healthcare workers
4.2.4 Study procedure
The study procedure consisted of four sections: i) documentation preparation, ii) sampling and recruitment, iii) data collection, and iv) data analysis.
Documentation preparation
Documents were prepared for the focus group discussions, semi-structured interviews, self-administrated questionnaire, and direct observations. All documents were developed in the Thai language.
Preparing documents included the following steps:
1) Reviewing international guidelines for hospital hand hygiene and the literature on factors affecting hand hygiene compliance; reviewing the TDF definitions[88] on healthcare professional behaviours.[169]
2) Ensuring that questions on documents were based on applying TDF and the previously described barriers and enablers to hand hygiene practice based on previous reviews.
3) Working with the infection control team (ICT) of the hospital site to ensure that all questions were appropriate in this setting
4) Developing an observation form, to enable assessment of current hand hygiene practice in HCWs. This required working with the infection control team (ICT) at the hospital site to create a form which can be feasibly applied for the routine work of ICT as well as for the purpose of this study. Hand hygiene opportunities were defined according to the WHO Hand Hygiene Guidelines, [29] and classified as one of five moments for hand hygiene according to these guidelines.
5) Piloting the form amongst a sample of participants (n=30) working at the study site. Piloting indicated that providers clearly understood the form, and no changes were necessary.
6) Submitting all documents including the protocol, informed consent form, participant information sheet, form for hand hygiene observation and proposed questionnaire
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(including a questionnaire for the focus group discussion, questionnaire for the semi-structured interviews, and the self-administrated questionnaire) to the relevant ethical committee.
Sampling and recruitment
i. A list of HCWs was provided by the hospital's Human Resources department. Recruitment documents (including an invitation letter, study information, an informed consent form, and a questionnaire) were sent to all eligible HCWs at all wards including 16 ICUs and 36 non-ICU
in-patient wards. HCWs, who voluntarily agreed to participate in the study and signed the informed consent form, were included in the study. Participants who refused to
participate in the study or refused to sign the informed consent form were excluded.
ii. For the self-administrated questionnaire, all participants who agreed to sign the informed consent form and complete the questionnaire were recruited.
iii. For focus groups, ten wards from four departments were purposively sampled to obtain a diverse range of participants in term of their professional role and clinical areas in which they worked. One representative of each type of HCW (including physicians, registered nurses (RNs), infection control ward nurses (ICWNs), and nurse-aides) joined in the focus group discussions.
iv. For semi-structured interviews, five selected key administrators, (including the director of the hospital, head of hospital infection control, head of laboratory, and attending physician), who were working in infection control at the hospital were invited to be participants.
v. Observations of hand hygiene practices were performed in the same wards as those used in focus groups discussion. Participants in observational activities were selected by choosing 6 HCWs of each job category including physicians, nurses, practical nurses, nurse-aides, medical students and student nurses working in that ward.
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Data collection
i. The questionnaire survey was conducted during November 2010 to January 2011.
ii. The focus group discussion and semi-structured interviews were undertaken over a period of six months from April 2011. Focus group discussion and interviews were conducted in Thai and observed by members of the hospital ICT. Informed consent was obtained before starting each focus group and interview. HCWs that voluntarily agreed to participate in the study and signed the informed consent form were included in the study. Participants who refused to participate in the study or refused to sign the informed consent form were excluded.
