American Journal of Infection Control 48 (2020) 1506−1515

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American Journal of Infection Control

journal homepage: www.ajicjournal.org

State of the Science Review

Patient education on infection control: A systematic review

Sahar Hammoud MSc, BSc a,*, Faten Amer MSc, BSc a, Szimonetta Lohner PhD, MD b,

la Kocsis PhD, Habil, MD c
Be
a
Doctoral School of Health Sciences, Faculty of Health Sciences, University of P
ecs, P
ecs, Hungary
b
Cochrane Hungary, Clinical Center of the University of P
ecs, Medical School, University of P
ecs, P
ecs, Hungary
c
Department of Medical Microbiology and Immunology, Medical School, University of P
ecs, P
ecs, Hungary

Key Words: Background: Lately, suggestions have been emphasizing the importance of engaging patients and family
Infection control measures members in infection control (IC) through participation and education after showing that patients and family
Infection prevention education members can aid in preventing the transmission of health care-associated infections. However, assessing
Patient engagement patient education on IC measures in hospitals is poorly investigated.
Patient involvement
Purpose: To identify all available studies in the literature that assessed hospitalized patients’ education on IC
Patient information
measures.
Hospitalized patients
Methods: PubMed, Embase, and CINAHL were searched from inception till May 6, 2020 without restrictions.
We used Strengthening the Reporting of Observational Studies in Epidemiology tool for assessing the report-
ing quality of each eligible study.
Main Findings: Of the 6,740 identified papers, 25 were eligible for inclusion. Education on health care-associ-
ated infections was investigated in 8 studies, education on central line-associated bloodstream infections in
1, education on surgical site infections in 2, education on hand hygiene in 12, education on isolation ratio-
nale, precautions, usage of personal protective equipment in 3, and education on respiratory hygiene in 1. In
general, a low percentage of patient education on IC was found in most of the included papers.
Conclusions: The low percentage of patient education on IC in hospitals highlights the need for additional
emphasis on patient involvement in IC. Further studies are needed to assess patient education on several IC
measures and to explore the education of family members as well.
© 2020 The Author(s). Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control
and Epidemiology, Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/)

Health care-associated infections (HAIs) are considered the most
adverse event faced by patients throughout the world.1,2 The Center
for Diseases Control and Prevention (CDC) estimates that 5%-10% of
patients inside hospitals acquire an HAI.3,4 While studies showed
that around 30%-70% of HAIs can be prevented,2,5,6 the elevated rates
of HAIs due to multidrug-resistant organisms have led to an increase
in morbidity and mortality7 making the HAIs a patient safety con-
cern.2 Several types of invasive devices and interventions are utilized
to treat patients and support their recovery. Infections can be associ-
ated with the use of these devices, such as catheters or ventilators.
HAIs include central line-associated bloodstream infections (CLABSI),
* Address correspondence to Sahar Hammoud, MSc, BSc, Doctoral School of Health

cs, Vo
Sciences, Faculty of Health Sciences, University of Pe € ro
€smarty utca 4, Pe

cs 7621,
Hungary
E-mail addresses: hammoud.sahar@etk.pte.hu, sahar.hammoud0@gmail.com
(S. Hammoud).
Conflicts of interest: None to report.
catheter-associated urinary tract infections, and ventilator-associated
pneumonia. Also, surgical site infections (SSI) may arise at surgery
sites. The CDC operates to monitor and avoid these infections since
they represent a vital risk to patient safety.8
To improve the quality of provided care, many suggestions
aroused to empower the patients by involving them in their process
of care.9,10 Patient empowerment has earlier been known as patient
involvement, partnership, and patient-centered care. Patient empow-
erment refers to permitting patients to achieve the information and
build the needed skills to make decisions and contribute to their care
process by educating and encouraging them to participate in all
aspects.10,11 Later on, suggestions on engaging the patient in many
infection control (IC) aspects were given,10 after showing that
patients, their family members, and visitors can aid in preventing the
transmission of HAIs inside hospitals.12,13
The Joint Commission International accreditation standards for
hospitals mentioned patient and family engagement in IC by stating
in Prevention and Control of Infection standard 11 (PCI.11); “Patients

