Infection Prevention and Behavioral Interventions - Overview of Infection Prevention Programs - Table of Contents - APIC

5.
Infection Prevention and Behavioral Interventions | Overview of Infection Prevention Programs | Table of Contents | APIC 12/30/20, 2:49 PM
Infection Prevention and Behavioral

Interventions
Author(s): Patricia Posa, RN, BSN, MSA, FAAN
St Joseph Mercy Health System
Ypsilanti, MI
Published: October 3, 2014
Abstract
As is the case with patient care treatment regimens, infection
prevention processes in healthcare institutions are often reliant on
healthcare personnels' compliance with behavioral recommendations.
This chapter reviews the application of behavioral science theories as
a guide for planning new or improving existing strategies to prevent
the spread of healthcare-associated infection. It also suggests some
general principles including environmental strategies to apply when
developing educational programs and campaigns purposed to change
behavior.
Key Concepts
Programs to influence the human behavior aspect of infection
prevention must be strategically planned, with reference to relevant
behavioral science theories.
Behavioral science theory applied in infection prevention can make
practitioners more efficient and effective by helping them focus on
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5. Infection Prevention and Behavioral Interventions | Overview of Infection Prevention Programs | Table of Contents | APIC 12/30/20, 2:49 PM
factors likely to be important while avoiding investment of time and

resources into factors unlikely to be important.
The body of human behavior theory is very large and growing.
Although theories presented in this chapter are only a small number
of the whole, they are selected because they are widely used and
tested in diverse settings for a range of behavioral challenges.
Even with sophisticated theoretical underpinnings and best practice
implementation, behavior change theories are rarely fully
successful. The current state of health promotion and behavior
theory application is not sufficient for the complexity of most
behavioral challenges, including those in healthcare environments.
Use of theory will improve our success, not assure total victory
over behavioral problems.
A focus on behavior change must be supported by organizational
policies and procedures and environmental strategies to enhance
the effect obtained by behavioral strategies implemented through
infection prevention and control programming.
Background
How could it be possible that in a society with abundant medical
technology, well-trained clinicians, and widespread access to
healthcare that a key problem in treating illness is the failure of
patients to take prescribed medication leading to more than $100
billion dollars in unnecessary healthcare costs annually?1How could it
be possible that after generations of warnings from health

professionals about one in five adults in the United States still smoke
cigarettes?2How could it be possible that with widespread
understanding among healthcare personnel regarding the means of
transmission of healthcare-associated infections (HAIs), there is
extensive failure to practice effective hand hygiene in hospitals and
nursing homes?3These paradoxes illustrate the fact that our stunning
progress in medical science and engineering has far outstripped our
understanding of the dynamics of learning and human behavior.
Ronald A. Heifetz, a renowned leadership scholar, has identified two

types of challenges when implementing change: technical and
adaptive. "Technical is defined as those that can be solved by the
knowledge of the experts, whereas adaptive requires new learning."4
Technical work is easier than adaptive work. Yet, as the "what," it is

only about 20 percent of the change. Adaptive work, the greater
percentage of transition, is the "how"—where the community that
needs to change must engage in the process, overcome resistance,
and put new wisdom into practice. Infection preventionists (IPs) have
been far too simplistic in their approach to addressing the human
factors of healthcare, whether the focus is on the educational
component of patient care or advancing the adoption of best
practices among healthcare personnel.
Programming, either directed at patients or healthcare personnel,

should be strategically planned. That is, at the very least, the planner
should articulate what it is they want people (the target group) to do.
Table 5-1 has examples of potential behavior change objectives
pursued by IPs. With the starting point of a behavioral objective, IPs
can then work backward to analyze all the factors that must be
addressed in order for that behavior to take place in the target group.
Some of the factors will be self-evident from tried and true clinical
practice, whereas some factors are established after a thorough
research effort. It is easy to find examples of "conventional wisdom"
that turned out to be incorrect. Nevertheless, thoughtful and
resourceful IPs can sometimes solve problems without reference to
sophisticated theories or rigorous clinical trial and error evaluation.
Courageous leaders in infection prevention will ask hard questions to
be sure what passes for routine practice is ultimately evidence based,
not just a matter of tradition and convenience.
Table 5-1 Behavioral Objectives Relevant to Infection Prevention

