Comments on Koppelaar et al, 'Determinants of implementation of primary preventive interventions on patient handling in healthcare: a systematic review'. OEM 2009;66:353-360

Koppelaar et al put forward an interesting view on implementation in their article. They state that the results of interventions will depend not only on the effectiveness of the intervention itself but also on appropriate implementation in the actual work situation. However, the term implementation and the use of the supportive reference by Groll and Grimshaw are not used in their proper context here. The idea is that once an intervention has been shown to be effective, it should be implemented into health care, meaning that it should be used in 100% of the situations in which it is appropriate. Koppelaar et al confuse this with the actual process of the intervention in an evaluative trial. I think that these are two different processes with different determinants. Since there is no evidence of effectiveness of interventions that aim at preventing adverse health effects of handling patients by healthcare workers, these interventions should not be implemented in practice. If one would like to improve these types of interventions in research projects, there should be a clear idea of how the intervention works. Based on these ideas a maximum powerful intervention can be developed and evaluated. Once proven effective, the intervention should be implemented in health care. Also in their review the majority of the studies cited does not have a statistically significant positive outcome, neither is there a relation with the outcome of the study and the 'barriers and facilitators' for implementation.

Moreover, we would like to point out that the review does not deserve the adjective systematic. The inclusion criteria are unclear because there is no definition of the study designs to be included. Arbitrarily, qualitative studies are excluded. The search is limited only to Medline and Web of Science and it is unclear why important databases such as Embase, Cinahl and OSHrom are not searched. There is language bias because only studies written in English are included. Especially for implementation, one could expect to find studies to be published in national languages. Even though it is an objective to assess the influence of barriers and facilitators on the effectiveness of interventions, there are no methods or results for this objective. The lack of an assessment of study quality in combination with the inclusion of any study type makes that the reader has no idea what the validity of the results of the included studies is. The authors acknowledge this as a limitation of their study in the discussion section. However, in my view, all these problems together make it impossible to interpret the results of the review.

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Jos Verbeek, MD PhD Finnish Institute of Occupational Health Cochrane Occupational Health Field Kuopio Finland

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