The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review.

BACKGROUND: Novel coronaviruses and influenza can cause infection, epidemics, and pandemics. Improving hand hygiene (HH) of the general public is recommended for preventing these infections. This systematic review examined the effectiveness of HH interventions for preventing transmission or acquisition of such infections in the community. METHODS: PubMed, MEDLINE, CINAHL and Web of Science databases were searched (January 2002-February 2022) for empirical studies related to HH in the general public and to the acquisition or transmission of novel coronavirus infections or influenza. Studies on healthcare staff, and with outcomes of compliance or absenteeism were excluded. Study selection, data extraction and quality assessment, using the Cochrane Effective Practice and Organization of Care risk of bias criteria or Joanna Briggs Institute Critical Appraisal checklists, were conducted by one reviewer, and double-checked by another. For intervention studies, effect estimates were calculated while the remaining studies were synthesised narratively. The protocol was pre-registered (PROSPERO 2020: CRD42020196525). RESULTS: Twenty-two studies were included. Six were intervention studies evaluating the effectiveness of HH education and provision of products, or hand washing against influenza. Only two school-based interventions showed a significant protective effect (OR: 0.64; 95% CI 0.51, 0.80 and OR: 0.40; 95% CI 0.22, 0.71), with risk of bias being high (n = 1) and unclear (n = 1). Of the 16 non-intervention studies, 13 reported the protective effect of HH against influenza, SARS or COVID-19 (P < 0.05), but risk of bias was high (n = 7), unclear (n = 5) or low (n = 1). However, evidence in relation to when, and how frequently HH should be performed was inconsistent. CONCLUSIONS: To our knowledge, this is the first systematic review of effectiveness of HH for prevention of community transmission or acquisition of respiratory viruses that have caused epidemics or pandemics, including SARS-CoV-1, SARS-CoV-2 and influenza viruses. The evidence supporting the protective effect of HH was heterogeneous and limited by methodological quality; thus, insufficient to recommend changes to current HH guidelines. Future work is required to identify in what circumstances, how frequently and what product should be used when performing HH in the community and to develop effective interventions for promoting these specific behaviours in communities during epidemics.

Effectiveness of interventions to improve the public's antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review.

Background: A global antimicrobial resistance (AMR) awareness intervention targeting the general public has been prioritized. Objectives: To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public. Methods: Five databases were searched between 2000 and 2016 for interventions to change the public's AMR awareness and/or antimicrobial stewardship behaviours. Study designs meeting the Cochrane Effective Practice and Organization of Care (EPOC) criteria, non-controlled before-and-after studies and prospective cohort studies were considered eligible. Participants recruited from healthcare settings and studies measuring stewardship behaviours of healthcare professionals were excluded. Quality of studies was assessed using EPOC risk of bias criteria. Data were extracted and synthesized narratively. Registration: PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016050343). Results: Twenty studies were included in the review with nine meeting the EPOC criteria. The overall risk of bias was high. Nineteen studies were conducted in high-income countries. Mass media interventions were most common (n = 7), followed by school-based (n = 6) and printed material interventions (n = 6). Seventeen studies demonstrated a significant effect on changing knowledge, attitudes or the public's antimicrobial stewardship behaviours. Analysis showed that interventions targeting schoolchildren and parents have notable potential, but for the general public the picture is less clear. Conclusions: Our work provides an in-depth examination of the effectiveness of AMR interventions for the public. However, the studies were heterogeneous and the quality of evidence was poor. Well-designed, experimental studies on behavioural outcomes of such interventions are required.

Building capacity for point of care alcohol-based handrub (ABHR) and hand hygiene compliance among health care workers in the rural maternity and surgical units of a hospital in Cameroon.

