The exploratory factor analysis showed no subclasses within the questionnaire. It presented a single factor test (Fig. 8). The Bartlett test of the hypothesis that at least one factor was included in the questionnaire, was significant at p
Similar to many others [5, 26, 27, 29], we used the BQ as a starting point because it has a reliable, valid and objective construction [5, 7, 9, 26, 31]. The BQ has already been modified for specialized fields of medicine such as surgery by Ubbink , because its good critical appraisal of study design and interpretation of study results. We decided to use the multiple-choice format of the BQ instead of the free text answers of the FT or the binary answer format of the ACE tool . The ACE tool, which uses a dichotomous question type, yields high inaccuracy due to 50% success from the participant guessing the right answer . In the BQ, the participant has to choose one of five answer options, which makes the effect of random guessing smaller . In comparison to the BQ and ACE tools, the open answer questions of the FT query a larger EbM range, but are more difficult and more time-consuming to grade . Qureshi  adapted the Fresno Test for dental students, in which problems with a subjective evaluation of free answers were noticed. The questionnaire that Qureshi used is not available for free viewing. The questionnaire chosen by us provides a combination of manageable effort and accuracy of assessment, as already mentioned by different research groups [7, 29].
The studies by Lai and Buljan show that the original Berlin questionnaire (part A) covers five domains [5, 29]. These mental constructs include study design, internal validity, the magnitude of effect/clinical importance, application and diagnostic accuracy. Due to the explorative factor analysis that we performed, we could not detect any subgroups in our questionnaire. We cannot confirm this factor structure with our data shown by Lai and Buljan.
The achieved values of the BQD reached acceptable data values. Similar to the original Berlin questionnaire, two parts of 15 questions were used. In a future setting, a larger pool of questions including new psychometric valuable items would allow a higher degree of reliability, as already mentioned in the Discussion. The BQD has not been validated in English yet. The questionnaire can currently only be used in German speaking countries. The English version of the BQD must be validated against the German version in the future.
The Berlin Questionnaire for Dentistry is a reliable and valid test to assess the competence of dental students in EbD. The study highlights the importance of valid measuring instruments to capture Evidence-based Dentistry knowledge. The effort to modify existing questionnaires and instruments for other applications should not be underestimated. Therefore, we hope that this pilot study will encourage further efforts to expand this questionnaire or to develop new instruments that assess EbD skills.
LI made a substantial contribution toward the acquisition, analysis, writing and approval process of the manuscript; AM analysed and interpreted the data; MR supported the conception of the questionnaire and the collection of the data; TW contributed toward writing the manuscript; SR drafted the work; SG performed all steps and contributed significantly toward writing the manuscript. All authors read and approved the final manuscript.
The questionnaire was distributed among 94 physicians, and 90 responded (response rate of 95.7%). The initial number of items in the KAP domains of the Noor Evidence-Based Medicine Questionnaire were 15, 17, and 13, respectively; however, two items in the practice domain with communalities
This questionnaire can be used to evaluate the knowledge, attitudes, and behaviour of healthcare professionals toward EBM. Future testing of this questionnaire among other medical personnel groups will help expand the scope of this tool.
The Fresno test is considered the best questionnaire. It evaluates both competency and skills related to EBM and, thereby, serves as a reliable and accurate method for detecting instruction impact . However, the assessment of inter-rater reliability, internal consistency, and discrimination were intimately dependent on the population which has taken the test and are all likely to be lower with a more homogenous group of evidence-based medicine learners . While the adapted Fresno test is relevant to rehabilitation professionals and has removed some statistical questions . The Assessing Competency in EBM (ACE) tool, in addition to the Fresno test, is also a reliable and validated instrument for evaluating EBM competency among healthcare practitioners. The ACE method offers a novel method of assessment as it evaluates user performance in four main steps; however, its application across various patient scenarios remains limited . Notably, the use of multiple EBM tests has resulted in the incongruous assessment of available EBM domains in a sample because of the heterogeneity of items on these tools .
