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recommend interventions to improve hand hygiene. However, the evidence on the optimum content and how it is should be delivered remain unclear. In addition, evidence for the use of monitoring technology is insufficient to recommend its use.31,40,43 Theory-informed interventions are recommended by the Cochrane systematic review.27 The significant findings of Huis et al28 suggest that targeting social influence, attitude, self-efficacy, and intention may enhance effectiveness, but the evidential basis for this is somewhat lacking.
Limits of the evidence and recommendations for future research
Caution is required when interpreting these findings because only 1 systematic review was at low risk of bias. Reviewers should use quality assessment tools and follow best-practice review guide- lines.48–58 Transparency in reporting of methods should be ensured to minimize bias in future studies. Systematic reviews were restricted in that they largely comprised before-and-after studies; more robust study designs are required moving forward. Also, reviewers rarely conveyed the total sample size, and the type of HCW was often not further defined. These reporting omissions likely reflect the absence of this detail in primary studies. How- ever, this information is necessary to interpret generalizability; what works in one population may differ in another.59 Primary studies tended to run over short time periods; the longer-term effect60 of HH interventions has not yet been established. Researchers should consider this when designing studies. In conclusion, in this systematic review of systematic reviews,
we found predominantly low-quality evidence that interventions to improve HCW HHC are effective. The evidence is sufficient to recommend the implementation of interventions to improve HCW HHC (with the exception of monitoring technology), but it is insufficient to make specific recommendations about the con- tent and how the content should be delivered. To fill existing research gaps and to develop a more viable evidence base to enable the generation of recommendations for practice, sys- tematic reviews should follow reporting guidelines, and primary studies need to utilize more robust research designs.
Acknowledgments.
Financial support. The Scottish Healthcare Associated Infection Prevention Institute (SHAIPI) is a research consortium set up through a grant from the Chief Scientist Office of the Scottish Infection Research Network. SHAIPI supports a program of work carried out by members of the Safeguarding Health through Infection Prevention Research Group at Glasgow Caledonian University. L.P., J.M., P.F., and J.R. conducted the work for this systematic review of systematic reviews in their SHAIPI-funded time.
Conflicts of interest. L.P. is the Director of Studies for a PhD student (LG) whose study is being supported by SureWash. L.P. is leading, and L.G. is working on, another study supported by SureWash. L.P. and L.G. have 2 SureWash Elite machines on loan for data collection purposes for these 2 studies. All other authors report no conflicts of interest relevant to this article.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.262
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