https://doi.org/10.1016/j.ajic.2020.05.039
0196-6553/© 2020 The Author(s). Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. This is an open access article under
the CC BY license (http://creativecommons.org/licenses/by/4.0/)
 S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
and families are encouraged to participate in the implementation and
use of infection prevention and control practices in the hospital.”14
The same standard also requires educating the patients and their
families on IC “The hospital provides education about infection pre-
vention and control to patients and families.”14 In addition, the CDC
guideline for isolation precautions clearly mentioned that informa-
tion about standard precautions especially hand hygiene (HH), respi-
ratory hygiene/cough etiquette, and other IC practices could be
shared with the patients upon their hospital admission. Further infor-
mation on isolation precautions can be given when isolation is
started. Additional information about the reason for isolation initia-
tion, the usage of personal protective equipment (PPE), the risk to
health care staff, and other IC-related measures can also be pro-
vided.12 Despite this interest, assessing patient education on IC in
hospitals is poorly investigated. Moreover, no systematic reviews
were done to examine patient education on IC. Hence, this systematic
review addresses this knowledge gap by investigating studies that
assessed patient education on IC measures in hospitals, summarizing
them, and comparing their results.
METHODS
This review was prepared and is reported according to the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines.15
Inclusion and exclusion criteria
To be included, any primary study needed to meet all of the fol-
lowing criteria: (1) a study on human beings of any age and gender;
(2) a study on patients admitted to hospitals or discharged patients
who were previously hospitalized as inpatients; (3) not focusing on
specific diseases (Tuberculosis, Hepatitis B, HIV, Influenza, etc...); (4)
conducted inside of hospitals; (5) assessing patients’ education on IC
measures (irrespective of the instrument used for assessing educa-
tion); (6) including 1 or more of the following IC measures: HH, respi-
ratory hygiene/cough etiquette, HAIs and/or HAIs risks including;
CLABSI, catheter-associated urinary tract infections, ventilator-asso-
ciated pneumonia, and SSI, reason for isolation, isolation precautions,
and usage of PPE. Qualitative studies were excluded since most of
them lacked numerical measurements. Studies assessing the impact
of IC patient education without measuring the education were
excluded. Studies conducted on the general population and out-ser-
vice unit patients were excluded.
Search strategy and study selection
A systematic search strategy was developed using Medline via
PubMed (www.pubmed.gov) by combining terms for “hospitalized
patients,” “education,” and “infection control.” Then, the Medline
strategy was adapted for Embase (www.embase.com) and CINAHL
(www.ebscohost.com). Details for the search strategy are supplied in
Appendix A.
Electronic searches were carried out from inception until May 6,
2020. However, it should be mentioned that an alert system was set
up on the 3 electronic search databases to get all new studies being
published in the same search topic. When this paper was submitted
for publication, no additional studies had been recognized that fit our
systematic review’s objective. The systematic search was conducted
without any restriction on the study type, research design, language
of publication, publication date, or publication status. To avoid selec-
tion bias, unpublished papers (including theses, conference abstracts,
and technical reports) were searched using OpenGrey (www.open
grey.eu), and hand searching was also done on the reference lists of
all the eligible articles. The search strategy was developed by the first
1507
and the third authors and the electronic database search was con-
ducted by the first author. The selection of eligible studies was done
by the first and the second authors independently, starting by
inspecting the titles and abstracts to eliminate irrelevant papers.
Then, full paper texts were carefully examined to decide the final
papers’ inclusion list. In the case of disagreements between
reviewers, articles were discussed first, and then, a third reviewer
was consulted in case the disagreement was not resolved.
Reporting quality assessment and data extraction
We used Strengthening the Reporting of Observational Studies in
Epidemiology tool16 for assessing the reporting quality of each eligi-
ble study. A data extraction form was designed based on guidelines
(Cochrane Handbook for Systematic Reviews of Intervention).17 The
extracted data included the following: author’s name, year of publi-
cation, the objective of the study, country, type of the study, duration,
participants, mean age, sample size, the tool used to assess patient
education on IC measures, psychometric properties, and the main
results. To avoid selective reporting within studies, authors were con-
tacted to obtain additional information about missing data. To avoid
multiple publication bias and missing outcomes, a careful examina-
tion of papers was done by 2 reviewers independently. Reporting
quality assessment and data extraction were done by the first and
the second authors independently.
Data synthesis
A table summarizing the included studies was established. We
defined the main results (outcomes) of each study as related to our
review objective.
RESULTS
Study selection and characteristics of included studies
As a result of database searching, 6,714 records were retrieved.
Also, 26 other records were identified through other sources. So, we
had a total of 6740 records. Duplicates were removed (n = 1,154),
then irrelevant papers were excluded based on their titles and the
abstracts (n = 5,434). As a result, the 152 full-texts studies were
examined. After a careful examination, 127 studies were excluded.
So, 25 studies were eligible for the review. Details of the study selec-
tion process are shown in Figure 1.
A summary of the study characteristics is presented in Table 1. Of
the 25 included studies, 19 were cross-sectional,18-36 3 pre- and post-
intervention studies,37-39 2 quasi-experimental,40,41 and 1 observa-
tional cohort study.42 Studies were conducted in high-, upper-
middle, and middle-income countries; the United States of America
(USA, n = 12), Canada (n = 1), Australia (n = 2), the United Kingdom
(UK, n = 2), Scotland (n = 1), France (n = 2), Italy (n = 1), Singapore
(n = 1), China (n = 1), Lebanon (n = 1), and Ghana (n = 1).
Results of individual studies
Patient education on HAIs was investigated in 8 studies. Miller
et al33 found that 69% of patients said that the risk of acquiring a nos-
ocomial infection (NI) was not explained to them during their hospi-
talization in a survey conducted among 976 discharged patients in
