia have also reported comparable gender distributions \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv+VwU0w\"\u003e[26, 31]\u003c/a\u003e although in Sweden this distribution was more balanced \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc\"\u003e[40]\u003c/a\u003e. In our survey, 73% of osteopaths had a previous degree in a healthcare profession regulated in Spain. This is consistent with other surveys conducted in Spain \u003ca href=\"https://paperpile.com/c/AFaecu/qfI1G\"\u003e[33]\u003c/a\u003e, where the majority of osteopaths have reported a previous degree in physiotherapy and postgraduate training in osteopathy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEBP attitudes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participating Spanish osteopaths agreed that EBP is necessary in the practice of osteopathy, with the majority interested in learning or improving the skills necessary to incorporate EBP into their practice. Overall, attitudes toward EBP were positive. In fact, this favourable view of EBP is in accordance with other healthcare professions, such as nursing \u003ca href=\"https://paperpile.com/c/AFaecu/1gQQY+QMYwU\"\u003e[41, 42]\u003c/a\u003e, physiotherapy \u003ca href=\"https://paperpile.com/c/AFaecu/Bl2RE+A2mXt+1SZqR\"\u003e[11, 43, 44]\u003c/a\u003e, dentistry \u003ca href=\"https://paperpile.com/c/AFaecu/ppRKb\"\u003e[45]\u003c/a\u003e and chiropractic \u003ca href=\"https://paperpile.com/c/AFaecu/3vDPY\"\u003e[12]\u003c/a\u003e, as well as osteopaths in other countries \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc+VwU0w+1btJv\"\u003e[26, 31, 40]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003eAlthough attitudes towards EBP were generally positive, a considerable number of respondents (30%) believed that EBP placed an unreasonable demand on their practice. This item was much less reported by Australian (17%) \u003ca href=\"https://paperpile.com/c/AFaecu/VwU0w\"\u003e[31]\u003c/a\u003e, UK (16%) \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv\"\u003e[26]\u003c/a\u003e and Swedish osteopaths (17%) \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc\"\u003e[40]\u003c/a\u003e. This suggests that almost one-third of our sample may be experiencing difficulties in integrating EBP into their daily practice. Therefore, further efforts are required to enhance the competence, skills and efficiency of implementing the components of EBP amongst osteopaths in Spain. A possible explanation for these contrasting findings could be the lack of professional regulation in Spain, even compared to osteopathy in Sweden, where like Spain, osteopathy is also an emerging profession. However, in Sweden, there are far fewer OEIs (currently just one), and just a single osteopathic association of which the majority of osteopaths are members of \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc\"\u003e[40]\u003c/a\u003e. The relatively higher number of OEIs in Spain and the diversity of educational focus (such as time spent on EBP) may explain the burden that Spanish osteopaths perceive in enacting EBP.\u003c/p\u003e\n\u003cp\u003eResearch from nursing and physical therapy has found the level of professional education to be predictive of the propensity to adopt EBP; although, other factors were also influential, such as desire to learn, practicality (i.e. non-interference with productivity or patient flow) and beliefs about EBP \u003ca href=\"https://paperpile.com/c/AFaecu/G5PCW+AVye9\"\u003e[46, 47]\u003c/a\u003e. Indeed, there was some indication in our study that participating osteopaths had a misconstrued understanding of the EBP paradigm, with a large proportion of participants believing that EBP did not take into consideration the patient's perspective. Other studies have also indicated that osteopaths view EBP as a threat to the professional identity of the profession \u003ca href=\"https://paperpile.com/c/AFaecu/KMTNa+hdrfa+QcqH4\"\u003e[24, 25, 48]\u003c/a\u003e. This suggests that Spanish osteopaths might benefit from revisiting the fundamental purposes of contemporary EBP which seeks to prioritise ethical care, is relationship-based, advocates shared decision-making and relates the evidence to the individual patient\u0026rsquo;s context and situation\u003ca href=\"https://paperpile.com/c/AFaecu/lbrSh\"\u003e[7]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEBP skills\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipating Spanish osteopaths perceived their EBP skill level to be low to moderate, which is relatively lower than that reported among osteopaths in other countries \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv+VwU0w+yyQyc\"\u003e[26, 31, 40]\u003c/a\u003e, chiropractors \u003ca href=\"https://paperpile.com/c/AFaecu/3vDPY\"\u003e[12]\u003c/a\u003e and physiotherapists \u003ca href=\"https://paperpile.com/c/AFaecu/Bl2RE\"\u003e[43]\u003c/a\u003e. A notable insecurity among participants related to the conduct of clinical studies or systematic reviews. This finding was somewhat expected as these advanced research activities are not typically taught within undergraduate clinical programs.