BACKGROUND: Hand hygiene (HH) is challenging in health care, but particularly in resource-limited settings due to a lack of training, resources, and infrastructure. This study aimed to evaluate the implementation of wall-mounted alcohol-based handrub (ABHR) at the point of care (POC) on HH compliance among health care workers in a Cameroon hospital. METHODS: It was a three-stage before and after study. The first stage involved baseline collection of ABHR utilization and HH compliance data. The second stage included the implementation of ABHR at the POC, supported by an implementation strategy involving HH training, monitoring and feedback, and HH champions. The third stage involved postimplementation data collection on ABHR use and HH compliance. RESULTS: 5,214 HH opportunities were evaluated. HH compliance significantly increased from 33.3% (baseline) to 83.1% (implementation stage) (P < .001) and to 87.2% (postimplementation stage) (P < .001). Weekly ABHR usage increased significantly during implementation (5,670 ml), compared to baseline, (1242.5 ml, P = .001), and remained high in postimplementation (7,740 ml). CONCLUSIONS: Continuous availability of ABHR at POC, supported by implementation strategy, significantly increased HH compliance and ABHR use. Learning from this study could be used to implement ABHR at POC in other facilities.

Interventions for preventing or controlling health care-associated infection among health care workers or patients within primary care facilities: A scoping review.

BACKGROUND: This review aimed to synthesize the evidence on infection prevention and control interventions for the prevention of health care-associated infection among health care workers or patients within primary care facilities. METHODS: PubMed, CINAHL, EMBASE, and CENTRAL databases were searched for quantitative studies published between 2011 and 2022. Study selection, data extraction, and quality assessment using Cochrane and Joanna Briggs tools, were conducted by independent review with additional sensitivity checking performed on study selection. RESULTS: Four studies were included. A randomized trial and a cross-sectional survey, respectively, found no statistical difference in laboratory-confirmed influenza in health care workers wearing N95 versus medical masks (P = .18) and a significant inverse association between the implementation of tuberculosis control measures and tuberculosis incidence (P = .02). For the prevention of surgical site infections following minor surgery, randomized trials found nonsterile gloves (8.7%; 95% confidence interval, 4.9%-12.6%) to be noninferior to sterile gloves (9.3%; 95% confidence interval, 7.4%-11.1%) and no significant difference between prophylactic antibiotics compared to placebo (P = .064). All studies had a high risk of bias. CONCLUSIONS: Evidence for infection prevention and control interventions for the prevention of health care-associated infection in primary care is very limited and insufficient to make practice recommendations. Nevertheless, the findings highlight the need for future research.

Effectiveness of national and subnational interventions for prevention and control of health-care-associated infections in acute hospitals in high-income and upper-middle-income counties: a systematic review update.

This systematic review, commissioned and funded by WHO, aimed to update a review of infection prevention and control (IPC) interventions at a national level to inform a review of their IPC Core Components guidelines (PROSPERO CRD42021297376). CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS were searched for studies meeting Cochrane's Effective Practice and Organisation of Care (EPOC) design criteria, published from April 19, 2017, to Oct 14, 2021. Primary research studies examining national IPC interventions in acute hospitals in any country with outcomes related to rates of health-care-associated infections were included. Two independent reviewers extracted data and assessed quality using the EPOC risk of bias criteria. 36 studies were categorised per intervention type and synthesised narratively: care bundles (n=2), care bundles with implementation strategies (n=9), IPC programmes (n=16), and regulations (n=9). Designs included 21 interrupted time-series, nine controlled before-and-after studies, four cluster-randomised trials, and two non-randomised trials. Evidence supports the effectiveness of care bundles with implementation strategies. However, evidence for IPC programmes and regulations was inconclusive as studies were heterogeneous regarding populations, interventions, and outcomes. The overall risk of bias was high. Recommendations include the involvement of implementation strategies in care bundles and for further research on national IPC interventions with robust study designs and in low-income and middle-income settings.

Systematic review on factors influencing the effectiveness of alcohol-based hand rubbing in healthcare.

