Silva et al. Implementation Sci (2021) 16:92
https://doi.org/10.1186/s13012-021-01164-6
SYSTEMATIC REVIEW Open Access
Dissemination interventions to improve
healthcare workers’ adherence with infection
prevention and control guidelines: a systematic
review and meta-analysis
Marcus Tolentino Silva1, Tais Freire Galvao2, Evelina Chapman3, Everton Nunes da Silva4 and
Jorge Otávio Maia Barreto3*
Abstract
Background: The COVID-19 pandemic has challenged health systems worldwide since 2020. At the frontline of
the pandemic, healthcare workers are at high risk of exposure. Compliance with infection prevention and control
(IPC) should be encouraged at the frontline. This systematic review aimed to assess the effects of dissemination
interventions to improve healthcare workers’ adherence with IPC guidelines for respiratory infectious diseases in the
workplace.
Methods: We searched CENTRAL, MEDLINE, Embase, and the Cochrane COVID-19 Study Register. We included rand-
omized controlled trials (RCTs) and cluster RCTs that assessed the effect of any dissemination strategy in any health-
care settings. Certainty of evidence was assessed using the GRADE approach. We synthesized data using random-
effects model meta-analysis in Stata 14.2.
Results: We identified 14 RCTs conducted from 2004 to 2020 with over 65,370 healthcare workers. Adherence to IPC
guidelines was assessed by influenza vaccination uptake, hand hygiene compliance, and knowledge on IPC. The most
assessed intervention was educational material in combined strategies (plus educational meetings, local opinion
leaders, audit and feedback, reminders, tailored interventions, monitoring the performance of the delivery of health
care, educational games, and/or patient-mediated interventions). Combined dissemination strategies compared to
usual routine improve vaccination uptake (risk ratio [RR] 1.59, 95% confidence interval [CI] 1.54 to 1.81, moderate-cer-
tainty evidence), and may improve hand hygiene compliance (RR 1.70; 95% CI 1.03 to 2.83, moderate-certainty). When
compared to single strategies, combined dissemination strategies probably had no effect on vaccination uptake (RR
1.01, 95% CI 0.95 to 1.07, low-certainty), and hand hygiene compliance (RR 1.16, 95% CI 0.99 to 1.36, low-certainty).
Knowledge of healthcare workers on IPC improved when combined dissemination strategies were compared with
usual activities, and the effect was uncertain in comparison to single strategy (very low-certainty evidence).
Conclusions: Combined dissemination strategies increased workers’ vaccination uptake, hand hygiene compliance,
and knowledge on IPC in comparison to usual activities. The effect was negligible when compared to single dissemi-
nation strategies. The adoption of dissemination strategies in a planned and targeted way for healthcare workers may
increase adherence to IPC guidelines and thus prevent dissemination of infectious disease in the workplace.
*Correspondence:
3
Oswaldo Cruz Foundation, Brasília, Brazil
Full list of author information is available at the end of the article
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
,Silva et al. Implementation Sci (2021) 16:92 Page 2 of 15
Trial registration: Protocol available at http://osf.io/aqxnp.
Keywords: Infection prevention and control, Acute respiratory tract infections, Clinical practice guideline, Guideline
adherence, Implementation strategies, Implementation outcomes, Health personnel
Contributions to the literature accounting for 30% of total hospitalizations related to
COVID-19 in Wuhan during January 2020 [13]. By the
• Research has addressed implementation strategies in end of the first quarter of 2020, COVID-19 infections
healthcare services, but there remains a lack of reliable were estimated to be between 10 and 20% among health-
evidence on specific implementation strategies to sup- care workers in Italy [12].
port the implementation of IPC guidelines in different Since the healthcare setting seems to play an important
contexts. role in the spread of the disease [14], achieving high com-
• These findings contribute to the recognition of the best pliance with IPC measures requires changes in behavior
available evidence and research gaps on the effects of and changes in the workplace. There are still gaps in the
dissemination interventions to improve healthcare pro- processes of translating the best evidence into practice.
fessionals’ adherence to the IPC guidelines for infec- In this context, it is important to know which implemen-
tious respiratory diseases in the workplace. tation strategies based on dissemination interventions
• Interventions to improve adherence to IPC guidelines are the most effective to improve healthcare workers’
are relevant to global, national, and local contexts and adherence to IPC recommendations [15–17].
can help to reduce implementation gaps in the pan- Health-related information dissemination is primar-
demic setting, as well as to prepare for future health ily focused on communicating research results, targeting
emergencies. and tailoring the findings and messages to an appropriate
audience (‘help to make it happen’) [18, 19]. Dissemina-
tion also involves an active and personalized process, a
necessary step for knowledge adoption and implementa-
Background tion in the field of public health or clinical practice [20].