the USA. Similarly, Hammoud et al21 revealed that 34.5% of patients
and family members were educated on HAIs and the risk of acquiring
an HAI during their hospital stay in a cross-sectional survey among
223 patients and family members, and 217 nurses in Lebanon. Like-
wise, Madeo et al36 found that 33% of patients received information
on HAIs from previous hospitalization in a survey among 110 patients
1508 S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
Records identified through database
searching
PubMed = 2714
Additional records identified through
Embase = 2824
CINAHL = 1176
(n = 6714)
Records after duplicates removed
(n = 5586)
Records screened
(n = 5586)
Full-text articles assessed for
eligibility
(n = 152)
Studies included in qualitative
synthesis
(n = 25)
Fig 1. PRISMA flow diagram of the study selection process.
The PRISMA flow diagram details our search results and selection process applied during the review.
in the UK. Whereas Seale et al28 revealed that 22.3% of patients stated
that they had previously received information on HAIs in a cross-
sectional survey among 511 patients in Australia and Merle et al32
mentioned that 20% of patients received information regarding NI
during their hospitalization and 6.2% received information on risk
factors of NI in a cross-sectional survey among 65 inpatients in
France. At the same time, Ocran et al35 found that 24.8% of patients
were informed about HAIs by a health care officer in a cross-sec-
tional survey among 210 patients and 71 health care workers
(HCW) in Ghana, while Abbate et al20 revealed that 15.1% of patients
received information on HAIs from their health care professionals in
a cross-sectional survey among 450 patients in Italy, and Smyth
et al27 showed that 4.8% of patients received information about the
risks of HAIs from a nurse at hospital in a cross-sectional survey
among 42 patients in the USA.
Education on CLABSI was investigated in 1 study by Anderson
et al22 who showed that 46% of patients recalled receiving an infor-
mational flyer regarding CLABSI and 76% mentioned that the HCW
other sources
(n = 26)
Records excluded
(n = 5434)
Full-text articles excluded,
with reasons
(n = 127)
No related outcomes = 99
Wrong population = 5
Multiple publication of single
study = 3
No full text available = 9
Qualitative = 10
Others = 1
talked to them about risks of infection with the central line in a
cross-sectional survey among 50 patients in the USA.
Education on SSI was investigated in 2 studies. Anderson et al31
found that 84% of patients had discussions about SSI with their HCW,
60% recalled receiving an informational flyer regarding SSI, and 54%
learned about SSI in hospital in a cross-sectional survey among 50
surgical patients in the USA. Similarly, Hari et al26 showed that 95.2%
of patients received written education on infection (SSI), 93.5% ver-
bal, and 6.5% received education by demonstration in a cross-sec-
tional survey among 62 surgical patients in the USA.
Education on HH was investigated in 12 studies. Ong et al38
showed that 20.4% of patients received education on HH in the prein-
tervention phase, while in the postintervention patient education on
HH showed an improvement of 48.1% (X2 = 26.517, P < .001) in a pre-
intervention and postintervention audit among 54 patients in Singa-
pore, unlike Haverstick et al37 who found that 53% of patients were
always encouraged to clean their hands on specific times, but the
rate decreased to 46% postintervention in a preintervention and
Table 1
Characteristics of included studies
Author Objective
Knighton et al18 To obtain information from
2020 patients with recent hospital
stays on their perceptions of
barriers to and facilitators of
patient HH, and their satis-
faction or lack of satisfaction
with their ability to main-
tain HH practice during their
recent past hospitalization
Srigley et al24 To assess the HH knowledge,
2020 attitudes, and practices of
inpatients, in preparation for
implementation of a patient
HH improvement program
Li Y. et al30 2019 To investigate inpatient
knowledge, attitudes, and
practice of HH during hospi-
tal stay, and to identify some
factors influencing practice
compliance, which may con-
tribute to the design of
effective patient HH promo-
tion strategies
Minejima et al23 To identify current gaps in
2019 patient understanding and
attitudes toward UTIs with
respect to the disease and its
management in a medically
underserved population
Hammoud To assess nurses' awareness
et al21 2017 level of IC, and determine
the role of this awareness in
implementing patient and
family education
Haverstick To determine if increased
et al37 2017 access to HH products and
patient education could
improve patients’ HH and
reduce the transmission of
HAIs
Country Study type Duration of data Sample size Mean age (years) Data collection tool Psychometric Outcome related to review
collection properties
USA Cross-sectional January till April 107 patients 63.5 § 14.69 A modified version of Reliability: Cronba- 16.8% (18/107) reported
2018 a questionnaire by ch's alpha = 0.848 never being reminded to
Sunkesula et al 2015 clean their hands, 29.9%
(32/107) almost never,
28% (30/107) some-
times, 24.3% (26/107)
often, and 0.9% (1/107)
being reminded very
often
Canada Cross-sectional 1 week (Between 268 patients and/or 65.2 (survey) and Questionnaire + - 55.1% of patients indicated
2014 and 2015) their caregivers 65.9 (interview) interviews that staff had informed
S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
them about the impor-
tance of HH while in the
hospital
China Cross-sectional November till 310 (242 47.80 § 18.066 Self-designed, struc- Reliability: Cronba- 30.6% (95/310) received
December 2017 patients + 68 fam- tured questionnaire ch's alpha = 0.867 education on HH from
ily members) HCW. (35.6% if calcu-
lated out of all sources
267)
USA Cross-sectional January 2015 till 120 patients 53 § 16 Structured Questions were not 28% (33/120) reported
July 2016 questionnaire validated for receiving information
reproducibility from their health care
provider about appro-
priate hygiene measures
to prevent a UTI
Lebanon Cross-sectional May till June 2016 223 (116 31.8% of patients Developed - 34.5% of patients and fam-
patients + 107 and family mem- questionnaire ily members were edu-
family members) bers between [26- cated on HAIs and their
and 217 nurses 35] risks. 21.1% educated on
respiratory hygiene.
29.1% provided with
brochures on HH and/or
respiratory hygiene.
79.4% of those in isola-
tion (34 participants)
were informed about
the reason of isolation
and 82.4% were edu-
cated on the usage of
PPE
USA Preintervention and 4 months (August 172 patients (Prein- - Questionnaires by - Preintervention: 53% of
postintervention 2013) tervention: Burnett et al 2008 patients were always
16 + postinterven- encouraged to clean
tion 156) and 33 their hands on specific
staff times, the rate
decreased to 46%
postintervention
1509
(continued on next page)
 1510
Table 1 (Continued)

