In the present study, we provide a comprehensive map of the facilitators and barriers to EBM in health systems that have been classified into six main aspects including “attitudes toward EBP and research,” “external factors,” “contextual factors,” “policies and procedures,” “resources,” and “research capacity and data availability”. In a study, facilitators and barriers to evidence use in program management and decision-making within health care organizations were divided into four distinct groups: informational, organizational, individual, and interactional . Another study revealed seven themes to describe both barriers and facilitators: training, attitudes, consumer demand, logistical considerations, institutional support, policy, and evidence .
In this regard, however, several studies were conducted to identify facilitators and barriers of EBM or EBDM in health organizations; they only focused on some aspects of just one or two of these factors and did not present a comprehensive and complete set or framework for them [11,12,13,14,15,16].
In the following, we discussed the main aspects in two general categories of facilitators and barriers to EBM.
In this research, EBM facilitators were categorized into six main aspects and 24 sub-aspects. Humphries et al. divided facilitators into five principal themes (information, structure and process of the organization, culture of the organization, and individuals’ skills and interactions), and 15 sub-theme . Jessani et al. mentioned nine domains for facilitators (financial, time, work culture, networks, experience, instructional reputation, geographic location, other actors, and relevance) . Sosnowy et al. divided factors affecting EBDM into two main scopes: internal and external factors with themes such as strong leadership, workforce capacity, resources, funding and program mandates, political support, and access to data and program models suitable to community conditions . In this regard, some of the differences in the categorization of the EBM or EBDM facilitators may be due to the type, scope, extent, and main objectives of the studies. Also, the different attitudes of the authors can lead to the various classification of the factors. However, none of the previous studies did present a complete and comprehensive classification of the factors that facilitate the development and implementation of EBM in the health system or had not examined the trend or recurrence of these affecting factors on EBM.
Attitudes toward EBM
In the “attitudes toward EBM” aspects, four sub-aspects that were identified the most frequent ones based on the previous studies were “use of evidence as an organizational value” (14 (28.5%)) and “desire and political will” (13 (26.5%)). Schleiff et al. in their study explained that EBDM does not take place in a depoliticized vacuum. Political alliances and priorities, knowledge brokers, and other factors have a substantial role to play in applying EBM in health organizations. Hence, after the leaders determined the evidence priorities, they can identify processes for their generation and use them by using political commitments to set up structures to support it .
In this aspect, the most mentioned sub-aspects were “interaction between researchers and decision-makers and participatory decision-making” (12 (24.5%)). This interaction assists to create consensus between researchers and managers or decision-makers, which can facilitate and promote evidence use [10, 14, 25,26,27,28,29,30,31,32]. The relationship between researchers and decision-makers leads to making decisions on more accurate, reliable, and up-to-date information and thereby avoid waste of limited resources. Building or strengthening partnerships with schools, hospitals, community and social services organizations, private businesses, universities, and law enforcement can increase EBM in organizations, too .
Among six sub-aspects of the “contextual factors” aspect, “strong leadership” (23 (47%)), “organizational/administrative support” (22 (45%)), and “teamwork, collaboration, and communication” (21 (43%)) were the most repeated concepts in the literature. Encouragement of decision-makers to use evidence in their decision-making process can be considered as a change in organizations. Strong leadership and organizational support are the crucial components of a successful change in any organization . On the other hand, proactive leadership can be associated with a more positive attitude toward evidence-based practice (EBP) . Provision of incentives and motivations [2, 10, 17, 27, 28, 30, 35, 36] and explicit effort to capture synergies between various components of the organizations  by a strong and determined leader are the actions that can encourage the members to focus more on the EBM. As well as, presence of multidisciplinary, diverse management teams , virtual communication networks [29, 32, 35], interactive web-based meeting (webinars) , face-to-face meetings [28, 30] and brainstorming [10, 29], and use of common language and terminology  can facilitate teamwork and consequently enhance the use of evidence in the decision-making process in the organizations.
Policies and procedures
This aspect included four sub-aspects. “Workforce development, empowerment and training leaders/staff” was the most frequent sub-aspect (31 (63%)) in this aspect. Empowering the decision-maker and building capacity to use evidence in the decision-making process can lead to more usage of evidence in an organization. Also, evaluating the implementation of the decisions taken can lead to reinforcing and institutionalizing the use of EBM in the organization. Considering this, some factors such as “executive training programs” [2, 27, 30, 39], “leadership training” [25, 30], “offering the organization as a learning laboratory for Ph.D. and other senior students” , “increasing number of graduate programs that incorporate training in empirically supported treatments” , “conduct interactive workshops” [28, 44], “consultations” , “sending staff to external training programs,” “adapting training to specific specialties or clienteles” , “in-service and multidisciplinary training,” and “skills-based training”  can improve EBM. Decision-maker needs to learn how to gather and appraise evidence . Training the individuals about EBM may enrich their attitude and understanding of the importance of EBM .
