Effectiveness of educational interventions in knowledge, attitude, and practice for preventing respiratory infections: a systematic review and meta-analysis

Linhares, Francisca Márcia Pereira; Abreu, Wilson Jorge Correia de; Melo, Priscila de Oliveira Cabral; Mendes, Ryanne Carolynne Marques Gomes; Silva, Thaís Araújo da; Gusmão, Tarcila Lima Alcântara de; Guedes, Tatiane Gomes

doi:10.1590/0034-7167-2021-0522

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REVIEW • Rev. Bras. Enferm. 75 (04) • 2022 • https://doi.org/10.1590/0034-7167-2021-0522 copy

Effectiveness of educational interventions in knowledge, attitude, and practice for preventing respiratory infections: a systematic review and meta-analysis

Efectividad de las intervenciones educativas en conocimiento, actitud y práctica para la prevención de infecciones respiratorias: revisión sistemática y metaanálisis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to demonstrate the effectiveness of educational interventions in knowledge, attitude and practice for preventing respiratory infections in adults and older adults.

Methods:

this is a systematic review carried out in 11 databases. Primary studies, without language and time restrictions, of the randomized, non-randomized and before-and-after clinical trial type, were selected. The risk of bias was assessed by two independent researchers, and the methodological quality was generated by the Grading of Recommendations, Assessment, Development and Evaluation.

Results:

the intervention effectiveness was evidenced in seven studies. The results of the random effects meta-analysis show that there is a statistically significant difference between knowledge about preventing respiratory diseases, with an OR of 2.82 (95%CI 1.70 to 4.69) for the occurrence of events represented by improved knowledge.

Conclusions:

most studies show the effectiveness of educational interventions, which was determined through the Knowledge, Attitude and Practice survey.

Descriptors:
Evaluation of the Efficacy-Effectiveness of Interventions; Respiratory Tract Diseases; Health Education; Disease Prevention; Systematic Review

