Infection Control & Hospital Epidemiology


supported by 4 narrative syntheses, which described positive findings, largely without reference to statistical sig- nificance.27–29,42 Furthermore, 3 narrative syntheses on mon- itoring technology found scarce evidence for effectiveness in improving HHC in general.31,40,43 Healthcare-associate infection rates. In 4 systematic reviews,


most or all primary studies that measured HAI rates showed a reduction in HAI rates, although significance levels were not always stated.25,30,33,36/37 Results were more mixed in 4 other systematic reviews reporting HAI data,27,31,35,43 and there were no significant decreases in HAI rates in relevant primary studies included within 2 systematic reviews.39,40 The final systematic review did not report HAI results.42


Intervention content and effectiveness


Supplemental Table 7 summarizes findings of 10 systematic reviews that considered the relationship between intervention content and effectiveness. One meta-analysis38 indicated that interventions with more components, as conceptualized by WHO in their multimodal strategy for HH,2 did not see larger increases in HHC.2 Conversely, within the same systematic review, 2 further meta-analyses of primary studies assessing the same combination of components showed that using all components of the WHO multimodal strategy for HH (OR, 1.82; 95% CI, 1.69– 1.97) seems more effective in improving HHC than including only feedback, education, and reminders (OR, 1.47; 95% CI, 1.12– 1.94).38 Additionally, in a network meta-analysis,30 interventions that supplemented the WHO multimodal strategy for HH with incentives, goal setting, or accountability produced further improvements in HHC than ‘training and education’ or ‘system change’ (OR not reported) and the WHO multimodal strategy for HH alone (OR, 1.82; 95% CI, 0.2–12.2). Doronina et al26 reached a similar conclusion in their narrative synthesis. Naikoba and Hayward18 emphasized that combining educa-


tion with written material, reminders, and continued performance feedback can have a marked effect on HHC compared to single interventions comprising reminders or regular performance feedback, which in turn are more effective than one-off education and ABHR provision. Neo et al32 also proposed that effectiveness may be enhanced by multimodal interventions, as well as facilities design and planning and financial rewards. In another narrative synthesis, multimodal interventions supplying ABHR were as conducive to improving HHC as those without.36/37 Meta-analytic findings suggest that providing (OR, 2.81; 95% CI, 1.32–5.96) in contrast to not providing (OR, 1.55; 95% CI, 1.13–2.11) perfor- mance feedback in a multimodal intervention is more likely to improve HHC.33 However, the Cochrane authors concluded that it is unclear whether multimodal over single interventions are preferable, or which components add the most value.27 With regard to monitoring technology, Mitchell et al31


reported that devices delivering a real-time reminder that HH was indicated but not actioned were consistently linked to increased HHC, while systems with periodic feedback by man- agers produced variable findings. However, in assessing devices that give reminders without feedback, aggregate feedback without reminders, or individual feedback and reminders, Srigley et al40 found limited evidence to recommend any specific technology.


2Increase in HHC for interventions with 1–2 components (OR, 3.44; 95% CI, 1.11–


10.68), 3–4 components (OR, 2.16; 95% CI, 1.82–2.55), and ≥5 components (OR, 2.49; 95% CI, 1.74–3.56).


Delivery of educational interventions and effectiveness


Cherry et al25 considered the relationship between how the educational interventions were delivered and effectiveness. Delivery of education was separated into 6 groups of education with (1) demonstration; (2) no demonstration; (3) self-study; (4) video; (5) demonstration and video, and (6) an online element. However, they were unable to identify a method of delivery that was more effective than another.25


Use of theoretical frameworks


Huis et al28 found a significant positive correlation between the effectiveness of interventions tested in controlled studies and the number of theoretical determinants of behavior (n=1–5) addressed (r=.961; P=.009).3 They also noted that less com- monly addressed determinants (ie, social influence, attitude, self- efficacy, and intention) were mainly targeted in interventions addressing ≥4 determinants.28 Gould et al27 reported interven- tions lacked convincing theoretical underpinning. Likewise, Srigley et al39 observed that it was often unclear how theory informed interventions, that typically not all theoretical con- structs were represented, and that measures of theoretical con- structs were not always consistent with guidelines. No theoretical approach appeared more effective at improving HHC than another.39


Discussion


This systematic review has, for the first time, identified, described, and synthesized the existing evidence base of systematic reviews of interventions to improve HHC among HCWs. In addition, the systematic review was conducted in a transparent and rigorous manner and benefited from a comprehensive literature search, spanning a wide period with no language restrictions. The results of 15 of 18 systematic reviews that reported overall effectiveness showed positive effects of interventions on HCW HHC, across various healthcare settings for different professional groups. However, 6 of 11 systematic reviews that extracted HAI data described mixed or nonsignificant findings. Several reviewers advocated multimodal interventions, incorporating performance feedback and extending the WHO multimodal strategy for HH over single interventions to elicit improvements in HCW HHC. Still, this conclusion was not unanimous. Regarding theory, tar- geting higher numbers of theoretical determinants of behavior (up to 5) appears to increase effectiveness, with interventions that address social influence, attitude, self-efficacy, and intention especially effective. There was no clear link between how educa- tional interventions were delivered and effectiveness.


Limits of the evidence and recommendations for practice


Although a substantial number of systematic reviews showed positive effects of interventions to improve HHC among HCW, only 1 systematic review had a low risk of bias.27 This systematic review concluded that there was sufficient evidence to


3One theoretical determinant (n=3): median relative difference (improvement), 17.6


(range, −8.8 to 61). Two theoretical determinants (n=1): relative difference (improve- ment), 25.7. Three theoretical determinants (n=3): median relative difference (improvement), 42.3 (range, 19.5–82.7). Four theoretical determinants (n=2): median relative difference (improvement), 43.9 (range, 14.8–73). Five theoretical determinants (n=3): median relative difference (improvement), 49.5 (range, −8.6 to 429). And 7 theoretical determinants (n=1): relative difference (improvement), 9.7.


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