Severe acute respiratory syndrome coronavirus 2 (SARS- Implementation strategies designed for healthcare
CoV-2), which causes coronavirus disease 2019 (COVID- workers include a number of different interventions.
19), continues to spread globally since the declaration Such interventions involve various components to be
of the COVID-19 pandemic in 2020 [1–6]. Knowledge delivered through a variety of modalities and in differ-
about transmission, signs and symptoms, and prognos- ent contexts. Due to the vast set of interventions aiming
tic factors has evolved rapidly and improved decision- to disseminate guidelines or recommendations in health
making for this global threat [6]. Governments have services, the Cochrane Effective Practice and Organiza-
implemented different non-pharmacological strategies tion of Care (EPOC) taxonomy [21] is a practical way to
to control person-to-person transmission, such as use of identify implementation strategies targeted at workers
masks, quarantine, and social distancing, which has led and designed to improve adherence to IPC guidelines.
to control of the spread [3, 7]. A combination of these Implementation strategies are targeted at healthcare
strategies seems to be key for their success, which con- organizations and mainly include audit and feedback,
tinues to be dynamic with emerging variants, changes patient or provider education, reminders, mentoring, etc.
in policies, and disease waves—within and across coun- [21].
tries—, which increases the disease burden [8]. At the Implementation strategies related to dissemination
same time, an unprecedented global effort has also ena- must be fostered in health services to support behav-
bled the development of high-efficacy vaccines [9]. ior changes of healthcare professionals in the workplace
At the frontline of the pandemic, healthcare work- aiming at increasing adherence to guidelines for IPC [17].
ers are considered at high risk of exposure [10]. Several These strategies can improve the delivery, practice, and
factors increase this risk, such as prolonged exposure organization of healthcare services in different scenarios
to large numbers of infected and asymptomatic peo- [22, 23].
ple, inadequate personal protection due to shortage of Behavior change of healthcare providers may require
personal protective equipment or respirator reuse and complex approaches and several factors could influence
extended use policies, and insufficient training for infec- adherence to IPC guidelines when managing respira-
tion prevention and control (IPC) [11]. In China, 4% tory diseases, for instance, factors related to the message
of COVID-19 cases were in healthcare workers [12], itself and the way of disseminating it, factors related to
, Silva et al. Implementation Sci (2021) 16:92 Page 3 of 15
organizational culture, and other contextual factors [17, judgements). We judged the risk of bias as “low,” “high,”
23, 24]. These and other factors should be considered or “unclear” and provided support for judgement of the
when deciding to implement different dissemination following items: sequence generation, allocation conceal-
strategies in healthcare settings [25, 26]. ment, blinding of participants and personnel, blinding
In this scenario, we reviewed the current literature of outcome assessors, incomplete outcome data, selec-
to assess the effects of dissemination interventions to tive outcome reporting, and other sources of bias. We
improve healthcare workers’ adherence to IPC guidelines adopted “unclear risk” only in cases of lack of informa-
for respiratory infectious diseases in the workplace. tion about the methods.
Data extraction strategy
Methods
All authors extracted data from the studies (MTS, TFG,
This systematic review was conducted following the
EC, ENS, JOMB) using a customized form in Covidence,
Cochrane handbook for methods [27] and the reporting
which were cross-checked by a second author (MTS,
adhered to the Preferred Reporting Items for Systematic
TFG).
Reviews and Meta-Analysis (PRISMA) 2020 statement
We collected characteristics of the studies (author, year
[28]. A previous protocol was developed and published
of research, country, setting, study design, inclusion and
in the Open Science Framework repository (http://osf.io/
exclusion criteria, sponsorship source, conflicts of inter-
aqxnp).
est), characteristics of the study participants, description
of the interventions, and results.