Title	Year/Country	Participants/Educational resource/KAP dimensions/Outcome measurement	Duration time of educational intervention/effectiveness of interventions
1. Increasing knowledge about influenza vaccination in a primary care setting through educational interventional(²⁷27 Adekoya OA. Increasing the knowledge of influenza vaccination in a primary care setting through educational intervention [Tese]. Irvine: Brandman University; 2018.)	2018 United States	A total of 40 adults and older adults among men and women in the DMV metropolitan area. All are Family Clinic patients. They are aged between 18-100 years, with different levels of education/printed text/knowledge/measured through pre- and post-test.	The intervention lasted 90 days. A pre-test instrument was applied, then educational leaflets were used to educate patients about the importance of vaccination against influenza, and a post-test was subsequently applied. Efficacy was observed to increase knowledge about Influenza vaccination, which was verified by the significant difference (p<0.001) between the scores obtained by the participants in pre- and post-intervention moments. A 33% increase in knowledge was identified, with a 95%CI from 33.11 to 39.19.
2. Evaluation of Influenza Prevention in the Workplace Using a Personally Controlled Health Record: Randomized Controlled Trial(²⁸28 Bourgeois F, Simons WW, Olson K, Brownstein JS, Mandl KD. Evaluation of influenza prevention in the workplace using a personally controlled health record: randomized controlled trial. J Med Internet Res. 2008;10(1):e5. https://doi.org/10.2196/jmir.984 https://doi.org/10.2196/jmir.984... )	2008 Canada	Intervention group: 71 (adults); Control group: 54 (adults). Employees Hewlett Packard companies/digital text (media)/KAP/measured through pre- and post-test.	The intervention duration ranged between 27 and 29 days. It proved to be effective in increasing knowledge about Influenza, with a statistically significant difference (p<0.05) between the control and experimental groups. Participants in the intervention group were more likely to consider that: the Influenza vaccine is effective (OR=5.6; 95%CI=1.7 to 18.5); there are actions that make it possible to prevent the flu (OR=3.2; 95%CI=1.1 to 9.2); the influenza vaccine probably does not cause serious reactions (OR=4.4; 95%CI=1.3 to 15.3). However, Influenza immunization rates did not differ between the intervention and control groups.
3. Improving older adults’ knowledge and practice of preventive measures through a telephone health education during the SARS epidemic in Hong Kong: A pilot study(²⁹29 Chan SSC, So WKW, Wong DCN, Lee ACK, Tiwari A. Improving older adults’ knowledge and practice of preventive measures through a telephone health education during the SARS epidemic in Hong Kong: a pilot study. Int J Nurs Stud. 2007;44(7):1120-7. https://doi.org/10.1016/j.ijnurstu.2006.04.019 https://doi.org/10.1016/j.ijnurstu.2006.... )	2007 China	A total of 118 adults and older adults registered in a social service, aged 55 years and over and who speak Cantonese/structured guidance/knowledge and practice/measured through pre- and post-test.	The intervention lasted 7 days. There was no statistically significant effect (p>0.05) in increasing knowledge about the main transmission routes (droplets, direct physical contact and urine/stool) of SARS before and after the intervention. The intervention proved to be effective for the practical outcome regarding the adoption of preventive measures. Practice in this context was statistically different (p<0.01) for the following actions after receiving the intervention: covering the mouth when sneezing/coughing, washing hands after sneezing/coughing, washing hands after feeding and wearing a mask in public (p<0.05)
4. Patient and family education in HSCT: improving awareness of respiratory virus infection and influenza vaccination. A descriptive study and brief intervention(³⁰30 Ferguson PE, Jordens CFC, Gilroy NM. Patient and family education in HSCT: improving awareness of respiratory virus infection and influenza vaccination: a descriptive study and brief intervention. Bone Marrow Transplant. 2010;45(4):656-61. https://doi.org/10.1038/bmt.2009.209 https://doi.org/10.1038/bmt.2009.209... )	2010 Australia	Patients undergoing hematopoietic stem cell transplantation (HSCT), their families and friends/structured/knowledge and practice/measured through self-administered questionnaires before and after the session and participants’ self-report about vaccination.	The intervention lasted 60 days. Using the Health Belief Model, a 5-minute education session was developed to inform participants about the risks of respiratory virus infection, preventative measures, and their effectiveness. Participants received a letter, addressed to their general practitioner, requesting flu vaccination. The intervention increased awareness (knowledge) that post-transplant influenza can be fatal or require intensive care (68-87%, p=0.003). The intervention increased knowledge of effective prevention strategies (41-78%, p<0.0001), including vaccination (11-58%, p<0.0001) and belief (practice) among friends (but not patients/family members) that home vaccination reduces the risk of post-HSCT flu (57-97%, p<0.0001 and 76-81%, p=0.2, respectively).
5. Tuberculosis prevention and the effect of correctional staff education on practice outcomes(³¹31 Grady T. Tuberculosis prevention and the effect of correctional staff education on practice outcomes [Thesis]. Phoenix: Grand Canyon University; 2018.)	2008 United States	A total of 42 adults in the prison context (team: prison officers, administrators, dentists, nurses, nursing technicians, medical service providers and maintenance staff from different areas of the prison)/printed text/knowledge/measured through pre- and post-test.	The intervention lasted 7 days. After the pre-test, an increase in compliance with tuberculosis policies was observed. The study presented a 1.2 - 3.3 CI, a percentage variation of 10.1% and a coefficient of variation of 13.5%.
6. Development of an intervention to reduce transmission of respiratory infections and pandemic flu: Measuring and predicting hand-washing intentions(³²32 Miller S, Yardley L, Little P; PRIMIT team. Development of an intervention to reduce transmission of respiratory infections and pandemic flu: measuring and predicting hand-washing intentions. Psychol Health Med. 2012;17(1):59-81. https://doi.org/10.1080/13548506.2011.564188 https://doi.org/10.1080/13548506.2011.56... )	Miller S, Yardley L, Little P./2012/England	A total of 84 adults attending 15 UK universities/digital text (media)/attitude/measured using scales.	The intervention duration was not informed. Effectiveness was evidenced for attitude (p<0.05), since those who received coping messages (messages about the effectiveness of hand washing to reduce the risk of infection) had a 2.44 times higher probability (95%CI=0.96 to 6.18) of having intentions to increase their frequency of hand washing. In contrast, the threat condition (messages about the negative consequences of pandemic flu) had very little effect on the intended increases in handwashing frequency (OR=0.93, 95%CI=0.36-2.38).
7. Evaluation of a cold/flu self-care public education campaign(²⁴24 Vingilis E, Brown U, Koeppen R, Hennen B, Bass M, Peyton K, et al. Evaluation of a cold/flu self-care public education campaign. Health Educ Res. 1998;13(1):33-46. https://doi.org/10.1093/her/13.1.33 https://doi.org/10.1093/her/13.1.33... )	1998 England	Intervention group: 105 (families^* * The sample consisted of families and did not discriminate which members were. ); Control group: 102 (families)/printed text/knowledge/measured through pre- and post-test.	The intervention lasted 14 days. It showed low effectiveness in knowledge about prevention and self-care measures against colds. This conclusion is supported by the fact that only two of the thirteen questions analyzed presented significant results (p<0.01) in the acquisition of adequate knowledge, which presented an increase variation from 13 to 44%.
8. The impact of a health campaign on hand hygiene and upper respiratory illness among college students living in Residence halls(³³33 White C, Kolble R, Carlson R, Lipson N. The impact of a health campaign on hand hygiene and upper respiratory illness among college students living in residence halls. J Am Coll Health. 2005;53(4):175-81. https://doi.org/10.3200/JACH.53.4.175-181 https://doi.org/10.3200/JACH.53.4.175-18... )	2005 United States	University students from 4 residences on a university campus (Intervention group: 188/control group: 295)/printed text, digital texts (e-mail) and inputs/KAP/measured by means of pre- and post-test.	The intervention lasted 56 days. In terms of knowledge, regarding hand washing, there was a mean score of 5.14 (±0.98) in the experimental group after the intervention and 4.70 (±1.34) in the control group, with differences statistically significant (p<0.01). The attitudes of hand washing and use of sanitizers increased over time in both groups, but more so in the experimental, with statistically significant differences (p<0.01). The effectiveness of the intervention on handwashing behavior (practice) increased over time, with statistically significant differences (p<0.01) between the experimental and control groups. Among the participants who received the intervention, women washed their hands significantly (p<0.01) more frequently than men (washes per hour score: 0.49 vs. 0.40, respectively), but the same difference was not significant for gel sanitizer use.