Author Objective Country Study type Duration of data Sample size Mean age (years) Data collection tool Psychometric Outcome related to review
collection properties

Pokrywka To assess HH practice in
et al40 2017 patients, to improve the
opportunities for patient HH
through staff education and
patient assistance, to ask the
question if improving
patient HH opportunities in
the hospital could affect the
occurrence of Clostridium
Difficile infection
USA Quasi-experimental November 2013 and 657 patients. Phase 59.6 preintervention Questionnaire - Phase one: (Preinterven-
March 2016 one: 388 (97 pre- and 60.8 tion): 34% of patients
intervention + 291 postintervention received verbal or writ-
postintervention) ten education on HH,
phase two: 269 (Postintervention):
(80 baseline + 189 patient education on HH
follow-up) increased to 64%
(P<0.0001). Phase two:
(Baseline): 48% of
patients received verbal
or written education on
HH, (Follow-up survey):
patient education on HH

S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515

increased to 53%
Ong et al38 2017 To improve patients' knowl- Singapore Preintervention and March 2013 (1 54 patients - Developed audit tool - Preintervention: 20.4%
edge on HH postintervention week) and June via JBI-PACES and received education on
audit 2013 (1 week) GRIP HH. Postintervention:
Patient education on HH
showed improvement of
48.1% (P<0.001)
Lerondeau To evaluate the satisfaction France Observational March till July 2012 90 patients (30 iso- Median (isolated Questionnaire: Patient - 40% (12/30) of isolated
et al42 2017 and the psychological cohort lated and 60 patients 69) and satisfaction (qualita- patients received infor-
impact (anxiety) of isolation nonisolated) (nonisolated 64) tive scale) +Anxiety mation about isolation
precautions in hospitalized Spielberger scale precautions and 36.6%
patients in a French acute- (11/30) about their
care university hospital infectious status
Sunkesula To determine patients' opin- USA Preintervention and February till Sep- 100 patients - Questionnaire + direct - 88% (88/100) of patients
et al39 2015 ions on HH and evaluate postintervention tember 2014 observation of disagreed that they
patient HH practices patient HH received information
performance about the importance of
HH
Smyth et al27 To study the knowledge of Australia Cross-sectional April 2013 till April 42 patients 56 Questionnaire by - 4.8% (2/42) received infor-
2015 HAIs held by patients in 2014 Madeo et al 2008 mation about the risks
Australian hospitals of HAIs from a nurse at
hospital.
Seale et al28 To ascertain patients’ knowl- Australia Cross-sectional May till December 511 patients 65 Questionnaire - 22.3% (114/511) stated
2015 edge of, risk awareness of, 2013 that they had previously
and attitude toward HAIs received information on
and common IC strategies, HAIs
as well as their perceptions
of participating in an
engagement program aimed
at preventing HAIs
Ocran et al35 To assess the knowledge of Ghana Cross-sectional 6 months 210 patients and 71 55.2% of patients Questionnaire - 24.8% of patients (52/210)
2014 HCW and patients on HAIs, HCW [25-30] were informed about
sources of knowledge of HAIs by a health care
these infections, sources of officer
these infections, and their
attitude to prevent these
infections
Barker et al19 To examine factors associated USA Cross-sectional October 2012 till 207 patients Median 63 Developed - 74.2% reported frequent
2014 with HH practices of hospi- May 2013 questionnaire reminders from HCW to
tal patients wash their hands

