Journal of Hospital Infection (2004) 58, 113

www.elsevierhealth.com/journals/jhin

REVIEW

The Lowbury lecture: behaviour in infection

control
D. Pitteta,b,*

a
Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
b
Division of Investigative Sciences, Imperial College of Medicine, Science and Technology, London, UK

Received 16 September 2003; accepted 2 June 2004

KEYWORDS Summary The majority of healthcare-associated infections result from cross-

Behaviour; Infection
control; Hand hygiene;
Healthcare workers;
Nosocomial infection
transmission related to inappropriate patient-care practices. Improving
practices frequently implies modifying healthcare workers behaviour, a
key challenge of todays infection control. To improve healthcare workers
compliance with practices, infection control should learn from the
behavioural sciences. Social cognitive models can help to improve our
understanding of human behaviour. Cognitive determinants that shape
behaviour are acquired through the socialization process and are susceptible
to change. Some models have been applied to evaluate predictors of health
behaviour but, so far, none have been successfully applied to explain
behaviour in the field of infection control. Successful strategies to improve
infection control practices result from their multidimensional aspect.
Similarly, social models that include several levels of cognitive determinants
have more chance of success to explain change in behaviour. Concrete
examples applied to infection control issues are presented, including special
references to hand hygiene behaviour. The theory of ecological perspective,
based on the idea that behaviour is viewed as being affected by and affecting
multiple levels of influence, and that it both influences and is influenced by
the social environment, seems promising to explain behaviour modification.
Studies are needed to assess the key determinants of infection control
practices and behaviour promotion among the different populations of
healthcare workers, and to implement and evaluate the impact of the
different components of multimodal programmes to promote optimal
infection control practices.
Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

*Corresponding author. Address: Infection Control Programme, Department of Internal Medicine, University of Geneva Hospitals,
1211 Geneva 14, Switzerland. Tel.: 41-22/372-98-28; fax: 41-22/372-39-87.
E-mail address: didier.pittet@hcuge.ch

0195-6701/$ - see front matter Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2004.06.002
2 D. Pittet
Introduction
Microbiology and epidemiology have made signifi-
cant contributions to the field of infection control.
However, most healthcare-associated infections
are endemic and result from cross-transmission
related to inappropriate patient-care practices. To
improve healthcare workers (HCWs) compliance
with practices, infection control teams should learn
from behavioural sciences. Infection control pro-
fessionals play key roles in the identification and
prevention of nosocomial infections. They act as
observers, educators and, ultimately, should
become agents of change. Changing behaviour and
shifting social norms at multiple levels through the
HCW community are among the key challenges of
infection control today (Figure 1).
Behavioural sciences in infection control
Although a modification of patient-care practices is
vital for infection prevention, this issue has
received little attention in the medical literature.
Education has always been an integral part of
infection control. Low knowledge of infection
control measures after training has been shown
repeatedly.1 3 Furthermore, the degree of knowl-
edge about transmission precautions does not
necessarily predict appropriate behaviour.4,5
Thus, education must be conducted in such a way
that practices are modified appropriately.
Guidelines have been issued to help HCWs
prevent infections and improve patient safety, but
these are usually not applied strictly or are applied
poorly. Availability of guidelines alone frequently
has a poor impact on HCW knowledge and beha-
Figure 1 Key determinants of infection control
programmes.
viour. In addition, the application of some guide-
lines are unrealistic in daily working conditions6
because of the mandatory increase in resources
required.
Although modification of patient-care practices
is vital for infection prevention, there are few
original studies on this issue. Seto7 identified three
fields of study in the behavioural sciences with
some degree of relevance to the field of infection
control: social psychology, organizational beha-
viour and consumer behaviour. By applying a basic
concept from each field, Seto and others evaluated
the validity of these theories to achieving staff
compliance with different infection control policies
in the hospital.7 15 Table I summarizes the field of
study, the design of the interventions, and the main
results of examples of application of behavioural
theories to the field of infection control. Figures
2 4 illustrate the results of the interventions.
A further example of the role of social power in
infection control was demonstrated by the Study on
the Efficacy of Nosocomial Infection Control (SENIC)
project.16 In this study, 7046 nurses were surveyed
to demonstrate the type of social power that was
most likely to explain the compliance of HCWs to
follow advice and practices proposed to reduce
infection rates. Of the six bases for power,
coercive, reward, legitimate, expert, referent or
informational, the analysis revealed that both
informational and expert power best explained
the positive impact of infection control on nurses,
together with surveillance data and performance
feedback.17 Similar findings were observed for
infection control nurses in Hong Kong.7 Impor-
tantly, however, housekeeping personnel were
Figure 2 Discontinuation of recapping among 208
nurses five weeks after the introduction of sharps
boxes comparing three different strategies (A,B,C; see
also Table I); adapted from reference.11 (B) Prepared to
comply; (A) not prepared to comply.

