Critical Appraisal of Research

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Journal of Hospital Infection 91 (2015) 202e210

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Journal of Hospital Infection

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Review

Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review

J.A. Srigley a,*, K. Corace b, D.P. Hargadon a, D. Yu a, T. MacDonald c, L. Fabrigar c, G. Garber a

a Public Health Ontario, Toronto, Ontario, Canada bUniversity of Ottawa, University of Ottawa Institute of Mental Health Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada cDepartment of Psychology, Queen’s University, Kingston, ON, Canada

A R T I C L E I N F O

Article history: Received 12 April 2015 Accepted 27 June 2015 Available online 4 August 2015

Keywords: Behaviour Hand hygiene Psychology

* Corresponding author. Address: BC Childre V6H 2N9. Tel.: þ1 604 875 2305.

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.jhin.2015.06.019 0195-6701/Crown Copyright ª 2015 Published

S U M M A R Y

Background: Despite the importance of hand hygiene in preventing transmission of healthcare-associated infections, compliance rates are suboptimal. Hand hygiene is a complex behaviour and psychological frameworks are promising tools to influence healthcare worker (HCW) behaviour. Aim: (i) To review the effectiveness of interventions based on psychological theories of behaviour change to improve HCW hand hygiene compliance; (ii) to determine which frameworks have been used to predict HCW hand hygiene compliance. Methods: Multiple databases and reference lists of included studies were searched for studies that applied psychological theories to improve and/or predict HCW hand hygiene. All steps in selection, data extraction, and quality assessment were performed indepen- dently by two reviewers. Findings: The search yielded 918 citations; seven met eligibility criteria. Four studies evaluated hand hygiene interventions based on psychological frameworks. Interventions were informed by goal setting, control theory, operant learning, positive reinforcement, change theory, the theory of planned behaviour, and the transtheoretical model. Three predictive studies employed the theory of planned behaviour, the transtheoretical model, and the theoretical domains framework. Interventions to improve hand hygiene adherence demonstrated efficacy but studies were at moderate to high risk of bias. For many studies, it was unclear how theories of behaviour change were used to inform the interventions. Predictive studies had mixed results. Conclusion: Behaviour change theory is a promising tool for improving hand hygiene; however, these theories have not been extensively examined. Our review reveals a sig- nificant gap in the literature and indicates possible avenues for novel research. Crown Copyright ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection

Society. All rights reserved.

n’s & Women’s Hospital, Laboratory Medicine, Room 2J3, 4500 Oak Street, Vancouver, BC, Canada

(J.A. Srigley).

by Elsevier Ltd on behalf of the Healthcare Infection Society. All rights reserved.

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210 203

Introduction Data extraction and quality assessment

Healthcare worker (HCW) hand hygiene compliance rates are known to be suboptimal, despite pressure from regulatory bodies worldwide to improve compliance and abundant evi- dence that hand hygiene prevents healthcare-associated in- fections (HCAIs).1,2 Improvement strategies to date have largely focused on a multimodal approach, typically including provision of soap and water and/or alcohol-based hand rub (ABHR) at point of care, training and education, reminders, administrative support, and measurement of compliance rates.2 However, achieving significant and sustained improve- ment has been challenging.3

Hand hygiene is increasingly recognized as a complex behaviour with numerous motivators and barriers.2 Re- searchers have begun to focus on applying behavioural psy- chology to bring about improvement. Psychological frameworks have been shown to be effective tools in guiding behaviour change in a variety of settings, including HCW behaviour.4

The primary objective of this systematic review was to determine the effectiveness of interventions based on psy- chological frameworks to improve HCW hand hygiene compli- ance. The secondary objective was to determine which psychological frameworks/theories have been used to predict HCW hand hygiene compliance, including facilitating factors and barriers, as these may be used to design interventions in the future.

Methods

Search strategy

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, The Joanna Briggs Institute, SocINDEX, and Cochrane Database of Systematic Reviews (CENTRAL) from database inception until June 5th, 2014. We also searched reference lists of included studies and relevant review articles for additional eligible studies. The search strategy was developed by a team of experienced librarians (Appendix A).

