Journal of Hospital Infection xxx (2015) 1e9

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

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
b
University of Ottawa, University of Ottawa Institute of Mental Health Research, Ottawa Hospital Research Institute, Ottawa,
Ontario, Canada
c
Department of Psychology, Queens University, Kingston, ON, Canada

A R T I C L E I N F O S U M M A R Y

Article history: Background: Despite the importance of hand hygiene in preventing transmission of
Received 12 April 2015 healthcare-associated infections, compliance rates are suboptimal. Hand hygiene is a
Accepted 27 June 2015 complex behaviour and psychological frameworks are promising tools to influence
Available online xxx healthcare worker (HCW) behaviour.
Aim: (i) To review the effectiveness of interventions based on psychological theories of
Keywords: behaviour change to improve HCW hand hygiene compliance; (ii) to determine which
Behaviour frameworks have been used to predict HCW hand hygiene compliance.
Hand hygiene Methods: Multiple databases and reference lists of included studies were searched for
Psychology 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 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection
Society. All rights reserved.

* Corresponding author. Address: BC Childrens & Womens Hospital, Laboratory Medicine, Room 2J3, 4500 Oak Street, Vancouver, BC, Canada
V6H 2N9. Tel.: 1 604 875 2305.
E-mail address: jocelyn.srigley@cw.bc.ca (J.A. Srigley).

http://dx.doi.org/10.1016/j.jhin.2015.06.019
0195-6701/Crown Copyright 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. All rights reserved.

Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
2 J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9
Introduction
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.
Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
Data extraction and quality assessment
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
 J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9
Identification
Records identified through
database searching
(n = 918)
Records after duplicates removed
(n = 876)
Screening
Records screened
(n = 876)
Full-text articles
Eligibility
assessed for eligibility
(n = 232)
Studies included in
Included
qualitative synthesis
(n = 7)
Figure 1. Overview of study selection.
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 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
Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
3
Records excluded
(n = 644)
Full-text articles excluded,
with reasons
(n = 255)
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)
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 4.27, P 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

4
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand

Summary of included studies

Study Year Region Study design Study type Setting Participants N Theoretical Outcome Results
framework variable(s)
Fuller et al.7 2012 UK Stepped-wedge Intervention 16 acute Nurses, doctors, Not reported Operant Observed hand Intention-to-treat analysis
cluster general healthcare learning hygiene showed significant increase
randomized and two assistants theory compliance; in hand hygiene compliance
trial teaching and others alcohol rub in intensive treatment units
hospitals and soap (odds ratio: 1.44; P < 0.001)
procurement but not acute care of the
elderly units after
implementation of

J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9

intervention campaign.
30% increase in soap
procurement in intensive
treatment units.
Harne-Britner 2011 USA Quasi- Intervention Tertiary Nurses and 1203 Change Observed hand No significant differences
et al.11 experimental care personal theory hygiene in hand hygiene adherence
(controlled teaching care assistants and othersa compliance; between positive
beforeeafter) hospital unit infection reinforcement, risk of
rates non-adherence, and
control groups at six-month
follow-
up (P 0.69). No significant
change in unit infection
rates at six-month follow-up
(P 0.09).
Mayer et al.13 2011 USA Controlled Intervention Tertiary Healthcare 36,123 hand Theory of Observed hand Hand hygiene compliance
beforeeafter care workersa hygiene planned hygiene in experimental groups
and time-series hospital moments behaviour compliance; significantly increased
and positive MRSA and VRE compared to controls
reinforcement infection rates 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 Intervention Four Nurses 11,247 hand Theory of Observed hand Hand hygiene compliance
beforeeafter teaching hygiene planned hygiene increased from 62% to
hospitals moments behaviour compliance; 75% following intervention.c
and positive MRSA Significant increases in
reinforcement bacteraemia observed compliance for
rates nurses and medical staff
 (c2 43.05, P < 0.001
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand

and c2 33.8, P < 0.001,

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 2013 Thailand Observational Prediction Tertiary Nurses, nurse 123 Transtheoretical Observed and Higher mean observed

