PEER REVIEW HISTORY ARTICLE DETAILS VERSION 1 - REVIEW. Veronika Williams University of Oxford, UK 07-Dec-2015

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1 PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form ( and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. TITLE (PROVISIONAL) AUTHORS ARTICLE DETAILS Why is there variation in the practice of evidence-based medicine in primary care? A qualitative study Ranita, Hisham; Ng, Chirk Jenn; Liew, Su May; Nurazira, Hamzah; Ho, Gah Juan VERSION 1 - REVIEW Veronika Williams University of Oxford, UK 07-Dec-2015 This is a very interesting, well written and important paper. I only have some minor issues which need ot be addressed. 1. Please add further detail on ethical approval, was this sought and if not why not. 2. What was the overall methodology used? I understand you have used thematic analysis as a tool to analyse data but which overall theoretical framework/ methodology did you use? 3. The finding about patients demanding certain medication or refusing others, particularly in private clinics, is very interesting and challenges the medical 'power' relationship model. It also raises the issue of communicating EBM to patients and how best to do this. Although I am aware that this is beyond the scope of this study it would add further insights to your discussion. Amanda McCullough Centre for Research in Evidence-Based Practice 11-Dec-2015 BMJ Open: first published as /bmjopen on 9 March Downloaded from Study title: Why is there variation in the practice of EBM in primary care? A qualitative study This is a well thought out and useful piece of research identifying three key barriers to implementing evidence-based practice in Malaysian primary care: lack of knowledge and skills, workplace culture and evidence based medicine as a threat to clinical practice. The methods used are appropriate and I do not have any major concerns about the methodological quality of the study. I ve made some suggestions on how the manuscript is reported to aid the reader and future reproducibility. Major on 18 March 2019 by guest. Protected by copyright.

2 1. Line 23, page 5 Please describe how theory of planned behaviour was used to inform the topic guide. 2. I found it a little confusing to keep track of the themes that emerged from each primary care facility. Could you incorporate a diagram of your coding framework (mentioned line 55, page 5)? 3. You could consider re-structuring the results to compare themes across settings i.e. put the theme e.g. resources then below compare each of the settings side by side: Academic primary care doctors had access to online library private health clinics struggled to gain financial support. In line with private and practitioners, pub health practitioners struggled to get access to appropriate drugs This would allow a direct comparison between the different facilities. 4. Lines 13-36, page 7 - Quotes for lack of knowledge and skills are from academics primary care doctors did other groups feel the same? 5. Lines 9, It would be useful to know if all doctors agreed with these statements and others throughout the results or if most, few or some doctors agreed, and where there were any deviations from these beliefs. 6. In the first para of the discussion, I suggest re-stating the 3 key themes using the exact titles e.g. personal attitude of doctors (line50, page 13) should be EBM as a threat to good clinical practice. Then go through each theme, in order, in a separate paragraph and discuss them in the context of the existing evidence. 7. Please emphasise the level of academic GPs (40%) involved in the study as a limitation that would affect the transferability of findings (line 29, page 16). Minor 1. Line 31, page 4 - How many clinics did you recruit from? What was your refusal rate? 2. Line 22, page 4 do you mean that you triangulated the date from focus groups, interviews and field notes? If so, please rephrase and move down to the data analysis section. 3. Line 20, page 2 and line 40, page 16 should patients be doctors? 4. Where healthcare professionals is mentioned in the methods, I suggest changing this to doctors to reduce any ambiguity. 5. An English language check, particularly of the quotations would be helpful as there were a few that did not make complete sense e.g. line 30 because it needs lots of reference should this be references? and line 39 top to down should this be top down? 6. Line 48, page 10 remove the word la. 7. Suggest removing line 6-8 on page 3 - it would be better to start with line 10 evidence-based medicine (EBM)

3 8. Please explain what medical officers are. 9. In Table 1 you could add % because the n values for each characteristic. 10. Line 27 and 44, page 11 - What do the codes Rh and A stand for? 11. Implications Please remove the last 3 lines from this section as the study s results to not support this statement. SE Zwolsman Academic Medical Centre - University of Amsterdam the Netherlands 20-Dec-2015 Your research emphasises an important topic in the field of EBM. Practice variations have an implication on the decisions that are made in GP practice. Because variation exists, it is important to find out why some practices adopt EBM more easily than other practices. Your research question is therefore particularly relevant. The methods could however be described more sufficiently. I find it hard to see a difference in the methodology that is described for the interviews and the methodology for the focus groups. It seems as if the methodology for both these methods is comparable, but then I do miss information about how the interviews and focus groups were done specifically. For instance: was the topic list identical? what information was given about the study? what information was given about EBM? It would help if methodology for both research methods is described separately. Please do this in research design paragraph of the abstract as well. The translations of the interviews are not done in a good English language. Below you find some additional point regarding your manuscript: Introduction p3 line 55 factors --> what factors? barriers and facilitators? line 57 add "in Malaysia" to the sentence Methods p4 line 38 here it says that you purposively recruited participants. Can you tell more about what participants were selected/ what choices were made here? line 56 what kind of workshop? what kind of lecturers? Results p6 line 19 how many physicians were part of the focus groups? line 45 relatively many medical officers took part in the study. Does that have an influence on the outcomes of this study? p7 line 54 how was attitude assessed? Discussion The discussion sheds a light on the results from this study. However,