Research capacity and data availability
In this aspect, three sub-aspects have existed. Accordingly, “relevance, reliable, interpretable and understandable evidence” was the most mentioned sub-aspect (10 (20%)) in studies. Evidence is the fundamental part of EBM, so the data for use should be real-time, synthesized, and from different agencies , and if so, the managers can make good decisions. Without this information, wrong decisions will be made, and it can lead to not only the organization that does not improve but may push it away from its desired goals.
Different types of factors were explained which can impede the development of EBM in the organization. In this research, the identified barriers in literature are divided into six main aspects with 27 sub-aspects. Liang et al. identified 12 barriers in three levels including a broader level, organization, and individual manager . Humphries et al. identified five main themes (information, the structure and process of the organization, the culture of the organization, and individuals’ skill and interaction) and 28 sub-themes . Pagoto et al. identified six themes for barriers: attitude toward EBP, training, logistical, policy, evidence, institutional support, and consumer demand  which is somehow similar to this study. Majdzadeh et al. mentioned three main themes (decision-makers’ characteristics, decision-making environment, and research system) and 14 sub-themes for EBDM barriers in Iran’s health system . Again, none of the previous studies about the barriers of the EBM in health systems did present a complete set of factors. Moreover, it seems that the type, scope, extent, and main objectives of the studies and also the different attitude of the authors leads to the various classification of the factors.
Attitudes toward EBM
In this aspect, both the “resistance to change” (14 (28.5%)) and “lack of confidence/interest about the values or the accuracy of research data or the researchers” (13 (26.5%)) were most repeated in previous researches. Adaption to various changes in organizations is unavoidable . Resistance to change may be due to inappropriate use of power, challenges to cultural norms and institutionalized practices, lack of understanding, inappropriate timing, inadequate resources, incorrect information, or employees’ suspicion of honorable management intentions . Moving toward EBM is considered as a change in an organization that causes fear for the managers or staff. Fear of change toward the unknown leads to resistance to change, so proper strategies and policies such as training, education, or compensations are essential to successful changes .
In the “external factors” aspect, “competing interests and priorities” which is defined as “the need for a hierarchy of approaches that allow to competing for organizational priorities and a balance between reactive and proactive management”  was most cited (17 (35%)) in the literature. It was explained in the studies that often centralized , heterogeneous , or politically influenced decisions [10, 50] might prevent the managers of the health organizations from making efficient decisions based on the best available evidence.
Among the “contextual factors,” “weak Organizational leadership” (20 (41%)) and “weak culture of decision-making based on evidence” (18 (37%)) were the most repeated sub-aspects in the literature. It is clear that no program or change in the organization will be successful without the commitment and support of the leader and senior officials of the organization. Also, the implementation of any plan and reforms requires the existence of a suitable cultural context and infrastructure. Culture is an important basic element to support changes in an organization, as well as to move toward EBM . Organizational culture plays a significant role in innovation and changes . Developing a dominant culture for EBM is essential in organizations to ensure that decisions are well appraised by research evidence.
Policies and procedures
In this aspect, “limited knowledge and skills to access, interpret, appraise, and synthesize research evidence, or in research methods or foreign language” was the most cited sub-aspect (26 (53%)) by the previous studies. According to a previous study, inadequate technical training to enable managers to interpret research findings was a barrier to adequate accessibility to scientific evidence . Applying EBM needs to learn how to search and evaluate different evidence critically from scientific findings to experts’ opinions and even some economic data, which requires some new managerial skills . Besides, training the staff about EBDM can lead to not only an understanding of the importance of its implication in the organization but also they can learn how to acquire, assess, adapt, and apply researches in the organizational decision-making process . Also, Walker et al. stated that librarians could be a crucial part of improving understanding and use of evidence in the organization by raising awareness of evidence-based resources among the employees. Thus, creating a strong communication between librarians and decision-makers can increase the use of evidence .
“Time constraint for collecting and interpretation of information, engaging in research or implementation of an evidence-based decision making” was identified as an important and frequent (33 (67%)) sub-aspect in the “limited resources” aspect. Health workers are overworked, so time constraints are one of the barriers to using evidence. Organizations should provide the essential tools to facilitate quick and easy access to the required research, ensuring appropriate journal subscriptions, and providing relevant links on the organizations’ intranet  to overcome these time constraints to some extent.
Research capacity and data availability
“Lack of relevant or high-quality evidence” (24 (49%)) and “inadequate/uneven access to evidence” (22 (45%)) were the sub-aspects that were mentioned in much other literature. Uncertain/unreliable evidence [40, 42], non-useful format , not available data in an extractable format , and gaps in evidence [24, 36, 41, 48]/inadequate research findings  were mentioned by other studies as the items that can prevent the evidence-based decisions. Limited access to the electronic databases and experts’ opinions leads to barriers in using evidence in the decision-making process . Evidence is the main part of the EBDM process; therefore, inadequate access to evidence can make it difficult to go toward EBM.
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