BACKGROUND: The effectiveness of hand rubbing with alcohol-based handrub (ABHR) is impacted by several factors. To investigate these, World Health Organization (WHO) commissioned a systematic review. AIM: To evaluate the impact of ABHR volume, application time, rubbing friction and hand size on microbiological load reduction, hand surface coverage or drying time. METHODS: Medline, CINAHL, Web of Science and ScienceDirect databases were searched for healthcare or laboratory-based primary studies, published in English, (1980- February 2021), investigating the impact of ABHR volume, application time, rubbing friction or hand size on bacterial load reduction, hand coverage or drying time. Two reviewers independently performed data extraction and quality assessment. The results are presented narratively. FINDINGS: Twenty studies were included in the review. Categories included: ABHR volume, application time and rubbing friction. Sub-categories: bacterial load reduction, hand size, drying time or hand surface coverage. All used experimental or quasi-experimental designs. Findings showed as ABHR volume increased, bacterial load reduced, and drying times increased. Furthermore, one study showed that the application of sprayed ABHR without hand rubbing resulted in significantly lower bacterial load reduction than poured or sprayed ABHR with hand rubbing (- 0.70; 95%CI: - 1.13 to - 0.28). Evidence was heterogeneous in application time, volume, technique, and product. All studies were assessed as high risk of bias. CONCLUSIONS: There is insufficient evidence to change WHO recommendation of a palmful of ABHR in a cupped hand applied for 20-30 s or manufacturer-recommended volume applied for about 20 s (Centers for Disease Control and Prevention). Future hand hygiene research should standardise volume, application time, and consider hand size.

Comparing the effectiveness of hand hygiene techniques in reducing the microbial load and covering hand surfaces in healthcare workers: Updated systematic review.

BACKGROUND: This review, commissioned by the World Health Organization (WHO), examined the effectiveness of the WHO 6-step hand hygiene (HH) technique in reducing microbial load on hands and covering hand surfaces, and compared its effectiveness to other techniques. METHODS: Medline, CINAHL, ProQuest, Web of Science, Mednar, and Google Scholar were searched for primary studies, published in English (1978-February 2021), evaluating the microbiological effectiveness or hand surface coverage of HH techniques in healthcare workers. Reviewers independently performed quality assessment using Cochrane tools. The protocol for the narrative review was registered (PROSPERO 2021: CRD42021236138). RESULTS: Nine studies were included. Evidence demonstrated that the WHO technique reduced microbial load on hands. One study found the WHO technique more effective than the 3-step technique (P = .02), while another found no difference between these 2 techniques (P = .08). An adapted 3-step technique was more effective than the WHO technique in laboratory settings (P = .021), but not in clinical practice (P = .629). One study demonstrated that an adapted 6-step technique was more effective than the WHO technique (P = .001). Evidence was heterogeneous in application time, product, and volume. All studies were high risk of bias. CONCLUSIONS: Eight studies found that the WHO 6-step technique reduced microbial load on healthcare workers' hands; but the studies were heterogeneous and further research is required to identify the most effective, yet feasible technique.

Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory.

BACKGROUND: Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives. METHODS: This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'. RESULTS: Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners. CONCLUSIONS: This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.

A visual affective analysis of mass media interventions to increase antimicrobial stewardship amongst the public.