Using a modified Delphi method, the questionnaires were structured to encourage research team members to participate in the final round to clarify the problems and present arguments that explain their views . Four experts, including a public health physician, a family medicine specialist, an evidence-based medicine expert, and a biostatistician, were involved in the development process. Each item is dealt with in detail to ensure that it is appreciated in the same way by all respondents. It avoided unclear content in one item or a double-barreled item, complicated or ambiguous words, different thoughts or notions.
Two sets of questionnaires were prepared for each item to ask for a similar context but differently. With ten respondents, including experts in the field and healthcare professionals, the 45-item questionnaires underwent cognitive debriefing. For consistency, appropriateness, and significance, each item was evaluated. The wordings of several items have been updated accordingly.
The Noor EBM questionnaire originally comprised knowledge, attitude, and practice domains with 15, 17, and 13 items. All three domains required responses on a five-point Likert scale with the knowledge and attitude domains using the Strongly Agree = 5/Agree = 4/Neutral = 3/Disagree = 2/Strongly Disagree = 1 scale, and the practice domain using the Always = 5/Often = 4/Sometimes = 3/Seldom = 2/Never = 1 scale. Reverse scoring was used for negatively worded items.
Convenient sampling was applied wherein the researcher explained the present study and distributed an informed consent form. Once the participant understood and consented to join the study, they were given the self-administered questionnaire and were encouraged to self-complete the EBM scale. The questionnaire was written in English, as it is a global language and used to train doctors in most medical schools. Upon completion, questionnaires were checked for completeness of responses, and the participants were thanked for their co-operation. Participation in the present study was not expected to lead to any potential or foreseeable risk.
The research proposal was approved by the Research and Ethics Committee of the Universiti Sains Malaysia (USM/JEPeM/18040195) and the National Research Medical Registration (NMRR-18-349-40727). All patients gave written informed consent before answering the questionnaire. Confidentially of the data were maintained through anonymity and presented as grouped data.
The advent of EBM and the growing role of the evidence from these studies in the decision making process has necessitated the assessment of relevant competencies among healthcare providers. This Noor EBM questionnaire was intended for use among healthcare professionals, including medical officers and specialist physicians, and hence adequately represents the target population during the evaluation of psychometric parameters in the tool.
Psychometric analysis of the Noor EBM questionnaire confirms that this tool is of high quality. The questionnaire may be used to evaluate competency, attitude, and behaviour toward EBM among healthcare professionals.
The Berlin questionnaire and the Fresno Test are validated instruments for assessing the effectiveness of education in evidence-based medicine. These questionnaires have been used in diverse settings.
For KQ1 and KQ3 (direct evidence of benefits and harms of screening) and KQ2 (accuracy of screening tools), studies of asymptomatic adults with OSA or persons with unrecognized OSA symptoms were included. For KQ1 and KQ3, randomized clinical trials (RCTs) comparing screened groups with nonscreened groups and reporting on health outcomes were eligible. For KQ2, prospective cohort studies and cross-sectional studies assessing the accuracy of screening questionnaires or clinical prediction tools (alone or followed by an unattended home sleep test) compared with polysomnography conducted in a sleep laboratory were eligible. For KQ2, studies limited to persons referred to sleep laboratories for suspected OSA were excluded. For KQ3 (harms of screening), studies eligible for KQ1 or KQ2 that reported harms of screening or diagnostic tests (eg, false-positive results leading to unnecessary treatment, anxiety, distress, or stigma) were eligible.
Key Question 2. What is the accuracy of screening questionnaires, clinical prediction tools, and multistep screening approaches (eg, using a questionnaire followed by home-based oximetry/testing) in identifying persons in the general population who are more or less likely to have OSA, including for specific subgroups of interest?
The STOP-BANG questionnaire includes 8 dichotomous items (snoring, tiredness, observed apnea, blood pressure, BMI, age, neck circumference, and gender).30,31 The 4 studies assessing the accuracy of the STOP-BANG questionnaire enrolled diverse populations and used different scoring criteria and additional variables to determine a positive screen result.25-28 Detailed characteristics of each study are reported in Table 1. 2b1af7f3a8