Eligibility criteria

Randomized controlled trials (RCTs), non-RCTs, time series, controlled beforeeafter studies, and quasi-experimental studies (including uncontrolled beforeeafter) were consid- ered for inclusion if they applied a psychological theory to improve and/or predict HCW hand hygiene. Based on the guidance of the Medical Research Council that complex in- terventions involving behaviour should be grounded in theory, studies that did not explicitly name a psychological framework were excluded.5 The study population had to consist of any HCW group (e.g. physicians, nurses, allied health practitioners, technicians) and could be conducted in any healthcare setting, including acute care and long-term care. Studies had to include hand hygiene compliance as an outcome but were excluded if self-reported hand hygiene compliance was the only outcome.

Only published, peer-reviewed studies were included; studies published solely in abstract form were excluded. Studies were excluded if they were not published in English or if they did not supply primary data.

The eligibility criteria were pilot-tested on a selection of studies and then all retrieved titles and abstracts were inde- pendently assessed by two reviewers (D.Y., D.P.H.). If the in- clusion/exclusion criteria could not be adequately assessed, the full article was obtained and reviewed. Disagreements were resolved by a third reviewer (J.A.S.) when the primary reviewers could not reach consensus.

After piloting a data extraction form, two reviewers (D.Y., D.P.H.) independently assessed each included article and extracted information including study methodology, setting, interventions, and outcomes. Disagreements were resolved by a third reviewer (J.A.S.).

The risk of bias of each included study was assessed inde- pendently by two investigators (D.P.H., J.A.S.) using an intern- ally developed resource, the Public Health Ontario MetaQAT tool, to guide the critical appraisal process.

Data synthesis

Summary tables of included studies were developed. Narrative synthesis was conducted based on the Economic and Social Research Council guidance report.6 We also evaluated study quality in relation to the demonstrated efficacy of each psychological framework for each of the primary outcomes.

Results

The literature search yielded 918 citations, of which seven studies met eligibility criteria (Figure 1). Four studies addressed our primary objective by evaluating interventions based on psychological frameworks, and three predictive studies of hand hygiene behaviour met our secondary objective (Table I). It was not possible to perform meta-analysis due to heterogeneity in study design, intervention, and outcomes.

Studies of hand hygiene interventions based on psychological frameworks

Fuller et al. performed a three-year stepped wedge cluster RCT involving 60 wards [44 acute care units for the elderly (ACEs) and 16 intensive therapy units (ITUs)] across 16 hospitals in England and Wales that were already implementing the na- tional multimodal hand hygiene programme.7 Following a baseline period, hospitals were randomized into the interven- tion every two months. The first component of the intervention was based on goal-setting and control theories. In goal-setting theory, specific and challenging goals, in combination with clear feedback, are used to increase the frequency of a desired behaviour.8 Control theory focuses on the role of feedback in reducing discrepancy between ideal and performed behav- iours.9 HCWs were encouraged to set goals and action plans to perform hand hygiene, and feedback was provided on their compliance. The second phase of the intervention was informed by operant learning theory, which emphasizes the importance of reinforcing desired behaviours.10 HCWs were provided positive reinforcement in the form of praise or re- wards for following recommended hand hygiene practices. The primary, secondary, and tertiary outcome measures were directly observed hand hygiene compliance, ABHR and soap

Id en

tif ic

at io

n Sc

re en

in g

In cl

ud ed

El ig

ib ili

ty

Records identified through database searching

(n = 918)

Records after duplicates removed (n = 876)

Records screened (n = 876)

Full-text articles assessed for eligibility

(n = 232)

Studies included in qualitative synthesis

(n = 7)

Not informed by behavioural or psychological theory (n = 194)

No objective measure of hand hygiene compliance (n = 22)

Non-HCW population (n = 4)

Not peer reviewed (n = 2)

Study did not use primary data (n = 3)

Records excluded (n = 644)

Full-text articles excluded, with reasons

(n = 255)

Figure 1. Overview of study selection.