Participants were interviewed in their work place, in a private area which only the research team could access. Focus groups took place in a meeting room at the study site. Focus groups and interviews were noted on the form and recorded on audiotape.
iii. Observation of hand hygiene practices were performed in the same wards as those used in the focus groups discussion. Observations were performed by trained observers with a clear understanding of the WHO guidelines for hand hygiene.[102] Before collecting data, Cohen’s
kappa (for two raters) was used to assess inter-rater reliability.[170] Results from the observations were entered into an observation form derived from the WHO Hand Hygiene
Guidelines.[102] One opportunity of hand hygiene counted as one observation. Results from the observations were entered into an observation form derived from WHO Hand Hygiene Guidelines.[102] The observations were conducted during February to April 2011.
iv. The questionnaire consisted of three parts: the first part was concerned with general information; the second part contained questions to assess current knowledge; and the last part contained questions to assess beliefs about hand hygiene following the TDF. Questions regarding personal knowledge were derived from hand hygiene knowledge questionnaires from the WHO guideline for hand hygiene. [30] Hand hygiene knowledge questionnaires had 8 scale items and scores between 0 and 25. Likert scales with five points were used to capture each participant's degree of agreement with a statement (1 = strongly disagree, 5 = strongly
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agree). There were 16 questions with these scale items and total scores could range between 16 and 80.
v. The focus group discussions made use of five open-ended questions to assess culture and group behavior of HCWs towards infection control and hand hygiene practice. The contents of the interviews covered five mains issues including: (i) current hand hygiene practice, (ii)
reasons for performing hand hygiene, (iii) guidelines on hand hygiene, (iv) obstacles/barriers for hand hygiene practices, and (v) promotions or campaigns to
improve hand hygiene.
vi. The semi-structured interviews consisted of six open-ended questions to assess obstacles to improving infection control and hand hygiene. The contents of the interview covered six mains issues: (i) effective infection control, (ii) knowledge about hand hygiene practice, (iii) attitude toward hand hygiene, (iv) resources, (v) organizational authority of hospital infection control department, and (vi) monitoring and feedback system on infection control.
vii. Hand hygiene observations were recorded in the observation form provided in the WHO guidelines for hand hygiene. [30]
Example questions of each form for capturing the 14 TDF domains are shown in Appendix C.2.
Data analysis
Analysis was performed for both the quantitative data (including data from questionnaire and observations) and for qualitative data (including data from focus groups and interviews).
Quantitative data
Descriptive statistics were used to describe general characteristics of HCWs' current knowledge and current hand hygiene practices. Estimates of internal consistency were calculated for theoretical domains and factors using Cronbach’s alpha with a cutoff of 0.60 which is considered sufficient for preliminary research.[171] Domain scores were based on responses measured on a five-point Likert scale. For negatively worded items, the scale scores were reversed. A mean score of each domain was
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used in the analysis. For identifying barriers and enablers to good hand hygiene practice, a low mean value was taken to suggest that a particular domain may be a barrier, and a high mean value was taken to suggest that it may be an enabler.
Pearson’s correlation coefficients were used to assess correlations between domain scores; these
were defined as weak (0.0 to 0.39), moderate (0.40 to 0.69), or strong (0.70 to 1.0).[172] All analysis was performed using STATA version 14.0 (StataCorp LP, College station, Texas).
Qualitative data
All text data were directly recorded by audiotape and by manual writing on forms. The recordings were transcribed verbatim and transcriptions verified prior to analysis. All the data were analyzed line-by-line until a clear sense of the relationship among the themes emerged. Content analysis was applied using the TDF themes for analysis.[173]
The set of transcript data was analyzed following six steps:
1) Coding and describing transcripts
The 14 TDF domains[88] were taken from standard definitions (Appendix C.2) to classify
“utterances” (coded interview quotes) from the transcript. The coding scheme was generated as guidance to ensure consistency in coding. Each transcript was coded into the 14 TDF domains.
2) Generating specific data
Specific beliefs were generated for each utterance in all TDF domains. A specific belief is
“a collection of participant responses with a similar underlying theme that suggests a problem and/or influence on the target behaviour”.[88]
3) Identification of relevant theoretical domains
Identification and classification of specific data into constructs of each TDF definition was performed.[91] The approach to identification was adapted from Bocart et al., which used psychological theory to inform the choice of methods to implement a hand hygiene
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intervention. [97] An example question for each theoretical construct represented within each domain is presented in Table 4.1.
