Title: The readiness of hospital pharmacists in Kuwait to practise evidence-based medicine: A cross-sectional study

Transcription

1 Author s response to reviews Title: The readiness of hospital pharmacists in Kuwait to practise evidence-based medicine: A cross-sectional study Authors: Ali Buabbas (ali.buabbas@hsc.edu.kw) Fatemah Alsaleh (fatemah.alsaleh@hsc.edu.kw) Hamza Al-Shawaf (hamza@hsc.edu.kw) Ali Abdullah (a.abdullah89@ymail.com) Abdullah Almajran (aalmajran@hsc.edu.kw) Version: 1 Date: 26 Aug 2017 Author s response to reviews: 26th August 2017 To: Dr. Emma Cookson Editor of the BMC Medical Informatics and Decision Making Dear Dr. Cookson, We thank you and the reviewers for assessing our manuscript (MIDM-D ) and providing constructive comments to improve it. As requested, please find below our response to the reviewers comments. Per your , only two reviewers (reviewer #1 and reviewer #2) provided comments and those are addressed in detail below and applicable changes were made in the manuscript. Text that was added is highlighted in yellow to facilitate the review of the revised manuscript.

2 Editor s comments: 1. Please change the title of the Introduction to Background. The title of the Introduction was changed to Background. Please see page 4, line 58. This change was also done in the abstract. 2. Please change the title of the Methodology section to Methods The title of the Methodology was changed to Methods. Please see page 7, line 141. This change was also done in the abstract. 3. In the ethics approval and consent to participate section of the declarations please add details of how consent was sought from the participants (i.e. written or verbal) and please confirm that it was informed consent. As requested, detail of how consent was sought from the participants was added to the manuscript page. Please see page 26, lines : All participants were approached during their working shifts and were invited verbally to take part in the study. For those who agreed to participate, a written informed consent form was obtained accordingly. 4. In the authors contributions section, add a statement confirming that all authors read and approve the final version of the manuscript. As suggested, the following sentence was added (please see page 27, lines ): AJB and all the co-authors read and approved the final version of the manuscript 5. Please upload additional file 1 as a separate additional file. Please also add a description of it after the references in the min manuscript file and include the following: - File name (e.g. Additional file 1) - File format including the correct file extension for example.pdf,.xls,.txt,.pptx (including name and a URL of an appropriate viewer if format is unusual) - Title of data

3 - Description of Data Instead of having additional file, we decided to add Table 1 to the body of the manuscript. Please see page 11, line 225: Table 1: Socio-demographic factors and their associations with computer literacy. 6. Please include a list of figure legends at the end of the main text (after the references) There are no legends under the figures. A list of the figures titles was added after the references. (page 29, line 654). List of Figures: Figure 1: The pharmacists self-reported confidence skills required for practising EBM Figure 2: The Pharmacists use of varied resources Figure 3: Attitudes and opinions of pharmacists towards EBM use in pharmacy practice Figure 4: The Pharmacists' barriers to incorporate EBM in pharmacy practice Figure 5: The most Facilitators for implementing EBM in pharmacy practice Reviewer #1 comments: Dr. Lezleyanne Hanna I enjoyed reading this interesting article relating to an important subject area; suggestions and comments about how I think it could be enhanced further are provided below. I. Abstract 1. Background: - I think there is a typo in the first sentence- as should be and. The typo error was corrected from as to and. Please see page 2, line 29.