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210204

consumption, and the prevalence of meticillin-resistant Staphylococcus aureus (MSRA)-positive swabs, respectively.

Thirty-three of the randomized units implemented the intervention. Intention-to-treat analysis revealed a significant increase in hand hygiene compliance in ITUs [odds ratio (OR): 1.44; P < 0.001] but not on ACEs (OR: 1.06; P ¼ 0.5). Per- protocol analysis demonstrated significant increases in hand hygiene compliance on both types of ward, with improvements of 10e13% in ACUs and 13e18% on ACEs. A significant 30% in- crease in liquid soap procurement was also observed in ITUs but there was no significant change in ABHR procurement on either type of ward. Due to difficulties with data collection and MRSA screening, no conclusions about the effect of the intervention on HCAIs could be drawn.

Harne-Britner et al. performed a controlled beforeeafter study of staff education and positive reinforcement among registered nurses and patient care assistants across three medicalesurgical units at an urban hospital in the USA.11 The study was informed by change theory and operant learning, combined with aspects of behavioural, organizational, and social science that were not further specified by the au- thors.10,12 Change theory postulates that driving forces push individuals towards performing behaviour whereas restraining forces oppose such changes; driving forces must be greater than restraining forces in order for change to occur.12 Partici- pants in the control group received education by completing a

self-study module on handwashing, whereas the intervention groups completed the same module but also received positive reinforcement (a sticker-reward system) or information on the risks of non-compliance with hand hygiene. Hand hygiene compliance and unit HCAI rates were measured.

Although the intervention resulted in a 15.5% increase in hand hygiene compliance among the positive reinforcement group during the first month (c2 ¼ 4.27, P ¼ 0.039), this effect was not sustained throughout the intervention period. After six months, there were no significant differences in hand hygiene compliance or HCAI rates between the groups.

Mayer et al. conducted a six-year, two-part study on 12 patient care units at a single tertiary-care hospital in the USA.13

The initial phase was a one-year stepped wedge study of an intervention informed by the theory of planned behaviour.14

According to this theory, intentions to perform a given behav- iour are determined by attitudes (subjective evaluation of the behaviour and outcomes of the behaviour), subjective norms (assessments of whether close others would approve of the behaviour) and perceived behavioural control (assessment of whether one is ready and able to enact the behaviour); in- tentions are then predictive of behaviour. In this study, atti- tude change was attempted via educational campaigns. Subjective norms were communicated through monthly audits and reports of hand hygiene compliance, and perceived behavioural control was addressed by strategically positioning

Table I

Summary of included studies

Study Year Region Study design Study type Setting Participants N Theoretical

framework

Outcome

variable(s)

Results

Fuller et al.7 2012 UK Stepped-wedge cluster randomized trial

Intervention 16 acute general and two teaching hospitals

Nurses, doctors, healthcare assistants and others

Not reported Operant learning theory

Observed hand hygiene compliance; alcohol rub and soap procurement

Intention-to-treat analysis showed significant increase in hand hygiene compliance in intensive treatment units (odds ratio: 1.44; P < 0.001) but not acute care of the elderly units after implementation of intervention campaign. 30% increase in soap procurement in intensive treatment units.

Harne-Britner et al.11

2011 USA Quasi- experimental (controlled beforeeafter)

Intervention Tertiary care teaching hospital

Nurses and personal care assistants

1203 Change theory and othersa

Observed hand hygiene compliance; unit infection rates

No significant differences in hand hygiene adherence between positive reinforcement, risk of non-adherence, and control groups at six-month follow- up (P ¼ 0.69). No significant change in unit infection rates at six-month follow-up (P ¼ 0.09).