Searches
We searched Cochrane Central Register of Controlled Data synthesis and presentation
Trials (CENTRAL; 2020, Issue 9) in the Cochrane Library We sought data for adherence to IPC guidelines in each
(searched on 23 September 2020); MEDLINE (via Ovid; intervention group assessed in the studies according
1946 to 23 September 2020); Embase (via Ovid; 1974 to to the nature of the data. We grouped the outcomes of
23 September 2020); and Cochrane COVID-19 Study similar enough studies according to the intervention and
Register (February 2020 to 23 September 2020; http:// longest available follow-up. For vaccine uptake, we col-
covid-19.cochrane.org). We screened the references of lected the number of healthcare workers vaccinated and
related Cochrane systematic reviews and the list of refer- the total number of personnel assessed in each group.
ences of the included studies. Hand hygiene compliance data relied on the number of
An information specialist conducted our search of the hand hygiene actions by all hand hygiene opportunities
literature, which was revised by a content expert. Com- (before patient contact, before aseptic task, after body
plete information on the search strategies is available fluid exposure, after patient contact, after contact with
in the protocol. We limited the searches to randomized patient surroundings). Knowledge about IPC data was
controlled trials (RCTs) and no other limits were applied. based on the number of individuals assessed and meas-
Search outputs were imported into Covidence platform ured for knowledge in each group (mean and standard
(www.covidence.org) to remove duplicates and perform deviation of the test score or score improvement and
further review steps. interquartile range).
We calculated the mean differences (MD) for knowl-
edge on IPC and risk ratios (RR) of vaccination uptake
Selection process and hand hygiene compliance outcomes along with 95%
The team of review authors (MTS, TFG, EC, ENS, JOMB) confidence intervals (CI). Outcome effect of each inter-
in pairs and independently screened titles and abstracts vention was assessed in comparison to usual activities or
at Covidence platform. After screening the first 100 stud- other strategies. As studies’ interventions relied on mul-
ies, the team met to assess disagreements and adjust the tiple dissemination interventions, effects were presented
selection process. We resolved disagreements by con- separately into “combined strategies vs. usual activi-
sensus. The same process was applied to select studies in ties” and “combined strategies vs. single strategies.” We
full text that were considered eligible based on title and adopted random-effects meta-analysis for all outcomes
abstract screening. [27], considering the outcomes as related but slightly
divergent intervention effects. For the cluster RCTs
Study quality assessment included, we calculated the design effect using the intra-
We used the Cochrane risk-of-bias tool for RCT ver- cluster correlation coefficient, the number of clusters and
sion 1 [29], integrated with Covidence [30], to assess the average sample size of each cluster. We calculated the
the included studies (dual; second reviewer checks all
https://doi.org/10.1186/s13012-021-01164-6
SYSTEMATIC REVIEW Open Access
Dissemination interventions to improve
healthcare workers’ adherence with infection
prevention and control guidelines: a systematic
review and meta-analysis
Marcus Tolentino Silva1, Tais Freire Galvao2, Evelina Chapman3, Everton Nunes da Silva4 and
Jorge Otávio Maia Barreto3*
Abstract
Background: The COVID-19 pandemic has challenged health systems worldwide since 2020. At the frontline of
the pandemic, healthcare workers are at high risk of exposure. Compliance with infection prevention and control
(IPC) should be encouraged at the frontline. This systematic review aimed to assess the effects of dissemination
interventions to improve healthcare workers’ adherence with IPC guidelines for respiratory infectious diseases in the
workplace.
Methods: We searched CENTRAL, MEDLINE, Embase, and the Cochrane COVID-19 Study Register. We included rand-
omized controlled trials (RCTs) and cluster RCTs that assessed the effect of any dissemination strategy in any health-
care settings. Certainty of evidence was assessed using the GRADE approach. We synthesized data using random-
effects model meta-analysis in Stata 14.2.
Results: We identified 14 RCTs conducted from 2004 to 2020 with over 65,370 healthcare workers. Adherence to IPC
guidelines was assessed by influenza vaccination uptake, hand hygiene compliance, and knowledge on IPC. The most
assessed intervention was educational material in combined strategies (plus educational meetings, local opinion
leaders, audit and feedback, reminders, tailored interventions, monitoring the performance of the delivery of health
care, educational games, and/or patient-mediated interventions). Combined dissemination strategies compared to
usual routine improve vaccination uptake (risk ratio [RR] 1.59, 95% confidence interval [CI] 1.54 to 1.81, moderate-cer-
tainty evidence), and may improve hand hygiene compliance (RR 1.70; 95% CI 1.03 to 2.83, moderate-certainty). When
compared to single strategies, combined dissemination strategies probably had no effect on vaccination uptake (RR
1.01, 95% CI 0.95 to 1.07, low-certainty), and hand hygiene compliance (RR 1.16, 95% CI 0.99 to 1.36, low-certainty).