4 Reviewer: 1 I do miss "a next step". For instance: What do you think of your outcomes looking at the specific settings? What do you think of the answers given? Do you think the primary care physicians have a clear view on the definition of EBM? What is expected from them regarding EBM in practice? What do you expect from them in practice? Is it realistic? What variation do you see between the different practices and what do you think of that? My advise is to add more implications for practice and further research with a focus on the practice variations and the corresponding different approach to EBM. VERSION 1 AUTHOR RESPONSE This is a very interesting, well written and important paper. I only have some minor issues which need to be addressed. 1. Please add further detail on ethical approval, was this sought and if not why not. The ethics approval is stated at the end of the manuscript according to the requirement by BMJ Open. 2. What was the overall methodology used? I understand you have used thematic analysis as a tool to analyse data but which overall theoretical framework/ methodology did you use? We used the phenomenological approach as the overall methodology and have included the following sentence in the manuscript (Page 4, line 4). We conducted a qualitative study using a phenomenological approach to explore the participants personal views and experiences. 3. The finding about patients demanding certain medication or refusing others, particularly in private clinics, is very interesting and challenges the medical 'power' relationship model. It also raises the issue of communicating EBM to patients and how best to do this. Although I am aware that this is beyond the scope of this study it would add further insights to your discussion. We have added the following sentence in the Discussion: (Page 16, line 6) Patient values may conflict with doctor s advice based on evidence. This may be overcome by using the shared decision making model where both parties discuss, negotiate and agree on the decision (Charles C, 1997). Reviewer: 2 Reviewer Name: Amanda McCullough Institution and Country: Centre for Research in Evidence-Based Practice, Bond University, Australia This is a well thought out and useful piece of research identifying three key barriers to implementing evidence-based practice in Malaysian primary care: lack of knowledge and skills, workplace culture and evidence based medicine as a threat to clinical practice. The methods used are appropriate and I do not have any major concerns about the methodological quality of the study. I ve made some suggestions on how the manuscript is reported to aid the reader and future reproducibility. Major 1. Line 23, page 5 Please describe how theory of planned behaviour was used to inform the topic

5 guide. We asked open ended questions exploring views and understanding towards EBM (attitudes), how their practice is being influenced by their peers (subjective norms) and their workplace culture (control). We have included the following sentence in the manuscript (Page 5, line 7). Open ended questions were asked during the interview to explore views and understanding towards EBM (attitudes), how their practice is being influenced by their peers (subjective norms) and their workplace culture (control). 2. I found it a little confusing to keep track of the themes that emerged from each primary care facility. Could you incorporate a diagram of your coding framework (mentioned line 55, page 5)? We have included the coding framework shown in Table 2 to make it easier for the readers to follow the themes (Page 7, line 2) The summary of coding framework is presented in Table 2 (Page 7, line 2) Table 2. Core themes that influenced the implementation of EBM practice Themes 1) Lack of knowledge and skills in searching and applying evidence 2) EBM culture in the workplace Academic primary care settings Doctors attitude towards EBM Access to EBM resources, training and expertise Private health clinics Patient s preference Doctors prefer to treat patients based on experience Lack of resources Public health clinics Doctors adherence to guidelines and specialist Lack of time Drugs availability Patients compliance Access to information Outdated guidelines 3) EBM as a threat to good clinical practice 3. You could consider re-structuring the results to compare themes across settings i.e. put the theme e.g. resources then below compare each of the settings side by side: Academic primary care doctors had access to online library private health clinics struggled to gain financial support. In line with private and practitioners, pub health practitioners struggled to get access to appropriate drugs This would allow a direct comparison between the different facilities. We have now summarised the themes in Table 2 and we believe that this will allow the readers to understand the flow of the themes. It would also allow comparison across each primary care settings (Page 7, line 2) 4. Lines 13-36, page 7 - Quotes for lack of knowledge and skills are from academics primary care doctors did other groups feel the same? We have included quotes by other groups under this theme in the manuscript (Page 8, line 10)