Mayer et al.13 2011 USA Controlled beforeeafter and time-series

Intervention Tertiary care hospital

Healthcare workersa

36,123 hand hygiene moments

Theory of planned behaviour and positive reinforcement

Observed hand hygiene compliance; MRSA and VRE infection rates

Hand hygiene compliance in experimental groups significantly increased compared to controls following implementation of the theory of planned behaviour intervention (P < 0.001). Overall increase in hand hygiene compliance following implementation of positive reinforcement campaign.b No significant change in MRSA or VRE infection rates.c

Pontivivo et al.15 2012 Australia Uncontrolled beforeeafter

Intervention Four teaching hospitals

Nurses 11,247 hand hygiene moments

Theory of planned behaviour and positive reinforcement

Observed hand hygiene compliance; MRSA bacteraemia rates

Hand hygiene compliance increased from 62% to 75% following intervention.c

Significant increases in observed compliance for nurses and medical staff (c2 ¼ 43.05, P < 0.001 and c2 ¼ 33.8, P < 0.001,

(continued on next page)

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Table I (continued )

Study Year Region Study design Study type Setting Participants N Theoretical

framework

Outcome

variable(s)

Results

respectively). No significant change in observed compliance for allied health workers. Rates of S. aureus infections decreased from 0.6e2.55 to 0e0.65 infections per 10,000 occupied bed-days following intervention.b

Eiamsirakoon et al.19

2013 Thailand Observational Prediction Tertiary care hospital

Nurses, nurse assistants, doctors, technicians, and students

123 Transtheoretical model and theory of planned behaviour

Observed and self-report of hand hygiene compliance

Higher mean observed 5MHH compliance was predicted by higher transtheoretical model stage of change (11.1% for precontemplation vs 28.4% for maintenance; P ¼ 0.04). Positive attitude associated with 5MHH compliance (odds ratio ¼ 1.49, P ¼ 0.04). Significant positive correlations for attitude (r ¼ 0.19, P ¼ 0.03), perceived behavioural control (r ¼ 0.20, P ¼ 0.02), total theory of planned behaviour scores (r ¼ 0.21, P ¼ 0.2) and observed 5MHH compliance.

Fuller et al.20 2014 UK Qualitative cross-sectional survey

Prediction 13 hospitals Nurses, doctors, allied healthcare workers, ancillary staff and other/unknown

Not reported Theoretical domains framework

Observed hand hygiene compliance

Majority of non-compliant hand hygiene episodes were explained by the memory/attention/ decision-making (42%) and knowledge (26%) domains.

O’Boyle et al.18 2001 USA Longitudinal observational

Prediction Four teaching hospitals

Nurses 120 Theory of planned behaviour

Observed hand hygiene compliance

Theory of planned behaviour variables were significantly associated with intention and self-reported hand hygiene compliance, but not observed compliance.

MRSA, meticillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci; 5MHH, five moments for hand hygiene. a Not further specified by authors. b No control group and no time-series analysis performed. c Authors did not report statistical significance.

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ABHR in convenient locations. Following the initial interven- tion, positive reinforcement strategies (e.g. rewards and motivational campaigns) were implemented hospital-wide for five years. The study outcomes were directly observed hand hygiene compliance and hospital-acquired MRSA and vancomycin-resistant enterococci infection rates.

Hand hygiene compliance in the experimental groups increased significantly compared to controls (P < 0.001) following the initial theory of planned behaviour intervention. At the start of the hospital-wide positive reinforcement inter- vention, hand hygiene compliance rates were 28e68%, increasing to 59e81% by the end of the study. No significant changes in infection rates were reported.

Pontivivo et al. tested an intervention based on the trans- theoretical model of change and the Pathman awareness-to- adherence model at a teaching hospital in Sydney, Australia, using a beforeeafter design.15e17 In the transtheoretical model, behaviour change is conceptualized as a readiness-to- change model, in which an individual progresses through a series of stages from precontemplation (not ready to change) to action and maintenance (adopting the new behaviour and sustaining it).16 Pathman’s model was developed to assist the adoption of clinical guidelines and employs a combination of education, auditing, and feedback to assist individuals in adopting and adhering to recommended practices.17 The ma- jority of HCW participants were nurses, and outcomes included directly observed hand hygiene compliance and healthcare- associated Staphylococcus aureus bacteraemia rates. Their theory-based intervention consisted of coaching, competi- tions, group evaluation and feedback, and executive endorse- ment of hand hygiene compliance. It was unclear how the transtheoretical model was used to inform their intervention; rather, the intervention appeared to address the various stages in the Pathman model.