4 - You make a point of specifically mentioning drugs, treatments and medical procedures as separate entities- what is the difference between a drug and treatment here? In the manuscript, treatment is a broader term meaning a therapeutic plan that includes medicines or drugs. However, to avoid the confusion, we rephrased the whole sentence to be (please page 2, line 29): The volume of medical literature is on the increase.. - Later you state that pharmacists need to have up-to-date knowledge of treatment to make the best clinical decisions. Do they not need to have up-to-date knowledge of drugs/medicines when making clinical decisions (rather than just treatments )? In regards to the up-to-date knowledge of drugs, we changed the word treatments to medicines. Please see page 2, line no Change aims to aimed. Done. Please see page 2, line 31 - 'Readiness' almost implies that evidence-based medicine is a new concept (rather than being over 20 years old). In regards to the EBM, certainly it's not a new concept. However, EBM is relatively a new concept in the health care system in Kuwait. For healthcare professionals to practice it efficiently, they need to acquire adequate knowledge and skills, in addition to their willingness to go for it positively. The importance of healthcare professionals readiness was emphasized in the literature due to the fact that the current abilities of the individuals can inhibit or support the introduction of new practices. Consequently, the word readiness in the manuscript means the degree of preparedness of pharmacists to participate and succeed based on their capabilities (knowledge, skills, and attitudes). 2. Methods: - Were the interviews one-to-one? It would be useful to expand on data analysis in this section (particularly with regard to the qualitative aspect of the study). It is not very clear what the

5 Chi-square test was going to be used for. Some readers may not be familiar with the term 'pharmacy directors'. Taking reviewer s comments into consideration, we added the following sentence to the methods section of the abstract (please see page 2, lines 35-37): one-to-one, face-to-face semi-structured interviews were conducted with six chief pharmacists to discuss and identify the barriers and facilitators of implementing EBM in the hospitals In regards to the data analysis, this statement was added to the abstract (page 2, lines 37-39): Quantitative and qualitative analytical measures were undertaken for the data acquired from the questionnaires and interviews, respectively. Also, more detailed information on undertaking the analysis of the interview data was added to the methods section in the main manuscript, under the statistical analysis. Please see page 10, lines : The interviews were transcribed verbatim. Field notes were taken during and after the interviews to ensure that all important information were documented. A qualitative approach comprising of thematic analysis was undertaken for data analysis. A coding frame was developed based on the themes identified during the interviews. Subsequently, the data relating to each theme/subtheme were constantly revisited until it was evident that no new themes emerged. The term pharmacy directors was modified to chief pharmacists. This change was applied all over the manuscript. 3. Results: - Have you any statistical significance to report (otherwise it is still difficult to see why Chisquare test was necessary/what data it was used on)? Details about the chi-square test were added in the methods section (page 10, and lines ): The chi-square test was applied to find any association or significant difference between the socio-demographic factors (age, gender, educational status, computer literacy, and previous exposure to research) and other items in the questionnaire (pharmacist s attitude, knowledge and skills). Results were considered statistically significant at p< 'Nearly half' - I might change this to 'Over half' or since the figure is 53.4%. As suggested, Nearly half was modified to Over half. Please see page 2, line 'Supported resources' - do you mean they require support/they require additional resources?

6 To clarify the sentence, we added the following modification:...if necessary resources such as computers and internet connection were provided. Please see page 3, lines It might be useful to cut back on the results relating to EBM knowledge so that you can add more about perceived/real barriers (since this was part of the aim and is also mentioned in the conclusion). We removed some results regarding EBM knowledge as suggested, and replaced them with the main barriers to EBM. Please see page 3, lines 47-49: Barriers to EBM practice were identified, which included limited access to EBM resources (75%), a lack of personal time and patient overload (71.6%). 4. Conclusions: - It seems from the Results section that at least half of the pharmacists did have EBM skills (could formulate answerable questions and literature search/retrieve research evidence) yet one of the concluding comments is that they lacked skills. Also, just because they couldn't apply the evidence in practice, doesn't necessarily mean they lacked the necessary skill to do so. It isn't clear how 'support from the decision-makers in the Ministry of Health (MoH) in Kuwait would diminish all barriers'. The results section should include some relevant barriers so that the reader can see how such support would diminish these and you may want to soften the wording ('all barriers') as it is difficult to imagine how getting support could resolve all issues. Considering the reviewer s comments, we rephrased the entire conclusion section in the abstract and the main manuscript. Please see abstract page 3, lines 52-56, and manuscript page 24, lines II. Manuscript 1. Introduction: - As per the abstract - you make a point of specifically mentioning 'drugs', 'treatments' and 'medical procedures' as separate entities - what is the difference between a 'drug' and a 'treatment' here? Later you state that pharmacists need to have up-to-date knowledge of 'treatments' to make the best clinical decisions. Do they not need to have up-to-date