Knowledge of healthcare workers on IPC improved when combined dissemination strategies were compared with
usual activities, and the effect was uncertain in comparison to single strategy (very low-certainty evidence).
Conclusions: Combined dissemination strategies increased workers’ vaccination uptake, hand hygiene compliance,
and knowledge on IPC in comparison to usual activities. The effect was negligible when compared to single dissemi-
nation strategies. The adoption of dissemination strategies in a planned and targeted way for healthcare workers may
increase adherence to IPC guidelines and thus prevent dissemination of infectious disease in the workplace.
*Correspondence:
3
Oswaldo Cruz Foundation, Brasília, Brazil
Full list of author information is available at the end of the article
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
,Silva et al. Implementation Sci (2021) 16:92 Page 2 of 15
Trial registration: Protocol available at http://osf.io/aqxnp.
Keywords: Infection prevention and control, Acute respiratory tract infections, Clinical practice guideline, Guideline
adherence, Implementation strategies, Implementation outcomes, Health personnel
Contributions to the literature accounting for 30% of total hospitalizations related to
COVID-19 in Wuhan during January 2020 [13]. By the
• Research has addressed implementation strategies in end of the first quarter of 2020, COVID-19 infections
healthcare services, but there remains a lack of reliable were estimated to be between 10 and 20% among health-
evidence on specific implementation strategies to sup- care workers in Italy [12].
port the implementation of IPC guidelines in different Since the healthcare setting seems to play an important
contexts. role in the spread of the disease [14], achieving high com-
• These findings contribute to the recognition of the best pliance with IPC measures requires changes in behavior
available evidence and research gaps on the effects of and changes in the workplace. There are still gaps in the
dissemination interventions to improve healthcare pro- processes of translating the best evidence into practice.
fessionals’ adherence to the IPC guidelines for infec- In this context, it is important to know which implemen-
tious respiratory diseases in the workplace. tation strategies based on dissemination interventions
• Interventions to improve adherence to IPC guidelines are the most effective to improve healthcare workers’
are relevant to global, national, and local contexts and adherence to IPC recommendations [15–17].
can help to reduce implementation gaps in the pan- Health-related information dissemination is primar-
demic setting, as well as to prepare for future health ily focused on communicating research results, targeting
emergencies. and tailoring the findings and messages to an appropriate
audience (‘help to make it happen’) [18, 19]. Dissemina-
tion also involves an active and personalized process, a
necessary step for knowledge adoption and implementa-
Background tion in the field of public health or clinical practice [20].
Severe acute respiratory syndrome coronavirus 2 (SARS- Implementation strategies designed for healthcare
CoV-2), which causes coronavirus disease 2019 (COVID- workers include a number of different interventions.
19), continues to spread globally since the declaration Such interventions involve various components to be
of the COVID-19 pandemic in 2020 [1–6]. Knowledge delivered through a variety of modalities and in differ-
about transmission, signs and symptoms, and prognos- ent contexts. Due to the vast set of interventions aiming
tic factors has evolved rapidly and improved decision- to disseminate guidelines or recommendations in health
making for this global threat [6]. Governments have services, the Cochrane Effective Practice and Organiza-
implemented different non-pharmacological strategies tion of Care (EPOC) taxonomy [21] is a practical way to
to control person-to-person transmission, such as use of identify implementation strategies targeted at workers
masks, quarantine, and social distancing, which has led and designed to improve adherence to IPC guidelines.
to control of the spread [3, 7]. A combination of these Implementation strategies are targeted at healthcare
strategies seems to be key for their success, which con- organizations and mainly include audit and feedback,
tinues to be dynamic with emerging variants, changes patient or provider education, reminders, mentoring, etc.
in policies, and disease waves—within and across coun- [21].
tries—, which increases the disease burden [8]. At the Implementation strategies related to dissemination
same time, an unprecedented global effort has also ena- must be fostered in health services to support behav-
bled the development of high-efficacy vaccines [9]. ior changes of healthcare professionals in the workplace
At the frontline of the pandemic, healthcare work- aiming at increasing adherence to guidelines for IPC [17].
ers are considered at high risk of exposure [10]. Several These strategies can improve the delivery, practice, and
factors increase this risk, such as prolonged exposure organization of healthcare services in different scenarios
to large numbers of infected and asymptomatic peo- [22, 23].
