Efficacy of the multimodal strategy for Hand Hygiene compliance : an integrative review

OBJECTIVE
Evaluate, from the literature, the effectiveness of the implementation of the multimodal strategy for health professionals compliance with Hand Hygiene and its sustainability over time.


METHOD
Integrative review, with a view to answering the following question: "Is the implementation of the multimodal strategy effective in health professionals compliance with Hand Hygiene and can it be sustained over time?". The MEDLINE, SCOPUS, LILACS and CINAHL databases were used to retrieve the primary articles.


RESULTS
Twenty-five studies were analyzed. Among the components of the multimodal strategy, three need to be better worked: health education, feedback from practices and management involvement. Although it needs to focus more on its five elements, interventions based on the multimodal strategy have favored HH compliance and its long-term sustainability.


CONCLUSION
The strategy proved to be effective for HH compliance, especially when all integrating components are adequately addressed.


INTRODUCTION
Health Care-Related Infections (HCAI) represent a global challenge for patient safety.In recent years, greater concern has been expressed by health agencies and institutions to control and prevent the risk of such infections and at the same time to improve and ensure safe and quality care (1)(2) .Currently, they are considered a serious public health problem, as it affects millions of people, increasing morbidity and mortality, increasing antimicrobial resistance and excessive spending for health systems that could be preventable by basic precautionary measures, Hand Hygiene (HH) (1,3) .
Since 2005, the World Health Organization (WHO) has been adopting some strategies to be used in order to prevent the risks inherent to HCAI.In 2009, the multimodal strategy was recognized and disseminated internationally to improve compliance with HH practices, since hand washing is the simplest, most cost-effective and least costly measure to minimize the spread of pathogens and thus control and prevent the HCAI (1)(2) .The multimodal strategy prioritizes five key components that favor the change of practices and behaviors, namely: change in the system, which is related to the infrastructure of the institution; education and training of health professionals; evaluation and feedback of Hand Hygiene; reminders in the workplace and favorable institutional security environment (1) .
Recent research has demonstrated the importance of promoting adequate HH technique compliance among health professionals in order to reduce the high rates of infections caused by multidrug resistant microorganisms (4)(5)(6)(7)(8)(9) .However, low compliance with these practices remains a challenge for practitioners and health institutions, especially in developing countries, which may present an HCAI rate up to 20 times higher than in developed countries (10) .
In Brazil, the rates of compliance with registered HH remain below the recommended level, with an average of 50% compliance in the health institutions investigated (11) .The reasons for low compliance have multifaceted characteristics, which are related from the physical structure and support existing in the institution, available material and human resources, to professional behavior, conditioned, among others, to the process of education (11)(12) .
In this context, the multimodal strategy has been encouraged by several health agencies worldwide as a complete tool to achieve satisfactory results, since only the educational training does not guarantee the continuous improvement of HH practice (8) .Accordingly, the active participation of the heads and managers of the institutions was also highlighted, since the valuation of the change to maintain the favorable security environment can be considered effective for the change and maintenance of the indexes of improvement of HH compliance throughout the time (9,13) .
It is emphasized that efficacy in the context of health can be defined as the promotion of services widely available to all who can benefit, through scientific knowledge, to avoid both underutilization and excessive use of technologies (14) .Thus, the multimodal strategy is considered effective when, after its implementation in health institutions, it increases the HH compliance by health professionals and remains sustained over time (1)(2)(3) .

OBJECTIVE
This study aims to evaluate, from the literature, the effectiveness of the implementation of the multimodal strategy for health professionals compliance with Hand Hygiene and its sustainability over time.

