Article Text

Dissemination of systematic reviews in a hospital setting: a comparative survey for spreading use of the Cochrane Library
  1. Yi-Hao Weng1,
  2. Chih-Cheng Hsu2,
  3. Ya-Hui Shih2,
  4. Heng-Lien Lo2,3,
  5. Ya-Wen Chiu2,4,
  6. Ken N Kuo2,3
  1. 1Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
  2. 2Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
  3. 3Center for Evidence Based Medicine, Taipei Medical University, Taipei, Taiwan
  4. 4School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
  1. Correspondence to Dr Ya-Wen Chiu, Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 35053, Taiwan; bettychiu{at}; yawenchiu{at}


Introduction The Cochrane Library is the most important online evidence retrieval database of systematic reviews. Since 2007, the National Health Research Institutes has offered Taiwan's regional hospitals free access to the Cochrane Library. This study investigated how these hospitals disseminate its utilisation.

Methods The usage rate of Cochrane reviews was measured in the participating hospitals from January 2008 to December 2009. Thereafter, a questionnaire survey was conducted for each regional hospital disseminator at the beginning of 2010 to analyse their methods of disseminating Cochrane reviews.

Results The hospitals were stratified into three groups according to the relative rate of access: high (n=15), medium (n=16) and low (n=13). In comparison with the low-usage hospitals, the high-usage hospitals tended to assign a disseminator of evidence-based medicine to take charge of the dissemination of Cochrane reviews (p<0.001). In addition, the high-usage hospitals more often used the following six methods: providing relevant information via email (p<0.05), investing in early adopters (p<0.05), using assistance from designated personnel (p<0.05), highlighting the activity of early adopters (p<0.05), conducting workshops (p=0.001), and inviting experts to speak (p<0.001). There was no significant difference between high- and low-usage hospitals in organisational barriers.

Conclusion This study has identified several helpful strategies used by Taiwan's hospitals to enhance dissemination of the Cochrane Library, including raising of awareness, active delivery of information, mentoring relationships, and educational training. The data suggest that disseminating evidence-based medicine simultaneously is a key element.

  • Systematic reviews
  • evidence-based medicine
  • dissemination
  • Cochrane Library
  • altitude medicine
  • biotechnology and bioinformatics
  • education and training (see medical education and training)
  • neonatology

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Evidence-based medicine (EBM), clinical practice based on scientific evidence, has become a core competence for health professionals who wish to improve healthcare quality.1 Because the volume of published evidence continues to grow extremely rapidly, analysing current information is an increasingly difficult task. By offering synthesised summaries of individual studies that are worthy of further reflection, systematic reviews can help to alleviate this problem.2 Physicians can save time and facilitate clinical decision-making by using systematic reviews.3

The Cochrane Library is the pre-eminent online database of systematic reviews.4 Cochrane reviews are conducted with well-established methodological standards to enrol randomised controlled trials, which is a scientific method that uses an epidemiologically experimental design to gain unbiased treatment results by using objectively collected data and statistical analysis.5 ,6 Updates to incorporate new evidence and address identified errors are applied regularly.7 The Cochrane Library is thus regarded as the most important EBM resource.8–11 However, its use has not yet spread throughout the world.12 ,13 Although free access is available in some countries through national licensing,14–17 this is not the case in Taiwan.

Understanding the marketing of Cochrane Library usage is important to healthcare policymakers and stakeholders for strategic development. Very little evidence-based research, however, has elucidated how awareness can be raised and how it can be used for decision-making.18 Some theories on ways to enhance its dissemination have been proposed, including raising awareness, delivering information, mentoring relationships, and education.19 ,20 The first step in the process is to increase awareness. Second, delivery of information may serve as a channel to increase rate of usage. Third, mentoring relationships, such as support from early adopters and designated personnel, can enhance dissemination.12 Fourth, education and training can increase knowledge of and skill in how to access and further maximise levels of self-sufficiency in its efficient use.21 For example, academic detailing by early adopters has proven valuable for changing behaviour.22