Practice: Examples
Example 1: By the end of the next six months, 80% of the hospital's staff
working in general patient areas will be following hand hygiene best practice
all or almost all of the time.
working in surgical suites will be following hand hygiene best practice all or
almost all of the time.
working in intensive care (ICU/CICU/NICU) units will be following hand
hygiene best practice all or almost all of the time.
Example 4: By the end of the next six months, 75% of the managed care
organization patients directed to take antibiotics will be taking their
medications correctly and for the proper duration.
Example 5: By the end of the next six months, 90% of clinicians will use
correct gloving techniques when at risk for exposure to patient bodily fluids all
or almost all of the time.
Perhaps more times than not, when IPs are seeking to modify
behavior among patients or healthcare personnel, it will not be
obvious what factors should be addressed. For many years, it was
not apparent what factors were important to help smokers quit or to
support a diabetic patient's compliance to diet. Painful experience
has taught that giving people more information about their smoking,
about their diabetic diet, or about their infection will often not result
in desirable behavior change. In this common void of not being sure
what will work, behavior change theory can provide a useful guide.
Basic Principles
In everyday experience, conversations often start with the phrase,
"My theory on that is …" followed only by someone's homespun
hunch about the way of the world. Although this makes for
stimulating talk between friends and coworkers, the point of
discussion is not really theory in a scientific sense. Behavioral science
theories used in health promotion are not the product of water cooler
banter, but based on rigorous testing of components (or constructs)
of a researcher's ideas. Scientific behavioral theories have a long
gestation period, during which the research team will carefully add,
subtract, and modify factors, always working toward a better way to
predict how people will act in a given set of circumstances. Put
another way, the researchers seek to find the most ideal circumstance
composed of factors that will bring about the greatest change in
people's behavior.
The end result of this work is to be able to define strategies that have
proven successful in facilitating people to adopt desirable health-
related behavior (e.g., eat more fruits and vegetables) or to cease
acting in an unhealthful way (e.g., decrease binge drinking or
smoking). For example, a theory may define principles to motivate
someone to take medication correctly. It is also important to
understand that theory tells us, by default, what factors are not
important. Theory suggests what to do and what not to do. Table 5-2
identifies behavioral theories widely used in health promotion and
potentially helpful when applied to infection prevention practices. This
box's list is only illustrative not exhaustive.
Table 5-2 Behavioral Science Theories Applicable to Infection

Prevention Practice
Health Belief Model

Social Cognitive Theory
Transtheoretical Model
Diffusion Theory
Organizational Development Theory
In-depth presentation of each of these may be found in a number of texts.4
Healthcare personnel are seemingly hard-wired to address health

education problems by giving people information. Telling, or giving
people information, may take the form of one of a number of
strategies including one-on-one exchanges with patients or healthcare
personnel, group teaching, instructional materials, or electronic media.
While giving information may have a role in bringing about change, it
is rarely self-sufficient. Most IPs know this in their heart-of-hearts, but
providing facts and giving information is often the only tool available.
Yet, what might be a more effective approach?
For guidance on this, consider a health promotion planning model

called PRECEDE/PROCEED.5This model shows that an educational
diagnosis, which proposes that a target behavior, stated as a

behavioral objective (see Table 5-1), may be changed by factors
sorted into three categories: predisposing, enabling, and reinforcing.
Predisposing factors are ones that will motivate people to make a
change. Examples of predisposing factors include factual information,
supportive attitudes and beliefs, and personal values. Although
attitudes, beliefs, and values are difficult to change, the usual
approach is to use educational and communication strategies to
establish factual understanding and build attitudes that will help
people to begin the change process. Theory provides guidance on
what facts, attitudes, and beliefs are important (see Table 5-3).
Once people are motivated to begin the change process, enabling

factors will capture their capacity to change. Capacity to change boils
down to two issues: (1) do they have necessary skills and capability,
and (2) do they have the necessary resources? For example, if the
objective is for the healthcare personnel to use best practice gloving
procedures, do they have appropriate gloves accessible when they
need them and can they demonstrate the correct procedure for
gloving? If the objective is for family or significant others visiting in
the hospital to carry out best practice hand hygiene, do they have
ready access to hand sanitizer and instruction? Training and coaching
for skill development or by helping people obtain access to needed
resources may improve enabling factors.
The last category of factors that supports change is called reinforcing