(continued on next page)

Table 1 (Continued)
Author Objective
Anderson et al To examine patients’ aware-
a22 2013 ness and understanding of
CLABSI risks and
consequences
Anderson et al To examine patients’ aware-
b31 2013 ness and understanding of
SSI risks and consequences
Ardizzone To explore nurses’ and
et al41 2013 patients’ perceptions of
patient HH and to determine
the effectiveness of an edu-
cational intervention
directed at the nursing staff
about patient HH
Hari et al26 2012 To determine the exact rates
and reasons for postsurgical
readmissions for patients
who had undergone Pan-
creaticoduodenectomy and
identify what postoperative
education was delivered to
patients and families
Madeo et al36 To determine patients
2008 reported knowledge, aware-
ness, attitudes, and beliefs
on HAIs
Burnett et al 25 To determine whether or not
2008 patients who required assis-
tance with personal hygiene
were encouraged and pro-
vided with facilities to do so,
and to gain an insight into
HCWs’ perceptions towards
patient HH
Abbate et al 20 To document the level of
2008 knowledge, attitudes, and
behavior, and to identify
their determinants regard-
ing HAIs among medical and
surgical patients admitted to
hospitals in Italy
Country Study type Duration of data Sample size Mean age (years) Data collection tool Psychometric Outcome related to review
collection properties
USA Cross-sectional July till October 50 patients 46% [50-64] Developed Questionnaire was 46% (23/50) recalled
2011 questionnaire reviewed and receiving an informa-
improved by tional flyer regarding
physicians, CLABSI. 76% (38/50)
nurses, and infec- mentioned that the
tion HCW talked to them
preventionists about risks of infection
with the central line
USA Cross-sectional July till October 50 patients 84% ≤ 64 Developed - 84% (42/50) had discus-
2011 questionnaire sions about SSI with
their HCW. 60% (30/50)
recalled receiving an
informational flyer
S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
regarding SSI. 54% (27/
50) learned about SSI in
hospital
USA Quasi-experimental 5 months 71 patients and 42 - A modified version of Already validated 14% of patients were
nurses a validated ques- always encouraged to
tionnaire by Burnett clean their hands on
et al 2008 + Obser- specific times, 34%
vation of HH often, 15.5% sometimes,
performance 11% rarely, and 25.5%
never encouraged
USA Cross-sectional January 2006 till 62 patients - Patient medical - 95.2% (59/62) received
December 2008 records written education on
infection (SSI), 93.5%
(58/62) verbal, and 6.5%
(4/62) received educa-
tion by demonstration
UK Descriptive survey 4 weeks 110 patients - Developed Examined for face 33% received information
questionnaire validity and on HAIs from previous
suitability hospitalization
Scotland Descriptive survey January 2007 22 patients and 33 75 (patients) Developed question- The patient ques- 5% (1/22) of patients were
nurses naire + observation tionnaire was pre- always encouraged to
of HH performance tested and piloted clean their hands on
to maximize its specific times, 9% (2/22)
reliability and often, 9% (2/22) some-
validity times, 22% (5/22) rarely,
and 55% (12/22) never
encouraged
Italy Cross-sectional June till October 450 patients 51 Questionnaire All items in the orig- 15.1% received informa-
2006 inal version of the tion on HAIs from health
questionnaire care providers
were assessed to
ensure practica-
bility and validity
(continued on next page)
1511

