Evidence-based practice among physiotherapists in India: a nationwide survey of knowledge, attitude, and implementation behavior

Introduction

Globally, the World Health Organization upholds health as a human right, and fundamental to it is the sub-specialty of universal health coverage (UHC) (World Health Organization, 2021). UHC emphasizes the expectation of accessing effective quality healthcare services at the right time and place while bearing manageable costs (Ghandour & Truche, 2022; Bertram et al., 2024). Evidence-based practice (EBP) integrates the best available research and patient-centred knowledge, blended with experience in the clinical field (Mishra, 2024; Mittal et al., 2024) and EBP is expected of healthcare professional. Healthcare professionals are expected to practice evidence-based. As a result, by the time the students in the health care profession complete their studies, they should be equally confident in applying evidence-based practice (Olsen et al., 2013). It is a foundation for improving the effectiveness of physiotherapy interventions and enhancing the quality of physiotherapy services (Scurlock-Evans, Upton & Upton, 2014).

World Physiotherapy, previously known as the World Confederation for Physical Therapy (WCPT), advocates physiotherapists to embrace EBP principles with an emphasis on managing patients and communities based on the best available evidence  (Schubert, 2019; Rushton et al., 2011; World Physiotherapy, 2019). While there is an increase in the international trends toward implementing EBP, the awareness and practice of EBP among physiotherapists in India have been less researched, specifically their understanding, recommendations, and compliance (Panhale, Bellare & Jiandani, 2017; Nolan & Bradley, 2008; Majdzadeh et al., 2012). The majority of published literature is concentrated on the integration of EBP in developed Western countries, assessing the barriers and enablers for EBP integration, but has neglected the challenges that are specific to the Indian context, including limited resources, institutional and cultural variations (Scurlock-Evans, Upton & Upton, 2014; ShahAli et al., 2023; Panhale & Bellare, 2015). Although physiotherapy plays a central role in managing non-communicable diseases like pre- and post-operative rehabilitation of sports injuries, post-stroke rehabilitation, cardio-respiratory rehabilitation, movement disorders, women’s health, and musculoskeletal disorders, etc., there is a growing belief that EBP use is inconsistent and hence, may lead to inferior patients’ outcomes (Achttien et al., 2013; Mendonça et al., 2022; Lee, Choi & Jeoung, 2022; Zaidi & Ahmed, 2022; Nielsen et al., 2015; Desmeules et al., 2012).

Based on the few published studies in India, the physiotherapists generally hold a favorable attitude and agree that EBP is important (Panhale, Bellare & Jiandani, 2017; Panhale & Bellare, 2015; Thakkar, 2018). At the same time, limited knowledge, skill deficiencies, and non-reliance on the current scientific evidence are observed among the physiotherapists. The barriers to EBP implementation across the literature are limited access to resources, lack of formal training, and lack of support. It is important to understand the knowledge, attitude, and barriers to implementing EBP among physiotherapists in India to set up strategies, improve capacity building, and formulate effective policy with institutional changes required to support sound clinical decision-making and legitimize the profession (Morales-Osorio et al., 2024). This research seeks to address this gap by examining how knowledge of EBP, awareness of its principles, and its implementation by physiotherapists in India respond to the global call for EBP implementation to embrace what is described as the best practice of informed decision-making concerning the realities of the resources that are both relevant as well as desirable. We hypothesize that there is a positive relationship between the knowledge and attitude towards evidence-based practice and implementation behaviour among physiotherapists in India.

Results

Perceived barriers to EBP

Among the provided list of perceived barriers to implementation of EBP, the participants reported lack of time (51.6%) as the greatest barrier, followed by limited skills in database searching (49.3%), lack of resources (47.5%), and limitations in clinical applicability (45.5%). And most of the participants (70%) expressed that they are interested in EBP in physiotherapy (Fig. 1).

