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Interventions to improve healthcare workers’ hand hygiene compliance: A systematic review of systematic reviews

Published online by Cambridge University Press:  11 December 2018

Lesley Price Open the ORCID record for Lesley Price [Opens in a new window] ,
Jennifer MacDonald ,
Lucyna Gozdzielewska ,
Tracey Howe ,
Paul Flowers ,
Lesley Shepherd ,
Yvonne Watt  and
Jacqui Reilly
Lesley Price*
Affiliation:
Safeguarding Health through Infection Prevention Research Group, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
Jennifer MacDonald
Affiliation:
Safeguarding Health through Infection Prevention Research Group, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
Lucyna Gozdzielewska
Affiliation:
Safeguarding Health through Infection Prevention Research Group, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
Tracey Howe
Affiliation:
School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
Paul Flowers
Affiliation:
Safeguarding Health through Infection Prevention Research Group, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
Lesley Shepherd
Affiliation:
Health Protection Scotland, Glasgow, Scotland, United Kingdom
Yvonne Watt
Affiliation:
School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
Jacqui Reilly
Affiliation:
Safeguarding Health through Infection Prevention Research Group, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom Health Protection Scotland, Glasgow, Scotland, United Kingdom
*
Author for correspondence: Lesley Price, Safeguarding Health through Infection Prevention Research Group, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, UK. E-mail: L.Price@gcu.ac.uk
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Abstract

Objective

To synthesize the existing evidence base of systematic reviews of interventions to improve healthcare worker (HCW) hand hygiene compliance (HHC).

Methods

PRISMA guidelines were followed, and 10 information sources were searched in September 2017, with no limits to language or date of publication, and papers were screened against inclusion criteria for relevance. Data were extracted and risk of bias was assessed.

Results

Overall, 19 systematic reviews (n=20 articles) were included. Only 1 article had a low risk of bias. Moreover, 15 systematic reviews showed positive effects of interventions on HCW HHC, whereas 3 reviews evaluating monitoring technology did not. Findings regarding whether multimodal rather than single interventions are preferable were inconclusive. Targeting social influence, attitude, self-efficacy, and intention were associated with greater effectiveness. No clear link emerged between how educational interventions were delivered and effectiveness.

Conclusions

This is the first systematic review of systematic reviews of interventions to improve HCW HHC. The evidence is sufficient to recommend the implementation of interventions to improve HCW HHC (except for monitoring technology), but it is insufficient to make specific recommendations regarding the content or how the content should be delivered. Future research should rigorously apply behavior change theory, and recommendations should be clearly described with respect to intervention content and how it is delivered. Such recommendations should be tested for longer terms using stronger study designs with clearly defined outcomes.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 12 , December 2018 , pp. 1449 - 1456
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Healthcare-associated infections (HAIs) have serious consequences for patients and healthcare systems, leading to longer hospital stays, increased mortality and morbidity, and financial burden.Reference Marchetti and Rossiter 1 , 2 In Europe, ~80,000 hospital patients suffer at least 1 HAI on any given day, yielding an overall prevalence of 5.7%. 3 HAIs also affect millions of patients worldwide annually. 3 – Reference Nejad, Allegranzi, Syed, Ellis and Pittet 7

Organisms that cause HAIs can be transmitted to patients through healthcare worker (HCW) hands contaminated by patient contact or touching the patient environment. 2 Effective hand hygiene (HH) is thus critical to preventing HAIs,Reference Allegranzi and Pittet 8 which is reflected by the emphasis on HCW compliance with HH guidelines. Such HH guidance relates to both opportunity and technique. Opportunity concerns when to do HH, and the World Health Organization (WHO) specify Five Moments. 2 Technique relates to how to enact HH, with 2 main procedures internationally: the Six Step 2 and Three StepReference Boyce and Pittet 9 techniques. However, HCW compliance with this guidance is suboptimal. 2 , Reference Arias, Garcell, Ochoa, Arias and Miranda 10 – Reference Widmer, Conzelmann, Tomic, Frei and Stranden 17

A major challenge within healthcare systems is how to improve hand hygiene compliance (HHC) among HCWs. An early systematic review identified 21 primary studies evaluating HH interventions for HCWs.Reference Naikoba and Hayward 18 A plethora of primary studies and a growing number of systematic reviews have since assessed the effectiveness of interventions to improve HCW HHC. To assist practitioners in optimizing HHC among HCWs, this review aims to synthesize the evidence base of systematic reviews of interventions to improve HCW HHC.