Table 1 (Continued)
Author Objective
Gasink et al29 To compare satisfaction with
2008 inpatient care between iso-
lated and nonisolated
patients, and to assess iso-
lated patients' perception
and understanding of con-
tact isolation
Duncan et al34 To explore patient's feelings
2007 about asking health care
professionals to wash their
hands prior to a clinical pro-
cedure, and to explore if
MRSA status and access to
patient information about IC
would influence anxiety
about asking
Merle et al32 To investigate the knowledge
2005 and opinions of surgical
patients regarding NI
Miller et al33 To determine if patients were
1989 aware of the risk of acquir-
ing a NI, satisfied with the
current information on NI
provided by the medical
community, the level of
investment they want hos-
pitals to make in IC, and the
extent to which they are
willing to pay for increased
investment in this area
HH, hand hygiene; HCW, health care worker; UTIs, urinary tract infections; IC, infection control; HAIs, health care-associated infections; PPE, personal protective equipment; JBI-PACES, Joanna Briggs institute practical application of clin-
ical evidence system; GRIP, getting research into practice; CLABSI, central line associated-bloodstream infection; SSI, surgical site infection; CAHPS, the consumer assessment of health care providers and systems; MRSA, methicillin-resis-
tant staphylococcus aureus; NI, nosocomial infection; CI, confidence interval.
1512
Country Study type Duration of data Sample size Mean age (years) Data collection tool Psychometric Outcome related to review
collection properties
USA Cross-sectional 7th August till 25th 86 patients (43 iso- Median 54 CAHPS question- Nonvalidation of the 46.2% (18 out of 39 iso-
August 2006 lated and 43 naire + additional CAHPS for face to lated patients) reported
nonisolated) questions to assess face interviews that the rationale and
perception and procedures for isolation
understanding of were adequately
isolation explained to them
UK Descriptive survey - 109 patients 25% [31-45] Semistructured - 25.3% (25/99) received
questionnaire information about
MRSA and handwashing
upon hospital admis-
sion, 3.6% (4/109) men-
tioned staff members as
S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
a source of information
and 29.3% (32/109)
mentioned patient
information leaflets in
hospital
France Cross-sectional - 65 patients Median 54 Questionnaire - 80% (52, 95% CI [68.2-
88.9]) of patients didn't
receive information
regarding NI during
their hospitalization,
while 20% (13 patient)
did. 6.2% received infor-
mation on risk factors of
NI. 10.8% received on IC
methods and 6.2% on
the organization of IC in
the hospital.
USA Mail-based ques- October 1986 and 976 patients 51 Mail-based - 69% (672) of patients said
tionnaire survey February 1987 questionnaire that the risk of acquiring
a NI was not explained
to them during their
hospitalization.
 S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
postintervention study among 172 patients and 33 staff in the USA.
Whereas Sunkesula et al39 showed that 88% of patients disagreed
that they received information about HH in the preintervention
phase of a preintervention and postintervention study among100
patients in the USA. At the same time, Pokrywka et al40 found that
34% of patients received education on HH prior to intervention in
phase 1 and 48% in the baseline survey of phase 2 in a quasi-experi-
mental study among 388 patients in phase 1 (97 preintervention and
291 postintervention) and 269 patients in phase 2 (80 baselines and
189 follow-ups) in the USA, while the percentage of HH education
increased to 64% (P < .0001) postintervention in phase 1 and to 53%
in the follow-up survey of phase 2. Barker et al19 showed that 74.2%
of patients reported frequent reminders from HCW to wash their
hands in a cross-sectional survey among 207 patients in the USA,
while Srigley et al24 revealed that 55.1% of patients indicated that
staff had informed them about the importance of HH while in the
hospital in a cross-sectional survey among 268 patients and/or care-
givers in Canada. Li Y. et al30 found that 30.6% of patients and family
members received education on HH from HCW in a cross-sectional
survey among 310 participants (242 patients and 68 family mem-
bers) in China similarly, Hammoud et al21 showed that 29.1% of
patients and family members were provided with brochures on HH
and/or respiratory hygiene unlike, Duncan et al34 who revealed that
only 3.6% of patients received information about handwashing and
methicillin-resistant Staphylococcus Aureus (MRSA) from their staff
members upon hospital admission and 29.3% of patients mentioned
patient information leaflets in hospital as a source of their informa-
tion in a survey among 109 inpatients in the UK. Similarly, Burnett
et al25 showed that only 5% of patients were always encouraged to
clean their hands on specific times in a cross-sectional survey among
22 patients and 33 nurses in Scotland, and Knighton et al18 revealed
that 0.9% of patients reported being reminded very often to clean
their hands in a cross-sectional survey among 107 discharged
patients in the USA while, Ardizzone et al41 found that 14% of patients
were always encouraged to clean their hands on specific times in a
quasi-experimental study among 71 patients and 42 nurses in the
USA.
Education on isolation rationale, precautions, and usage of PPE
was investigated in 3 studies. Gasink et al29 reported that 46.2% of
isolated patients mentioned that the rationale and procedures for iso-
lation were adequately explained to them in a cross-sectional survey
among 86 patients (43 isolated and 43 nonisolated) in the USA; simi-
larly, Lerondeau et al42 showed that 40% of isolated patients received
information about isolation precautions and 36.6% about their infec-
tious status in an observational prospective cohort study among 90
patients including 30 isolated and 60 nonisolated in France. At the