	Certainty assessment							Certainty
Nº	Outcome	Study	Risk of bias	Inconsistency	Indirect evidence	Inaccuracy	Others	Certainty
1	Knowledge	Randomized Clinical Trials	Grave^* * There was no blinding for educational intervention.	Non-severe	Non-severe	Non-severe	None	⨁⨁⨁◯ MODERATE
1	Attitude	Randomized Clinical Trials	Grave^* * There was no blinding for educational intervention.	Non-severe	Non-severe	Non-severe	None	⨁⨁⨁◯ MODERATE
1	Practice	Randomized Clinical Trials	Grave^* * There was no blinding for educational intervention.	Non-severe	Non-severe	Non-severe	None	⨁⨁⨁◯ MODERATE

		Certainty assessment						Certainty
Nº	Outcome	Study	Risk of bias	Inconsis-tency	Indirect evidence	Inaccuracy	Others	Certainty
6	Knowledge	Non-Randomized Controlled Trials and before-and-after studies	Severe^* * The assessment time between intervention and outcome, in most studies, was considered inadequate;	Severe^†,‡,^§ § Different ways of recruiting participants;	Non-severe	Severe^\|\| \|\| Pre- and post-tests were applied by different evaluators (students, health service professionals and researchers);	None	⨁◯◯◯ VERY LOW
2	Attitude	Non-Randomized Controlled Trials and before-and-after studies	Severe^* * The assessment time between intervention and outcome, in most studies, was considered inadequate; ,^\|\| \|\| Pre- and post-tests were applied by different evaluators (students, health service professionals and researchers);	Severe^¶ ¶ Participants came from different scenarios and realities;	Non-severe	Severe^ Different sample sizes;	None	⨁◯◯◯ VERY LOW
3	Practice	Non-Randomized Controlled Trials and before-and-after studies	Severe^* * The assessment time between intervention and outcome, in most studies, was considered inadequate; ,^† † Different types of educational technologies used in the intervention; ,^‡ ‡ Study participants ranged from adults to older adults; ,^§ § Different ways of recruiting participants; ,^\|\| \|\| Pre- and post-tests were applied by different evaluators (students, health service professionals and researchers); ,^¶ ¶ Participants came from different scenarios and realities;	Severe^¶ ¶ Participants came from different scenarios and realities; ,^†† †† Inaccuracy of the effectiveness of multimodal educational interventions.	Non-severe	Severe^ Different sample sizes;	None	⨁◯◯◯ VERY LOW

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[1] Corresponding author: Tatiane Gomes Guedes E-mail: tatigguedes@yahoo.com.br