Discussion

This study provided a comprehensive evaluation of EBP awareness with knowledge and implementation achievements among 2,966 physiotherapists. We observed significant differences in engagement with EBP across professional roles, regions, and educational levels. Physiotherapists employed in private practice and home care settings reported higher EBP scores than their counterparts in government hospitals. This disparity may be attributed to greater autonomy, enhanced access to treatment resources, and a stronger emphasis on patient-centred care among private and home-based practitioners. The adoption of EBP showed regional variations because Rajasthan, along with Bihar, Chhattisgarh, and Haryana, exhibited better engagement compared to Jammu & Kashmir, Himachal Pradesh, and Maharashtra. EBP implementation success depends heavily on resource availability and institutional backing, according to these identified differences. Furthermore, physiotherapists with doctoral-level education demonstrated superior EBP skills, highlighting the critical role of advanced education in developing evidence-based decision-making abilities among clinicians. Studies have demonstrated that advanced education in postgraduate programs helps healthcare providers properly understand research data alongside their capability to transform scientific evidence into clinical practice for better patient results (Hasani et al., 2020; Ashworth et al., 2014; van der Leeuw et al., 2012).

The study observed a discrepancy between positive attitudes and suboptimal implementation of EBP. While participants demonstrated favorable attitudes, their knowledge and behavioral application of EBP were moderate, aligning with global trends where enthusiasm for EBP often outstrips practical adoption (Morales-Osorio et al., 2024; Hasani et al., 2020). The regression analysis highlighted educational attainment and workplace as dominant predictors of EBP competency, collectively explaining 46.1% of the variance in total EBP scores. Private practitioners and those with advanced degrees (e.g., PhDs) reported higher EBP engagement, echoing findings from similar studies in Saudi Arabia (Hasani et al., 2020). Barriers such as lack of time (51.6%), limited skills in database navigation (49.3%), and resource shortages (47.5%) were prominent, mirroring challenges identified in Latin America and in India (Morales-Osorio et al., 2024; Patel & Jhala, 2024). Further, a systematic review reporting the barriers of EBP implementation in physiotherapy involving 29 studies estimated that lack of time (53%, 95% CI [44.0–62.0]) was the most frequently reported barrier, which is consistent with the findings reported in this study (Paci et al., 2021). However, the review found that language limits and lack of access were among the top barriers. Conversely, in this study lack of skills, lack of resources, and application limitations were among the top reported barriers which is more typical of the developing countries.

Notably, the negative correlation between knowledge and attitude scores suggests that clinicians with lower EBP literacy may overestimate their readiness to implement EBP, underscoring the need for targeted educational reforms. Prospective research should examine if redesigning the undergraduate curriculum will address the EBP knowledge deficiency during initial physiotherapy education (Patel, Shah & Prakash, 2025). The adoption of EBP depended on personnel backgrounds, geographic locations, and licensing body policies, as demonstrated by the regression analysis (Gleadhill et al., 2022; Dalheim et al., 2012; Pitsillidou et al., 2021; Young & Ward, 2001). Traditional demographic factors, including clinical experience duration and age, alongside gender proved to be either minimal or sporadic in their contributions to readiness for EBP Private practice physiotherapists received more points in EBP surveys since they encounter less bureaucracy and their incentives align with staying aware of the latest evidence-based practices (Young & Ward, 2001; Al-Kubaisi, Al-Dahnaim & Salama, 2010; Bernhardsson et al., 2014). Positive attitudes toward EBP among a wide range of healthcare professionals, including nurses, physiotherapists, physicians, occupational therapists, and psychologists, have been demonstrated by previous studies (Silva et al., 2021; O’Donnell, 2004; Weng et al., 2015). Research must explore what impact private practice autonomy has on EBP adoption versus the barriers that government institutions raise against evidence-based practice implementation (Paci et al., 2021).

