In recently published research, behaviour change theory has been formally applied to address two key aspects of hand hygiene behaviour: firstly, in addressing key determinants of hand hygiene when designing the initial intervention, and secondly in the phase of implementing the intention.
Designing the intervention
Suggestions for the steps needed to develop the behaviour change intervention by using the TDF were reviewed by Frech et al.[94] This produced a four-step approach to guide the choice of the most appropriate components of an implementation intervention (Table 2.6).
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The Medical Research Council guidance in developing and evaluating complex intervention also described key elements in the development and evaluation process, which considered identifying or developing theory as key step.[95]
For hand hygiene behaviour, factors that influence hand hygiene compliance among HCWs have been addressed in several studies using qualitative methods.[96-99]
Important advantages (protection of patient and self), disadvantages (time, hand damage), referents (supportive: patients, colleagues; unsupportive: some doctors), barriers (being too busy, emergency situations), and facilitators (accessibility of sinks/products, training, reminders) were identified among Australian hospital-based nurses.[96] It was argued that interventions to improve nurses’ hand hygiene practice across the five moments needed to "focus on individual strategies to combat distraction from other duties, peer-based initiatives to foster a sense of shared responsibility, and management-driven solutions to tackle staffing and resource issues".[96]
A number of key determinants that physicians believe influence whether or not and when they practice hand hygiene have been addressed. This has helped to identify potential individual, team, and organization targets for behavior change interventions.[98] Semi-structured interviews based on the 14 TDFs of a behaviour change framework have been employed to explain health-related behaviour change that influences physician hand hygiene compliance. This study identified nine relevant domains influencing hand hygiene behaviour including “knowledge”; “skills”; “beliefs about capabilities”; “beliefs about consequences”; “goals”; “memory, attention, and decision processes”;
“environmental context and resources”; “social professional role and identity”; and “social influences”.[98]
Consideration of HCWs’ “real-time” explanations for noncompliance identified “Memory/
Attention/Decision Making” and “Knowledge” as two key behavioral domains commonly linked to noncompliance. This suggests that hand hygiene interventions should target both “conscious decision
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making and automatic processes (working on “auto-pilot”) by, for example, using “If-Then” plans and ensuring good knowledge.” Fuller et al. argued that a TDF to investigate HCW’s “real-time”
explanations of noncompliance provides a "coherent" way to design hand hygiene interventions.[99]
In summary, understanding existing causes of poor hand hygiene compliance and which barriers and enablers need to be addressed is an important requirement for designing hand hygiene promotion interventions having a good chance of success.
Implementing the intervention
Huis et al. published a systematic review of hand hygiene improvement strategies and applied a behavioural approach in their analysis.[100] This led to a taxonomy of behavioural change techniques
which was used to identify targeted determinants. Determinants of behaviour change are the determinants targeted by a systematically developed strategy i.e. things that have been identified
for altering behaviours. Theoretically, the application of a chosen behaviour change activity as part of the hand hygiene improvement strategy will alter a specific behavioural determinant, which in turn will change behaviours. An example application of behaviour change techniques for improving hand hygiene from this study is presented in Table 2.7.
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Table 2.5: Steps for developing a theory-informed implementing intervention, from French et al., 2012[94]
Step Tasks
STEP 1: Who needs to do what, differently? • Identify the evidence-practice gap
• Specify the behaviour change needed to reduce the evidence-practice gap
• Specify the health professional group whose behaviour needs changing STEP 2: Using a theoretical framework, which
barriers and enablers need to be addressed?
• From the literature, and experience of the development team, select which theory (ies), or theoretical framework(s), are likely to inform the pathways of change
• Use the chosen theory(ies), or framework, to identify the pathway(s) of change and the possible barriers and enablers to that pathway
• Use qualitative and/or quantitative methods to identify barriers and enablers to behaviour change STEP 3: Which intervention components
(behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers?
• Use the chosen theory, or framework, to identify potential behaviour change techniques to overcome the barriers and enhance the enablers
• Identify evidence to inform the selection of potential behaviour change techniques and modes of delivery
• Identify what is likely to be feasible, locally relevant, and acceptable and combine identified components into an acceptable intervention that can be delivered
STEP 4: How can behaviour change be measured and understood?