Methods

Protocol and registration

This systematic review followed a published protocolReference Currie, Duguid and Flowers 19 and is reported according to the PRISMA guidelines.Reference Moher, Liberati, Tetzlaff and Altman 20

Inclusion criteria

Systematic reviews were included if they evaluated any intervention to improve HHC among HCWs. Interventions could 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 restrictions were placed on the design of primary studies within systematic 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 HHReference Price, MacDonald and Melone 21 and systematic review methods. 22 Database searches were broadly similar; 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 criteria or lacked sufficient information to allow an informed judgement 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 (Supplemental Table 2). Risk of bias within systematic reviews was assessed using the ROBIS tool (Supplemental Table 3).Reference Whiting, Savović and Higgins 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.Reference Popay, Roberts and Sowden 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.Reference Naikoba and Hayward 18 , Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 Reference list checks did not identify any further papers.

Fig. 1 PRISMA flow diagram outlining the systematic review selection process.

Systematic review characteristics

The characteristics of the 19 systematic reviews are summarized in Supplemental Table 4. Overall, 15 narrative syntheses,Reference Naikoba and Hayward 18 , Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Kingston, O’Connell, Dunne and O’Connell 29 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ranji, Shetty and Posley 35 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Srigley, Corace and Hargadon 39 – Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 3 meta-analyses,Reference Ofek Shlomai, Rao and Patole 33 , Reference Picheansathian 34 , Reference Schweizer, Reisinger and Ohl 38 and 1 network meta-analysisReference Luangasanatip, Hongsuwan and Limmathurotsakul 30 were published between 2001 and 2017, with 15 published after 2010.Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Ofek Shlomai, Rao and Patole 33 , Reference Schweizer, Reisinger and Ohl 38 – Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 Primary studies in included systematic reviews were published from 1986 to 2016 and ranged in number from 3Reference Stiller, Salm, Bischoff and Gastmeier 41 to 73.Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 Collectively,Footnote 1 236 unique primary studies were cited. However, some primary studies were included in >1 systematic review. The degree of overlap has been quantified and presented in a transparent mannerReference Cheung, Weir, Mayhew, Kozloff, Brown and Grimshaw 44 , Reference Lorimer, Kidd, Lawrence, McPherson, Cayless and Cornish 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 developedReference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 or low- or middle-income countries,Reference Vindigni, Riley and Jhung 42 systematic reviews were open to primary studies from all countries. Regarding healthcare settings, 13 systematic reviews included primary studies conducted in hospitals.Reference Cherry, Brown, Bethell, Neal and Shaw 25 , Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 , Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Ofek Shlomai, Rao and Patole 33 – Reference Ranji, Shetty and Posley 35 , Reference Srigley, Corace and Hargadon 39 – Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 In addition, 6 systematic reviews included primary studies conducted in hospitals in addition to elder care homes;Reference Kingston, O’Connell, Dunne and O’Connell 29 nursing homes;Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 long-term care facilities; Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Schweizer, Reisinger and Ohl 38 care homes for people with disabilities;Reference Naikoba and Hayward 18 and/or primary care facilities.Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Kingston, O’Connell, Dunne and O’Connell 29