same time, Hammoud et al21 mentioned in their study that 79.4% of
isolated participants were informed about the reason for placing
them in isolation, and 82.4% were educated on the usage of PPE.
Education on respiratory hygiene/cough etiquette was investi-
gated in 1 study only by Hammoud et al21 who showed that 21.1% of
patients and family members were educated on this measure.
Patient education on other IC measures was investigated; Mine-
jima et al23 showed that 28% of patients reported receiving informa-
tion from their health care provider about appropriate hygiene
measures to prevent urinary tract infections (UTIs) in a cross-sec-
tional survey among 120 patients in the USA, and Merle et al32
reported that 10.8% of patients received information on IC methods
and 6.2% on the organization of IC in the hospital.
Concerning the data collection tools used in the included studies,
23 studies employed questionnaires (structured and semistructured)
while, 1 of the 3 preintervention and postintervention studies by Ong
et al38 involved a developed audit tool and 1 study by Hari et al26
used patient medical records. As for the validity and reliability of the
instruments, Knighton et al, and Li et al18,30 mentioned the Cronbach
1513
alpha values of the reliability of the questionnaire while, Abbate et al,
Anderson et al, Burnett et al, and Madeo et al20,22,25,36 indicated that
the questionnaires were assessed for validity but values were not
reported. Minejima et al and Gasink et al23,29 stated that no validation
was done; Ardizzone et al41 stated that the questionnaire was already
validated, and no process of validity and reliability was reported in all
the remaining studies.
Reporting quality assessment
Strengthening the Reporting of Observational Studies in Epidemi-
ology checklist16 defines 5 headings; title and abstract, introduction,
methods, results, and discussion, with several items below each
heading to indicate whether this particular item was well reported in
each study. First, the abstract was well reported in all eligible studies,
except for Barker et al, Smyth et al, Seale et al, Gasink et al, and Sun-
kesula et al19,27-29,39 where the abstracts were very brief and lacking
numerical values of key results. Second, the introduction was prop-
erly described in all eligible studies, except for Smyth et al, Seale
et al, and Merle et al27,28,32 where the scientific background was
explained very briefly. Third, in the methods section, study design,
setting, and participants were well reported in all eligible studies but,
Hammoud et al, Merle et al, and Duncan et al21,32,34 did not mention
the dates and period of data collection. The variables were reported
in the methods section of all studies, except for Smyth et al, Anderson
et al, and Miller et al27,31,33. Efforts to address the potential risk of
bias were described by Gasink et al, Duncan et al, Madeo et al, Ong
et al, and Sunkesula et al29,34,36,38,39. Only Gasink et al, Li et al, Ong
et al, and Ardizzone et al29,30,38,41 described how the study size was
arrived at. In the statistical methods part, only Ong et al38 explained
how missing data were addressed. Fourth, the results section; only
Knighton et al, Burnett et al, Hari et al, Seale et al, Duncan et al,
Madeo et al, Ardizzone et al, and Lerondeau et al18,25,26,28,34,36,41,42
gave the reasons for nonparticipation. The characteristics of study
participants were well reported in all eligible studies, except for
Hammoud et al, Haverstick et al, Ong et al, Sunkesula et al, and Pok-
rywka et al21,37-40. All studies did not indicate the number of partici-
pants with missing data for each variable of interest, except for
Smyth et al and Gasink et al27,29. Outcome data were well reported in
all studies. In the main results subsection, only Barker et al, Abbate
et al, Minejima et al, Seale et al, and Li et al19,20,23,28,30 reported the
unadjusted and adjusted estimates and their precision. None of the
studies reported any other analysis done. Fifth, the discussion sec-
tion; summary of key results and overall interpretation of results
were well reported in all eligible studies. Studies’ limitations were
reported by all, except for Hammoud et al, Smyth et al, Duncan et al,
Ocran et al, and Ong et al21,27,34,35,38. Knighton et al, Barker et al,
Anderson et al, Minejima et al, Srigley et al, Burnett et al, Seale et al,
Gasink et al, Li et al, Anderson et al, Miller et al, and Haverstick
et al18,19,22-25,28-31,33,37 discussed the generalizability of the study
results. Finally, the source of funding was reported by Knighton et al,
Barker et al, Minejima et al, Srigley et al, Burnett et al, Seale et al, Li Y.
et al, Ocran et al, Haverstick et al, Ong et al, Sunkesula et al, Ardizzone
et al, and Lerondeau et al.18,19,23-25,28,30,35,37-39,41,42
DISCUSSION
Summary of main results
The present paper is the first systematic review that identifies the
studies that assess hospitalized patients’ education on IC measures.
Each of the 25 included studies had 1 or more outcomes that matched
our review’s outcomes. Education on HAIs was investigated in 8 stud-
ies, education on CLABSI in 1, education on SSI in 2, education on HH
in 12, education on isolation rationale, precautions, and usage of PPE
1514 S. Hammoud et al. / American Journal of Infection Control 48 (2020) 1506−1515
in 3, education on respiratory hygiene in 1, and education on other IC
measures in 2 studies.
Overall completeness and applicability of evidence
A low percentage of patient education was noticed in all studies
that assessed education on HAIs while, a better percentage was noted
in the study that assessed education on CLABSI,22 and in the 2 studies
that assessed education on SSI.26,31 It is important to mention that
Hari et al26 stated that “post-discharge education was inconsistent
and no evidence of learning was shown.” Also, we should highlight
that the sample size included in these 3 studies was small (50
patients Anderson et al, 62 Hari et al, and 50 Anderson et al22,26,31).