7 knowledge of drugs/medicines when making clinical decisions (rather than just 'treatments')? As per the abstract, similar changes were made to the background section of the manuscript. Please see page 4, line 60 and Saying that 'evidence-based medicine (EBM) is a practice in medicine or pharmacy' could be a bit confusing for readers (especially when one of the definitions provided mentions clinicians only and later you refer to 'evidence-based pharmacy' rather than EBM, and you also mention dentists). Also, 'evidence-based practice' and 'evidence-based healthcare' are broader than the original concept of EBM and potentially more inclusive of other healthcare disciplines than medicine. To avoid the confusion, the practice of medicine or pharmacy was replaced with EBM term (page 4, line 69. This modification was applied all over the manuscript to ensure the consistency. - You may want to say 'The American Association of Colleges of Pharmacy (AACP) among others...' i.e. they are not the only pharmacy organisation to do this and you could perhaps include other examples here. More examples of international organizations were provided in the text. Please see page 4, lines 75-78: The American Association of Colleges of Pharmacy (AACP) (8), The International Pharmaceutical Federation and the World Health Organization have emphasized on the importance of evidence-based practice for good pharmaceutical care. The reference list was updated accordingly. - "Little research has been found on pharmacists and EBM" Several studies have been conducted although these largely relate to community pharmacists rather than hospital. That being said, some of the barriers such as a lack of time, knowledge and support have been reported within these studies and have relevance to your work too. I have included examples of these at the end of this review, in the reference section. Taking the reviewer s suggested references which are more related to our topic and are pharmacy focused, we expanded this section of the introduction. Please see page 5, lines : The extant literature includes ample research aimed at investigating the doctor s perception towards using EBM, including the barriers (10, 11, 12, 13, 14). Also, several studies have been found related to pharmacists and EBM, where most of them were largely related to community pharmacy, focusing on over-the-counter medications (15, 16, 17, 18). These studies revealed the importance of EBM in the practice of pharmacists. As a result, EBM was found to be a familiar concept among most pharmacists, although, practising it has experienced a number of

8 deficiencies or barriers (15, 16, 17, 18). A quantitative study was conducted in Northern Ireland to investigate the community pharmacists attitudes towards evidence-based practice for overthe-counter medication (15). The study concluded that pharmacists being familiar with the evidence-based practice does not imply that they are ready to practice evidence-based. On the contrary, the mind-set of the pharmacist should be improved in order to acquire the knowledge and skills for good pharmacy practice, and strive to be evidence-based (15). In this context, several barriers were identified through qualitative studies (interviews) in the United Kingdom, namely, the pharmacists lack of knowledge of EBM, and the skills required to utilize the best databases for finding research evidence and critically evaluating it (16, 17, 18, 19). Also, due to the busy schedule of the community pharmacist, limited time was reported. Restricted online resources (17) and lack of evidence of effectiveness were also reported as barriers to evidencebased practice in community pharmacy (16, 17, 19). Some studies showed specific barriers associated with community pharmacists, such as being uncomfortable in presenting evidence when the patient asks for over-the-counter medication (15, 16). Therefore, ongoing training for pharmacists in real life evidence-based practice was recommended in almost all related studies (15, 18, 19). The reference list was updated accordingly. - You could mention some of the specific barriers as reported in the wider literature. Specific barriers were added to the background, please see page 5, line It is a bit confusing to state that hospital pharmacists have to know about medicines for various reasons (to answer questions and propose treatment plans for clinical cases) yet then to mention evidence in the context of 'selecting the best treatment' only, and not in relation to advice provision/answering queries too. - We made some modifications to make the statements clearer. Please see page 6, and line : In clinical practice, hospital pharmacists practise numerous tasks that require them to have up-to-date knowledge of medicines in order to answer questions raised by patients, doctors or any other healthcare practitioner. The clinical experience of the pharmacist is not always adequate in providing the best pharmaceutical care; however, by using the most upto-date evidence from the literature together with the experience, the medicine will be determined properly for the medical case. 2. Aims and objectives: - Please write these in past tense.