Population

All systematic reviews were open to primary studies of any type of HCW, with the exception of Doronina et al,Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 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;Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Ofek Shlomai, Rao and Patole 33 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 n=3;Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 and n=6Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 ) 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),Reference Picheansathian 34 ABHR accessibility,Reference Stiller, Salm, Bischoff and Gastmeier 41 educational interventions,Reference Cherry, Brown, Bethell, Neal and Shaw 25 interventions using psychological theory,Reference Srigley, Corace and Hargadon 39 monitoring technology,Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 or quality improvement strategies.Reference Ranji, Shetty and Posley 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,Reference Stiller, Salm, Bischoff and Gastmeier 41 followed by ‘training and education’ (n=16)Reference Naikoba and Hayward 18 , Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Srigley, Corace and Hargadon 39 , Reference Vindigni, Riley and Jhung 42 and ‘reminders’ (n=15).Reference Naikoba and Hayward 18 , Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Ofek Shlomai, Rao and Patole 33 , Reference Ranji, Shetty and Posley 35 , Reference Schweizer, Reisinger and Ohl 38 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 The least common component was ‘safety climate,’ which was mapped in 10 systematic reviews.Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ranji, Shetty and Posley 35 , Reference Schweizer, Reisinger and Ohl 38 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43

Outcomes

Hand hygiene compliance was measured by direct observation (n=13),Reference Naikoba and Hayward 18 , Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 – Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ofek Shlomai, Rao and Patole 33 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Schweizer, Reisinger and Ohl 38 , Reference Srigley, Corace and Hargadon 39 , Reference Stiller, Salm, Bischoff and Gastmeier 41 , Reference Vindigni, Riley and Jhung 42 unobtrusive observation (n=2),Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 , Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 video camera (n=4),Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Schweizer, Reisinger and Ohl 38 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 mobile handheld devices (n=1),Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 electronic monitoring (n=9),Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Vindigni, Riley and Jhung 42 or self-report (n=3).Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Ritchie, Iqbal, Macpherson, Riches and Stout 37 , Reference Vindigni, Riley and Jhung 42 Proxy measures, such as rate or number of HH events (n=4),Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 ABHR consumption or soap use (n=11),Reference Naikoba and Hayward 18 , Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Schweizer, Reisinger and Ohl 38 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 , Reference Stiller, Salm, Bischoff and Gastmeier 41 and procurement of ABHR or soap (n=2),Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Srigley, Corace and Hargadon 39 were also employed. A lack of longer-term evaluation of HHC was observed in 11 systematic reviews.Reference Naikoba and Hayward 18 , Reference Cherry, Brown, Bethell, Neal and Shaw 25 – Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ofek Shlomai, Rao and Patole 33 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Vindigni, Riley and Jhung 42 HAI rates were reported in 11 systematic reviews.Reference Cherry, Brown, Bethell, Neal and Shaw 25 , Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Ofek Shlomai, Rao and Patole 33 , Reference Ranji, Shetty and Posley 35 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Srigley, Corace and Hargadon 39 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 , Reference Vindigni, Riley and Jhung 42 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 Bacterial load on HCW hands, organizational culture, and psychological variables were not reported in any systematic reviews.

Study designs

In 3 systematic reviews,Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 , Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 primary studies were required to meet the Cochrane Effective Practice and Organization of Care methodological criteria for randomized controlled trials (RCTs), nonrandomized trials, controlled before-and-after studies, or interrupted time series (ITS). 46 Across the other systematic reviews, before-and-after studies were common,Reference Naikoba and Hayward 18 , Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 – Reference Ofek Shlomai, Rao and Patole 33 , Reference Ranji, Shetty and Posley 35 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Schweizer, Reisinger and Ohl 38 – Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 although 5 reviewers did not specify the design of the included primary studies.Reference Cherry, Brown, Bethell, Neal and Shaw 25 , Reference Picheansathian 34 , Reference Stiller, Salm, Bischoff and Gastmeier 41 – Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 Although Kingston et alReference Kingston, O’Connell, Dunne and O’Connell 29 described all primary studies as ‘clinical trials,’ this term was not defined, and ITS and before-and-after studies were included.Reference Chudleigh, Drey, Moralejo and Gould 47