OBJECTIVES: In an innovative approach to improve the contribution of health psychology to public health we have analysed the presence and nature of affect within the visual materials deployed in antimicrobial stewardship interventions targeting the public identified through systematic review. DESIGN: A qualitative analysis focused on the affective content of visual materials garnered from a systematic review of antibiotic stewardship (k = 20). METHODS: A novel method was devised drawing on concepts from semiotics to analyse the affective elements within intervention materials. RESULTS: Whilst all studies examined tacitly rely on affect, only one sought to explicitly deploy affect. Three thematic categories of affect are identified within the materials in which specific ideological machinery is deployed: (1) monsters, bugs, and superheroes; (2) responsibility, threat, and the misuse/abuse of antibiotics; (3) the figure of the child. CONCLUSIONS: The study demonstrates how affect is a present but tacit communication strategy of antimicrobial stewardship interventions but has not - to date - been adequately theorized or explicitly considered in the intervention design process. Certain affective features were explored in relation to the effectiveness of antimicrobial resistance interventions and warrant further investigation. We argue that further research is needed to systematically illuminate and capitalize upon the use of affect to effect behaviour change concerning antimicrobial stewardship. Statement of contribution What is already known on this subject? The (mis)use of antibiotics and consequent risk of antimicrobial resistance is a critical public health problem. If sufficient action is not taken, global society will face the 'post-antibiotic' era, in which common infections will lead to death for many millions. Key desirable behavioural changes are decreased patient demands for antibiotics, use of them for targeted purposes alone, and compliance with prescribed dosing. There is a growth of interest in the role of affect in mass media interventions designed to engage publics and produce health-related behavioural change. What does this study add? This article presents a novel analytic approach to understanding and intervening within behaviour change in public health that may complement other types of analysis. We present findings specifically from an 'affective' analysis based on semiotics in which we critically interrogated the visual imagery being deployed in mass media public health interventions concerning antimicrobial stewardship. Three thematic categories of affect are identified within the materials in which specific ideological machinery is deployed and that demonstrate some association with intervention effectiveness worthy of further investigation and testing.

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

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.

Investigating the effect of preparation for and participation in a hand-sanitizing relay on nursing students' ability to recall the WHO 6-step hand hygiene technique.

This study explored whether preparation for a hand-sanitizing relay affected nursing students' ability to recall, 12 months later, the World Health Organization 6-step hand hygiene technique. No significant difference was observed in recall between those who participated in the relay and those who did not (P = .736). The most frequently missed step was Step 3 (palm to palm with fingers interlaced). Our results suggest that regular feedback may be an important additional component in future interventions.

What are the 'active ingredients' of interventions targeting the public's engagement with antimicrobial resistance and how might they work?

OBJECTIVES: Changing public awareness of antimicrobial resistance (AMR) represents a global public health priority. A systematic review of interventions that targeted public AMR awareness and associated behaviour was previously conducted. Here, we focus on identifying the active content of these interventions and explore potential mechanisms of action. METHODS: The project took a novel approach to intervention mapping utilizing the following steps: (1) an exploration of explicit and tacit theory and theoretical constructs within the interventions using the Theoretical Domains Framework (TDFv2), (2) retrospective coding of behaviour change techniques (BCTs) using the BCT Taxonomy v1, and (3) an investigation of coherent links between the TDF domains and BCTs across the interventions. RESULTS: Of 20 studies included, only four reported an explicit theoretical basis to their intervention. However, TDF analysis revealed that nine of the 14 TDF domains were utilized, most commonly 'Knowledge' and 'Environmental context and resources'. The BCT analysis showed that all interventions contained at least one BCT, and 14 of 93 (15%) BCTs were coded, most commonly 'Information about health consequences', 'Credible source', and 'Instruction on how to perform the behaviour'. CONCLUSIONS: We identified nine relevant TDF domains and 14 BCTs used in these interventions. Only 15% of BCTs have been applied in AMR interventions thus providing a clear opportunity for the development of novel interventions in this context. This methodological approach provides a useful way of retrospectively mapping theoretical constructs and BCTs when reviewing studies that provide limited information on theory and intervention content. Statement of contribution What is already known on this subject? Evidence of the effectiveness of interventions that target the public to engage them with AMR is mixed; the public continue to show poor knowledge and misperceptions of AMR. Little is known about the common, active ingredients of AMR interventions targeting the public and information on explicit theoretical content is sparse. Information on the components of AMR public health interventions is urgently needed to enable the design of effective interventions to engage the public with AMR stewardship behaviour. What does this study add? The analysis shows very few studies reported any explicit theoretical basis to the interventions they described. Many interventions share common components, including core mechanisms of action and behaviour change techniques. The analysis suggests components of future interventions to engage the public with AMR.