• Identify mediators of change to investigate the proposed pathways of change
• Select appropriate outcome measures
• Determine feasibility of outcomes to be measured
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Forty-one studies of experimental and quasi-experimental research on hand hygiene improvement strategies were reviewed in this study. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Relatively few studies addressed social influence, self-efficacy, attitude, and intention. There were thirteen studies using controlled designs to assess the effects of improvement strategies on hand hygiene behaviour. The reported effectiveness of the strategies varied substantially, but most controlled studies showed positive results as assessed by relative difference in hand hygiene compliance. Relative difference is defined here as the compliance in the intervention group minus the compliance from the control group) divided by the compliance from the control group after the intervention. The median effect for these strategies was a relative difference (improvement) of 17.6% in hand hygiene compliance. The effect size from one controlled study addressing two determinants was a relative difference of 25.7%.
The relative difference increased from 42.3% in the three studies addressing three determinants to 43.9% for the two studies addressing four determinants. The relative difference was 49.5% for the three studies that addressed five determinants. By focusing on determinants of behaviour change, the authors argued, it is possible to find valuable and otherwise hidden components in hand hygiene improvement strategies. The authors also argued that addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change hand hygiene behaviour. Addressing combinations of different determinants showed better results. This indicated a need for more creativity in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention.
In a study by McAteer et al., semi-structured interviews to identify the barriers to and facilitators of implementation were performed with 17 ward coordinators who had delivered a feedback intervention to improve hand hygiene.[101] The lower scoring domains and those indicating low likelihood of successful implementation of trial interventions were “environmental context and resources”, “beliefs about capabilities”, “social influences”, and “emotion”. The lowest scoring domain
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was “environmental context and resources”. Lack of time, understaffing, perceived negativity from co-workers, and stress were identified as challenges. Ward coordinators described difficulties finding time to implement the trial within the context of existing routines and increased clinical workload
because of staffing issues. In these instances, implementing the trial became a low priority.
Ward coordinators stated that, whereas they felt equipped to deliver the intervention, they had concerns about their capabilities to do so within the context of available time and staffing. The higher scoring domains and those indicating greater likelihood of successful implementation of the trial were
“behavioral regulation, “motivation”, “skills, “knowledge”, and “professional role”. Ward coordinators reported that they believed they had the relevant skills, understanding, and motivation to implement the intervention.[101]
In summary, behaviour change theory and techniques can help find new pathways for increasing hand hygiene and can also be valuable for classifying and understanding previously described approaches.
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Table 2.6: Example of application of behaviour change techniques for improving hand hygiene behaviour by determinants from a systematic review of studies of the promotion of hand hygiene in HCWs, from Huis et al., 2012[100]
Determinants Behaviour change technique Description of the activity in studies
Knowledge Provide general information Educational sessions or educational materials Increase memory or understanding
of information
Group discussion, answering questions, clarification
Awareness Risk communication Information about risks of non-adherence or inadequate hand hygiene (infection rates, costs)
Delayed feedback of behaviour Overview of recorded hand hygiene behaviour
Direct feedback of behaviour Using a system to make professionals aware of their hand hygiene behaviour soon after planned execution
Social influence Provide information about peer behaviour Information about peers’ opinions of correct hand hygiene
Provide opportunities for social comparison Group sessions with peers in which discussion and social comparison of hand hygiene practices can occur
Mobilise social norm Exposing the professional to the social norm of important others (not peers) such as opinion leaders
Attitude Persuasive communication Positive consequences of proper hand hygiene Reinforcement of behavioural progress Praise, encouragement, or material rewards
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Table 2.6: Example of application of behaviour change techniques for improving hand hygiene behaviour by determinants from a systematic review of studies of the promotion of hand hygiene in HCWs, from Huis et al., 2012[100] (cont.)
Determinants Behaviour change technique Description of the activity in studies
Self-efficacy Modeling Use of a role model. Demonstration of proper hand hygiene behaviour in group, class, or team
Verbal persuasion Messages designed to strengthen control beliefs about the way of performing correct hand hygiene
Guided practice Teaching skills and providing feedback. Specific instruction for correct hand hygiene behaviour
Plan coping responses Identification and coping with potential barriers
Set graded tasks, goal setting Desired hand hygiene behaviour is achieved with a stepwise model Intention General intention information Explanation of the goals and targets concerning hand hygiene
Agree to behavioural contract Contract or commitment with formulated goals of hand hygiene behaviour
Action control Use of cues Reminders
Facilitation of behaviour
Provide materials to facilitate behaviour Supportive materials are provided for the healthcare workers
Continuous professional support Involves service provided by infection control team or working group, and/or an additional nurse who attends the implementation
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