Risk of bias within systematic reviews

Overall, 13 systematic reviews had a high risk of bias,Reference Naikoba and Hayward 18 , Reference Cherry, Brown, Bethell, Neal and Shaw 25 , Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 , Reference Kingston, O’Connell, Dunne and O’Connell 29 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 – Reference Picheansathian 34 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 , Reference Schweizer, Reisinger and Ohl 38 , Reference Stiller, Salm, Bischoff and Gastmeier 41 – Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 5 systematic reviews had an unclear risk of bias,Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Ranji, Shetty and Posley 35 , Reference Srigley, Corace and Hargadon 39 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 and 1 systematic review had a low risk of bias (Table 1).Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 The most common methodological weaknesses within systematic reviews related to synthesis and findings, for example, not reporting individual study results, not including all primary studies in the synthesis, or not addressing biases in the synthesis. Other common methodological weaknesses within systematic reviews were not reporting a risk of bias assessment or the process for data extraction and risk of bias assessment.

Table 1 Risk of Bias Within Systematic Reviews

Effectiveness of HH interventions

Hand hygiene compliance. In total, 18 systematic reviews reported the overall effectiveness of interventions in improving HCW HHC (Supplemental Table 6). Also, 2 meta-analyses showed similar increases (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.40–2.97Reference Ofek Shlomai, Rao and Patole 33 ; and Peto OR, 1.96; CI, 1.56–2.46Reference Picheansathian 34 ). Luangasanatip et alReference Luangasanatip, Hongsuwan and Limmathurotsakul 30 found that 18 of 22 pairwise comparisons (82%) showed both stepwise increases in HHC during intervention implementation and a trend for increasing HHC postintervention. In 8 narrative syntheses, most or all primary studies reported significant improvements in HHC.Reference Cherry, Brown, Bethell, Neal and Shaw 25 , Reference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 , Reference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 , Reference Ranji, Shetty and Posley 35 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 – Reference Srigley, Corace and Hargadon 39 , Reference Stiller, Salm, Bischoff and Gastmeier 41 Overall effectiveness was further supported by 4 narrative syntheses, which described positive findings, largely without reference to statistical significance.Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 – Reference Kingston, O’Connell, Dunne and O’Connell 29 , Reference Vindigni, Riley and Jhung 42 Furthermore, 3 narrative syntheses on monitoring technology found scarce evidence for effectiveness in improving HHC in general.Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 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.Reference Cherry, Brown, Bethell, Neal and Shaw 25 , Reference Luangasanatip, Hongsuwan and Limmathurotsakul 30 , Reference Ofek Shlomai, Rao and Patole 33 , Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 37 Results were more mixed in 4 other systematic reviews reporting HAI data,Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 , Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Ranji, Shetty and Posley 35 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 and there were no significant decreases in HAI rates in relevant primary studies included within 2 systematic reviews.Reference Srigley, Corace and Hargadon 39 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 The final systematic review did not report HAI results.Reference Vindigni, Riley and Jhung 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-analysisReference Schweizer, Reisinger and Ohl 38 indicated that interventions with more components, as conceptualized by WHO in their multimodal strategy for HH, 2 did not see larger increases in HHC.Footnote 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).Reference Schweizer, Reisinger and Ohl 38 Additionally, in a network meta-analysis,Reference Luangasanatip, Hongsuwan and Limmathurotsakul 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 alReference Doronina, Jones, Martello, Biron and Lavoie-Tremblay 26 reached a similar conclusion in their narrative synthesis.

Naikoba and HaywardReference Naikoba and Hayward 18 emphasized that combining education 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 alReference Neo, Sagha-Zadeh, Vielemeyer and Franklin 32 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.Reference Ritchie, Iqbal, Macpherson, Riches and Stout 36 / Reference Stout, Ritchie and Macpherson 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) performance feedback in a multimodal intervention is more likely to improve HHC.Reference Ofek Shlomai, Rao and Patole 33 However, the Cochrane authors concluded that it is unclear whether multimodal over single interventions are preferable, or which components add the most value.Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27

With regard to monitoring technology, Mitchell et alReference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 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 managers produced variable findings. However, in assessing devices that give reminders without feedback, aggregate feedback without reminders, or individual feedback and reminders, Srigley et alReference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 found limited evidence to recommend any specific technology.