\u003c/p\u003e\n\u003cp\u003eAnother self-reported skill-deficit related to the implementation of research findings, that is, the process of applying research evidence into clinical practice. This coincides with the perceived barriers of EBP uptake reported by participants, of which half of our sample identified insufficient skills in applying research findings as a barrier to EBP utilisation. In fact, this is a problem affecting many healthcare professions, where considerable \u0026lsquo;research-practice gaps\u0026rsquo; exist \u003ca href=\"https://paperpile.com/c/AFaecu/peeFu+tl3cz+V3A7t\"\u003e[49\u0026ndash;51]\u003c/a\u003e. However, these research-practice gaps can be attributed to more than just insufficient knowledge and skills; organizational factors, and social and attitudinal behaviours are also important contributors \u003ca href=\"https://paperpile.com/c/AFaecu/peeFu\"\u003e[49]\u003c/a\u003e. We argue that all of these factors are likely to be responsible for the limited application of research evidence in Spanish osteopathic practice given the historical lack of research culture within the profession in both the clinical and academic domain.\u003c/p\u003e\n\u003cp\u003eThe impact of research culture on EBP use was supported to some extent by the association between EBP use and number of hours engaged in research work and teaching in the higher education sector. When this finding is compared against surveys of Australian \u003ca href=\"https://paperpile.com/c/AFaecu/VwU0w\"\u003e[31]\u003c/a\u003e or UK \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv\"\u003e[26]\u003c/a\u003e osteopaths, there are similarities in the number of hours dedicated to research activities (i.e. 0-15 hours/week; Spain=72%, Australia=84%, UK=72%), though Spanish osteopaths did seem to dedicate more hours to teaching in the higher education sector (i.e. 1-30 hours/week; Spain=28%, Australia=15%, UK=18%). Hence, one might expect Spanish osteopaths to have a higher perceived level of EBP-related skill, although this was not the case. This raises questions about the integration of EBP and research into Spanish osteopathic curricula.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse EBP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA moderately-low level of engagement in EBP activities was reported in our sample. An interesting finding was that around 1 in 5 participants had not searched an online database or used scientific literature to change their clinical practice in the month preceding the survey. This behaviour can be partially explained by the types of information sources used by our sample. The main source of information used by participants to inform their clinical decision-making was traditional knowledge, followed by published clinical evidence and peer opinion or textbooks. These results highlight the importance of traditional knowledge to Spanish osteopaths; a finding that also can be extended to osteopaths in Australia \u003ca href=\"https://paperpile.com/c/AFaecu/VwU0w\"\u003e[31]\u003c/a\u003e, UK \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv\"\u003e[26]\u003c/a\u003e and Sweden \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc\"\u003e[40]\u003c/a\u003e, who also report traditional knowledge as the primary source of information used to inform clinical decision-making. However, while Australian and UK osteopaths cited clinical guidelines as their second most frequently used information source, in the present study, Spanish osteopaths rated these guidelines as their sixth most frequently used source of information and in comparison, it was reported in ninth position by Swedish osteopaths \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc\"\u003e[40]\u003c/a\u003e. Given that clinical guidelines typically represent the best available evidence in a field, a considerable research-practice gap may be evident in Spanish and Swedish osteopathic practice.