Regional discrepancies in EBP scores highlight the impact of localized factors such as infrastructure, access to training, and professional development opportunities. The moderate EBPQ scores in India reflect a broader pattern observed in low- and middle-income countries, where systemic constraints like fragmented healthcare access and under-resourced institutions hinder EBP integration (Ganesh, Khan & Khan, 2024). For instance, the emphasis on workplace settings—private clinics outperforming government hospitals—parallels findings from a Saudi Arabian study, where institutional support and autonomy facilitated EBP adoption (Dirbas & Al Haddad, 2024). The influence of advanced education aligns with global evidence that postgraduate training enhances critical appraisal skills and research utilization (Scurlock-Evans, Upton & Upton, 2014). However, India’s unique challenges, such as regional disparities (e.g., low representation from Eastern states) and cultural preferences for traditional practices, necessitate context-specific strategies (Yoshikawa et al., 2020). These findings emphasize the need for region-specific capacity-building programs that integrate localized challenges such as infrastructure limitations and access to training (Sterba et al., 2020; JBI, 2024). Additionally, previous studies have demonstrated that membership in professional organizations significantly enhances EBP engagement by providing access to training and research resources (Burgers et al., 2003; Newman, Pyne & Cowling, 1998). Policymakers should consider strengthening institutional frameworks that facilitate continuous learning and professional development (Wong et al., 2021). Evaluation-based practice scores differ between regions due to specific factors that affect healthcare delivery infrastructure, together with training accessibility and professional growth opportunities (Hisham, Liew & Ng, 2018; Ambachew et al., 2023; Merza & Maani, 2023). The research demonstrates why targeted capacity-building initiatives need to develop regional programs that address the unique problems of infrastructure and training access in specific areas (Khan et al., 2018). Membership in professional organizations leads to better EBP engagement, according to research, because these organizations offer training and research assets to their members (Evans et al., 2014). Policy directors shall prioritize the establishment of institutional frameworks for professional development and continuing professional education. The identified barriers, particularly time constraints and skill gaps, resonate with barriers reported in Argentina, where physiotherapists struggled with critical appraisal and IT literacy (Bevacqua & Intelangelo, 2023; Kinney et al., 2023).

A few limitations would limit the generalizability of the findings of this study. First, the cross-sectional design does not allow us to explore the causal relationships between the identified factors and EBP engagement. Secondly, though this online survey recruited a large sample, the snowball sampling method would have led to non-representativeness, and the sample included a disproportionately high number of academic physiotherapists and variations in the geographic representation may limit the generalizability of the results to clinicians working in non-academic or clinical practice settings and under-represented regions. Third, the online format of the survey raises concerns about participant eligibility verification and the possibility of duplicate responses, the potential for social desirability bias, as well as over- or under-reporting of EBP behaviors, cannot be entirely ruled out. Finally, though this study used an established outcome tool (EBPQ), and the tool demonstrated good reliability (Cronbach’s alpha), justifying its transferability in the Indian context. Yet, it is important that country-specific factors might have influenced the scores obtained in this study, despite of the reliability reported. Hence, local contextual factors shall be considered while interpreting the findings. These limitations underscore the need for cautious interpretation and suggest that further studies using more controlled methodologies are warranted. Nevertheless, the following measures, like assuring anonymity and use of neutral language in the questions, might have reduced the desirability bias to some extent. Moreover, the larger sample-based data in this study would have enhanced the precision of the estimates reported in this study.

Conclusion

This nationwide study underscores the multifaceted factors influencing EBP adoption among Indian physiotherapists. The findings highlight the critical role of educational background, regional disparities, and practice settings in shaping EBP implementation. Targeted strategies, including curriculum enhancements, policy reforms, and regional capacity-building initiatives, are essential to fostering a more consistent and widespread adoption of EBP in physiotherapy practice across India. To cultivate a sustainable EBP culture in Indian physiotherapy, a compassionate, multi-level approach is essential. First, educational reforms must empower future practitioners by embedding EBP modules into curricula. This will equip students not just with theoretical knowledge but with hands-on workshops to navigate databases and interpret research. Second, institutions must cultivate a culture of inquiry: hospitals could foster EBP engagement by providing free access to critical resources like the Cochrane Library and dedicated time for evidence review by clinicians. Third, respecting patients’ cultural preferences for instance, integrating evidence-based yoga into rehabilitation protocols. Finally, educators must model EBP behaviors in everyday practice, demystifying its application, while national bodies like the IAP amplify this ripple effect through structured mentorship programs.

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