factors because their impact occurs after the target behavior has
been initiated and thereby determines whether it will continue into the
future. Reinforcement may come from the responses and interactions
of team members or supervisors to excellent performance or it may
come from observing the example of a role model, or it may come
from patients' visceral experience (e.g., soreness when beginning an
exercise program) consequent to the behavior. Reinforcing factors can
be managed to optimize behavioral compliance. An example
applicable to infection prevention practices is implementing hand
hygiene protocols that are based on the assumption that healthcare
personnel want to comply with safe patient care practices. Thus,
instead of a punitive response when noncompliance to hand hygiene
is observed, the organization using reinforcing factors would respond
with strategies to motivate proper hand hygiene techniques. For
instance, a positive approach would be "I notice that you did not use
hand hygiene prior to entering the patient's room and I know that you
want the best care for the patient. What would help to ensure your
compliance?" The organization may in this way identify that hand
sanitizers are not located for easy accessibility or that the dispensers
are not kept properly filled or that the healthcare personnel's hands
are often full of supplies prior to entering the room. Implementing
reinforcing factors to sustain practice is about knowing the "how," not
just the "what," of hand-hygiene compliance. An organization based
on promoting culture of patient-centered care, rewarding positive
behavior, and "drilling down" or analyzing the processes that lead to
compliance is predicted to sustain excellent performance and patient
outcomes.
Table 5-3 An Example of Educational Diagnosis of a Behavioral Target

Target: Eighty percent of
outpatients will take their
antibiotics correctly and for the
entire course of the prescribed
regimen.
Predisposing factors Patients will be able to summarize

the benefits of taking antibiotics
correctly, and the hazards of
failing to take them correctly.
Patients will believe that their
medication compliance will have
a major impact on their recovery.
Nursing staff will know the
consequences of exposure to
common HAIs.
Enabling factors Patients have the skill and the

confidence to take their antibiotics
correctly.
Patients are able to fill the
prescription or otherwise obtain
their antibiotic medications.
Workers in clinical areas have
easy access to sinks with
antimicrobial soap and hot water.
Reinforcing factors Patients' medication taking will be

encouraged and supported by
spouse or other family members.
Drug choice and dosage will be
carefully monitored by the
clinician to minimize side effects
that will discourage compliance
with the treatment plan.
Clinical staff members are
rewarded when observed washing
hands coming out of a patient
room.
This educational planning structure will make educational plans more

comprehensive, increase the likelihood of addressing the range of
critical issues determining success, and will identify logical points
where behavioral theory can be helpful.
REVIEW OF KEY BEHAVIORAL THEORIES

The oldest and most widely used behavioral theory is cognitive
theory. Based on abundant research and experiential evidence, the
cognitive approach is no longer tenable.6In brief, cognitive theory
prescribes that the way to change health-associated behavior is to

give people appropriate factual information. Once they know, they will
respond and change appropriately. A corollary is that unhealthy
behavior is attributed to ignorance of factual information about the
behavior and its consequences. To reiterate, possession of some facts
(not all facts) may be important for behavior change, but almost never
is enough to sustain long-term change unless other factors are
addressed. Factors that sustain change are addressed in the following
discussion of additional theories.
The Health Belief Model

The health belief model (HBM) is the oldest theory specifically
developed to understand and predict health-associated behavior. This
is done by focusing on the attitudes and beliefs of individuals. The

model was actually developed in response to the failure of a free
tuberculosis (TB) health screening program in the 1950s. Since then,
the HBM has been adapted to explore a variety of long- and short-
term health behaviors, including sexual risk behaviors and the
transmission of HIV/AIDS. Figure 5-1 illustrates the constructs of
HBM.
HBM starts with the nature of beliefs in a target group regarding how
serious a disease or health problem is and how likely they are to get
the disease. The target group may consist of one person or a class of
people, such as the employees of Hospital A. If the theory application
is to a group of people, some assessment will be required to
understand the prevailing beliefs. Whether the focus is on a single
individual or a group, the intervention would try to narrow any gap
between the actual seriousness and the beliefs that exist, and a gap
between actual susceptibility or risk and existing beliefs about this,
typically through education and communication methods and
materials.
This becomes more complicated when the task is to persuade staff to

take precautions so that patients do not succumb to an HAI. In this
example, healthcare personnel will have some beliefs regarding their
own susceptibility to infection in the context of their work, but their
beliefs about the susceptibility of patients as a result of worker
actions is one step removed. While research evidence does not shed
light on this, it might be supposed that the double motivations of self-
protection and patient protection should be stronger together than
either standing alone.
Figure 5-1.
The Health Belief Model.4
View Image !
Modifying factors have limited practical value. However, these factors

play a role in understanding the target group's learning needs and
might have an impact on the design of interventions. Modifying
factors include age group, gender, race and ethnic group,
socioeconomic status, rural or urban residence, religious affiliation,
and so forth.
Cues to action are communication messages or events that create
heightened awareness regarding the need to respond in some way.