METHOD
It is an integrative review of the literature, which proposes the synthesis of the results of previous studies on the same subject (15) .The integrative reviews have been highlighted in the area of Nursing in the last decade and this is due to its broad potential on specific subjects, which allows the nurses who are in clinical practice to perform nursing care based on scientific evidence (16) .
For the development of the same, six phases were covered: 1-selection of the hypothesis or question of research; 2 -search strategy (establishment of inclusion and exclusion criteria, database and selection of studies); 3 -categorization of studies (extraction, organization and summarization of data); 4-evaluation of studies included in the review; 5-interpretation of results and 6-synthesis of knowledge (15) .
To guide the study, the research question was elaborated following the PICO strategy (Participant, Intervention, Comparison and Outcomes) (17) : "Is the implementation of the multimodal strategy effective in health professionals compliance with Hand Hygiene and can it be sustained over time?".
Inclusion criteria were original scientific articles using a quantitative approach that used an intervention to improve HH compliance, using a standardized and validated WHO observation form to calculate HH compliance index, which considers the opportunity for HH and the action performed.It should be noted that articles published in English, Spanish or Portuguese were included in the period from 2009 to 2017.This period of time is justified by the year of dissemination of said strategy by WHO, which was in 2009.
Publications such as theses and dissertations, studies in which the method was not clearly and adequately described, carried out only with students and did not include at least two key components of the WHO multimodal strategy or were not available in full were excluded from the review.Data collection occurred between May and October 2017.
The primary studies were searched in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Literature in Health Sciences (LILACS), Current Nursing and Allied Health Literature (CINAHL) and SCOPUS.In order to ensure a careful search, the controlled descriptors (Health Science Descriptors (DeCS), Medical Subject Headings (MeSH) and CINAHL Headings were defined, and not controlled (keywords).The DeCS used were: higiene das mãos and pessoal de saúde, MeSH: hand hygiene and health personnel, and CINAHL Headings: handwashing and health personnel, and the keywords: adesão/compliance, intervenção/intervention, programa de avaliação/program evaluation aand estratégia multimodal/multimodal strategy.The use of the Boolean operator (AND) allowed access to articles with intersections between descriptors and keywords, and the terms were combined in different ways, according to each database, to ensure wide and adequate search.Chart 1 shows the search mechanism used in each database and the number of articles retrieved.Publications excluded because they are unavailable and/or are not original articles and/or do not answer the guiding question (n=8,835) 9,109 publications were found and 25 articles were eligible in order to compose the sample of the present study (Figure 1).
It should be noted that, in total, 166 articles selected for complete reading were excluded, of which 88 were excluded because they did not include at least two of the components of the multimodal strategy; 35 articles because they were not studies with the pre-established design; 15 articles because they did not present the adhesion index to pre and/or post-intervention HH; 14 articles because they are unavailable in full even after searching for switching service; 6 articles for being carried out in Primary Care; 5 because they were carried out only with students from the Health area and 3 because they were from another language, other than English, Portuguese or Spanish.In the selection of articles, a careful reading of the title and the abstract was carried out, in order to verify the adequacy with the guiding question and, later, a complete reading of the manuscripts for certification of the inclusion and exclusion criteria established, being analysis of the articles performed in a descriptive way.
25 reviews were carried out that were strictly linked to the research object.The selection and analysis of the studies were conducted by two researchers, independently, in order to avoid biases in the screening of articles and in the inferences of the results.

RESULTS
Based on the inclusion criteria, the final sample consisted of 25 articles.The main information extracted from the original article for this study is presented in Chart 2.
The study participants were composed of nursing staff, physicians and other health professionals, who predominantly worked in the adult Intensive Care Unit (ICU), medical clinic, emergency departments, pediatric clinic and surgical clinic.

<0.001
Note: NA -Not Available; P value: demonstrates whether the intervention was statistically significant to improve HH compliance after the implementation of the multimodal strategy.P -significant value <or equal 0.05.
Chart 2 (concluded) It was observed that the five components of the multimodal strategy were not included in 52% of the studies.System change was in twenty-four studies (96%); education/training in twentyfour (96%); evaluation and feedback in twenty-one (84%); workplace reminders in twenty-three (92%) and institutional security environment in thirteen publications (52%).It is noteworthy that only twelve studies used all the elements of this strategy, which represents, therefore, 48% of the studies included in the present sample.
With regard to the actions developed regarding the element change in the system, the availability of gel alcohol was present in the majority of studies that used this component, followed by increase of gel alcohol dispensers, paper towel, chlorhexidine, faucet with automatic sensor and washbasins.The most used educational and training strategies were lectures/courses addressing the theme of the five HH moments of the WHO, form of pathogen transmission and prevention and control of HCAI (23/25), followed by workshops (11/25).The preferred methodologies were theoretical presentations, using didactic resources such as slides, videos and films, practical demonstration and dialogue on the theme.The active methodology was cited in a study (21) , but did not present detailed information about its development.
The evaluation and feedback occurred through individually (02/20) or collective (11/20) meetings with the workers.In some studies weekly or monthly or quarterly reports were sent to department heads and/or hospital management (07/20).In all searches that had the reminder component in the workplace, educational posters were the preferred choice.Regarding research that explicitly made use of the institutional safety environment component, only three studies (7,23,27) clearly stated that managers and managers committed to follow up on the implementation of the multimodal strategy after the study.

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.
Regarding the time of evaluation, this occurred immediately after the intervention (8/25), immediately and/or in a period equal to or less than six months (8/25), for one year (5/25), for two years (1/25) for four years (2/25) and for six years (1/25).
Among the results of the data analysis, only three articles (12%) did not present statistically significant results (p value <0.05) to improve HH compliance after implementation of the multimodal strategy or showed a decrease in HH compliance over the evaluation time.The first of these studies carried out in Brazil (19) used three of the five components of the multimodal strategy -change in the system, evaluation and feedback, and reminders in the workplace; the second was held in Saudi Arabia (21) , and in addition to the three previous components, also used education and training for three weeks.The third one was also developed in Brazil (34) and included only three elements -change in the system, reminders in the workplace, and education and training for only one week.