In Taiwan's regional hospitals, physicians carry a heavy clinical load and often lack the time to search for evidence-based information.18 ,23 Under a collaborative project since the beginning of 2007, the National Health Research Institutes (NHRI) has offered them free access to Cochrane reviews to promote the application of EBM. The NHRI has also hosted a number of educational training sessions and simulations to disseminate the Cochrane Library.21 Despite the NHRI's considerable continuing efforts to encourage the system's use, its spread into regional hospitals has not been very wide. In this study, we explore which strategies used by Taiwan's regional hospitals could be helpful in spreading utilisation of the Cochrane Library. The data should help us to refine methods to promote access of Cochrane reviews.


Study population

Targets were regional hospitals in Taiwan. A regional hospital is defined as a secondary care hospital, as judged by Taiwan's Joint Commission of Hospital Accreditation. A total of 45 regional hospitals with around 3700 physicians were enrolled, covering 69.2% of the regional hospitals in Taiwan.

Study design

The study design is shown in figure 1. After the start of free access to Cochrane reviews provided by the NHRI in 2007, each participating hospital was required to assign someone to take charge of promotion of the Cochrane Library. The NHRI did not interfere in the selection of this leader or in their choices of strategies for promoting the Cochrane Library. Thereafter, their rates of Cochrane usage were measured from January 2008 to December 2009. At the beginning of 2010, a questionnaire survey was conducted to examine how they promoted the Cochrane Library. In this study, we compared strategies of dissemination between hospitals with different rates of access.

Figure 1

Study design for analyses.

Classification of regional hospitals

Each hospital was provided with a unique password to document individual hits. The online logs to the Cochrane Library of participating hospitals were examined for 24 months to determine actual usage. Rates were calculated as hits per physician. Regional hospitals were stratified into high-usage, medium-usage and low-usage groups according to their relative rates of access. An online login-monitoring program provided by John Wiley & Sons was used to measure the rate of access.

Questionnaire survey to determine strategies for promoting Cochrane reviews

A structured questionnaire was developed to examine seven methods of enhancing Cochrane Library dissemination, nine organisational barriers to its utilisation, and eight personal characteristics of respondents in each participating hospital (see online supplementary material for the questionnaire). The questionnaire was distributed to the Cochrane Library leader of each participating hospital. Questions on the organisational barriers were rated on a Likert five-point scale (strongly agree, agree, neutral, disagree and strongly disagree).

The study was approved by the NHRI's ethics review board. Content validity of the questionnaire was examined by nine experts with clinical service of more than 15 years each. The content validity index of the questionnaire was 0.95.

Data analysis

The Likert five-point scale was dichotomised for further analyses. A self-rating report of either strongly agree or agree was regarded as a favourable answer. The other three (neutral, disagree and strongly disagree) were viewed as an unfavourable perception.

Statistical analyses were conducted using a commercially available program (SPSS V.12.0 for Windows). Categorical variables were analysed using the χ2 test or Fisher's exact test. For comparison between groups with quantitative variables, the null hypothesis that there was no difference between each group was tested by analysis of variance. Significance was defined as p<0.05.


Stratification of regional hospitals by rate of access to the Cochrane Library

Only one leader did not return the questionnaire after a second follow-up. Excluding the one hospital from which no response was received, we analysed 44 hospitals. To examine the different levels of use, hospitals were stratified into 15 high-usage hospitals (more than 20 hits/physician/year), 16 medium-usage hospitals (10–20 hits/physician/year) and 13 low-usage hospitals (fewer than 10 hits/physician/year). Cut-off points were determined by examining the distribution of rates to identify neutral breaks.

The access rate was 56.80±58.20 (20.81–260.45) hits/physician/year in high-usage hospitals, 14.33±2.35 (10.16–18.74) hits/physician/year in medium-usage hospitals, and 6.43±2.13 (3.35–9.27) hits/physician/year in low-usage hospitals (mean±SD (range)).

