Review
Optimisation of infection prevention and control in acute health care by use of behaviour change: a systematic review

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Summary

Changes in the behaviour of health-care workers (HCWs) are required to improve adherence to infection prevention and control (IPC) guidelines. Despite heavy investment in strategies to change behaviour, effectiveness has not been adequately assessed. We did a systematic review to assess the effectiveness and sustainability of interventions to change IPC behaviour and assessed exploratory literature for barriers to and facilitators of behaviour change. 21 studies published from 1999 to 2011 met our inclusion criteria: seven intervention studies and 14 exploratory studies. Of the intervention studies none explicitly incorporated psychological theory and only two contained elements of social marketing in the design, although five addressed sustainability. All elicited behaviour change, reduction in infection risk, or both. The exploratory studies identified social and cultural factors that affect the IPC behaviour of HCWs. To improve the standard of research and broaden the evidence base, we recommend that quality criteria are added to existing systematic review guidelines to enable the inclusion of qualitative research and to ensure robust design, implementation, and reporting of interventions.

Introduction

Health-care-associated infection (HAIs) and increased resistance to antimicrobials have put infection prevention and control (IPC) at the forefront of initiatives to improve quality of care. Since 2007, the incidence of meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridium difficile infections in England, have decreased by 59%1 and 64%,1, 2 respectively. These falls have been attributed to the UK Government policy of increased mandatory surveillance, the publication of evidence-based guidelines, and the introduction of national HAI reduction programmes.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 The guidelines and policies, however, have not led to the standardisation of best practice:16, 17, 18, 19, 20 a review of evidence concluded that “compliance to infection control precautions is internationally suboptimal”.21 Hand hygiene, which is a cornerstone of IPC, illustrates this issue; despite the introduction of many initiatives, adherence to this practice remains at around 40%.22 Effective methods for changing the IPC behaviours of health-care workers (HCWs) are needed to reduce HAIs and improve patients' safety, although this area is currently understudied.23

Strategies to lower HAI rates have focused largely on widened implementation of standard IPC precautions. This approach assumes that the behaviour of HCWs is uniformly congruent with institutional policies,24 but in translation of these strategies into practice, social, cultural, and environmental factors that might affect behaviour are rarely taken into account. Despite the development of quality standards for the research and reporting of IPC intervention studies in hospitals,25 systematic reviews show inadequate study designs and poor efficacy, which suggests that interventions are insufficiently rigorous, even for activities such as hand hygiene26, 27 or MRSA prevention in nursing homes.28 Studies have rarely demonstrated understanding of how context affects the behaviour of HCWs during development, implementation, and assessment of interventions,29 even though the need to ground complex interventions in a theoretical framework that is supported by exploratory research is well recognised.30 Additionally, theoretical frameworks from psychology, social marketing, or other social sciences that address the issues of how to change behaviour and sustain such changes over time, remain underused.

Successful interventions to change behaviour implemented in community settings have generally been grounded in psychological frameworks.31, 32, 33, 34, 35 Crucially, these approaches have taken into account multiple factors that affect human behaviour, including rational (eg, motivation to comply with a best practice), contextual (eg, environmental factors that improve or impede a behaviour, such as access to sinks), and emotional features (eg, excessive stress). Thus, these approaches are likely also to be effective in changing the behaviour of HCWs. Although direct evidence for effectiveness among HCWs remains to be proven, the IPC context seems a likely area for successful application,20, 36, 37, 38, 39 particularly because guidelines, policy, and education initiatives have so far broadly yielded no sustained behaviour changes.16, 17, 18, 19, 20

Social marketing is a behaviour-change framework that has received growing support as a model for use in relation to IPC.40, 41, 42, 43 Since the UK Government published its white paper Choosing health: making health choices easier,44 social marketing frameworks have been widely applied within community interventions and national45, 46 and international47, 48 IPC campaigns. The social marketing approach involves the application of commercial marketing strategies to promote behaviour change,49 and draws on psychological theory, persuasion psychology, and marketing science.50 Campaigns are customer-centred initiatives based on the following features: an understanding of the target audience's experiences; analysis of current and formulation of desired future behaviours; consideration of what competes for people's time and attention; and development of an approach that is focused but avoids reliance on one method of behaviour change.42, 49, 50, 51 Marketing approaches are increasingly being used in health care to improve dissemination of information to HCWs and to promote behaviour change. The extent to which social marketing can enable behaviour change and effectively sustain change in IPC, however, is unknown.

Investment in initiatives aimed at changing the IPC-related behaviour of HCWs has been extensive.52 Interventions that effectively bring about sustained behaviour change are, therefore, clearly needed. The primary objectives of this systematic review were to assess the effectiveness and sustainability of interventions to change HCWs' behaviour and improve adherence to IPC guidelines within acute care. In this Review we define IPC behaviour as practices aimed at reducing or preventing the spread of HAIs, which we have based on the description “any infection by any infectious agent acquired as a consequence of a person's treatment in a hospital (or equivalent health facility), or which is acquired by a health care worker in the course of their duties”.7 In recognition that behaviour-change interventions do not typically conform to randomised controlled trial designs,53, 54 we aimed to assess all controlled and non-controlled intervention studies. Our secondary objectives were to assess the extent to which psychological and social marketing frameworks were used to change IPC behaviour and, if they were, whether these frameworks were related to intervention effectiveness, and to assess exploratory literature for HCWs' perceptions of the facilitators and barriers to the adoption of new IPC behaviours. As our systematic review revealed that the use of social marketing and psychological theory in intervention studies is in its nascent stage, we assessed the exploratory literature to assist in informing future behavioural interventions.

Section snippets

Methods

This systematic review was done according to PRISMA guidelines.55 Assessment of antibiotic prescribing studies was part of the systematic review, but the results are reported separately.56

Results

We reviewed 9123 abstracts and titles in the first assessment, and from these 573 full-text articles were selected, of which 382 focused on IPC behaviour or behaviour-change interventions. 21 (5·5%) of these 382 studies met the quality criteria and were included (figure).61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81 Meta-analysis of results was not possible because of the lack of homogeneity in study designs and interventions.

Seven of the included studies

Discussion

We identified few IPC intervention studies that met our quality criteria, which suggests that such work is at a very early stage. Few of the intervention studies explicitly incorporated any existing psychological or social marketing methods for behaviour change, although most assessed sustainability. Thus, despite social marketing gaining support as a model for behaviour change in IPC,40, 41, 42, 43 this and psychological theory have yet to penetrate robust IPC intervention studies. Therefore,

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