Examples include checkup reminder cards received from the dentist, a
caution or danger sign in the vicinity of some threat, and a serious
and sudden life-threatening medical problem in a family member. The
cue to action construct is similar to "teachable moment" in which a
person is, by circumstances, most ready to listen and learn. Cues to
action may have a very useful role in HAI prevention.
With respect to behaviors presented as solutions to a threatening

health problem, people will weigh the plusses and minuses, the pros
and cons, or, in HBM terminology, the benefits minus the barriers. In
order for a behavior change to occur, the person must anticipate
some gain: better health, social approval, financial savings, improved
functioning, pleasure, and so forth. Gains are balanced against
barriers: factors that make the change difficult or aversive
consequences. Examples of barriers include participation made
difficult by lack of childcare, ease of washing or disinfecting hands,
expense of the kits that include all supplies for line insertion or
maintenance, weight gain as a consequence of quitting smoking, and
the perceived relatively high cost of eating healthy foods compared to
junk food. The job of the IP or their designee is to make sure the
benefits of relevant behavior are well known, to provide additional
benefits (e.g., incentives), and to either eliminate barriers (e.g., provide
gloves that do not easily tear) or to empower people to overcome the
barriers (e.g., skills training).
The final construct in HBM is self-efficacy, which is the person's

confidence in their ability to change and to sustain it long term. An
example of a self-efficacy problem is the hopelessness seen in many
dieters who have failed on a long list of diets; they begin to feel they
cannot be successful. An example more pertinent to this discussion is
the confidence among nursing staff that with all the stresses, time
demands, and organizational chaos sometimes found in busy clinical
units, they are really able to follow best practice hand hygiene 100
percent of the time. Promotion of self-efficacy comes by training and
coaching in techniques, by providing supportive environments, and by
periodic reinforcements.
It is clear that HBM shows potential for applications to various

infection prevention behavioral challenges.7
Figure 5-2.
Reciprocal determinism from Social Cognitive Theory.4
View Image !
Social Cognitive Theory

Social cognitive theory (SCT) is built around the interaction of the
person (their knowledge, temperament, internal motives, skills), their
behavior, and the environment (physical, social, organizational). The
interaction of the three components is called reciprocal determinism
(Figure 5-2). It should be noted that the factors are linked, not in a
one-way cycle, but in a way where each influences the other. In other
words, while it is intuitive that environment will influence behavior, the
model asserts that behavior also exerts an influence on the
environment. For example, if you can get a critical mass of the staff
of a clinical unit to comply with best practice hand hygiene, the social
environment will be changed, providing a tipping point to impact
those staff members lagging behind. Likewise, not only does the
knowledge and attitudes impact behavior, but behavior change can
impact attitudes and beliefs. When state laws mandated adult use of
car seat belts, many people were resistant. However, with extended
experience in avoiding the consequences of disobeying the law,
attitudes in the population have softened so that seat belt use has
become a normal routine for most people, divorced from the threat of
penalties.
So what are the implications of SCT in infection prevention? To begin

with, a person's motivations, knowledge gaps, attitudes, and skill
level must be addressed. This should be done in a multiphasic way,
using varied methods in different places and times, over a term long
enough to provide repeated reinforcement. It will be equally important
to provide an environment supportive of change. This would include
such things as peer support, prompts from patients to professionals,
role modeling by leaders in the healthcare environment, compliance
incentives, and organizational provisions to facilitate best practice
behavior.
Some elements of HBM and SCT are compatible and complementary.