Delivery of educational interventions and effectiveness

Cherry et alReference Cherry, Brown, Bethell, Neal and Shaw 25 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.Reference Cherry, Brown, Bethell, Neal and Shaw 25

Use of theoretical frameworks

Huis et alReference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 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).Footnote 3 They also noted that less commonly addressed determinants (ie, social influence, attitude, self-efficacy, and intention) were mainly targeted in interventions addressing ≥4 determinants.Reference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 Gould et alReference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 reported interventions lacked convincing theoretical underpinning. Likewise, Srigley et alReference Srigley, Corace and Hargadon 39 observed that it was often unclear how theory informed interventions, that typically not all theoretical constructs were represented, and that measures of theoretical constructs were not always consistent with guidelines. No theoretical approach appeared more effective at improving HHC than another.Reference Srigley, Corace and Hargadon 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, targeting 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 educational 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.Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 This systematic review concluded that there was sufficient evidence to 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.Reference Mitchell, Betesh, Ravitz, Runyan and Umscheid 31 , Reference Srigley, Gardam, Fernie, Lightfoot, Lebovic and Muller 40 , Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 Theory-informed interventions are recommended by the Cochrane systematic review.Reference Gould, Moralejo, Drey, Chudleigh and Taljaard 27 The significant findings of Huis et alReference Huis, van Achterberg, de Bruin, Grol, Schoonhoven and Hulscher 28 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 guidelines. 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. However, this information is necessary to interpret generalizability; what works in one population may differ in another.Reference Michie and West 59 Primary studies tended to run over short time periods; the longer-term effect 60 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 content 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, systematic 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

Footnotes

PREVIOUS PRESENTATION: Results based on a search of the literature up to June 2016 were presented on September 19, 2017, at the Annual Conference of the Infection Prevention Society, held in the Manchester Central Convention Complex, England, United Kingdom. This presentation resulted in the following abstract: Price L, MacDonald J, Gozdzielewska L, et al. An overview of systematic reviews of interventions designed to improve healthcare workers’ hand hygiene compliance. J Infect Prev 2017;18:S56–S57.

Cite this article: Price L, et al. (2018). Interventions to improve healthcare workers’ hand hygiene compliance: A systematic review of systematic reviews. Infection Control & Hospital Epidemiology 2018, 39, 1449–1456. doi: 10.1017/ice.2018.262

1 Excluding primary studies in Ward et alReference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich 43 because it is unclear exactly how many reported HHC and/or HAI outcomes and only including 8 primary studies in Kingston et alReference Kingston, O’Connell, Dunne and O’Connell 29 with baseline and post-intervention HHC data, upon which conclusions about effectiveness were based.

2 Increase 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).

3 One theoretical determinant (n=3): median relative difference (improvement), 17.6 (range, −8.8 to 61). Two theoretical determinants (n=1): relative difference (improvement), 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.

