Disease infections among population in both community and healthcare settings have been the core business of healthcare providers for centuries. For the past few decades, an increased focus on the prevention and control of healthcare-associated infections (HAIs) has taken place. HAI is an infection acquired by a patient while receiving care in healthcare facility either hospital, outpatient clinic or others. Occupational infections acquired by the healthcare worker (HCWs) at workplace are also classified as HAIs (World Health Organization (WHO), 2011).
The overall prevalence of HAIs was reported to be higher in developing countries as compared to developed countries (Allegranzi et al., 2011). In the developed countries the prevalence varies between 5.1% and 11.6% while the prevalence rates vary from 5% to 19% in the developing countries (WHO, 2011). The most common HAIs among patients are respiratory infections such as pneumonia and lower respiratory tract infections (LRTI) (22.8%), urinary tract infections (UTI) (17.2%) and surgical site infections (SSI) (15.7%) (Health Protection Agency, 2012).
Occupational infections among HCWs are also similarly healthcare-related. For example, there are high risk of blood-borne infections such as Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) as a result of percutaneous exposure of contaminated sharps and also airborne infections can occur among HCWs (Occupational Safety & Health Administration U.S. Department of Labor, 2017). The most common occupational infection was chicken pox (66.7%), followed by measles (29.2%) and pulmonary tuberculosis (4.2%) (Assiri, Hathout, Anwar, Dalatony, & Kader, 2013).
HAIs and occupational infections have resulted in prolonged hospital stays and disability of patients, excess mortality, increased antimicrobial resistance, increased financial burden of the health organization as well as psychosocial and economic impacts on the patients and their family. When it affects the HCWs, it will give a bad impact to the quality and productivity of the healthcare services provided (WHO, 2011; Andersson, Bergh, Karlsson, & Nilsson, 2010).
In order to control and prevent HAIs, Standard Precautions (SP) practices need to be implemented. It summarises the strategies to be used to prevent transmission of microorganisms in healthcare settings (Centers for Disease Control and Prevention, 2016). SP include the use of hand washing, appropriate use of personal protective equipment, proper cleaning, disinfection and sterilisation of patient-care equipment, proper housekeeping, management of contaminated laundry and disposal of sharps and clinical wastes and cough etiquette to reduce droplet transmission (WHO, 2007; Siegel, Rhinehart, Jackson, & Chiarello, 2007).
In spite of widespread adoption of SP by organisations, there are gaps in their implementation as they require accountability and behavioural change from the HCWs in order to be implemented (Clock, Cohen, Behta, Ross, & Larson, 2010). Many interventions have been used to promote the practice of Standard Precautions as the basic requirement for infection prevention and control (IPC). The objective of this review is to assess the effectiveness of interventions that can be used to improve knowledge and practice of SP among HCWs.
From the review, five types of intervention have been identified. Of 14 reviewed studies, 11 implemented educational and training intervention (Adly et al., 2014; Atalla et al., 2016; Baldwin et al., 2010; Chauhan & Kumari, 2016; Edet et al., 2010; Mahrous, 2016; Mukthar et al., 2017; Nmadu et al., 2016; Rajini & Kalyani, 2016; Rose, 2015; Zeigheimat et al., 2016). They are either education intervention alone or with additional infection control support strategies or with theory-based intervention module. Other intervention strategies were self-instructed computer module with clinical case simulation and another study use a checklist and coloured cues as intervention (Kappes Ramirez, 2018; Ong et al., 2013). There is also a study evaluating the effect of California Healthcare-Associated Infection Prevention Initiative (CHAIPI) which provides intervention in the form of comprehensive technology services model that can identify and track infection outbreaks earlier, track antibiotic resistance, and mine data related to HAIs (Halpin et al., 2013).
However, in term of outcome measures, different studies used different measures to assess the knowledge and practice of Standard Precautions among HCWs. Two studies measured the knowledge, attitude/perception and practice score of SP (Atalla et al., 2016; Zeigheimat et al., 2016). Whereas, four studies measured the knowledge and practice score of SP (Adly et al., 2014; Mahrous, 2016; Mukthar et al., 2017; Nmadu et al., 2016). Another five studies assessed only the knowledge related to infection control in reducing HAIs (Chauhan & Kumari, 2016; Edet et al., 2010; Kappes Ramirez, 2018; Rajini & Kalyani, 2016; Rose, 2015). Meanwhile three studies measured the score of practice of SP alone (Baldwin et al., 2010; Halpin et al., 2013; Ong et al., 2013).
There are several limitations in this review. We found that majority (10 out of 14) of articles included have a serious risk of bias especially at the research design stage. Most of the studies adapted the quasi-experimental study design which has lack of randomisation in participants’ allocation to intervention or control group. Apart from that, there is heterogeneity in the outcome measurements across the studies which are difficult to compare and evaluate the best intervention among all studies.
Overall, observed knowledge and practice of Standard Precautions from variety of interventions increased with significant improvement even though most studies reported considerable variation in the baseline knowledge and practice, extent of differences both between and within subjects, as well as slight differences in practices assessed. Among interventions identified from this review are educational interventions with or without infection control support, theory-based intervention module, communication enhancement with checklist and coloured cues, self-instructed computer module and clinical simulation and California Health Associated Infection Prevention Initiative (CHAIPI).