J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9

et al.19 care assistants, model and self-report of 5MHH compliance was
hospital doctors, theory of hand hygiene predicted by higher
technicians, planned compliance transtheoretical model
and students behaviour stage of change (11.1%
for precontemplation vs
28.4% for maintenance;
P 0.04). Positive attitude
associated with 5MHH
compliance (odds
ratio 1.49, P 0.04).
Significant positive
correlations for attitude
(r 0.19, P 0.03),
perceived behavioural
control (r 0.20, P 0.02),
total theory of planned
behaviour scores (r 0.21,
P 0.2) and observed
5MHH compliance.
Fuller et al.20 2014 UK Qualitative Prediction 13 hospitals Nurses, doctors, Not reported Theoretical Observed hand Majority of non-compliant
cross-sectional allied healthcare domains hygiene hand hygiene episodes
survey workers, ancillary framework compliance were explained by the
staff and memory/attention/
other/unknown decision-making (42%)
and knowledge (26%)
domains.
OBoyle et al.18 2001 USA Longitudinal Prediction Four Nurses 120 Theory of Observed hand Theory of planned
observational teaching planned hygiene behaviour variables were
hospitals behaviour compliance 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.

5
c
Authors did not report statistical significance.
6 J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9
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 Pathmans 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 43.05, P < 0.001) and medical staff (c2 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
OBoyle 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 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
Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
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 (r 0.21, P 0.02), and a stronger correlation with
self-reported hand hygiene compliance (r 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 0.01); similarly, observed compliance was lower among
participants in precontemplation compared to those in main-
tenance (11.1% vs 28.4%, P 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
 J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9 7
operant learning (positive reinforcement), change theory, the

of public health?
the findings? within the scope
Can the results
theory of planned behaviour, and the transtheoretical model,

Assessment of
applicability

be applied
as well as three prediction studies based on the theory of

Unclear
planned behaviour, the transtheoretical model, and theoret-

Yes
Yes
Yes

Yes
Yes
Yes
ical domains framework.
The study of HCW hand hygiene has produced a considerable
amount of literature; however, very few studies are grounded
confident about in behaviour change theory. A previous systematic review of
Can I be

Unclear
Unclear
behaviour change strategies in infection prevention and con-
trol found no interventions that specifically mentioned any

Yes
Yes

Yes
No

No
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
Is the research Are the authors

transparent?

knowledge, this is the first review of psychological theories

explicit and
conclusions

that have been applied to hand hygiene compliance in

Yes
Yes
Yes
Yes
Yes
Yes
Yes
healthcare settings.
Assessment of validity

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-
methodology free

terventions that address knowledge, awareness, and facilita-

from bias?

tion alone.4 Of the studies included in this review, theory-

Yes
No
No
No

No
No
No

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
results clearly described? appropriate for the
scope of research?

benefit of applying behaviour change theory in infection pre-

methodology
Is the study

vention and control, although sustainability of improvement

and generalizability across divergent clinical settings is yet to
Yes
Yes
Yes
Yes
Yes
Yes
Yes

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
address a topic(s) presented methodology and procedures
Is the study Are the research Are ethics

Unclear

some cases where behavioural theories have been applied, the

precise operationalizations used in these studies have not fully
Yes
Yes

Yes

Yes
Yes
No

captured the constructs specified in the theories. In some

Assessment of reliability

cases, measures have not corresponded to the theoretical

definitions specified by the models. In other cases, failures to
described?

effectively represent key constructs have been more subtle.

Yes
Yes
Yes

Yes
Yes
Yes

For example, the theory of planned behaviour stresses the

No

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,
Unclear
relevant to the issue clearly?

the operationalization of the theory of planned behaviour

Yes

Yes
Yes
Yes
Yes

variables should be at the same level of specificity rather than

No

focusing on attitudes, subjective norms, and perceived

under investigation?

behavioural control related to hand hygiene in general.

Risk of bias assessment (MetaQAT) summary

Does the study

Assessment of

Moreover, whereas many studies cited behavioural frame-

relevance

works, the interventions tended to rely on standard multimodal

Yes
Yes
Yes
Yes
Yes
Yes
Yes

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-
Eiamsitrakoon et al.19

Harne-Britner et al.11

ability and sustainability of interventions that rely on

Pontivivo et al.15

rewarding appropriate hand hygiene behaviour is questionable.