Following implementation of the intervention, rates of hand hygiene compliance were significantly greater among nurses (c2 ¼ 43.05, P < 0.001) and medical staff (c2 ¼ 33.8, P < 0.001). There was no significant change in compliance among allied health practitioners. A non-significant reduction in S. aureus bacteraemia rates was also observed.

Studies using psychological frameworks to predict hand hygiene behaviour

O’Boyle et al. were among the first to apply psychological theory to HCW hand hygiene compliance.18 Using a longitudinal observational design, they compared compliant and non- compliant nurses at four teaching hospitals in the USA using the theory of planned behaviour. Nurses filled out a theory- based questionnaire and were then observed for 2 h or 10 hand hygiene opportunities. Whereas the model successfully predicted intention to handwash, which was related to self- reported hand hygiene, the correlation between self- reported and observed hand hygiene was low (r ¼ 0.21, P < 0.05). None of the theory of planned behaviour constructs were significantly related to observed hand hygiene compliance.

Eiamsitrakoon et al. conducted a study in a tertiary care hospital in Thailand with a sample comprised primarily of nurses.19 Researchers observed hand hygiene according to the World Health Organization ‘five moments of hand hygiene’ and

then gave participants a survey based on the theory of planned behaviour and transtheoretical model constructs.2 There was a weak but significant positive correlation between total theory of planned behaviour scores and observed hand hygiene compliance (r¼ 0.21, P¼ 0.02), and a stronger correlation with self-reported hand hygiene compliance (r¼ 0.53, P< 0.001). In addition, self-reported and observed hand hygiene compliance tended to increase with higher transtheoretical model stages of change. For example, self-reported hand hygiene compli- ance was lower for individuals in the precontemplation stage compared to those in the maintenance stage (64.7% vs 84.4%, P ¼ 0.01); similarly, observed compliance was lower among participants in precontemplation compared to those in main- tenance (11.1% vs 28.4%, P ¼ 0.04).

Fuller et al. used the theoretical domains framework to identify behavioural domains associated with hand hygiene compliance.20 They surveyed a sample of HCWs from 13 hos- pitals in England. The theoretical domains framework is an amalgam of 33 behaviour change theories and was developed primarily as an assessment tool to identify areas of focus for implementation researchers.21 Participants in the 2012 Fuller et al. RCT who were observed practising poor hand hygiene were asked to provide an explanation, which was coded and categorized using the theoretical domains framework. The majority of self-reported explanations for non-compliance were found to be related to memory/attention/decision- making (42%) and knowledge (26%) domains. Memory/ attention/decision-making includes forgetting to perform hand hygiene, lapses in concentration or awareness that result in missed hand hygiene opportunities, and being distracted by interruptions. Instances in which HCWs were unaware that hand hygiene practice was necessary were included in the knowledge domain.

Quality assessment

The risk of bias of the included studies was moderate to high (Table II). Among studies examining theory-informed in- terventions, the most significant limitation was a lack of clear descriptions indicating how interventions were designed to address theoretical behavioural constructs.7,11,13,15 Lack of adequate controls, unrepresentative HCW samples, and attri- tion also negatively influenced risk of bias and study quality.7,11,13

The quality of included predictive studies was influenced by a lack of clear inclusion/exclusion criteria and unrepresenta- tive samples.7,18,19 In addition, the Hawthorne effect could have influenced the behaviour of participants who were aware that their hand hygiene adherence was being evaluated, and social desirability bias may have affected self-reported reasons for non-compliance.18,20

Discussion

The goal of this systematic review was to identify studies that used psychological theories of behaviour change to inform interventions to increase or predict hand hygiene compliance among HCWs. In addition, we hoped to identify promising behavioural constructs that can be used to guide the devel- opment of assessment tools and inform future hand hygiene interventions. We identified four intervention studies that used

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J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210208

operant learning (positive reinforcement), change theory, the theory of planned behaviour, and the transtheoretical model, as well as three prediction studies based on the theory of planned behaviour, the transtheoretical model, and theoret- ical domains framework.