9 Done, the word aims was changed to aimed (page 7, line 136). - Did you identify the level of knowledge and skills required for EBM or did you identify pharmacists' current knowledge-base and skills in relation to EBM? In regards to identifying the knowledge of the pharmacists, we made the statement clearer to be: identifying the pharmacists current knowledge and skills in relation to EBM. Please see page 7, line Were you exploring barriers/facilitators in pharmacy 'settings' in general or in the one setting/context (in hospital)? In regards to exploring the perceived barriers and facilitators, we specified the research setting in the manuscript for further clarification (page 7, line 140): exploring the perceived barriers and facilitators with regards to implementing EBM in the hospital pharmacies. 3. Methods: - I think readers will understand the concept of 'government' versus 'private' hospitals, but perhaps clarify what is meant by 'secondary' and 'tertiary' hospitals. As suggested, we clarified the terms "secondary" and "tertiary" hospitals in the main manuscript (page 7, lines ). The clarification basically defined secondary hospital which is to provide general medical care, while "tertiary" hospital provides specialized medical care:...which provides general medical care (Ahmadi, Farwaniya, Jahra, Al-Sabah, Hawalli and Capital) and 22 tertiary hospitals located in the Al-Sabah Medical Region which provides specialised medical care. - Why were private hospitals excluded? Yes and the reason for excluding private hospitals from the current study was added to the manuscript (page 7, lines ): Private hospitals in Kuwait were excluded from the current study since they have different criteria and quality policies for recruiting pharmacists unlike government hospitals. Hence, this might affect the result of the current study. In addition to this, the current study did not aim at comparing the knowledge, attitude and practises of two different populations (governmental vs. private hospital pharmacists).

10 a) Questionnaire - Was the questionnaire anonymous or was identifiable demographic data collected? The questionnaire was anonymous, and for reassurance we added the statement (page 9, lines ): All participants were informed that their responses will be anonymous and used only for research purpose. - Expand on question-types and how responses were measured (rating, ranking, 5-point likert, open responses or mainly closed-type questions etc.). More details about the questionnaire were added to the manuscript, such as question types (openversus closed ended) and measurement scale used. Please see page 8, lines : All questions were closed and presented as select the appropriate answer. The questions in sections 2 to 4 were provided with a five-point Likert scale, except for section 2 - the section regarding pharmacists knowledge, which was provided with only a four-point Likert scale. - How did you try to maximize the response rate from the outset? To maximize the response rate, we planned two visits for every research site and this was clarified in the manuscript (please see page 8, lines ): The purpose of the second visit to the research setting was to collect the completed questionnaires and to invite more participants to enhance the response rate. - Explain why the questionnaires were distributed/prepared in English only when this potentially meant some pharmacists could not participate. An explanation for only using the English version of the questionnaire was added to page 8, line 164: The majority of the pharmacists graduate from the Health Sciences School, where the medium of education is only English. Therefore, the questionnaires were distributed in English. - You state that 'The questionnaires were distributed to all available hospital pharmacists during their duty shifts, wherein completed questionnaires were received on the same day or the day after.' How were the questionnaires distributed to all available hospital pharmacists