Theory-based planning often will draw upon more than one theory to
guide program development.
Figure 5-3.
Transtheoretical Model or Stage Theory.5
View Image !
Transtheoretical Model or Stage Theory
The principal concept behind stage theory is readiness. For any given
health-associated behavior, people will have diverse orientations to
change. Some will be unaware that a particular change is a desirable
option, whereas others have already completed the change but are at
risk of reversing their progress or relapsing. The corollary to the
recognition that people can be categorized by different levels of
change readiness is that the methods applied to different levels of
readiness will not be the same. For example, the infection prevention
practices needed by a newly employed environmental services worker
will be addressed in a way very different from providing refresher
training to an experienced medical technologist. See Figure 5-3 for an
illustration of transtheoretical model (TTM).
In the healthcare environment of a large institution, healthcare

personnel will be at all levels of readiness to change as outlined by
TTM. Perhaps the major group, the clinical professionals with
advanced degrees and training, will be in the maintenance stage of

readiness with a history of applying infection prevention techniques.
Yet, because of the lack of reinforcement or expectation of the
organization, they are at risk for relapse to substandard practices.
Stage theory provides the IP with concepts to tailor intervention
approaches to the readiness-related learning needs of the various
subgroups of the workforce.
Figure 5-4.
Stage theory applications to hand hygiene promotion.
View Image !
Having healthcare personnel complete brief questionnaires designed

to assess perceptions and practices regarding a recommended action,
such as hand hygiene, can be used to tailor the educational approach
to meet the level of stage-based readiness. In addition, groups
composed of different categories of healthcare personnel may be
gathered into focus groups and interviewed to establish stage of
readiness. Educational strategies are adapted accordingly in
addressing the needs of each of these groups. See Figure 5-4 for an
illustration of strategies tailored to each level of the TTM.
Positive Deviance
Positive deviance (PD) is a behavioral change approach that is based
on the observation that in any community there exists individuals who
have found uncommon practices and behaviors that enable them to
achieve better results than their peers, despite the similarities of
problems and available resources.8This theory is grounded in the
assumption that in every community there are untapped assets or
resources. With the PD approach, sustainable behavioral and social
change can be achieved through identification of solutions that
already exist within a system. PD design consists of four steps:
define, determine, discover, and design.8
This process has been successfully applied to infection prevention

and other health-related problems.8,9,10The Pittsburgh VA hospital
reduced the incidence of methicillin-resistant Staphylococcus
aureus by more than 50 percent in a year and a half using PD.8
Multiple hospitals, using PD, were able to significantly increase
compliance with hand hygiene.8,10One of the key principles of PD is

that the community must own the entire process. They must discover
the uncommon successful behaviors and design ways to expand them
into common practices that are used consistently monitoring their
own progress.
GENERAL CONCEPTS DRAWN FROM LEARNING

AND BEHAVIORAL SCIENCE THEORIES8
In addition to the formal theories discussed, there are some general
principles that should be considered when planning and implementing
education and communication campaigns for patients, family
members, or healthcare personnel. The following list of items provides
some guidance to enhance program planning:
1. Include representatives of the target group into your planning.

Not only does this promote ownership and responsibility, but it
also can also provide insight into what might be more effective
educational strategy.
2. If the target group has a lot of cultural diversity, it will be
important to secure planning input from groups not in the
cultural mainstream of the target group.
3. Repetition of concepts over time and with various instructional
or communication tools will enhance learning.
4. As much as possible, employ active learning strategies as
opposed to just relying on passive, one-way dissemination of
information.
5. Encouragement and recognition of mastery enhance learning.
Learners need to know that they understand, are meeting
expectations, and have strengthened their competency.
6. Multisensory learning is more effective. In developing
instructional and communication strategies, try to use visual,
auditory, and, as appropriate, the senses of taste, touch, and
smell. 7
Learners come with various levels of motivation, vocabulary and

health literacy, existing habits and conceptions, and life experiences.
Thus, an education program has to balance the efficiency of group
instruction and communication against the limits of effectiveness that
are a function of diverse learning needs in a group.
ENVIRONMENTAL STRATEGIES
Experience has taught that education and communications must be
supported by circumstances that facilitate action. For example, the
success of seat belt education was greatly enhanced when seat belt
use became mandatory. The success of youth tobacco education was
increased by policies making cigarettes more expensive. Efforts to
encourage employees to be more physically active can have greater
impact, for example, by designing company stairways that are