Demographics of Cochrane Library promotion leaders

There were significant differences in four personal characteristics among the three groups of Cochrane Library leaders: gender, director position, EBM disseminator and profession (table 1). When compared with respondents in the low-usage hospitals, those in the high-usage hospitals were more likely to be male (p<0.05), directors in clinical service (p<0.01), disseminators of EBM (p<0.001), and medical doctors (p<0.05). The other characteristics—age, working period, faculty (defined as respondents who served as teaching staff) and academic degree—showed no significant difference, but faculty members were more common in the high-usage group than the low-usage group.

Table 1

Demography of leaders of Cochrane review dissemination among 44 regional hospitals in Taiwan stratified into high, medium and low usage

Strategies for disseminating the Cochrane Library

The methods for promoting the Cochrane Library used by the leaders of regional hospitals are summarised in table 2. Overall, the most common method for spreading Cochrane Library use was providing relevant information via email (31/44, 70.5%), followed by conducting workshops (26/44, 59.1%), inviting experts to speak (24/44, 54.5%), obtaining assistance from designated personnel (23/44, 52.3%), posting relevant information (22/44, 50.0%), investing in early adopters (22/44, 50.0%), and highlighting the activity of early adopters (13/44, 29.5%). Compared with low-usage hospitals, disseminators in high-usage hospitals more often spread word about the Cochrane Library through the following six methods: (1) providing relevant information via email, (2) conducting workshops, (3) obtaining assistance from designated personnel, (4) inviting experts to speak, (5) investing in early adopters, and (6) highlighting the activity of early adopters. There was no significant difference in posting relevant information between the groups. Moreover, leaders in the high-usage group more often used three or more methods (86.7%) than those in the low-usage group (23.1%) (p<0.001).

Table 2

Comparison of strategies to promote use of Cochrane reviews in high-usage, medium-usage and low-usage hospitals

Organisational barriers to accessing the Cochrane Library

Overall, the most common barrier to using the Cochrane Library was lack of time because of heavy clinical load (79.5%), followed by deficient organisational environment (72.7%), insufficient incentive payment (61.4%), lack of capable designated personnel (50.0%), lack of support from superiors (50.0%), insufficient financial support (43.2%), lack of hardware for the internet (25.0%), lack of space for use (19.0%), and inconvenience (18.2%) (table 3). There was no significant difference in each barrier among high-usage, medium-usage and low-usage hospitals.

Table 3

Leaders' perceived barriers in regional hospitals of Taiwan stratified into high, medium and low usage


In this study, we designed a unique survey to verify the attributes of Cochrane Library dissemination. This survey examined how Taiwan's hospitals disseminated the free access to Cochrane reviews provided by the NHRI. The results indicate that a number of promotional strategies and personal characteristics of the disseminators are associated with its utilisation. To our knowledge, this study is the first attempt to investigate the evidence-based strategies behind diffusion of the Cochrane Library.16 ,24 ,25

The most significant factor is the disseminator of EBM in terms of personal characteristics. A promotional campaign for EBM is an effective way of disseminating the Cochrane Library. This is not surprising because Cochrane reviews are the reference standard for EBM.5 Acknowledgement of EBM has been regarded as a motivator to enhance the use of evidence.26 Favourable attitudes towards EBM may lead to sustained alterations in behaviour.27 Thus promoters who provide services to facilitate the adoption of EBM will enhance the spread of Cochrane Library usage. Furthermore, our results indicate that physicians are better disseminators than librarians. The role of librarians in spreading usage of the Cochrane Library has been debated.28–30 Librarians and physicians tend to have different promotional strategies for this. We speculate that most librarians who promote the Cochrane Library do not combine this with dissemination of EBM.