11 during their duty shifts (mailed to them/hand delivered by members of the researcher team etc.)? Secondly, how were the completed questionnaires collected? Did a researcher go round and collect these from all pharmacists and if so, what happened when there was nothing for the researcher to collect (were these pharmacists invited again to complete the questionnaire)? In regards to the way the questionnaires were distributed and collected back, this was clarified in the manuscript in page 8, lines : The questionnaires were distributed in-person to all available hospital pharmacists during their duty shifts, and completed questionnaires were collected on the same day, or the day after by the same researcher. The purpose of the second visit to the research setting was to collect the completed questionnaires and to invite more participants to enhance the response rate. The participants were encouraged to complete the questionnaire in the same day. All pharmacists were conveniently invited to take part in the study. - You state that 'Bar charts were used to describe each section of the questionnaire' - perhaps clarify that bar charts were used to display the results/findings/responses of each section of the questionnaire. Also, this isn't really statistical analysis (as per the heading) - it's just how you've chosen to display/present your results and isn't required to ascertain highest and lowest groups. The word Bar chart was removed from the statistical analysis section and the paragraph was rephrased to be (page 10, line 197): Data from the questionnaires were analysed and implemented through a graphical presentation using Statistical Package for the Social Sciences (SPSS) version In relation to the chi-square test, you could expand on what demographic factors/variables you used (did you compare male versus female responses etc.)? In regards to the Chi-square test, more details were provided. Please see page 10, lines The chi-square test was applied to find any association or significant difference between sociodemographic factors (age, gender, educational status, computer literacy, previous exposure to research) and other items in the questionnaire (pharmacist s attitude, knowledge and skills). Results were considered statistically significant at p<0.05. b) Interviews - Please clarify what is meant by a 'pharmacy director'

12 In regards to the term pharmacy directors, we modified it to chief pharmacists (see page 9, lines ):... with six chief pharmacists, who head the pharmacy department in the six healthcare regions, to discuss and identify the barriers and facilitators of implementing EBM in the hospitals. Chief pharmacists, in addition to their supervisory duties, are responsible about developing guidelines and regulations in their healthcare regions. This change was applied all over the manuscript. - Expand on how the directors were selected/recruited for the semi-structured interviews. Did you intend to interview six specifically from the outset (and why six) - otherwise this should be reported in the results section. We mentioned previously in the methods section that there are six healthcare regions in Kuwait, so we selected the heads of the pharmacy departments in these regions. We added a statement in the manuscript to make this clearer. Please see page 8, lines :.. one-to-one, face-toface semi-structured interviews were conducted, by a trained researcher, with six chief pharmacists who head the pharmacy department in the six healthcare regions to discuss and identify the barriers and facilitators of implementing EBM in the hospitals. - You state that "Pharmacy directors were approached and interviewed in their offices." How long between being 'approached' (invited) and being interviewed in their offices (i.e. did they have adequate time to decide whether they wanted to participate in the study)? The chief pharmacists found that EBM is an interesting topic, and this was mentioned in the manuscript (please see page 9, and line 186): on mentioning the reason of the visit, the chief pharmacists showed complete willingness to participate in this study. - You could mention whether the interviews were one-to-one and also provide some more detail about who conducted them (whether it was one trained researcher who did them all, for consistency of approach etc.) As suggested the following amendment was made in the manuscript (please see page 8 lines ):.. one-to-one, face-to-face semi-structured interviews were conducted, by a trained researcher, with six chief pharmacists who head the pharmacy department in the six healthcare regions to discuss and identify the barriers and facilitators of implementing EBM in the hospitals. - Was the interview schedule/topic guide piloted prior to interviewing the directors?