OBoyle et al.18

Individuals can habituate to rewards quickly and thus rewards

Mayer et al.13
Fuller et al.20
Fuller et al.7

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.
Table II

Study

Like other health behaviours (e.g. dieting, exercise, and

smoking cessation), hand hygiene is best understood in terms of

Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
8 J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9
socio-cultural, organizational, perceptual, cognitive, and psy- Conflict of interest statement
chological determinants. None declared.
Although the included studies add to our understanding of
HCW hand hygiene behaviour, many gaps in the literature Funding sources
remain. Thus far, studies have used models that are best suited None.
to explain deliberative behaviours.24 However, hand hygiene is
a repetitive, automatic behaviour that may lead to the for- Appendix A. Medline search strategy
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 No. Searches
drawing from theories that are well suited to explain sponta-
1 Hand Disinfection/ or Hand Hygiene/
neous, habitual behaviours, such as the MODE model of atti-
2 (((clean* or disinfect* or hygiene* or wash* or
tudeebehaviour consistency, the focus theory of normative
scrub*) adj3 hand?) or handwash*).mp.
conduct, or habit theories.24e26
3 limit 2 to (in data review or in process or
Importantly, the types of intervention strategies suggested
pubmed not medline)
by theories designed to explain spontaneous behaviour are
4 1 or 3
likely to differ from the intervention strategies that have thus
5 exp Health Personnel/ or Allied Health
far been explored in the literature. For example, although
Personnel/ or Emergency Medical
social norms have been a focus of deliberative theories such as
Technicians/ or Infection Control
the theory of planned behaviour, the focus theory of normative
Practitioners/ or Medical Staff/ or Nursing
conduct postulates that the types of norms most likely to in-
Staff/ or Nurses/ or Nurse Practitioners/ or
fluence spontaneous behaviours are different from those that
Physicians/
have been the focus of past interventions. Specifically, past
6 (((health* or hospital or acute care or primary
interventions have focused on targeting injunctive norms (i.e.
care or medical or infection control) adj2
perceptions of what other people think we should do), whereas
(worker? or staff or personnel or practitioner?
descriptive norms (i.e. perceptions of what other people are
or provider? or technician?)) or HCW? or HCP?
actually doing) are more likely to influence spontaneous be-
or doctor$ or physician? or nurs* or
haviours. Further, habit theories stress the importance of
paramedic* or clinician* or pediatrician* or
establishing strong automatic associations between perfor-
general practitioner* or pharmacist* or
mance of a behaviour and contextual cues at the time the
hospitalist* or midwi*).mp.
behaviour is initially instantiated and then ensuring that these
7 5 or 6
contextual cues are present in the environment where the
8 ((theor* adj2 (reasoned action or (planned
behaviour will later be performed.
adj1 behavio?r) or normative conduct or
Several limitations must be acknowledged when considering
social cognitive or self efficacy)) or
the findings of this review. First, studies were only included if
(model? adj2 (habit-goal or transtheoretical
the authors identified that their research had been informed by
or health belief or habit goal or (behavio?
a specific theory. If a theory was not named, the study would not
r* adj1 change?))) or health action
have been included, resulting in the exclusion of potentially
process).mp.
relevant works. Second, studies that did not use an objective
9 (fishbein or ajzen or fazio or cialdini or
measure of hand hygiene compliance and included only self-
prochaska or diclemente or rosenstock or
report were excluded, which eliminated some studies that
bandura or schwarzer or wood).mp.
applied psychological theories. However, issues with the accu-
10 8 or 9
racy and reliability of self-reported hand hygiene behaviour
11 (((behavio?r* or habit? or practice?) adj2
among HCWs are well documented, justifying the use of directly
(chang* or alter* or modif*)) or positive
observed compliance as a more robust outcome.2 Third, as non-
devian* or ((psychology or psychological*)
English publications were excluded, this review may have
adj3 (framework? or intervention* or
omitted pertinent studies published in other languages. Finally,
theor*))).mp.
we focused this review at the level of individual behaviour and
12 motivation/ or health behavior/ or guideline
excluded studies based on sociological theories, such as positive
adherence/ or health knowledge, attitudes,
deviance or frontline ownership; however, these strategies are
practice/ or emotions/ or psychological
also promising areas for future study.27
theory/ or px.fs.
Psychological frameworks of behaviour change demonstrate
13 11 or 12
significant potential for predicting hand hygiene behaviour and
14 attitude of health personnel/
informing interventions to improve hand hygiene compliance.
15 4 and 7 and 10
There is a clear need for additional research into the utility and
16 4 and 7 and 13
applicability of psychological models of behaviour change to
17 4 and 14
inform interventions to improve hand hygiene compliance
18 15 or 16 or 17
among HCWs. The development of theory-based interventions
19 limit 18 to english language
to improve HCW hand hygiene compliance has the potential to
20 limit 19 to (comment or editorial or letter)
increase the quality of care received by patients and limit the
21 19 not 20
spread of infections in healthcare settings.

Please cite this article in press as: Srigley JA, et al., Applying psychological frameworks of behaviour change to improve healthcare worker hand
hygiene: a systematic review, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.06.019
 J.A. Srigley et al. / Journal of Hospital Infection xxx (2015) 1e9
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