References

1. Marchetti, A, Rossiter, R. Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. J Med Econ 2013;16:1399–1404.Google Scholar
2. World Health Organization. WHO guidelines on hand hygiene in health care. World Health Organization website. http://www.who.int/gpsc/5may/tools/9789241597906/en/. Published 2009. Accessed January 11, 2018.Google Scholar
3. European Centre for Disease Prevention and Control. Summary: Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals. European Centre for Disease Prevention and Control website. https://ecdc.europa.eu/sites/portal/files/media/en/healthtopics/Healthcare-associated_infections/point-prevalence-survey/Documents/healthcare-associated-infections-antimicrobial-use-PPS-summary.pdf. Published 2009. Accessed January 11, 2018.Google Scholar
4. Allegranzi, B, Nejad, SB, Combescure, C, et al. Burden of endemic health-care-associated infection in developing countries: SYSTEMATIC review and meta-analysis. Lancet 2011;377:228–241.Google Scholar
5. Cassini, A, Plachouras, D, Eckmanns, T, et al. Burden of six healthcare-associated infections on European population health: estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study. PLoS Med 2016;13:e1002150.Google Scholar
6. Ling, ML, Apisarnthanarak, A, Madriaga, G. The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis. Clin Infect Dis 2015;60:1690–1699.Google Scholar
7. Nejad, SB, Allegranzi, B, Syed, SB, Ellis, B, Pittet, D. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ 2011;89:757–765.Google Scholar
8. Allegranzi, B, Pittet, D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305–315.Google Scholar
9. Boyce, JM, Pittet, D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep 2002;51:1–45.Google Scholar
10. Arias, AV, Garcell, HG, Ochoa, YR, Arias, KF, Miranda, FR. Assessment of hand hygiene techniques using the World Health Organization’s six steps. J Infect Public Health 2016;9:366–369.Google Scholar
11. Erasmus, V, Daha, TJ, Brug, H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283–294.Google Scholar
12. Laustsen, S, Lund, E, Bibby, BM, Kristensen, B, Thulstrup, AM, Møller, J. Effect of correctly using alcohol-based hand rub in a clinical setting. Infect Control Hosp Epidemiol 2008;29:954–956.Google Scholar
13. Park, H, Kim, S, Lim, Y, et al. Assessment of the appropriateness of hand surface coverage for healthcare workers according to World Health Organization hand hygiene guidelines. Am J Infect Control 2014;42:559–561.Google Scholar
14. Reilly, JS, Price, L, Lang, S, et al. A pragmatic randomized controlled trial of 6-step vs 3-step hand hygiene technique in acute hospital care in the United Kingdom. Infect Control Hosp Epidemiol 2016;37:661–666.Google Scholar
15. Thivichon-Prince, B, Barsotti, O, Girard, R, Morrier, J. Hand hygiene practices in a dental teaching center: measures and improve. Eur J Dent 2014;8:481–486.Google Scholar
16. Tschudin-Sutter, S, Sepulcri, D, Dangel, M, Schuhmacher, H, Widmer, AF. Compliance with the world health organization hand hygiene technique: a prospective observational study. Infect Control Hosp Epidemiol 2015;36:482–483.Google Scholar
17. Widmer, AF, Conzelmann, M, Tomic, M, Frei, R, Stranden, AM. Introducing alcohol-based hand rub for hand hygiene: the critical need for training. Infect Control Hosp Epidemiol 2007;28:50–54.Google Scholar
18. Naikoba, S, Hayward, A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers: a systematic review. J Hosp Infect 2001;47:173–180.Google Scholar
19. Currie, K, Duguid, C, Flowers, P, et al. An overview of systematic reviews and meta-analyses of interventions designed to improve healthcare workers’ hand hygiene compliance. York: PROSPERO 2016 CRD42016040027. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016040027. Published 2016. Accessed January 11, 2018.Google Scholar
20. Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–269.Google Scholar
21. Price, L, MacDonald, J, Melone, L, et al. Effectiveness of national and sub-national infection prevention and control interventions in high and upper-middle income countries: outcomes of a systematic literature review. Lancet Infect Dis 2018;18:e159–e171.Google Scholar