4.1 Education Intervention with or without Infection Control Support
Education intervention alone without infection control support improves the knowledge of Standard Precautions mainly, the attitude, practice and compliance to SP (Adly et al., 2014; Atalla et al., 2016; Mahrous, 2016; Mukthar et al., 2017; Nmadu et al., 2016; Zeigheimat et al., 2016). Education with additional strategy such as designated infection control nurse can also significantly improve compliance to Standard Precautions to a greater extends. Education with additional infection control support probably leads to little or no difference in MRSA prevalence (Baldwin et al., 2010). This may be due to more effort contributed by the infection control link nurse in reminding, observing and auditing the SP practice among the colleague. However, no change in the multidrugs resistant Staphylococcus Aureus (MRSA) prevalence in the study might be due to short study duration that cannot capture significant reduction in number of MRSA colonisations.
4.2 Theory-based Intervention Module
There are several studies showed improvement of compliance and practice of SP among HCWs after their enrolment in theory-based intervention module. Intervention module integrated with constructs of Health Belief Model (HBM) and Social Cognitive theories (SCT) are widely used in health studies in an attempt to predict or explain health behaviours. For example, HBM focused on one’s belief and perceptions such as the susceptibility and severity of acquiring infection due to failure in practicing recommended preventive measures such as SP, perceived benefits of practicing the SP and the perceptions on the obstacles in practicing SP (barriers) and the self-efficacy or one’s ability to successfully perform the recommended health behaviours. On the other hand, the SCT emphasized that human beings learn by observing others (vicarious learning), within the context of social interactions in the environment. The learned behaviours are central to one’s personality. Studies have proved that theory-based intervention module is important for a greater impact and desirable outcomes pertaining to compliance to SP practice (Zeigheimat et al., 2016; Mukthar et al., 2017).
4.3 Communication Enhancement with Checklist and Coloured Cues
Communication enhancement through checklists of radiology porters and coloured cues in the patient transfer form is used to alert the receiving staff on infectious status of the transferred patient. Both interventions improved compliance to Standard Precautions such as hand hygiene, glove and gown use, and overall adherence with infection control recommendations. However, this randomised crossover trial did not report the effect of both interventions on SP knowledge and MRSA prevalence (Ong et al., 2013). Overall, both interventions led to increase compliance to SP.
4.4 Self-instructed Computer Module and Clinical Stimulation
Interactive computer modules allow the use of all available technology to be incorporated as teaching tool. In this study, as a learning method, students were given access to a self-instructional computer module related to SP without guide from a teacher as well as self-assessment questions (Kappes Ramirez, 2018). At the end of the learning session, a clinical simulation was carried out for a clinical case in a nursing laboratory using dummy patients in a simulated clinical environment to identify relevant infection control measure pertaining to the specific cases. It was found that the student showed the best performance in the multiple-choice post-test and essay questions regarding SP knowledge as well as in the evaluation of a simulated scenario as compared to the control group. This study demonstrates that it is possible to transfer some teaching subjects on the prevention of HAIs to self-learning by means of virtual teaching strategies with good results. However, this intervention study has its limitation that it did not measure the practice or compliance to SP.
4.5 California Healthcare-Associated Infection Prevention Initiative (CHAIPI)
CHAIPI is an initiative funded by a private sector, the Blue Shield of California Foundation which funded USD$3.5 million to support the participation of 50 California hospitals in the CHAIPI. It offered participating hospitals to use automated surveillance technology (AST) as part of its grant. Participating hospital received education and training on HAI prevention best practices and guidelines, discussion as well as monthly measurement and reporting of results. Each participating hospital also conducted at least one HAI reduction project as a component of the collaborative (Blue Shield of California Foundation, 2009). This intervention in the form of combination of financial and technical support are able to demonstrate greater improvements in adoption and implementation of written evidence-based practices (EBP) for overall patient safety and prevention of HAIs and also in increasing HCWs compliance with SP practices. However, in term of HAIs rate, there were no significant differences in the changes between CHAIPI and non-CHAIPI hospitals over the time period from 2008 to 2010 (Halpin et al., 2013).
5.0 Conclusion and recommendation
As a conclusion, it is difficult to determine the most effective intervention or recommendation to improve knowledge and practice of SP due to limited studies being evaluated in a similar way as well as insufficient evidence on which to derive a conclusion. Although numerous interventions has been done to promote hand hygiene (Gould, Moralejo, Drey, & Chudleigh, 2010), as well as interventions tackling specific types of infections such as tuberculosis infection control, limited research has been conducted to measure the effectiveness of intervention related to SP as a whole, a bundle of infection control elements. However, the evidence presented in this review is applicable to practice worldwide.
In this review, it was found that education alone can improve knowledge on SP as well as self-instructed computer module and clinical simulation whereas education with additional infection control support may slightly improve practice and compliance. On the other hand, education with the use of cues and checklists, and financial and technical support such as CHAIPI can probably improve compliance to SP. Theory-based intervention modules are also important especially in promoting human behavioural change towards better compliance to SP practice.
It is recommended that further research to be carried out to determine which interventions are most effective. There is a need to minimise potential bias at the study design stage and throughout a research in order to produce a high quality findings and evidence. Standardized outcome measurement must also be established in order to compare and evaluate interventions promoting SP practice among HCWs in the future.