Table 4.1: The theoretical constructs used to analyses text data and example questions Theoretical constructs
Can you describe the guidelines to perform proper hand hygiene?
Can you discuss when to perform hand hygiene?
Can you describe why you should be performing hand hygiene?
Can you describe how the IC team/ICWN works?
Do you know what information the IC team/ICWN can collect?
Can you explain the proper procedure of performing hand hygiene?
How easy or difficult is it to perform hand hygiene on your unit?
Can you describe how to use the ____?
Do you know how to respond when the IC team/ICWN reminds you?
TDF 3: Social/ professional role and identity Professional identity
Professional role
What role will the IC team/ICWN play in enhancing hand hygiene?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
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Table 4.1: The theoretical constructs used to analyses text data and example questions (cont.) Theoretical constructs
represented within each domain a
Example questions to analyses text b
TDF 3: Social/ professional role and identity Social identity
Do you think the IC team/ICWN should determine how you perform hand hygiene?
Do you feel that the guidelines for performing hand hygiene with the IC team/ICWN are congruent with your
professional standard of practice?
Should proper hand hygiene be practiced at all levels of staff?
How difficult or easy is it for you to maintain proper hand hygiene?
What problems have you encountered when trying to practice proper hand hygiene?
What would help you to increase hand hygiene compliance?
How confident are you that you can increase compliance with the barriers and difficulties you face?
How well equipped and comfortable do you feel in increasing your level of hand hygiene compliance?
When using the IC team/ICWN?
How capable do you feel in maintaining increased compliance with hand hygiene? When using the IC team/ICWN?
How well will this the IC team/ICWN record your hand hygiene?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
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Table 4.1: The theoretical constructs used to analyses text data and example questions (cont.) Theoretical constructs
Does HCW wash their hand every time required for hand hygiene?
Does hand hygiene play an important role in your current practice? For yourself? For your patients? Can you explain why?
Do you believe that the IC team/ICWN will play an important role in your practice?
How will you feel if you are able to increase hand hygiene compliance? How will you feel if you do not?
Do you foresee any positive or negative outcomes of increased hand hygiene compliance on patient outcomes?
Staff outcomes? Do you foresee these
outcomes/consequences as long term or short term?
Do you foresee a negative consequence of using the IC team/ICWN? For patient outcomes? Staff outcomes?
What do you think will happen if hand hygiene compliance is not increased in terms of patient outcomes? Staff outcomes?
Do you think these are short- or long-term consequences?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
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Table 4.1: The theoretical constructs used to analyses text data and example questions (cont.) Theoretical constructs
Do you feel any reward / punishment can increase your hand hygiene compliance?
Would you like to increase your hand hygiene compliance?
Do you feel a need to increase your hand hygiene compliance?
What are your reasons for increasing your hand hygiene compliance?
Is there any aspect of your hand hygiene performance that you could improve on? Frequency, activity related?
Are there other things that you would like to achieve that might interfere with increasing your hand hygiene compliance?
Are there incentives to increasing hand hygiene compliance? If so, what are they?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
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Table 4.1: The theoretical constructs used to analyses text data and example questions (cont.) Theoretical constructs
How will the IC team/ICWN increase hand hygiene compliance?
Who needs to work differently for this to occur? When?
Where?
How do you know whether increased hand hygiene compliance has occurred?
What do you currently do in term of performing hand hygiene?
Is this new or existing behaviour that needs to become a habit?
Can the context be used to prompt you to perform hand hygiene?
(prompts: layout, reminders, equipment)
How long do you think the changes are going to take?
TDF 10: Memory, attention and decision processes Memory
Attention Attention control Decision making
Cognitive overload/tiredness
Do you usually perform hand hygiene? How often on a regular shift?
Do you consciously think and make the decision to wash your hands?
What factors influence that decision? Type of care activity?
Type of patient? Time?
