1450
have no comparator or be compared to usual care, another intervention, or historical control. Systematic reviews were required to report HHC as the primary outcome. Other outcomes of interest included bacterial load on HCW hands, HAI rates, organizational culture, and psychological variables. No restric- tions were placed on the design of primary studies within sys- tematic reviews.
Information sources and search
In September 2017, we searched 4 databases (CINAHL, EMBASE, MEDLINE, and PsycINFO) and 6 specialist registers (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Health Technology Assessment Database, and PROSPERO). No language or date of publication restrictions were applied. The search included index terms and text words relating to HH21 and sys- tematic review methods.22 Database searches were broadly simi- lar; modifications were made to account for minor differences in functionality (see Supplemental Table 1 for MEDLINE search). Due to limited functionality of specialist registers (except the Cochrane Database of Systematic Reviews), these searches were restricted to HH text words. We also manually searched the reference lists of included systematic reviews.
Systematic review selection
Systematic review selection was conducted in 2 stages, with all papers assessed by 2 independent reviewers. First, titles and abstracts of included papers were screened against the inclusion criteria. Second, papers that appeared to meet the inclusion cri- teria or lacked sufficient information to allow an informed jud- gement on relevance underwent full-text review. Disagreements were resolved via discussion or referral to a third reviewer.
Data collection and risk of bias within systematic reviews
A standardized tool was devised for data extraction (Supple- mental Table 2). Risk of bias within systematic reviews was assessed using the ROBIS tool (Supplemental Table 3).23 Data were extracted and risk of bias was assessed by 2 independent reviewers for 25% (n=5) of systematic reviews. The remaining systematic reviews were data extracted and assessed for risk of bias by 1 reviewer and checked by another. Disagreements were resolved through discussion or referral to a third reviewer.
Synthesis
Findings were synthesized following the Economic and Social Research Council’s guidance for narrative synthesis.24 Results
Systematic review selection
The search yielded 993 papers (Fig. 1). Following the removal of duplicates, 566 unique papers remained; all were screened against the inclusion criteria. Most papers (n=481) were discarded at the title or abstract stage, and 65 were excluded by full-text review (Fig. 1). Overall, 19 systematic reviews (n=20 articles) were included.18,25–43 Reference list checks did not identify any further papers.
Systematic review characteristics
The characteristics of the 19 systematic reviews are summarized in Supplemental Table 4. Overall, 15 narrative synth- eses,18,25–29,31,32,35,36/37,39–43 3 meta-analyses,33,34,38 and 1 network meta-analysis30 were published between 2001 and 2017, with 15 published after 2010.25–33,38–43 Primary studies in included sys- tematic reviews were published from 1986 to 2016 and ranged in number from 341 to 73.32 Collectively,1 236 unique primary stu- dies were cited. However, some primary studies were included in >1 systematic review. The degree of overlap has been quantified and presented in a transparent manner44,45: 139 (58.9%) primary studies were cited once; 46 (19.5%) were cited twice; 25 (10.6%) were cited 3 times; 17 (7.2%) were cited 4 times; 7 (3.0%) were cited 5 times; and 2 (<1%) were cited 6 times.
Countries and healthcare settings In all but 2 systematic reviews where inclusion was limited to primary studies conducted in developed32 or low- or middle- income countries,42 systematic reviews were open to primary studies from all countries. Regarding healthcare settings, 13 sys- tematic reviews included primary studies conducted in hospi- tals.25,26,28,30,31,33–35,39–43 In addition, 6 systematic reviews included primary studies conducted in hospitals in addition to
elder care homes;29 nursing homes;32 long-term care facilities; 27,32,36/37,38 care homes for people with disabilities;18 and/or pri- mary care facilities.27,29
Population All systematic reviews were open to primary studies of any type of HCW, with the exception of Doronina et al,26 which specified a particular professional group (nurses). Most systematic reviews included data from a range of HCWs (eg, nurses, doctors, healthcare assistants, and students), and 6 systematic reviews included at least 1 primary study (n=1;28,30,33,43 n=3;40 and n=632) with data from patients or visitors or relatives, but the proportions of the overall samples that were not HCWs were not reported.
Interventions With regard to types of interventions, 11 systematic reviews took an inclusive approach. Others focused on the introduction of alcohol-based hand rub (ABHR),34 ABHR accessibility,41 educa- tional interventions,25 interventions using psychological theory,39 monitoring technology,31,40,43 or quality improvement strate- gies.35 Supplemental Table 5 illustrates how the content of interventions evaluated in primary studies of each systematic review mapped onto the WHO multimodal strategy for HH.2 The most frequent component was ‘observation and feedback,’ which was mapped in all but 1 systematic review,41 followed by ‘training and education’
(n=15).18,25–33,35,38,40,43 The least common component was ‘safety climate,’ which was mapped in 10 systematic reviews.25–30,32,35,38,43
(n=16)18,25–39,42 and 1Excluding primary studies in Ward et al43 because it is unclear exactly how many
reported HHC and/or HAI outcomes and only including 8 primary studies in Kingston et al29 with baseline and post-intervention HHC data, upon which conclusions about effectiveness were based.
Lesley Price et al
‘reminders’
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