\u003c/p\u003e\n\u003cp\u003eNotwithstanding, there appear to be few differences in EBP use between these countries. Similar to our sample, the use of EBP among osteopaths in Australia, UK and Sweden is reported to be generally low \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc+1btJv+VwU0w\"\u003e[26, 31, 40]\u003c/a\u003e, as it is among US and Canadian chiropractors \u003ca href=\"https://paperpile.com/c/AFaecu/acviC+18b1T\"\u003e[9, 52]\u003c/a\u003e. Existing evidence suggests physical therapists have a relatively greater level of engagement with EBP \u003ca href=\"https://paperpile.com/c/AFaecu/jq7ZG+Bl2RE\"\u003e[43, 53]\u003c/a\u003e. Interestingly, two-thirds of our sample held a qualification in physiotherapy, which is common among osteopaths in Spain \u003ca href=\"https://paperpile.com/c/AFaecu/qfI1G+I6K0X\"\u003e[32, 33]\u003c/a\u003e. This result raises the question as to why participating osteopaths engage with EBP to a lesser extent than physiotherapists. One explanation is that to date, we have no data on Spanish physiotherapist engagement in EBP activities, which possibly could be different from other countries. Further, almost half of our sample received their highest qualification at least six years before the survey, and in Spain, EBP has been only recently integrated into physiotherapy curricular \u003ca href=\"https://paperpile.com/c/AFaecu/sopBF\"\u003e[54]\u003c/a\u003e. Osteopathy also has been traditionally embedded in clinical models and frameworks conceived by a small number of individuals from when the discipline was attempting to establish itself, leading to an uncritical development of the profession \u003ca href=\"https://paperpile.com/c/AFaecu/h9fnd\"\u003e[23]\u003c/a\u003e. An examination of the comparative uptake of EBP among different health disciplines in Spain may shed some further light on this issue.\u003c/p\u003e\n\u003cp\u003eIn terms of potential solutions to improving EBP uptake, education about EBP alone may not be sufficient \u003ca href=\"https://paperpile.com/c/AFaecu/Ingrs\"\u003e[55]\u003c/a\u003e. Findings from a recent scoping review suggest education programs aimed at improving local barriers may be a more effective method of improving EBP engagement \u003ca href=\"https://paperpile.com/c/AFaecu/7W6CS\"\u003e[56]\u003c/a\u003e. Within osteopathy, these barriers to EBP uptake are not entirely clear. Indeed, in the case of our respondents, most did not perceive there to be any major barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers and enablers for EBP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrevious surveys of osteopaths \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc+1btJv+VwU0w\"\u003e[26, 31, 40]\u003c/a\u003e have reported lack of clinical evidence in osteopathy (Australia=60%; UK=69%; Sweden=53%) and lack of time (Australia=53%; UK=57%) as major barriers to EBP uptake. Although none of the thirteen listed factors in the survey were identified as major barriers to EBP uptake among Spanish participants, lack of clinical evidence in osteopathy and lack of time were still considered the most notable issues of concern, with at least one-half of respondents reporting these as minor to moderate barriers.\u003c/p\u003e\n\u003cp\u003eOther important barriers related to lack of skills (applying research, research appraisal and interpreting research), showing the necessity to improve these abilities in order to encourage EBP uptake among new osteopaths. While education is important, there also needs to be a change in mindset, triggered by a comprehensive reflection that considers osteopathy as a healthcare profession that embraces science as a way to evolve and self-assess \u003ca href=\"https://paperpile.com/c/AFaecu/KMTNa\"\u003e[48]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003eExactly how EBP and research culture should be promoted among healthcare practitioners remains controversial. Several recent scoping reviews in the field of physiotherapy suggests some ideas \u003ca href=\"https://paperpile.com/c/AFaecu/pGTCe+7W6CS\"\u003e[56, 57]\u003c/a\u003e. The first consideration is that any strategy aimed at improving EBP uptake should be tailored to the local scenario to contextualize the training program. The second consideration is that multifaceted strategies (containing at least five elements) are more likely to be associated with significant changes in learning outcomes. Stander et al. (2018) also highlights the need for EBP training programmes to be underpinned by behaviour change models, learning theories and a concrete theoretical framework \u003ca href=\"https://paperpile.com/c/AFaecu/7W6CS\"\u003e[56]\u003c/a\u003e. A recent systematic review and Delphi survey proposes a set of 68 core competencies as a possible framework to inform the