ple, inadequate personal protection due to shortage of Behavior change of healthcare providers may require
personal protective equipment or respirator reuse and complex approaches and several factors could influence
extended use policies, and insufficient training for infec- adherence to IPC guidelines when managing respira-
tion prevention and control (IPC) [11]. In China, 4% tory diseases, for instance, factors related to the message
of COVID-19 cases were in healthcare workers [12], itself and the way of disseminating it, factors related to
, Silva et al. Implementation Sci (2021) 16:92 Page 3 of 15
organizational culture, and other contextual factors [17, judgements). We judged the risk of bias as “low,” “high,”
23, 24]. These and other factors should be considered or “unclear” and provided support for judgement of the
when deciding to implement different dissemination following items: sequence generation, allocation conceal-
strategies in healthcare settings [25, 26]. ment, blinding of participants and personnel, blinding
In this scenario, we reviewed the current literature of outcome assessors, incomplete outcome data, selec-
to assess the effects of dissemination interventions to tive outcome reporting, and other sources of bias. We
improve healthcare workers’ adherence to IPC guidelines adopted “unclear risk” only in cases of lack of informa-
for respiratory infectious diseases in the workplace. tion about the methods.
Data extraction strategy
Methods
All authors extracted data from the studies (MTS, TFG,
This systematic review was conducted following the
EC, ENS, JOMB) using a customized form in Covidence,
Cochrane handbook for methods [27] and the reporting
which were cross-checked by a second author (MTS,
adhered to the Preferred Reporting Items for Systematic
TFG).
Reviews and Meta-Analysis (PRISMA) 2020 statement
We collected characteristics of the studies (author, year
[28]. A previous protocol was developed and published
of research, country, setting, study design, inclusion and
in the Open Science Framework repository (http://osf.io/
exclusion criteria, sponsorship source, conflicts of inter-
aqxnp).
est), characteristics of the study participants, description
of the interventions, and results.
Searches
We searched Cochrane Central Register of Controlled Data synthesis and presentation
Trials (CENTRAL; 2020, Issue 9) in the Cochrane Library We sought data for adherence to IPC guidelines in each
(searched on 23 September 2020); MEDLINE (via Ovid; intervention group assessed in the studies according
1946 to 23 September 2020); Embase (via Ovid; 1974 to to the nature of the data. We grouped the outcomes of
23 September 2020); and Cochrane COVID-19 Study similar enough studies according to the intervention and
Register (February 2020 to 23 September 2020; http:// longest available follow-up. For vaccine uptake, we col-
covid-19.cochrane.org). We screened the references of lected the number of healthcare workers vaccinated and
related Cochrane systematic reviews and the list of refer- the total number of personnel assessed in each group.
ences of the included studies. Hand hygiene compliance data relied on the number of
An information specialist conducted our search of the hand hygiene actions by all hand hygiene opportunities
literature, which was revised by a content expert. Com- (before patient contact, before aseptic task, after body
plete information on the search strategies is available fluid exposure, after patient contact, after contact with
in the protocol. We limited the searches to randomized patient surroundings). Knowledge about IPC data was
controlled trials (RCTs) and no other limits were applied. based on the number of individuals assessed and meas-
Search outputs were imported into Covidence platform ured for knowledge in each group (mean and standard
(www.covidence.org) to remove duplicates and perform deviation of the test score or score improvement and
further review steps. interquartile range).
We calculated the mean differences (MD) for knowl-
edge on IPC and risk ratios (RR) of vaccination uptake
Selection process and hand hygiene compliance outcomes along with 95%
The team of review authors (MTS, TFG, EC, ENS, JOMB) confidence intervals (CI). Outcome effect of each inter-
in pairs and independently screened titles and abstracts vention was assessed in comparison to usual activities or
at Covidence platform. After screening the first 100 stud- other strategies. As studies’ interventions relied on mul-
ies, the team met to assess disagreements and adjust the tiple dissemination interventions, effects were presented
selection process. We resolved disagreements by con- separately into “combined strategies vs. usual activi-
sensus. The same process was applied to select studies in ties” and “combined strategies vs. single strategies.” We
full text that were considered eligible based on title and adopted random-effects meta-analysis for all outcomes
abstract screening. [27], considering the outcomes as related but slightly
divergent intervention effects. For the cluster RCTs
Study quality assessment included, we calculated the design effect using the intra-
We used the Cochrane risk-of-bias tool for RCT ver- cluster correlation coefficient, the number of clusters and
sion 1 [29], integrated with Covidence [30], to assess the average sample size of each cluster. We calculated the
the included studies (dual; second reviewer checks all