13 Please see page 9, line 179: The interview schedules were formulated by the research team after reviewing the literature of similar studies (13). The interview schedules were topic guided with probes to motivate the interviewee to provide more details about the topic. - Were the interviews digitally recorded at the time to aid with the transcription process? More detail was added to the interview section (Page 8, lines ): The interviews were noted manually due to the preference of most of the interviewees, who refused to audio-record the interview. - The mean interview duration should be reported in the results section, rather than as part of the methodology. The mean interview duration was moved from the methodology section to the results section. Please see page 15, line 300: The mean interview duration was 20 minutes. 4. Results: - There is repetition between the text and the figures. Did you do statistical analysis on the data presented in the figures (e.g. responses in relation to gender, years of experience) as this could be provided in the text whereas the overall frequencies could be presented in figures? There was not any statistical analysis performed on the data of the figures. The figures only represented the frequencies of the pharmacists' responses. The text only highlighted the key findings while the details were provided in the figures. - You could state p=0.025 (rather than including the word value). The word value was delated, and only p=0.025 was applied to all values. - Please explain what is meant by 'beginner pharmacist.' - The rank of employment for the pharmacists in the questionnaire is an official list that was obtained from the ministry of health. Beginner pharmacists is an employment rank given to the pharmacist during the first year of employment after graduation.

14 - Figures - ensure all are stand-alone items with titles and comprehensive axes labels. - Done. Also a list of the figures titles is provided after the references, please see page 26 and line You could include some more verbatim quotes for the interview part and clarify what the main themes were (since you conducted thematic analysis) from the outset. Otherwise it doesn't seem particularly qualitative in nature. If 'full of energy' is not a verbatim quotation, perhaps rephrase to 'motivated to learn/passionate about pharmacy'. Some more verbatim quotes that were documented manually during the interviews were added to the results section. Please see: Pages 15 and 16, lines : Well, I haven't heard about it as a concept...(ebm) could you explain it? does it need a specific knowledge for practising it? Page 16, lines : we believe in our staff.there are pharmacists specifically fresh graduates who are working and attempting to improve pharmacy image as a profession that has an important role in patient care. Page 17, lines : One of the interviewees stated: an official decision from the higher management is needed to start working evidence-based.this would be a good start-up for all the staff in which computers and internet access will be provided officially. Pages 17 and 18, line : One interviewee reported even patients they need to be aware about this practice so they will not refuse the evidence presenting to them and being confident towards the pharmacists' practice. In regards to the themes that emerged from the interviews, the following paragraph was added (page 15, lines ): The participants responses to the semi-structured questions were grouped into three themes: background on the concept of EBM, the adoption of EBM in pharmacy practice, and factors that facilitate or hinder the implementation of EBM in pharmacy practice in Kuwait. Under each theme, several sub-themes were introduced. As suggested, the phrase full of power was modified to who are passionate about pharmacy (please see page 16, line 316). - I think you should move the sentence about providing the definition of EBM to all of the pharmacy directors at the start of the interview into the methodology section (this is not a result).

15 The statement about providing the definition of EBM to the interviewee was moved to the methodology section as suggested (see page 9, lines ): Upon commencing the interview, the definition of EBM was introduced verbally to the interviewees 5. Discussion: - In the introduction section of the manuscript, you clearly outlined why EBM is important and hence why it was necessary to conduct your study in the first instance (and list the study aims and objectives), so it is repetitive to start the discussion with this too. The repetitive information in the beginning of the discussion section was deleted as suggested. - Perhaps rephrase: A 'good' pharmacist. Also, do you really need to understand those EBM terms to practise effectively? Could a pharmacist not use evidence-based summaries or guidelines to provide effective advice and treatment options in practice (i.e. use evidencebased resources that have interpreted this information already)? There are also plain language summaries of Cochrane Systematic Reviews that could be utilised in practice. A good pharmacist was amended to A good evidence-based practitioner... Please see page 20, line Regarding the impact of training - it will be difficult to sustain a change in practice if other key barriers remain (such as lack of support, time, internet access). Regarding the impact of training, this statement was added to the paragraph (page 20, lines ): However, it appears it will be difficult to sustain a change in practice through only offering training courses if other key barriers remain, such as luck of support, time, and internet access. - You state that "colleagues' advice and textbooks are not evidence-based or up-to-date sources" - is this definitely true? (advice provided by colleagues could be evidence-based based). I would possibly soften the phrase to say that these sources 'may' not be evidencebased or up-to-date. Considering the reviewer s comment, the sentence...are not evidence-based was modified to may not.. please see page 20, line 421.