development of EBP curricula for health professionals \u003ca href=\"https://paperpile.com/c/AFaecu/MJucq\"\u003e[58]\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eRegarding enablers, around 63% of participants considered free access to scientific evidence, access to the internet at work, access to free databases and online EBP education materials to be very useful enablers. This was in line with osteopath\u0026rsquo;s reports in other countries \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc+1btJv+VwU0w\"\u003e[26, 31, 40]\u003c/a\u003e. In the case of Spain, we argue that the national unification of osteopathic curricula and the inclusion of these programmes in universities are also necessary enablers to improving EBP uptake. These actions will potentially improve the consistency of programmes, ensure course content represents best practice, and help nurture a stronger research and EBP culture within the profession. While these actions might be difficult to accomplish in Spain without national professional regulation, results from Sweden (where osteopathy is also an unlicensed health profession) demonstrate that extensive exposure to EBP training (91% of Swedish osteopaths vs. 62% of Spanish osteopaths) correlates with higher perceived skills in EBP \u003ca href=\"https://paperpile.com/c/AFaecu/yyQyc\"\u003e[40]\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough the survey response rate exceeded the minimum sample size required, we noticed a high percentage of missing responses. As all responses were compulsory, this meant many respondents dropped out of the survey early, possibly due to survey fatigue. This was also an issue reported in a UK study of osteopaths \u003ca href=\"https://paperpile.com/c/AFaecu/1btJv\"\u003e[26]\u003c/a\u003e. Nonetheless, as the original English version of EBASE has demonstrated good internal consistency and acceptable test-retest reliability \u003ca href=\"https://paperpile.com/c/AFaecu/q2Bon+BIXGx\"\u003e[35, 36]\u003c/a\u003e, and the fact that survey fatigue was not detected during pilot testing, it was not considered appropriate to modify the number of survey items.\u003c/p\u003e\n\u003cp\u003eWhile the process of translating the questionnaire strictly followed standard methods reported by WHO \u003ca href=\"https://paperpile.com/c/AFaecu/BqwzO\"\u003e[37]\u003c/a\u003e, including a pilot study, the psychometric properties of the Spanish version of the questionnaire was not formally assessed, which could have impacted the validity and reliability of findings. As has occurred in other osteopathic surveys conducted in Spain \u003ca href=\"https://paperpile.com/c/AFaecu/qfI1G+I6K0X\"\u003e[32, 33]\u003c/a\u003e, a large proportion of responses came from two geographical regions (Catalu\u0026ntilde;a and Madrid). These results likely reflect the geographical distribution of osteopaths in Spain. Notwithstanding, there were a number of regions that were not well represented, whose views might potentially differ from the more well-represented regions. Recall bias and selection bias are other intrinsic limitations of the study design.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study furthers our understanding of Spanish osteopaths\u0026rsquo; attitudes, skills and use of EBP. Our results showed that participant\u0026rsquo;s attitudes toward EBP were largely positive. At least four out of five participating osteopaths agreed that EBP was necessary in the practice of osteopathy and professional literature and research findings were useful to their day-to-day practice. However, the perceived skills, use and engagement in EBP activities was reported as moderate to low. Fortunately, there was general interest in learning and improving the skills necessary to incorporate EBP into clinical practice. Our findings, therefore, suggest that appropriate educational initiatives and wider inclusion of osteopathic educational programmes into university environments would be helpful in assisting Spanish osteopaths to embrace EBP. Although, as discussed in this paper, the absence of osteopathy regulation in Spain could continue to curtail efforts to improve EBP uptake in this professional group.