The study of HCW hand hygiene has produced a considerable amount of literature; however, very few studies are grounded in behaviour change theory. A previous systematic review of behaviour change strategies in infection prevention and con- trol found no interventions that specifically mentioned any theory.22 However, that review considered all infection pre- vention and control behaviours, not just hand hygiene, and included only studies conducted in acute care settings. To our knowledge, this is the first review of psychological theories that have been applied to hand hygiene compliance in healthcare settings.

Interventions based on behavioural constructs (e.g. atti- tudes, intentions, self-efficacy) have been found to be more successful at increasing hand hygiene behaviour than in- terventions that address knowledge, awareness, and facilita- tion alone.4 Of the studies included in this review, theory- informed interventions had mixed results but generally pro- duced increases in hand hygiene compliance among HCWs, and two of three studies found that behavioural theory could pre- dict hand hygiene behaviour. This indicates the potential benefit of applying behaviour change theory in infection pre- vention and control, although sustainability of improvement and generalizability across divergent clinical settings is yet to be demonstrated.

Our review underscores the importance of clearly describing how the specific behavioural constructs are applied to inform the development of intervention strategies. We found that in some cases where behavioural theories have been applied, the precise operationalizations used in these studies have not fully captured the constructs specified in the theories. In some cases, measures have not corresponded to the theoretical definitions specified by the models. In other cases, failures to effectively represent key constructs have been more subtle. For example, the theory of planned behaviour stresses the importance of targeting constructs at the same level of speci- ficity as the behavioural outcome of interest. Thus, if the goal of a study was to predict or influence the degree to which healthcare workers apply ABHR prior to each patient contact, the operationalization of the theory of planned behaviour variables should be at the same level of specificity rather than focusing on attitudes, subjective norms, and perceived behavioural control related to hand hygiene in general.

Moreover, whereas many studies cited behavioural frame- works, the interventions tended to rely on standard multimodal programmes focusing on education, reminders, and availability of hand hygiene products.23 Specifically, interventions relied heavily on audit and feedback, education, and positive rein- forcement.7,11,13,15 Whereas positive reinforcement is an important construct in the behaviourist approach, the suit- ability and sustainability of interventions that rely on rewarding appropriate hand hygiene behaviour is questionable. Individuals can habituate to rewards quickly and thus rewards can lose their reinforcing properties.10 We posit that if in- terventions are to have lasting effects, they must go beyond simply increasing knowledge and incentivizing good behaviour. Like other health behaviours (e.g. dieting, exercise, and smoking cessation), hand hygiene is best understood in terms of

No. Searches

1 Hand Disinfection/ or Hand Hygiene/ 2 (((clean* or disinfect* or hygiene* or wash* or

scrub*) adj3 hand?) or handwash*).mp. 3 limit 2 to (‘in data review’ or in process or

‘pubmed not medline’) 4 1 or 3 5 exp Health Personnel/ or Allied Health

Personnel/ or Emergency Medical Technicians/ or Infection Control Practitioners/ or Medical Staff/ or Nursing Staff/ or Nurses/ or Nurse Practitioners/ or Physicians/

6 (((health* or hospital or acute care or primary care or medical or infection control) adj2 (worker? or staff or personnel or practitioner? or provider? or technician?)) or HCW? or HCP? or doctor$ or physician? or nurs* or paramedic* or clinician* or pediatrician* or general practitioner* or pharmacist* or hospitalist* or midwi*).mp.

