title: Effectiveness of a clinically integrated e-learning course in evidence-based medicine for reproductive health training: a randomized trial.
abstract: BACKGROUND
  For evidence-based practice to embed culturally in the workplace, teaching of evidence-based medicine (EBM) should be clinically integrated. In low-middle-income countries (LMICs) there is a scarcity of EBM-trained clinical tutors, lack of protected time for teaching EBM, and poor access to relevant databases in languages other than English.
  
  
  OBJECTIVE
  To evaluate the effects of a clinically integrated e-learning EBM course incorporating the World Health Organization (WHO) Reproductive Health Library (RHL) on knowledge, skills, and educational environment compared with traditional EBM teaching.
  
  
  METHODS
  International cluster randomized trial conducted between April 2009 and November 2010 among postgraduate trainees in obstetrics-gynecology in 7 LMICs (Argentina, Brazil, Democratic Republic of the Congo, India, Philippines, South Africa, Thailand). Each training unit was randomized to an experimental clinically integrated course consisting of e-modules using the RHL for learning activities and trainee assessments (31 clusters, 123 participants) or to a control self-directed EBM course incorporating the RHL (29 clusters, 81 participants). A facilitator with EBM teaching experience was available at all teaching units. Courses were administered for 8 weeks, with assessments at baseline and 4 weeks after course completion. The study was completed in 24 experimental clusters (98 participants) and 22 control clusters (68 participants).
  
  
  METHODS
  Primary outcomes were change in EBM knowledge (score range, 0-62) and skills (score range, 0-14). Secondary outcome was educational environment (5-point Likert scale anchored between 1 [strongly agree] and 5 [strongly disagree]).
  
  
  RESULTS
  At baseline, the study groups were similar in age, year of training, and EBM-related attitudes and knowledge. After the trial, the experimental group had higher mean scores in knowledge (38.1 [95% CI, 36.7 to 39.4] in the control group vs 43.1 [95% CI, 42.0 to 44.1] in the experimental group; adjusted difference, 4.9 [95% CI, 2.9 to 6.8]; P < .001) and skills (8.3 [95% CI, 7.9 to 8.7] vs 9.1 [95% CI, 8.7 to 9.4]; adjusted difference, 0.7 [95% CI, 0.1 to 1.3]; P = .02). Although there was no difference in improvement for the overall score for educational environment (6.0 [95% CI, -0.1 to 12.0] vs 13.6 [95% CI, 8.0 to 19.2]; adjusted difference, 9.6 [95% CI, -6.8 to 26.1]; P = .25), there was an associated mean improvement in the domains of general relationships and support (-0.5 [95% CI, -1.5 to 0.4] vs 0.3 [95% CI, -0.6 to 1.1]; adjusted difference, 2.3 [95% CI, 0.2 to 4.3]; P = .03) and EBM application opportunities (0.5 [95% CI, -0.7 to 1.8] vs 2.9 [95%, CI, 1.8 to 4.1]; adjusted difference, 3.3 [95% CI, 0.1 to 6.5]; P = .04).
  
  
  CONCLUSIONS
  In a group of LMICs, a clinically integrated e-learning EBM curriculum in reproductive health compared with a self-directed EBM course resulted in higher knowledge and skill scores and improved educational environment.
  
  
  BACKGROUND
  anzctr.org.au Identifier: ACTRN12609000198224.
authors.affiliation: Department of Research Policy and Cooperation, World Health Organization (WHO), Geneva, Switzerland.
authors.forename: Regina
authors.initials: R
authors.lastname: Kulier
authors.forename: Ahmet Metin
authors.initials: AM
authors.lastname: Gülmezoglu
authors.forename: Javier
authors.initials: J
authors.lastname: Zamora
authors.forename: M Nieves
authors.initials: MN
authors.lastname: Plana
authors.forename: Guillermo
authors.initials: G
authors.lastname: Carroli
authors.forename: Jose G
authors.initials: JG
authors.lastname: Cecatti
authors.forename: Maria J
authors.initials: MJ
authors.lastname: Germar
authors.forename: Lumbiganon
authors.initials: L
authors.lastname: Pisake
authors.forename: Sunneeta
authors.initials: S
authors.lastname: Mittal
authors.forename: Robert
authors.initials: R
authors.lastname: Pattinson
authors.forename: Jean-Jose
authors.initials: JJ
authors.lastname: Wolomby-Molondo
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Bergh
authors.forename: Win
authors.initials: W
authors.lastname: May
authors.forename: Joao Paulo
authors.initials: JP
authors.lastname: Souza
authors.forename: Shawn
authors.initials: S
authors.lastname: Koppenhoefer
authors.forename: Khalid S
authors.initials: KS
authors.lastname: Khan
mesh_terms: D000328:Adult; D003906:Developing Countries; D020375:Education, Distance; D019317:Evidence-Based Medicine / Q000193:education*; D005260:Female; D006176:Gynecology / Q000193:education; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D009774:Obstetrics / Q000193:education; D060728:Reproductive Health / Q000193:education*; D014944:World Health Organization