DISCUSSION
The increase in research related to this topic in the last five years, especially between the years 2016 and 2017, whose publications corresponded to more than 60% (17/25) of the studies included.This growth in scientific studies may be related to several factors, such as the serious negative impact of HCAI worldwide, priority to research aimed at prevention and control of HCAI, which also include the Brazilian Agenda of Priorities in Health Research, as it represents the fifth international goal of patient safety, as well as the encouragement given by WHO and other international and national agencies to the use of the multimodal strategy to improve HH compliance (38)(39)(40) .
According to the Global Human Development Index (HDI) (41) , approximately 85% (21/25) of the countries in which the studies included in this review occurred have a very high or high HDI (4-5,7- 8,13,19-21,23-31,34-37) .With respect to the medium and low HDI countries (4/25) (18,22,(32)(33) , all had a pre-intervention HH compliance of less than 30%, and a post-intervention compliance of less than 50%, except a study (18) (1/4) that reached 57% after the intervention.Some countries, such as Saudi Arabia (21,24,36) , Spain (7,20) and Qatar (8) , already had a higher pre-intervention rate than those with lower HDI, such as Ethiopia (22,32) , Indonesia (33) and India (18) .Also in this context, two studies carried out in Ethiopia (22,32) , a country with a low HDI, showed that pre-intervention HH compliance of 2.10% and 1.4% and even after educational implementation, post-intervention records remained at 12.70% and 11.70%, respectively.Similarly, a study conducted in Indonesia (33) , an average HDI country, found that even after the implementation of a multimodal strategy, compliance rates in medical and surgical clinical practice remained at 18.5% and 24.9%, respectively, and a study conducted in Brazil (19) , although classified as a high HDI country, also deserves to be highlighted, with 24.8% HH compliance even after applying these strategies.
A study (39) that evaluated the implementation of the multimodal strategy in five countries with different classifications of economic development verified a more significant improvement in HH in low-and middle-income countries than in high-income countries, probably because in places where basic knowledge and physical resources are scarce, the contribution of the multimodal strategy can provide immediate and substantial progress, albeit far from what has been advocated.Even so, multicomponent intervention has proven viable and sustainable in all hospitals, including those with limited resources, and should be strongly encouraged.
It should also be noted that the study conducted in Brazil (19) did not achieve a significant compliance rate, possibly due to the fact that it did not use the element of the education/training program, a key element to change practices and behaviors, besides presenting limitations related to the number of registered opportunities (pre-intervention 119 and post-intervention 117), which hinders the understanding, interpretation and inference of the analyzed data.
A study in three hospitals in Japan (26) showed that although HH compliance increased with the implementation of the five components of the multimodal strategy, the hospital that maintained the managers' commitment during and after the intervention was the one that most assured an increase in the rate of with approximately 30% increase, while the other two hospitals showed an increase of only 5% and 7%, respectively.
It is in this overview that studies (8, 21-22, 28, 30) have shown that the institutional safety environment, education and training of health professionals, and feedback evaluation are three key components for increasing HH compliance and are capable of sustaining compliance rates for periods of time, since they consider Permanent Education and vicarious learning as a means to obtain constant improvements.Thus, in order to ensure a continuous change of improvement in HH and sustainability of compliance rates, a multimodal approach is essential, in a combined, periodic and permanent manner (3,39) , which did not occur in the mentioned studies (19,22,(32)(33) .
WHO itself recommends that in order to achieve a successful and sustained improvement in HH, it is necessary to use several actions to address different institutional obstacles and behavioral barriers (2) .However, cultural changes do not occur quickly and spontaneously, they need to be permanent and always evaluated.The Brazilian Política Nacional de Educação Permanente em Saúde (PNEPS -freely translated as National Policy of Permanent Education in Health) considers health workers as the main agents of change, and the work environment is the ideal place to develop learning, enabling changes in professional practices (42) .
According to Bandura (43) , learning can be active or by observation, the latter being considered the main way to obtain knowledge, because it occurs by observing the behavior of other people and the experiences generated or obtained by them, called vicarious learning.In this sense, the importance of the social context for certain behaviors is evident, considering that encouragement for development comes from each subject, and that people reproduce behaviors or model themselves in some way according to others and the environment.
In this context, feedback from practices as a Permanent Education strategy can be considered a necessary and very useful element to increase and maintain HH improvement rates, since

