How Behavior Change Strategies Can Help Prevent Hospital Infections

On March 30, 2017 at the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, plenary speaker Matthew W. Kreuter, PhD, MPH, from The Brown School at Washington University in St. Louis, afforded conference attendees fresh insight on delivering health behavior change strategies in order to better prevent hospital infections.

According to Dr. Kreuter, the founding father of health behavior theory is Albert Bandura, who stressed that there are three essential factors that matter when it comes to behavior change: the person, the environment, and the behavior.

When it comes to the person who will be taking on the behavioral change, “what that person thinks, what they know, what they believe, [and] what they feel, [are] all personal-level variables [that] influence behavior,” Dr. Kreuter said. Environmental factors consist of social factors such as the individuals in your surroundings, laws or policies, or any other environmental conditions that “present or restrict opportunities for people to engage in particular behaviors.” Lastly, there is behavior itself, and the key takeaway that Dr. Kreuter stressed is that “behavior is not behavior is not behavior; it’s not one thing. The characteristics and the demands of different behaviors are different, and you have to understand those [differences] if you are going to be able to select appropriate strategies to change those behaviors.”

Dr. Kreuter emphasized that these variables aren’t siloed off; they affect one other. For example, just as environment can affect behavior, behavior can affect environment, and he referred to that interplay as “reciprocal determinism.”

Dr. Kreuter then proceeded to outline a three-step approach for assessing and addressing a problem from a behavioral science perspective. The first step is to “try to understand behavior, people, and environment for a particular behavior or set of behaviors.” Then, try to identify the determinants of that behavior. Finally, you can begin developing and testing strategies for that behavior.

To tackle the first step of the approach, understanding behavior, people, and environment is key. Some of the behaviors of particular interest in the healthcare setting consist of the following: sanitizing hands when going in and out of patient rooms, making sure healthcare workers are vaccinated or staying home when they are ill, antimicrobial stewardship, and adhering to guidelines for standard procedures such as removing catheters or central lines, among others. Doctors, nurses, and other healthcare workers are the people who are expected to perform these behaviors. They are all committed to improving their patients’ outcomes, but they may also have a little bit of what Dr. Kreuter refers to as “a curse of smartness,” which means that they may rely on their instincts or memory more than guidelines or checklists. The environment that all of this is happening in is also important, and in this instance it is hospitals and healthcare systems, which are complex, making the coordination of “getting everybody moving in the same direction” challenging. Furthermore, “the degree to which different systems are designed to support infection prevention can also vary,” Dr. Kreuter noted.

After gaining understanding, you must focus on identifying determinants of behaviors, or the factors that influence behaviors. According to Dr. Kreuter, there are three types: predisposing factors, enabling factors, and reinforcing factors.

Dr. Kreuter explained, “Predisposing factors are those that increase or decrease a person’s motivation to engage in behavior change, [while] enabling factors are those that support or hinder a person’s efforts to make a desired behavior change. ‘I’ve decided to change, I’m attempting to change this behavior, what is it that makes it easier or harder for me to do that?’ And then, reinforcing factors. ‘When I’ve actually engaged in the behavior, what happens next that encourages me or discourages me from continuing that desired behavior?’”

Examples of predisposing factors consist of: knowledge (awareness, understanding risks of hospital infections and the consequences of taking preventive action), attitudes (believing that preventive actions are very important), beliefs (believing that adherence to prevention standards will, in fact, make a difference), confidence (providers are confident that they can stand up to patients who insist on unnecessary antibiotics and will not prescribe them), and identity (how much a professional identity is entwined with preventive behaviors).

Examples of enabling factors consist of: skills (ways to encourage or even oppose one another pertaining to preventive practices), barriers/obstacles (some healthcare workers might hesitate to stay home from work when ill due to staffing shortages or fear of being perceived as unreliable), policies and culture (what are the key values of the organization), social and professional norms (will an organization give their workers recognition even if they do not excel at preventing hospital infections?), and systems, infrastructure, and design (sometimes safeguards that are put into place by healthcare organizations can vary).

Examples of reinforcing factors are: benefits/rewards (are healthcare workers recognized when they do prevent hospital infections? Do they get rewarded?), and conversely, consequences (if they do not reinforce preventive practices to ward off hospital infections, are there repercussions?).

Dr. Kreuter stressed that there are a few ways that behaviors vary; some are complex (making changes to diet) and some are simple (putting on your seatbelt); some are done only annually (such as vaccination) and some are done every day (handwashing). Some benefits of a behavior are certain (save money so that it accrues) and some are not (vaccination does not offer surefire protection). Some benefits of a behavior are immediate (brush teeth and my mouth feels cleaner), some are more long-term (eating healthier to prevent a heart attack). Some behaviors benefit the person directly (wearing a helmet protects individual personally from a crash) and some benefit others (smoking outside so children do not inhale it). When it comes to a behavior that is in accordance with social norms, it may be easier to perform than those that are not so widely accepted. So, how does this apply to preventing hospital infections?

According to Dr. Kreuter, the behaviors that are the easiest to change are the ones that are: simple, repeated, support social norms, and have both certain and immediate benefits to the individual performing the behavior change.

It turns out that many of the desired behaviors are easy; and, for the most part, habitual, such as performing hand hygiene or receiving a flu shot. The challenge lies in the fact that many of these behavior changes are beneficial to others more than the individual performing them. Conversely, the consequences are also experienced by someone else if they are not performed sufficiently. Dr. Kreuter explained, “It’s not as if the patient turns green and crumples up the moment you touch them with an unwashed hand.” The consequences are not always immediate, and, therefore, these yield low accountability.

In order to overcome these challenges, one must “identify meaningful benefits to the person engaging in the behavior,” said Dr. Kreuter. Trying to personalize the consequences for the person performing the behavior and changing professional norms will also help. Dr. Kreuter stressed that the motivation for engaging in a behavioral change will vary from person to person. He said, “We should never assume that our reason for doing a behavior (prevention!) or caring about it, is what is going to motivate people to act. Do we want people to do the behavior for our reasons or do we want [them] to do the behavior? I think it’s the latter.”

Dr. Kreuter stressed that behavior change focuses on two things: relevance to the individual’s life and self-reflection. He said, “Getting people to consider a behavior change/consequence [is easier when] it relates to them, their family, their life, and their career. When you can do that, then you have a chance. [But], how do you do that?” This can be done by making the individual aware that a problem exists, that it affects others, and that these other individuals who are affected are just like them. This way, they are more likely to reflect on the problem at hand and take preventive action.

Dr. Kreuter concluded, “Promoting behavior change in ways that make it very personally relevant, using authentic stories from credible messengers that stimulate emotion, trying to identify meaningful benefits and meaningful consequences for the behaviors that you’re trying to promote, providing people with performance feedback, changing social norms, addressing some of these biases we talked about,” all play a role in how behavior changes can work to prevent hospital infections.

DISCLOSURES

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SOURCE

SHEA Spring 2017 Conference

PRESENTATION

Plenary: May the Forces Be with You: Understanding How to Change Behavior