7 5 or 6 8 ((theor* adj2 (‘reasoned action’ or (planned

adj1 behavio?r) or ‘normative conduct’ or ‘social cognitive’ or ‘self efficacy’)) or (model? adj2 (‘habit-goal’ or transtheoretical or ‘health belief’ or ‘habit goal’ or (behavio? r* adj1 change?))) or ‘health action process’).mp.

9 (fishbein or ajzen or fazio or cialdini or prochaska or diclemente or rosenstock or bandura or schwarzer or wood).mp.

10 8 or 9 11 (((behavio?r* or habit? or practice?) adj2

(chang* or alter* or modif*)) or positive devian* or ((psychology or psychological*) adj3 (framework? or intervention* or theor*))).mp.

12 motivation/ or health behavior/ or guideline adherence/ or health knowledge, attitudes, practice/ or emotions/ or psychological theory/ or px.fs.

13 11 or 12 14 attitude of health personnel/ 15 4 and 7 and 10 16 4 and 7 and 13 17 4 and 14 18 15 or 16 or 17 19 limit 18 to english language 20 limit 19 to (comment or editorial or letter) 21 19 not 20

J.A. Srigley et al. / Journal of Hospital Infection 91 (2015) 202e210 209

socio-cultural, organizational, perceptual, cognitive, and psy- chological determinants.

Although the included studies add to our understanding of HCW hand hygiene behaviour, many gaps in the literature remain. Thus far, studies have used models that are best suited to explain deliberative behaviours.24 However, hand hygiene is a repetitive, automatic behaviour that may lead to the for- mation of a habit.14 It may be beneficial to consider hand hy- giene as a spontaneous behaviour involving non-thoughtful behavioural responses shaped by perceptions of the context and environment.24 Future interventions may benefit by drawing from theories that are well suited to explain sponta- neous, habitual behaviours, such as the MODE model of atti- tudeebehaviour consistency, the focus theory of normative conduct, or habit theories.24e26

Importantly, the types of intervention strategies suggested by theories designed to explain spontaneous behaviour are likely to differ from the intervention strategies that have thus far been explored in the literature. For example, although social norms have been a focus of deliberative theories such as the theory of planned behaviour, the focus theory of normative conduct postulates that the types of norms most likely to in- fluence spontaneous behaviours are different from those that have been the focus of past interventions. Specifically, past interventions have focused on targeting injunctive norms (i.e. perceptions of what other people think we should do), whereas descriptive norms (i.e. perceptions of what other people are actually doing) are more likely to influence spontaneous be- haviours. Further, habit theories stress the importance of establishing strong automatic associations between perfor- mance of a behaviour and contextual cues at the time the behaviour is initially instantiated and then ensuring that these contextual cues are present in the environment where the behaviour will later be performed.

Several limitations must be acknowledged when considering the findings of this review. First, studies were only included if the authors identified that their research had been informed by a specific theory. If a theory was not named, the study would not have been included, resulting in the exclusion of potentially relevant works. Second, studies that did not use an objective measure of hand hygiene compliance and included only self- report were excluded, which eliminated some studies that applied psychological theories. However, issues with the accu- racy and reliability of self-reported hand hygiene behaviour among HCWs are well documented, justifying the use of directly observed compliance as a more robust outcome.2 Third, as non- English publications were excluded, this review may have omitted pertinent studies published in other languages. Finally, we focused this review at the level of individual behaviour and excluded studies based on sociological theories, such as positive deviance or frontline ownership; however, these strategies are also promising areas for future study.27

Psychological frameworks of behaviour change demonstrate significant potential for predicting hand hygiene behaviour and informing interventions to improve hand hygiene compliance. There is a clear need for additional research into the utility and applicability of psychological models of behaviour change to inform interventions to improve hand hygiene compliance among HCWs. The development of theory-based interventions to improve HCW hand hygiene compliance has the potential to increase the quality of care received by patients and limit the spread of infections in healthcare settings.

Conflict of interest statement None declared.

Funding sources None.

Appendix A. Medline search strategy

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