16 - Consider rephrasing 'young ones'. Done; the word young ones was rephrased to the new graduates. Please see page 21, line In relation to the limitations - it wasn't necessarily the method of data collection (questionnaire-based study) that caused an overestimation in knowledge levels. It was due to the nature of the questions which didn't attempt to test knowledge or skills of EBM but rather sought respondents' opinions on their own knowledge and skills-base. We agree with the reviewer s point of view. We have looked at specific items and it came to our attention that the responses in our survey had roughly similar knowledge to regional and international studies, for examples studies no. 6, 7, and 23. Therefore, we agree with the reviewer s comment and have modified the relevant point. 6. Conclusions: - I don't think you've done your research justice here in the way this is currently written. Having positive attitudes and enthusiasm (willingness) would not typically prepare any healthcare professional for practice, regardless of the specific subject area. Most people will know that knowledge and skills are required to do something effectively so you would not need to conduct any research to reach this conclusion. Additionally, this section repeats some unnecessary generic information about why evidence-based practice is important which the reader will know from reading the introduction. Taking the reviewer s comments into consideration, we re-wrote most of the conclusion section (page 24, lines ): The hospital pharmacists in Kuwait showed good attitude and willingness towards EBM, however, they need to acquire adequate knowledge and skills for applying it in "real life" practise. From the overall findings, results showed that barriers do exist and hinder the practise of EBM. Therefore, in order to provide a good pharmaceutical care, support is needed from policy makers. With this respect, clinical implications were recommended to demonstrate how to overcome the barriers, wherein hospital pharmacists could be ready to practice EBM. - Implications for practice are very useful to include. In relation to offering incentives (and results section where financial incentives are mentioned) - do you think healthcare

17 professionals should be offered incentives to do something which is fundamentally a professional requirement enabling them to practice effectively? In regards to offering incentives for pharmacist, we added the phrase "at the initial stage of practice" to the statement to make it reasonable (page 25, line 523). This would encourage pharmacists to do more effort to make new practice successful. This was experienced in different real life practices and it was a successful attempt. 7. Author contributions - It might be better to use one way to describe authors, rather than a mixture of initials (AJB, FMA, HA) and names (Ali and Almajran). The authors names were re-written in a consistent format. Please see pages 26 and 27, lines References - Check for consistency of approach. For example, sometimes the whole journal name is used but other times abbreviations are used. Check the year for Toklu HZ rather than 2010? All suggested changes were made. Several references were added to the revised manuscript and the reference list was accordingly updated to the required format. (Reviewer #2 comments: Dr. Eman Abu-Gharbieh 1. Explain briefly the sample size calculation Preliminary fieldwork showed that there were a total of 445 pharmacists working in the governmental hospitals in Kuwait. All pharmacists working in the governmental hospital setting were conveniently invited to take part in the study. Following this approach was doable with the study resources and the time frame for data collection. A sentence was added to the manuscript to clarify this (please see manuscript page 8 line 171): All pharmacists were conveniently invited to take part in the study. 2. The research question is not matching the aim of the study, specify governmental hospitals