22. Search filters. Edinburgh: Scottish Intercollegiate Guidelines Network website. http://www.sign.ac.uk/methodology/filters.html. Published 2013. Accessed January 11, 2018.Google Scholar
23. Whiting, P, Savović, J, Higgins, JP, et al. ROBIS: a new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol 2016;69:225–234.Google Scholar
24. Popay, J, Roberts, H, Sowden, A, et al. Guidance on the conduct of narrative synthesis in systematic reviews. ESRC Research Methods Programme website. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.178.3100&rep=rep1&type=pdf. Published 2006. Accessed January 11, 2018.Google Scholar
25. Cherry, MG, Brown, JM, Bethell, GS, Neal, T, Shaw, NJ. Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22. Med Teach 2012;34:e406–e420.Google Scholar
26. Doronina, O, Jones, D, Martello, M, Biron, A, Lavoie-Tremblay, M. A systematic review on the effectiveness of interventions to improve hand hygiene compliance of nurses in the hospital setting. J Nurs Scholarsh 2017;49:143–152.Google Scholar
27. Gould, DJ, Moralejo, D, Drey, N, Chudleigh, JH, Taljaard, M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017;9:CD005186.Google Scholar
28. Huis, A, van Achterberg, T, de Bruin, M, Grol, R, Schoonhoven, L, Hulscher, M. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012;7:92.Google Scholar
29. Kingston, L, O’Connell, NH, Dunne, CP, O’Connell, NH. Hand hygiene-related clinical trials reported since 2010: a systematic review. J Hosp Infect 2016;92:309–320.Google Scholar
30. Luangasanatip, N, Hongsuwan, M, Limmathurotsakul, D, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. BMJ 2015;351:h3728.Google Scholar
31. Mitchell, MD, Betesh, J, Ravitz, N, Runyan, D, Umscheid, CA. Automated Hand Hygiene Monitoring Systems. Philadelphia, PA: Center for Evidence-based Practice, 2014.Google Scholar
32. Neo, JRJ, Sagha-Zadeh, R, Vielemeyer, O, Franklin, E. Evidence-based practices to increase hand hygiene compliance in health care facilities: an integrated review. Am J Infect Control 2016;44:691–704.Google Scholar
33. Ofek Shlomai, N, Rao, S, Patole, S. Efficacy of interventions to improve hand hygiene compliance in neonatal units: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2015;34:887–897.Google Scholar
34. Picheansathian, W. A systematic review on the effectiveness of alcohol-based solutions for hand hygiene. Int J Nurs Pract 2004;10:3–9.Google Scholar
35. Ranji, SR, Shetty, K, Posley, KA, et al. Prevention of Healthcare-Associated Infections. Vol 6 of Shojania KG, McDonald KM, Wachter RM, and Owens DK (editors). Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). AHRQ Publication No. 04(07)-0051-6. Rockville, MD: Agency for Healthcare Research and Quality, 2007. https://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap6/hainfgap.pdf. Published 2007. Accessed January 11, 2018.Google Scholar
36. Ritchie, K, Iqbal, K, Macpherson, K, Riches, E, Stout, A. The provision of alcohol based products to improve compliance with hand hygiene. Healthcare Improvement Scotland website. http://www.healthcareimprovementscotland.org/previous_resources/hta_report/hta_7.aspx. Published 2005. Accessed January 11, 2018.Google Scholar
37. Stout, A, Ritchie, K, Macpherson, K. Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review. J Hosp Infect 2007;66:308–312.Google Scholar
38. Schweizer, ML, Reisinger, HS, Ohl, M, et al. Searching for an optimal hand hygiene bundle: A meta-analysis. Clin Infect Dis 2014;58:248–259.Google Scholar
39. Srigley, JA, Corace, K, Hargadon, DP, et al. Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review. J Hosp Infect 2015;91:202–210.Google Scholar
40. Srigley, JA, Gardam, M, Fernie, G, Lightfoot, D, Lebovic, G, Muller, MP. Hand hygiene monitoring technology: a systematic review of efficacy. J Hosp Infect 2015;89:51–60.Google Scholar
41. Stiller, A, Salm, F, Bischoff, P, Gastmeier, P. Relationship between hospital design and healthcare-associated infection rates: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2016;5:51.Google Scholar
42. Vindigni, SM, Riley, PL, Jhung, M. Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance. Trop Med Int Health 2011;16:466–477.Google Scholar