6 Those statistics is my weakest! I ll just leave it if I don't know and because clinically we don't use it, to be frank with you. Basically I think this [EBM] are mainly for those who are interested in finding out the answer. I think you just want to know the p-value, what the conclusion is and what we need to do. (D, male, 32 years old, medical officer, public health clinic) I have to admit that it is hard to understand the methods and statistics. Not everything I will understand, if I don't understand I will attend the workshops or talks, and then I will probably understand. Personally I hate to read! I rather listen than to read (A, female, 48 years old, senior private general practitioners) 5. Lines 9, It would be useful to know if all doctors agreed with these statements and others throughout the results or if most, few or some doctors agreed, and where there were any deviations from these beliefs. We have included the reviewer s suggestions throughout the results where relevant and appropriate. 6. In the first para of the discussion, I suggest re-stating the 3 key themes using the exact titles e.g. personal attitude of doctors (line50, page 13) should be EBM as a threat to good clinical practice. Then go through each theme, in order, in a separate paragraph and discuss them in the context of the existing evidence. We have revised the discussion accordingly and have discussed these themes sequentially (Page 14, line 20). From our analysis, the practice of EBM is influenced by three key elements: lack of knowledge and skills in searching and applying evidence, EBM culture in the work place and EBM as a threat to a good clinical practice. 7. Please emphasise the level of academic GPs (40%) involved in the study as a limitation that would affect the transferability of findings (line 29, page 16). Although there were fewer participants from private clinics, we managed to reach data saturation. Therefore, we felt that despite the smaller number, the results would be transferable to an urban private clinic in Malaysia. Minor 1. Line 31, page 4 - How many clinics did you recruit from? What was your refusal rate? We purposively sampled clinics in Klang Valley and most of the participants that we approached agreed to be interviewed. As this is not a quantitative study, we did not calculate the non-response or refusal rate. 2. Line 22, page 4 do you mean that you triangulated the data from focus groups, interviews and field notes? If so, please rephrase and move down to the data analysis section. Yes, we did triangulate the data from focus groups, interviews and field notes. The sentence has been moved to data analysis section (Page 5, line 21) We used in-depth interviews, focus group discussions and field notes to triangulate the data. 3. Line 20, page 2 and line 40, page 16 should patients be doctors?

7 Yes, it should be doctors. It has been changed accordingly. The limitations of this study include doctors being mostly educated and the practices being located in urban centres. These factors may limit the transferability of the findings. 4. Where healthcare professionals is mentioned in the methods, I suggest changing this to doctors to reduce any ambiguity. We have replaced Healthcare professionals with doctors to reduce ambiguity. 5. An English language check, particularly of the quotations would be helpful as there were a few that did not make complete sense e.g. line 30 because it needs lots of reference should this be references? and line 39 top to down should this be top down? We have revised the sentences in line 30 and 39 according to the suggestions made by the reviewers. We have also proofread our manuscript to improve the language. 6. Line 48, page 10 remove the word la. The word la has been removed from all quotes. 7. Suggest removing line 6-8 on page 3 - it would be better to start with line 10 evidence-based medicine (EBM) The sentence line 6-8 has been removed as suggested by the reviewer. 8. Please explain what medical officers are. Medical officers are doctors who work in the public sector and do not have a postgraduate qualification (It has been included in the manuscript - Page 4, line 22) The participants included medical officers (doctors who work in the public sector and do not have a postgraduate qualification), family medicine specialists, primary care lecturers and general practitioners working in primary care settings. 9. In Table 1 you could add % because the n values for each characteristic. Due to the nature of the qualitative methodology, the results are not generalizable. Therefore, we feel that it may not appropriate to present the results as percentages. 10. Line 27 and 44, page 11 - What do the codes Rh and A stand for? It is the initial of the doctor s name. 11. Implications Please remove the last 3 lines from this section as the study s results to not support this statement. We decided to keep these 3 lines as suggested by Reviewer 3 and rephrased (Page 18, line 6) To reduce variation in practicing EBM, healthcare organizations should be committed to providing EBM training, resources and support services for the primary care doctors.