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.
it allows identifying gaps and implementing actions directed at behavior change.When performed immediately and individually, it has influenced the performance of professionals by allowing the identification of barriers that interfere in the HH compliance and seek timely solutions, as well as to detect the types of opportunities and the reason for failures for HH, highlighting the protagonism of the subject, that is, the central role of the health professional in the process of learning (20,30) .However, collective feedback is also an important alternative, since it is in the collective exercise of the process of knowledge construction that one can favor learning and enable the transformation of praxis (13,(43)(44) .This review evidenced that the studies that sustained compliance over time were supported by the management and involvement of the institution's leaders, as well as a multidimensional approach, such as the study carried out in Saudi Arabia (24) , which increased HH compliance of 60.8% before the intervention to 84.9% after one year, involving the leaders during the training workshops and providing monthly feedback to the workers, ensuring their prominence.
In this sense, a study carried out in Turkey (13) deserves special mention in maintaining the 91% rate of HH compliance after six years of the intervention period, with active participation of administrators during infection control meetings and education sessions with workers during all study follow-up.A similar survey, conducted in Taiwan (25) , maintained HH compliance in 83.4% after four years of intervention, with effective participation of management in the actions carried out and monthly feedback to health workers.
An experimental study in Lebanon (31) verified that the group that received weekly feedback individually and collectively was the one that achieved the highest rate of HH compliance after intervention, with a statistically significant result (p <0.001).It is worth noting the study by Visan et al. (8) , who during the meetings to feedback the practices, also provided certificates to the three best professionals of the adhesion, and together with the participation of management and active education, they sustained an index of 95.4% over four years.
It should be noted that the change in structure, represented mostly by the availability of alcohol gel and the supply of washbasins and paper towels, are no less important, since professionals need the means to perform HH, however, used alone, they are not able to change behaviors.The same thing happens with the component related to the distribution of reminders and posters at the health care site (19,21,30,32,34) .
In this element, it is worth mentioning the proposal made by Farhoudi et al. (4) , who chose to use colorful posters, in different sizes, similar to cartoons or comics that were changed monthly in order to attract the attention of health professionals.This strategy favored HH compliance, which was 29.8% to 71% after one year.Although the study did not provide information on how the cleanings were made, it is important to note that these should be cleanable and preserved, and the material should favor this technique, thus avoiding an effect contrary to the desired (45) .
With regard to greater sustainability over time in HH compliance, interventions that presented educational actions that included the five components of the multimodal strategy maintained higher post-intervention compliance rates (7,8,13,(24)(25)27,36) . The sef-sustaining average among these studies was 83%, and some factors, besides those related to infrastructure, can be considered as responsible for such results, such as intervention time, which ranged from three months to one year or more, lectures and workshops used concomitantly by means of practical elucidations, immediate and/or weekly feedback, monthly reports to team leaders and managers, professional effort recognition, placards at strategic locations, screenshots on computers, and institution's commitment to security environment.
It should be emphasized that health education has been shown to be effective in rising and maintaining HH compliance rates, as long as it allows for a re-signification of behaviors and assimilation of relevant information.Thus, innovative methods must replace conservative behaviors, in order to recognize the health professional as an active subject of his work process and to question reasons for non-compliance that transcend the domain of the individual and pass through structural, organizational, educational and management components.

Study limitations
The limitations of this review consider that some included studies do not present in detail the strategies implemented, such as time of intervention and evaluation after intervention, whose analysis may present subjectivity and information gaps.However, all data from the included surveys were collected from the direct observation by means of a validated instrument recommended by the World Health Organization, which is considered the gold standard when it is desired to verify compliance (37) , but which are subject to to the Hawthorne effect.

Contributions for the sectors of Health and Nursing
The results of the present study are important because they portray the setting about the effectiveness of the implementation of the multimodal strategy to improve HH through the descriptive analysis of its contemplated elements and sustainability of results over time.This review brought together some of the strategic actions developed and used in different countries and institutions that have proven to be effective for HH compliance, which may help in the planning and implementation of health education in the context of the theme, since HH compliance is a global challenge, with serious negative repercussions for patient safety and the quality of health services offered.

CONCLUSION
The implementation of the multimodal strategy proved to be effective for improving HH compliance and sustainability over time, especially when all five components of the intervention were used in an appropriate, articulated and interdependent manner.The results suggest that the use of isolated elements, such as the change in infrastructure or distribution of educational posters or punctual health education is not enough to guarantee HH compliance.Likewise, important elements should be considered in the planning and execution of said strategy to increase HH and ensure its sustainability, such as the involvement and commitment of management with security actions, individual and/or collective feedback and the use of active and permanent methodologies for health education.In this context, the achievement and dissemination of study results through multicomponent intervention is encouraged as a way to identify successful approaches, looking for possible implementation adequacy and continuous improvements in health care environments.

Figure 1 -
Figure 1 -Flowchart for identifying and selecting publications according to the PRISMA Statement Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative reviewValim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.

Chart 2 -
Synopsis of key information from the 25 primary studies included in the integrative review, Brazil,

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review Valim
MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.

Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review
Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al.