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eEBP\u003c/strong\u003e- Evidenced-based practice\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e - World Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOEIs\u003c/strong\u003e - Osteopathic Educational Institutions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEBASE\u003c/strong\u003e \u0026ndash; Evidence-Based practice Attitude and Utilization Survey\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Committee of Sagrado Coraz\u0026oacute;n Hospital, Barcelona (2019/81-CMF-HUSC). Study participation was anonymous and voluntary, and participants were able to withdraw from the survey at any time without repercussion. Informed consent was obtained from all subjects and all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study did not receive any financial support from any sponsor\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors' contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGA and CJ translated and adapted the questionnaire and established local recruitment strategies. GA and CJ drafted the first manuscript in collaboration with TS and OT. ML conducted the statistical\u0026nbsp;analysis and drafted the results. GA, CJ, TS, OT and ML critically interpreted the data, edited the manuscript and reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn\u0026rsquo;t. BMJ. 1996;312:71\u0026ndash;2. doi:10.1136/bmj.312.7023.71.\u003c/li\u003e\n\u003cli\u003eInnes SI, Leboeuf-Yde C, Walker BF. How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years. Chiropr Man Therap. 2018;26:8.\u003c/li\u003e\n\u003cli\u003eRabey M, Hall T, Hebron C, Palsson TS, Christensen SW, Moloney N. Reconceptualising manual therapy skills in contemporary practice. 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Physiotherapy. 2014;100:208\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eJette DU, Bacon K, Batty C, Carlson M, Ferland A, Hemingway RD, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786\u0026ndash;805.\u003c/li\u003e\n\u003cli\u003eIqbal A, Glenny A-M. General dental practitioners\u0026rsquo; knowledge of and attitudes towards evidence based practice. Br Dent J. 2002;193:587\u0026ndash;91; discussion 583.\u003c/li\u003e\n\u003cli\u003eBridges PH, Bierema LL, Valentine T. The propensity to adopt evidence-based practice among physical therapists. BMC Health Serv Res. 2007;7:103.\u003c/li\u003e\n\u003cli\u003eThorsteinsson HS, Sveinsd\u0026oacute;ttir H. Readiness for and predictors of evidence-based practice of acute-care nurses: A cross-sectional postal survey. Scand J Caring Sci. 2014;28:572\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eAlvarez G, Van Biesen T, Roura S. Professional identity in the evolution of osteopathic models: Response to Esteves et al. Int J Osteopath Med. 2020;36:58\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKristensen N, Nymann C, Konradsen H. Implementing research results in clinical practice- the experiences of healthcare professionals. BMC Health Serv Res. 2016;16:48.\u003c/li\u003e\n\u003cli\u003eBialocerkowski AE, Grimmer KA, Milanese SF, Kumar VSS. Application of current research evidence to clinical physiotherapy practice. J Allied Health. 2004;33:230\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eRangachari P, Rissing P, Rethemeyer K. Awareness of evidence-based practices alone does not translate to implementation: insights from implementation research. Qual Manag Health Care. 2013;22:117\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eAlcantara J, Leach MJ. Chiropractic Attitudes and Utilization of Evidence-Based Practice: The Use of the EBASE Questionnaire. Explore . 2015;11:367\u0026ndash;76.\u003c/li\u003e\n\u003cli\u003eFell DW, Burnham JF, Dockery JM. Determining where physical therapists get information to support clinical practice decisions. Health Info Libr J. 2013;30:35\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eGirabent-Farr\u0026eacute;s M, Bagur-Calafat C, Serra-Llobet P, S\u0026aacute;nchez-Puccini MB, Dom\u0026iacute;nguez-S\u0026aacute;nchez MA, Correa-Bautista JE, et al. Barriers to implementation of Evidence-Based Practice (EBP): a survey of Colombian and Spanish physiotherapists. Physiotherapy. 2015;101:e1256\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eStevenson K, Lewis M, Hay E. Do physiotherapists\u0026rsquo; attitudes towards evidence-based practice change as a result of an evidence-based educational programme? Journal of Evaluation in Clinical Practice. 2004;10:207\u0026ndash;17. doi:10.1111/j.1365-2753.2003.00479.x.\u003c/li\u003e\n\u003cli\u003eStander J, Grimmer K, Brink Y. Training programmes to improve evidence uptake and utilisation by physiotherapists: a systematic scoping review. BMC Med Educ. 2018;18:14.\u003c/li\u003e\n\u003cli\u003eLarsen CM, Terkelsen AS, Carlsen A-MF, Kristensen HK. Methods for teaching evidence-based practice: a scoping review. BMC Medical Education. 2019;19. doi:10.1186/s12909-019-1681-0.\u003c/li\u003e\n\u003cli\u003eAlbarqouni L, Hoffmann T, Straus S, Olsen NR, Young T, Ilic D, et al. Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey. JAMA Netw Open. 2018;1:e180281.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Evidence-based practice, Osteopathic medicine, Cross-sectional studies, Health care surveys","lastPublishedDoi":"10.21203/rs.3.rs-107863/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-107863/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAlthough evidence-based practice (EBP) is largely supported across healthcare professions, its implementation in manual therapy professions such as\u0026nbsp;osteopathy remains limited and debated. There is currently little knowledge of how EBP relates to osteopathy in Spain, and the attitudes, skills and utilisation of osteopaths.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e The main aim of this study was to investigate the attitudes, skills and use of EBP among Spanish osteopaths. A secondary aim was to identify barriers and facilitators for the adoption of EBP in the Spanish osteopathic context.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e National cross-sectional survey of Spanish osteopaths registered and non-registered to an osteopathic association in Spain. Eligible participants were invited by a range of recruitment strategies including email and social media campaigns to complete the Spanish-translated Evidence-Based practice Attitude and utilization Survey (EBASE) anonymously online. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 567 osteopaths completed the survey which represents an estimated response rate of approximately 9%. Participant’s attitudes toward EBP were largely positive. Most respondents agreed or strongly agreed that EBP was necessary in the practice of osteopathy (89.6%) and professional literature and research findings were useful to their day-to-day practice (88.9%). Levels of perceived skill in EBP were reported as low to moderate with lowest levels for items related to ‘research conduct’. Except reading/reviewing professional literature and using online search engines to find practice-related literature, participant engagement in all other EBP-related activities was generally infrequent. The perceived proportion of clinical practice that was based on clinical research evidence was reported to be very small. Main barriers to EBP uptake included a lack of clinical evidence in osteopathy and insufficient skills for applying research findings. Main facilitators of EBP uptake included access to full-text articles, internet at the workplace and online databases.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eSpanish osteopaths were largely supportive of evidence-based practice, had low to moderate skills in EBP and engaged in EBP activities infrequently. Formal regulation of the profession in Spain and the inclusion of osteopathic programs into the university sector would potentially improve EBP adhesion.\u003c/p\u003e","manuscriptTitle":"Attitudes, Skills and Use of Evidence-Based Practice Amongst Spanish Osteopaths: A Cross-Sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-11-24 15:46:52","doi":"10.21203/rs.3.rs-107863/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-07T09:51:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-06T12:58:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"bbd8e617-442e-472b-b5a4-4321130b2b31","date":"2020-11-22T09:06:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-20T05:41:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-19T13:22:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-19T13:17:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-18T14:17:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2020-11-12T15:40:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"63f6cd0c-2efa-481f-bbcb-ba47033d818b","owner":[],"postedDate":"November 24th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1189801,"name":"Health Economics \u0026 Outcomes Research"},{"id":1189802,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-02-14T15:00:48+00:00","versionOfRecord":{"articleIdentity":"rs-107863","link":"https://doi.org/10.1186/s12913-021-06128-6","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2021-02-10 15:00:31","publishedOnDateReadable":"February 10th, 2021"},"versionCreatedAt":"2020-11-24 15:46:52","video":"","vorDoi":"10.1186/s12913-021-06128-6","vorDoiUrl":"https://doi.org/10.1186/s12913-021-06128-6","workflowStages":[]},"version":"v1","identity":"rs-107863","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-107863","identity":"rs-107863","version":["v1"]},"buildId":"afDZ1USd8LLqUjqjB8QhT","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}