8 Reviewer: 3 Reviewer Name: SE Zwolsman Institution and Country: Academic Medical Centre - University of Amsterdam, the Netherlands Dear Ranita Hisham, Your research emphasises an important topic in the field of EBM. Practice variations have an implication on the decisions that are made in GP practice. Because variation exists, it is important to find out why some practices adopt EBM more easily than other practices. Your research question is therefore particularly relevant. 1) The methods could however be described more sufficiently. I find it hard to see a difference in the methodology that is described for the interviews and the methodology for the focus groups. It seems as if the methodology for both these methods is comparable, but then I do miss information about how the interviews and focus groups were done specifically. For instance: was the topic list identical? what information was given about the study? what information was given about EBM? It would help if methodology for both research methods is described separately. Please do this in research design paragraph of the abstract as well. The same topic guide was used and the same information was given for both interviews and focus groups. We did not treat them differently. We added the following sentence to the manuscript (Page 5, line 10) The same topic guide was used and the same information about the study was given for both interviews and focus groups. 2) The translations of the interviews are not done in a good English language. We have improved the language of the quotations in the manuscript. Introduction 3) p3, line 55 - factors --> what factors? barriers and facilitators? Yes. The factors include barriers and facilitators (Abstract & page 3, line 21) This study aimed to explore the factors, including barriers and facilitators, influencing the practice of EBM across various primary care settings in Malaysia based on the doctors views and experiences. 4) line 57 - add "in Malaysia" to the sentence The phrase in Malaysia has been added to the sentence (page 3, line 21) This study aimed to explore the factors, including barriers and facilitators, influencing the practice of EBM across various primary care settings in Malaysia based on the doctors views and experiences. Methods 5) p4, line 38 - here it says that you purposively recruited participants. Can you tell more about what participants were selected/ what choices were made here? We have included in the manuscript that the participants were selected using purposive sampling based on their EBM knowledge, work experiences and settings (Page 4, line 14) In this study, doctors were purposively sampled from both settings to achieve maximum variation based on EBM knowledge, working experiences and settings.

9 6) line 56 - what kind of workshop? what kind of lecturers? It is a clinical training workshop and the participants were the primary care lecturers. We have revised the sentences in the manuscript as follows: (Page 4, line 21) Most of the interviews were held at the doctors workplace except for one group of general practitioners who were interviewed after a clinical training workshop. The participants included medical officers (doctors who work in the public sector and do not have a postgraduate qualification), family medicine specialists, primary care lecturers and general practitioners working in primary care settings. Results 7) P6 line 19 - how many physicians were part of the focus groups? We have rephrased the sentence as follows: (Page 6, line 11). There were 37 primary care physicians who participated in six focus group discussions (n=31) and six individual in-depth interviews. 8) line 45 - relatively many medical officers took part in the study. Does that have an influence on the outcomes of this study? The medical officers comprised doctors working in both the academic primary care and public health clinics. They form the majority of doctors working in the public sector. Therefore, we feel that the bigger number of medical officers recruited in this study is justifiable. 9) p7 line 54 - how was attitude assessed? We assessed the attitude of the participants by exploring their views and understanding of EBM during the interview. As this is not a quantitative study, we did not use a questionnaire to assess their attitude. Discussion 10) The discussion sheds a light on the results from this study. However, I do miss "a next step". For instance: What do you think of your outcomes looking at the specific settings? What do you think of the answers given? Do you think the primary care physicians have a clear view on the definition of EBM? What is expected from them regarding EBM in practice? What do you expect from them in practice? Is it realistic? What variation do you see between the different practices and what do you think of that? My advice is to add more implications for practice and further research with a focus on the practice variations and the corresponding different approach to EBM. Implications for practice and further research have been added as follows: (Page 18, line 6). To reduce variation in practicing EBM, healthcare organizations should be committed to providing EBM training, resources and support services for the primary care doctors. VERSION 2 REVIEW Veronika Williams University of Oxford, UK 25-Jan-2016

10 I happy that all issues have addressed adequately. Amanda McCullough Centre for Research in Evidence-Based Practice, Bond University, Australia 29-Jan-2016 Thank you for your changes to the paper. I have two minor comments: I don't think the addition of "phenomenological" to the description of the data analysis approach is helpful, as it does not help to understand how the data were analysed. The second is that using the Dr initials plus their age, background etc might make them identifiable by one of their colleagues. The risk of this is low but could be minimised by using numbers as an alternative method of anonymisation. Great work. SE Zwolsman Academic Medical Center Amsterdam, the Netherlands 04-Feb-2016 With the adaptations meet it meets the requirements VERSION 2 AUTHOR RESPONSE Thank you for your changes to the paper. I have two minor comments: 1) I don't think the addition of "phenomenological" to the description of the data analysis approach is helpful, as it does not help to understand how the data were analysed. We have removed the addition of phenomenological approach to the description of the data analysis (Page 1, line 12) and (Page 4, line 4) We conducted a qualitative study to explore the participants personal views and experiences. 2) The second is that using the Dr initials plus their age, background etc might make them identifiable by one of their colleagues. The risk of this is low but could be minimised by using numbers as an alternative method of anonymisation. We have removed the initials and replaced with numbers as an alternative method of anonymisation, but we have remained their age as it reflects the experience of the doctor. All details of participants have been modified in results section.