How much attention do you have to pay to perform hand hygiene?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
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Table 4.1: The theoretical constructs used to analyses text data and example questions (cont.) Theoretical constructs
represented within each domain a
Example questions to analyses text b
TDF 10: Memory, attention and decision processes
Do you remember to perform hand hygiene? How?
Do you think the reminder system in the IC team/ICWN will enhance your hand hygiene?
Can you think of times where you might not perform hand hygiene, such as competing tasks or time constraints?
TDF 11: Environmental context and resources
Have you used a wearable alcohol dispenser device? How does this impact your hand hygiene performance?
To what extent do physical or resource factors, such as the availability and functioning of wall units and technology, facilitate or hinder performing hand hygiene?
Do you believe that the IC team/ICWN will enhance your hand hygiene performance?
Does hand hygiene play an important role on your unit? Can you explain why?
Do you believe that nursing staff on this unit are washing their hands when necessary?
To what extent do social influences facilitate or hinder performing hand hygiene? Social influence from your peers?
Will you or have you ever observed others performing hand hygiene?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
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Table 4.1: The theoretical constructs used to analyses text data and example questions (cont.) Theoretical constructs
Do you believe that there will be social influences from your peers to use the IC team/ICWN? Managers? Patients? Other groups?
Do you have role models in performing hand hygiene? Who?
TDF 13: Emotion
Does performing hand hygiene elicit an emotional response?
If so, what?
To what extent will emotional factors facilitate or hinder your hand hygiene?
Do you believe that emotional factors will influence the use of the IC team/ICWN?
TDF 14: Behaviour regulation Self-monitoring
Breaking habit Action planning
What initial steps need to be taken to improve hand hygiene compliance/ use the IC team/ICWN on an individual level?
How about on an organizational level?
Can you think of any procedures that would encourage increased hand hygiene compliance/ use of the IC team/ICWN?
a Theoretical constructs applied from Michie, et al. 2014.
bExample questions are adapted from Boscart, et al. 2012.
TDF = Theoretical Domains Framework; IC = infection control; ICWN = infection control ward nurse
79 4) Connecting and interrelating data
Following identification of the relevant theoretical domains, the beliefs were mapped for systematically analyzing interrelations within the behavioural domain into the COM-B system proposed by Michie et al., which considers capability, opportunity and motivation as all determining behaviour[37] (Table 4.2). This framework was validated for use in behaviour change and implementation research by Cane et al.[88] Capability, which includes having the necessary knowledge and skills, is defined as “the individual's psychological and physical capacity to engage in the activity concerned”.[37] Motivation is defined as “all those brain processes that energize and direct behaviour, not just goals and conscious decision-making”.[37] It includes “habitual processes, emotional responding, as well as analytical decision-making”.[37] Opportunity is defined as “all the factors that lie outside the individual that make the behaviour possible or prompt it”.[37]
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Table 4.2: Mapping of the Behaviour Change Wheel’s COM-B system to the TDF Domains, from Cane et al., 2012.[88] Motivation Reflective Social/Professional Role & Identity
Beliefs about Capabilities with non-compliance behaviour for hand hygiene. The interpretation was given for individual,
team, and organizational levels, (Table 4.3) that were likely to influence hand hygiene behaviour of HCW. This identification was important in further steps to design the potential intervention , and based on construct allocations proposed by Michie et al.[42]
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Table 4.3: Constructs in four theoretical domains, illustrating individual, team, and organizational levels, based on construct allocations reported by Michie et al., 2005.[42]
Domain Level
Results are presented in seven parts:
1) Sample characteristics
2) Current knowledge about hand hygiene 3) Current hand hygiene practices
4) Perceived barriers for non-compliance with hand hygiene 5) Current beliefs about hand hygiene behaviour
6) Summary of relevant domain findings by applying the TDF
7) Mapping domain findings to the Behaviour Change Wheel’s COM-B system.
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