attractive and inviting.
Conclusions
The lesson for IPs is that they should work with frontline staff to
improve infection prevention practices through application of theory-
based tools and processes to create sustainable change. They must
also build in environmental strategies to make best practices easier to
do. Examples of this include the number and placement of sinks and
hand sanitizers, the easy availability of gloves and supplies needed
for standard and transmission–based precautions, active involvement
and encouragement by institutional leaders so that a safety-oriented
climate is reinforced and sustained, use of soaps and sanitizers that
are less irritating to skin, use of touchless faucets and towel
dispensers, devices to monitor the frequency and duration of
handwashing, and automated electronic prompts to remind staff to
perform hand hygiene.
This combination of theory-based education, communications, and

environmental approaches, including both physical and organizational
circumstances, will greatly enhance the success of infection
prevention processes reliant on behavior change.
Future Trends
Infection prevention is at the interface between clinical care and
public health. Clinical care tends to be oriented to one case at a time
with an individual assessment-driven plan of care. On the other hand,
public health assesses and intervenes with entire communities or
target groups. To be most successful, infection prevention must
address clinical problems from a public health or systems approach.
The supplemental reading at the end of the chapter reviews some of
the published research on behavioral interventions in infection
prevention. However, we are a long way from a finished evidence
base. Much more research along those lines is waiting to be done.
While numerous theories have been applied to behavior problems in
infection prevention, there are many other theories that have not yet
been tested in the infection prevention arena. Furthermore, theory
researchers will undoubtedly demonstrate the validity of new theories
with relevance in the future
In addition, the evidence on effective public and institutional policies

that provide environmental supports for infection prevention is still in
its infancy. Furthermore, there are new technological tools that
provide solutions but also present new behavioral challenges. Finally,
we must understand how infection prevention practice in tertiary care
medical institutions translates to different settings of care and other
community sites, such as athletic facilities and jails, where infections
increasingly occur. This research agenda goes far out into the horizon
and will occupy young researchers perhaps for the better part of their
careers. Because of the very threatening rise in incidence of some of
the most serious HAIs, these research questions must be supported
and pursued.
International Perspective
Infection prevention is a concern in healthcare in every corner of the
globe. Because of the ease of international movement of people in
the 21st century, there is the prospect of the homogenization of the
microbial climate, requiring the same prevention efforts everywhere.
We have not really seen this in full bloom, but instead tremendous
diversity, even just within the United States, in the incidence of HAIs.
Nevertheless, infection prevention is required everywhere. It is fair to

ask whether policies and procedures considered best practice in
Western medical facilities are relevant and feasible in non-Western
cultures, often with limited resources. It is also fair to ask whether
behavioral theories, largely developed through research in Western
populations, translates well to other cultures. Even in the United
States, the recognized behavioral theories, such as those summarized
in this chapter, do not necessarily explain and predict behavior
perfectly. For example, we could use the HBM to design a campaign
promoting human papillomavirus vaccination. However, some
individuals and groups will have moral values related to use of the
vaccine that will trump the HBM constructs. This risk becomes even
more of a concern the further we are from psychosocial dynamics
considered normal in mainstream Western culture. This does not
mean that the theories are useless, but that it becomes even more
critical to include members of program target groups into early
planning so that you have "on-the-ground" perspectives of what
might or might not be effective in a particular culture or geographic
area.
The application of behavioral theories as tools to guide development

of infection prevention and control programs is still fairly new, even in
advanced nations and communities. This is even more the case in
disadvantaged parts of the world. Whenever our understanding of
best practice and the evidence base for interventions is deficient,
which it clearly is in infection prevention, the critical need for rigorous
evaluation is highlighted. We must determine what works and what
does not work, disseminating our findings so that the knowledge base
from intervention in the developed and the developing world are made
available to all infection preventionists.
Supplemental Resources
American Academy of Pediatrics Respiratory Syncytial Virus Policy.
Available at: Borghesi A, Stronati M. Strategies for the prevention of
hospital-acquired infections in the neonatal intensive care unit. J Hosp
Infect 2008;68:293–300.
Mah MW, Tam YC, Deshpande S. Social marketing analysis of 2 years

of hand hygiene promotion. Infect Control Hosp
Epidemiol 2008;29:262–270.
On the CUSP: Stop HAI, sponsored by Agency for Healthcare