43. Ward, MA, Schweizer, ML, Polgreen, PM, Gupta, K, Reisinger, HS, Perencevich, EN. Automated and electronically assisted hand hygiene monitoring systems: a systematic review. Am J Infect Control 2014;42:472–478.Google Scholar
44. Cheung, A, Weir, W, Mayhew, A, Kozloff, N, Brown, K, Grimshaw, J. Overview of systematic reviews of the effectiveness of reminders in improving healthcare professional behavior. Syst Rev 2012;1:36.Google Scholar
45. Lorimer, K, Kidd, L, Lawrence, M, McPherson, K, Cayless, S, Cornish, F. Systematic review of reviews of behavioural HIV prevention interventions among men who have sex with men. AIDS Care 2012;25:133–150.Google Scholar
46. Cochrane Effective Practice and Organisation Care. What study designs should be included in an EPOC review and what should they be called? EPOC Resources for review authors website. http://epoc.cochrane.org/sites/epoc.cochrane.org/files/public/uploads/Resources-for-authors2017/what_study_designs_should_be_included_in_an_epoc_review.pdf. Published 2017. Accessed January 11, 2018.Google Scholar
47. Chudleigh, J, Drey, N, Moralejo, D, Gould, DJ. Systematic reviews of hand hygiene in patient care post 2010. J Hosp Infect 2016;94:110–111.Google Scholar
48. Cochrane Effective Practice and Organisation Care. Suggested risk of bias criteria for EPOC reviews. EPOC Resources for review authors website. http://epoc.cochrane.org/sites/epoc.cochrane.org/files/public/uploads/Resources-for-authors2017/suggested_risk_of_bias_criteria_for_epoc_reviews.pdf. Published 2107. Accessed January 11, 2018.Google Scholar
49. Zingg, W, Castro-Sanchez, E, Secci, FV, et al. Innovative tools for quality assessment: integrated quality criteria for review of multiple study designs (ICROMS). Public Health 2016;133:19–37.Google Scholar
50. Wells, GA, Shea, B, O’Connell, D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. University of Ottawa website. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp Published 2000. Accessed January 11, 2018.Google Scholar
51. Jadad, AR, Moore, RA, Carroll, D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1–12.Google Scholar
52. Rosella, L, Bowman, C, Pach, B, Morgan, S, Fitzpatrick, T, Goel, V. The development and validation of a meta-tool for quality appraisal of public health evidence: meta Quality Appraisal Tool (MetaQAT). Public Health 2016;136:57–65.Google Scholar
53. Anderson, LA, Sharpe, PA. Improving patient and provider communication: A synthesis and review of communication interventions. Patient Educ Couns 1991;17:99–134.Google Scholar
54. Downs, SH, Black, N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–384.Google Scholar
55. Higgins, JPT, Altman, DG, Sterne, JAC. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0 (updated March 2011). The Cochrane Collaboration website. http://handbook.cochrane.org/ Published 2011. Accessed January 11, 2018.Google Scholar
56. Systematic reviews: CRD’s guidance for undertaking reviews in healthcare. Centre for Reviews and Dissemination website. http://www.york.ac.uk/crd/guidance/. Published 2009. Accessed January 11, 2018.Google Scholar
57. Higgins, JPT, Green, S. Cochrane handbook for systematic reviews of interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration website. http://handbook.cochrane.org/. Published 2011. Accessed January 11, 2018.Google Scholar
58. SIGN 50: A guideline developer’s handbook. Edinburgh: Scottish Intercollegiate Guidelines Network website. http://www.sign.ac.uk/sign-50.html. Published 2015. Accessed January 11, 2018.Google Scholar
59. Michie, S, West, R. Behaviour change theory and evidence: a presentation to Government. Health Psychol Rev 2013;7:1–22.Google Scholar
60. NICE guidelines PH49 Behaviour change: Individual approaches (Recommendation 10 Ensure behaviour change is maintained for at least a year). National Institute for Health and Care Excellence website. https://www.nice.org.uk/guidance/ph49/chapter/1-recommendations#recommendation-10-ensure-behaviour-change-is-maintained-for-at-least-a-year. Published 2014. Accessed January 11, 2018.Google Scholar
Figure 0

Fig. 1 PRISMA flow diagram outlining the systematic review selection process.

Figure 1

Table 1 Risk of Bias Within Systematic Reviews

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