18 As requested, governmental hospitals were specified as a target site for data collection. Please see manuscript: Page 2 (Abstract), line 31: This study aimed at assessing the readiness of governmental hospital... Page 7 (Aim and Objectives), line 136: This study aimed at assessing the readiness of the pharmacists working in governmental hospitals in Kuwait When EBM was included in pharmacy education Curricula in Kuwait, need to relate this with your findings. To our knowledge and as one of the authors is working in the Faculty of Pharmacy, the current curricula of pharmacy education in Kuwait does not include teaching EBM. However, some activities are indirectly learnt and gained throughout the studying years, such as searching the literature as part of case discussions or clinical forums. In the final year, students conduct a short-period graduation project as a requirement for completing the program. Accordingly some, but not all, would conduct scientific research projects where they come across different EBM skills and terms. A recommendation was already included in the clinical implication regarding this point: Please see the manuscript, page 25, lines : Teaching future generations of pharmacists the principles of EBM to be applied in pharmacy practice. The Faculty of Pharmacy of Kuwait University should incorporate an EBM module into the curriculum. To ensure best academic outcomes, course evaluation by students should be considered. Also see manuscript, introduction section, page 6, lines : In Kuwait, pharmacy education is offered mainly through B. Pharm and more recently, a Master degree is also offered in pharmaceutical sciences, in which EBM is not included in both curricula. 4. Give brief explanation of pharmacy programs offered in Kuwait (BPharm, Pharm D, postgraduate) A sentence was added in the introduction to illustrate the pharmacy programs available in Kuwait. See manuscript, page 6, lines : In Kuwait, pharmacy education is offered mainly through B. Pharm and more recently, a Master degree is also offered in pharmaceutical sciences, in which EBM is not included in both curricula.

19 5. Explain the role of pharmacist association to enhance pharmacy profession in Kuwait The reviewer raised a very interesting point should be made explicit in the manuscript. The role of Kuwait Pharmaceutical Association (KPA) in supporting pharmacy profession is now made clear through providing awareness seminars and training courses/workshops to develop pharmacists skills and knowledge in the context of practising EBM. Please see manuscript,: Page 24, lines : The Kuwait Pharmaceutical Association (KPA) should organise regular awareness seminars, distributing brochures and exhibiting roll-up banners in the healthcare organisation to show the importance of EBM in clinical practice. Page 25, line 521: Arranging training courses/workshops by the KPA for pharmacists, physicians and other Explain why you have excluded the private hospitals, ie is there a difference in pharmacy appointment criteria between private and governmental hospitals The private sector is an independent healthcare setting which is also governed through the Ministry of Health (MoH). However, they do have an independent criteria for appointment and policies that monitor that the quality of their services. Hence the aim of this study was not to compare the knowledge and attitude between two different populations (i.e. governmental hospitals vs. private hospital pharmacists), the private pharmacists were excluded from the current study. However, conducting a study in the future to explore the knowledge and attitude of private pharmacists with regard to practising EBM and comparing these to that of governmental pharmacists will be interesting. Please see manuscript pages 7 and 8, lines : Private hospitals in Kuwait were excluded from the current study since they have different criteria and quality policies for recruiting pharmacists unlike governmental hospitals. Hence, this might affect the result of the current study. In addition to this, the current study did not aim at comparing the knowledge, attitude and practises of two different populations (governmental vs. private hospital pharmacists). 7. Nationality is not necessarily associated with the country of which the degree is obtained, I cannot see evidence that pharmacists with good knowledge of EBM obtained their degrees from their original countries since source of the degree was not among the questions The reviewer raised a very good point comment which is related to the discussion paragraph (please see page 18, lines ). However the explanation provided in the discussion was based on the awareness of the researchers about the system in Kuwait, given that almost all pharmacy graduates are Kuwaitis and only minority of positions are given to the non-kuwaitis.

20 Also, the number of Kuwaiti pharmacy scholars (with funded scholarships) is way lower than the pharmacy graduates from Kuwait University. Based on this, we made this assumption in the discussion, however, it will be more convenient in future studies to include a question about country of graduation in the demographic section of the questionnaire. We are looking forward to receive a favorable final decision regarding our revised manuscript. Dr. Ali Buabbas Assistant Professor, Department of Community Medicine Faculty of Medicine, Kuwait University, Kuwait