We found that having the leader of Cochrane Library promotion in a director's position was associated with successful dissemination. This is probably because those who champion the Cochrane Library without an official title have less authority to use multiple methods to facilitate its spread. In addition, gender was a factor related to dissemination. However, this factor is profession related21: male physicians are more common (92.3%) than male librarians (14.3%).

Our study shows that multiple methods can successfully facilitate usage of Cochrane reviews. Effective attempts used raising of awareness, active delivery of information, mentoring relationships, training and education. Understanding the value of accessing the Cochrane Library is essential for the implementation of EBM.16 Furthermore, we found that active delivery of information via email was as an efficient way to increase usage. Our previous results indicate that doctors use the internet most in searches for medical knowledge in Taiwan.18 In contrast, our data show that passive delivery of information using a poster did not increase utilisation of the Cochrane Library. Furthermore, our study reveals that lack of time is the most significant barrier to accessing the Cochrane Library. Physicians are often pressed for time in the use of evidence.23 ,31 Thus, whatever can help potential users to save time in accessing the Cochrane Library, such as mentoring relationships and educational training, should accelerate its usage. Taken together, activities such as simulations, workshops and conferences could be effective methods for spreading usage of Cochrane reviews. Utilisation of Cochrane reviews in turn affects healthcare. These data suggest that multiple strategies are more useful for influencing EBM behaviour than a single method.

The strengths of this study are: (1) the questionnaire survey had a high response rate (97.8%); (2) the respondents were blinded since they did not know to which category their hospital was assigned; (3) the study minimised perception bias by examining the actual usage of the Cochrane Library.

Some limitations and methodological issues in this study should be cautiously interpreted. First, our questionnaire survey is self-reported, not an audit of actual practice. Second, this study was unable to identify the personal details of Cochrane Library users, as our survey was not linked to individuals. Nonetheless, a similar study of our previous questionnaire survey showed that age and faculty position were associated with usage of the online database.18 Further study to evaluate the characteristics of users may help us to improve strategies for promoting Cochrane systemic reviews. Third, the effects of institutional history on the participants, such as their own organisational change, were not determined. We believe that the frameworks of enrolled hospitals had no significant differences because their organisational barriers to the utilisation of the Cochrane Library were similar.32

In conclusion, our study has identified several key accelerators of Cochrane Library dissemination. The results suggest that multifaceted strategies, including educative training, social support and environmental influence, are helpful for increasing the library's utilisation in hospital settings. Our findings should provide stakeholders and promoters with valuable information for spreading use of the Cochrane Library. Further study is needed to assess the effect of access to Cochrane reviews on objective behaviour and patient outcome.

Main messages

  • Useful strategies for disseminating utilisation of the Cochrane Library include raising of awareness, active delivery of information, mentoring relationships, and educational training.

  • Disseminating evidence-based medicine is a key element in facilitating diffusion of Cochrane reviews.

Current research questions

  • To investigate the potential impact of spreading Cochrane reviews on patient outcome.

  • To identify personal characteristics in relation to usage of the Cochrane Library.

Key references

▶ Rosenbaum SE, Glenton C, Cracknell J. User experiences of evidence-based online resources for health professionals: user testing of the Cochrane Library. BMC Med Inform Decis Mak 2008;8:34.

▶ Chiu YW, Weng YH, Lo HL, et al. Impact of a nationwide outreach program on the diffusion of evidence-based practice in Taiwan. Int J Qual Health Care 2010;22:430–6.

▶ Carboneau C. Using diffusion of innovations and academic detailing to spread evidence-based practices. J Healthc Qual 2005;27:48–52.


We are grateful to the participants who gave their time in this study.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:


  • Funding This work was supported by a research grant from the National Health Research Institutes, Taiwan (PH-099-SP02).

  • Competing interests None.

  • Ethics approval Ethics Review Board of the National Health Research Institutes.

  • Provenance and peer review Not commissioned; externally peer reviewed.