This better level of education can be explained since patients with
central lines and those undergoing surgeries are at a higher risk of
acquiring an HAI and thus are given more attention by the HCW. A
low percentage of education was also recognized when educating on
HH, except the study by Barker et al19 (74.2%) although HH is sug-
gested to be the most effective approach to prevent the transmission
of HAIs.43-46 At the same time, asking patients to remind their health
care professionals to perform HH is considered as 1 of the pioneering
strategies to promote patient empowerment.46-51 When educating
on isolation rationale, precautions, and usage of PPE, we recognized a
high level of education by 1 study only21 but it is notable here that
the sample of isolated participants was small in the 3 studies that
assessed education on these measures, (34 Hammoud et al, 39 partic-
ipant Gasink et al, and 30 Lerondeau et al21,29,42). We think these
results may be biased due to the small sample size. Finally when edu-
cating on other IC measures, also a low level of education was recog-
nized. Given the low percentage of education on IC measures in most
of the studies included in this review, we believe that patient educa-
tion on IC is not being adequately done inside hospitals although it is
recommended by the CDC as mentioned earlier.12 On the other hand,
only 2 studies were found to assess patient education on more than 1
IC measure (Hammoud et al and Merle et al 21,32), and this highlights
the necessity of having more research that aims at assessing patient
education on several IC measures and not only assessing education
related to 1 IC measure especially, after the late suggestions on
engaging the patients in many IC aspects as a way to prevent the
transmission of HAIs10 and after the global discussion of empowering
patients to maintain their safety.52-57
As stated before, only a few studies reported assessing the validity
and reliability of the questionnaires used. The validity and reliability
of the questionnaire are essential points to be mentioned since the
questionnaire should be able to measure accurately what it is
intended to measure.58,59 Besides, the rise in diverse populations
internationally and the necessity for cross-cultural and multinational
research show a remarkable requirement for researchers to have
access to valid and reliable instruments, hence this would improve
the validity and the generalizability of the cross-cultural health
research.60-62
Reporting quality assessment
In general, the abstracts and introductions were well reported in
all studies, so readers can have an informative summary of each
study, to realize the study’s background, and to judge its impact on
the existing knowledge.16 Additionally, several gaps were found in
reporting the methods, results, and discussion sections. The methods
section should include all details that explain what was planned and
how implementation was done to allow the readers to understand all
the study’s characteristics, and to be able to criticize whether the
mentioned method was able to deliver the results reliably and val-
idly. As for the results section, it should reflect a clear idea about
what was established in the study, starting with the participant’s
enrollment, giving characteristics of the study participants, reporting
the main results, and finally the secondary analysis. Concerning the
discussion part, documenting and arguing the limitation of research
is a vital point in scientific writing. On the other hand, reporting the
external validity and presenting information about the applicability
of the study results in other circumstances is essential. Finally, the
source of funding and the role of funders have to be stated to avoid
any doubt about the influence of the funders on the research
conclusion.16
Strengths and weaknesses of the review
Our review has some limitations: first, for some studies, few data
were not available (mean age and duration of data collection) even
after contacting the authors26,32,34,36-39,41; second, studies that
assessed general population were excluded from this review and
only studies on hospitalized patients were included; third, studies
that assessed patient education on specific diseases were excluded
(Tuberculosis, Hepatitis B, HIV, etc.), these studies may include out-
comes related to education on some IC measures. Finally, qualitative
studies were also excluded. On the other hand, we believe that this
review has several strengths. First, it is the first systematic review
that identifies the studies that assess hospitalized patients’ education
on IC. Second, the search was conducted without any restrictions.
Third, the 25 studies included in this review have an international
scope; they were conducted in America, Australia, Europe, Asia, and
Africa, and in high-, upper-middle-, and middle-income countries.
CONCLUSIONS
In conclusion, the present systematic review reveals a low per-
centage of patient education on IC measures. Our results show that
only 2 studies assessed patient education on more than 1 IC measure.
This result highlights a gap in the present assessment of patient edu-
cation and involvement in IC. Hospitals have to emphasize the impor-
tance of patient engagement and education on IC and encourage the
patients to involve themselves in their process of care by asking their
HCW to provide them with information. Further studies are needed
to assess patient education on IC, such studies can reveal a validated
and standardized questionnaire that can be used further by other
researchers. Moreover, future studies can assess the IC education of
family members as well.
Acknowledgments
We would like to thank Mr. Bashar Farran who contributed to
editing the writing language of this paper.
SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be found
in the online version at https://doi.org/10.1016/j.ajic.2020.05.039.
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