Research and Quality (AHRQ). 2013. Available at
https://www.ahrq.gov/professionals/education/curriculum-
tools/cusptoolkit/index.html.
Pessoa-Silva CL, Hugonnet S, Pfister R, et al. Reduction of health

care associated infection risk in neonates by successful hand hygiene
promotion. Pediatrics 2007;120:e382–e390.
Pittet D. The Lowbury lecture: Behavior in infection control. J Hosp

Infect 2004;58:1–13.
Pyrek KM. Handwashing and cross contamination: Old issue, new

approaches. Infection Control Today March, 2004.
Sax H, Allegranzi B, Uckay I, et al. "My five moments for hand

hygiene": a user-centered design approach to understand, train,
monitor and report hand hygiene. J Hosp Infect 2007;67:9–21.
Sax H, Uckay I, Richet H, et al. Determinants of good adherence to

hand hygiene among healthcare workers who have extensive
exposure to hand hygiene campaigns. Infect Control Hosp
Epidemiol 2007;28:1267–1274.
Whitby M, Pessoa-Silva CL, McLaws ML, et al. Behavioral

considerations for hand hygiene practices: the basic building blocks.
J Hosp Infect 2007;65:1–8.
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5.

Infection Prevention and Behavioral

Published: October 3, 2014

factors likely to be important while avoiding investment of time and

be possible that after generations of warnings from health

Ronald A. Heifetz, a renowned leadership scholar, has identified two

Technical work is easier than adaptive work. Yet, as the "what," it is

Programming, either directed at patients or healthcare personnel,

Table 5-1 Behavioral Objectives Relevant to Infection Prevention

Table 5-2 Behavioral Science Theories Applicable to Infection

Health Belief Model

In-depth presentation of each of these may be found in a number of texts.4

Healthcare personnel are seemingly hard-wired to address health

For guidance on this, consider a health promotion planning model

diagnosis, which proposes that a target behavior, stated as a

Once people are motivated to begin the change process, enabling

The last category of factors that supports change is called reinforcing

Table 5-3 An Example of Educational Diagnosis of a Behavioral Target

Predisposing factors Patients will be able to summarize

Enabling factors Patients have the skill and the

Reinforcing factors Patients' medication taking will be

This educational planning structure will make educational plans more

REVIEW OF KEY BEHAVIORAL THEORIES

prescribes that the way to change health-associated behavior is to

The Health Belief Model

is done by focusing on the attitudes and beliefs of individuals. The

This becomes more complicated when the task is to persuade staﬀ to

The Health Belief Model.4

Modifying factors have limited practical value. However, these factors

Cues to action are communication messages or events that create

heightened awareness regarding the need to respond in some way.

With respect to behaviors presented as solutions to a threatening

barriers (e.g., skills training).

The final construct in HBM is self-eﬃcacy, which is the person's

It is clear that HBM shows potential for applications to various

Reciprocal determinism from Social Cognitive Theory.4

Social Cognitive Theory

So what are the implications of SCT in infection prevention? To begin

Some elements of HBM and SCT are compatible and complementary.

Transtheoretical Model or Stage Theory.5

Transtheoretical Model or Stage Theory

In the healthcare environment of a large institution, healthcare

advanced degrees and training, will be in the maintenance stage of

Stage theory applications to hand hygiene promotion.

Having healthcare personnel complete brief questionnaires designed

This process has been successfully applied to infection prevention

compliance with hand hygiene.8,10One of the key principles of PD is

GENERAL CONCEPTS DRAWN FROM LEARNING

1. Include representatives of the target group into your planning.

Learners come with various levels of motivation, vocabulary and

impact, for example, by designing company stairways that are

This combination of theory-based education, communications, and

In addition, the evidence on eﬀective public and institutional policies

Nevertheless, infection prevention is required everywhere. It is fair to

The application of behavioral theories as tools to guide development

Mah MW, Tam YC, Deshpande S. Social marketing analysis of 2 years

On the CUSP: Stop HAI, sponsored by Agency for Healthcare

Pessoa-Silva CL, Hugonnet S, Pfister R, et al. Reduction of health

Pittet D. The Lowbury lecture: Behavior in infection control. J Hosp

Pyrek KM. Handwashing and cross contamination: Old issue, new

Sax H, Allegranzi B, Uckay I, et al. "My five moments for hand

Sax H, Uckay I, Richet H, et al. Determinants of good adherence to

Whitby M, Pessoa-Silva CL, McLaws ML, et al. Behavioral