WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
18.
Behavioural considerations
18.1 Social sciences and health behaviour
Hand hygiene behaviour varies significantly among HCWs within
the same unit, institution 494,656,688 or country, 787 thus suggesting
that individual features could play a role in determining
behaviour. Social psychology attempts to understand these
features, and individual factors such as social cognitive
determinants may provide additional insight into hand hygiene
behaviour. 724,767,788,789
18.1.1 Social cognitive variables
Over the last quarter of the 20th century, it was stated that
social behaviour could be best understood as a function
of people’s perceptions rather than as a function of real life
(objective facts, etc.). 790 This assumption gave birth to several
models which were based on social cognitive variables and
tried to better understand human behaviour. The determinants
that shape behaviour are acquired through the socialization
process and, more importantly, are susceptible to change –
for which reason they are the focus of behavioural models. In
other areas of health-care promotion, the application of social
cognitive models in intervention strategies has regularly resulted
in a change towards positive behaviour. 790 Some of the so-called
“social cognitive models” applied to evaluate predictors of health
behaviour include: Health Belief Model (HBM); Health Locus of
Control (HLC); Protection Motivation Theory (PMT); Theory of
Planned Behaviour (TPB); and Self-efficacy Model (SEM). The
cognitive variables used in these models are:
• knowledge;
• motivation;
• intention: a person’s readiness to behave in a given way,
which is considered to be the immediate antecedent of
behaviour;
• outcome expectancy: an individual’s expectation that a
given behaviour can counteract or increase a threat and
how one perceives the threat;
• perception of threat: based on the perceived risk/
susceptibility and the perceived severity of the
consequences;
• perceived behavioural control (self-efficacy): the perception
that performance of a given behaviour is within one’s
control;
• subjective norm: beliefs about the expectations of an
important referent towards a given behaviour; 790,791
• behavioural norm: an individual’s perception of the
behaviour of others; 792 subjective and behavioural norms
represent the perceived social pressure towards a certain
behaviour.
18.1.2 Modelling human behaviour
Current models and theories that help to explain human
behaviour, particularly as they relate to health education, can
be classified on the basis of being directed at the individual
(intrapersonal), interpersonal, or community levels. The social
cognitive models mentioned above deal with intrapersonal
and interpersonal determinants of behaviour. Among the
community-level models, the Theory of Ecological Perspective
(also referred to as the Ecological Model of Behavioural
Change) can successfully result in behavioural change. This
theory is based on two key ideas: (i) behaviour is viewed as
being affected by and affecting multiple levels of influence; and
(ii) behaviour both influences and is influenced by the social
environment. Levels of influence for health-related behaviour
and conditions include intrapersonal (individual), interpersonal,
institutional and community factors. 758
Intrapersonal factors are individual characteristics that
influence behaviour such as knowledge, attitudes, beliefs and
personality traits.These factors are contained in social cognitive
determinants. 790
Interpersonal factors include interpersonal processes and
primary groups, i.e. family, friends and peers, who provide
social identity, support and role definition. HCWs, like others in
the wider community, can be influenced by or are influential in
their social environments. Behaviour is often influenced by peer
group pressure, 688,732 which indicates that responsibilities for
each HCW’s individual group should be clearly recognized and
defined.
Community factors are social networks and norms that exist
either formally or informally between individuals, groups and
organizations. For example, in the hospital, the community level
would be the ward. 758 Community-level models are frameworks
for understanding how social systems function and change,
and how communities and organizations can be activated.
The conceptual framework of community organization models
is based on social networks and support, focusing on the
active participation and development of communities that can
help evaluate and solve health problems. Lower hand hygiene
rates in non-nursing staff during ward-specific observations
may, in part, be the result of inconsistent influences from
the immediate social or community environment for those
doctors, student HCWs, and agency nursing staff who move
in and out or between subspecialities. Public policy factors
include local policies that regulate or support practices for
disease prevention, control and management. The role of local
community-based communication through ward-based liaison
or link infection control nurses should be considered when
attempting to have HCWs adopt a core infection control policy.
18.1.3 Application of social sciences to the infection control
field
Few studies have applied social sciences to assess HCWs’
behaviour related to infection control practices. Seto
identified three fields of study in the behavioural sciences
with some degree of relevance to the field of infection control:
social psychology, organizational behaviour and consumer
behaviour. 788 By applying a basic concept from each field,
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