Table I Application to infection control of behavioural science research
Field of study Definition Intervention
Social psychology How people think, influence Application of the Theory of Reasoned Action.a13 The
and relate to each other objective of the study was to assess the impact of in-
service education on HCWs with or without
behavioural intent to stop the recapping of needles by
comparing simple announcements though the nursing
hierarchy (A), with informational posters and
pamphlets (B), or both methods combined with in-
service lectures (C)
Organizational behaviour How people act within the Approach based on participatory decision-making
organization (PDM) defined as exerting influence resulting from the
employee assuming an active role in a decision-making
process.14 A questionnaire survey was applied to HCWs
to ask which best described the practice in the hospital
when new policies involving patient-care practices
were introduced, and how much the type of PDM would
affect staff compliance to the new policy
Consumer behaviour How and why consumers buy Based on the theory that within social groups, opinion
and consume leaders exert a significant amount of social influence
over others.15 Ward opinion leaders, identified by a
sociometric tool, participated in in-service education
to implement a new guideline on urinary catheter
care. Wards were randomized to benefit (A) or not (B)
from demonstration tutorials by opinion leaders
Agreeables, those prepared to comply; Non-agreeable, those not prepared to comply.
Adapted from reference.7
a
The Theory of Reasoned Action13 assumes that people behave rationally and that, generally, the intention to act is the result of considerable mental liberation. The theory states that this
behavioural intent predicts actual behaviour.
Results
On average, 59% of nurses discontinued recapping
needles, with the largest proportion in group C (85%),
followed by groups B (66%), and A (21%). Important
differences were observed according to the
behavioural intent; communication through the
nursing hierarchy was rather ineffective for those with
the behavioural intent (the agreeables), for whom
the message through posters and pamphlets was
sufficient and further persuasion by in-service lectures
showed no additional effect. In contrast, for those
without the intent (the non-agreeables), in-service
lectures were needed to reinforce the message
251 nurses participated. Most respondents indicated
that autocratic types of PDM best described the
practices. Nurses recommended that a full PDM
process (subordinates are invited to contribute their
opinion and suggestions in a group discussion and the
decision is made according to the consensus of the
entire group) should be initiated to improve
compliance with the introduction of new policies. The
proposal was that ward representatives would be
invited to join a central decision-making group in the
hospital to vote on behalf of their colleagues
Direct observation of urinary care practices revealed a
significant decrease in the proportion of incorrect
practices following the intervention in the two groups.
The improvement was more dramatic in wards who
benefited from the intervention of the opinion leaders
(62% versus 42% in group A compared with 69% versus
62% in group B)
The Lowbury lecture: behaviour in infection control
Ref Comments
11 In this field, attitude change, social influence and
compliance have been studied and many data may be
relevant to the field of infection control. In practical
terms, assessing the proportion of HCWs with the
behavioural intent before the introduction of a new
policy might help its introduction
7 Organizational behaviour is considered as an integral
part of management science. Hospitals are large and
complex institutions and management strategies
applied to industry might be relevant. In practical
terms, full PDM and efforts to reach consensus would
help enhance staff compliance to newly introduced
infection control measures
12 Understand human behaviour in the context of
marketing a product. Application in infection control
would be introduction of new policies, and new
methods and ideas. In practical terms, it may be
beneficial to involve ward nurses or HCWs identified as
opinion leaders to obtain active participation and
improve the implementation of infection control
interventions
3
4 D. Pittet
Figure 3 Hospital practice to introduce new policies compared with predicted staff compliance (see Table I for
details); adapted from reference.7
more responsive to legitimate and coercive power,
and less responsive to informational power than
nurses in this latter study. Therefore, as stated by
Seto, when addressing housekeeping personnel, it
would be better to present the request as coming
from a legitimate superior together with evidence
of their supervisors endorsement.7
Seto et al.18 also demonstrated that information
transmission by opinion leaders was significantly
more effective to implement a new guideline on
urinary catheter care than other strategies without
this approach (Table I). The importance of role
models has already been observed19 and used as an
integral part of hand hygiene promotional cam-
Figure 4 Direct observation of urinary care practices
before and after education programmes involving or not
involving opinion leaders; adapted from reference.12 (B)
Lecture only; (A) opinion leader and lecture.
paigns in the intensive care setting with positive
results.20 23 Finally, the belief of being a role model
for other colleagues was an independent predictor
of doctors compliance in our institution.24
Understanding human behaviour
During the latter half of the 20th century, it was
suggested that social behaviour could best be
understood as a function of peoples perceptions
rather than as a function of real life. This assump-
tion gave birth to several models based on social
cognitive variables to improve understanding of
human behaviour. Cognitive variables used in these
models include: knowledge, motivation, intention,
perception of threat, outcome expectancy, per-
ceived behavioural control and social pressure
(Table II). These determinants shape behaviour;
they are acquired through the socialization process
and, importantly, are susceptible to change (Figure
5).
Some social cognitive models (Health Belief
Model, Health Locus of Control, Protection Motiv-
ation Theory, Theory of Planned Behaviour, and the
Self-Efficacy Model) have been applied to evaluate
predictors of health behaviour, although the first
three are known to be weak predictors. But, so far,
few studies have applied these models to evaluate
HCWs perceptions towards infection control prac-
tices.25 29 Furthermore, none have been success-
fully applied to change behaviour in the field of
infection control. Understanding the motivation
underlying a given behaviour in a specific situation
is one of the first steps to design more efficient

Table II Cognitive determinants of human behaviour
Determinant Definition
Knowledge Refers to the individual level of information on a given issue
Motivation Refers to the readiness to be concerned about a given issue
Intention Refers to the cognitive representation of an individuals
readiness to perform a given behaviour. It is considered as the
immediate antecedent of behaviour
Perception of threat Threat perception is based on two beliefs: the perceived
risk/susceptibility and the perceived severity of the
consequences
Outcome expectancy/Attitude Based on an individuals expectancy that a given behaviour can
counteract/increase a threat and how the individual values the
threat
Perceived behavioural control/Self- Both determinants are similar and refer to the perception that
efficacy performance of a given behaviour is self-controlled
Social pressure Normative beliefs refer to the perceived behavioural
expectations of such important referent individuals or groups
such as the individuals spouse, family, friends, teacher, etc.
Subjective norm is the perceived social pressure to engage or
not in a behaviour. Behavioural norm refers to the individuals
perception of actual partners behaviour
a
Social cognitive models include: Health Belief Model (HBM), Health Locus of Control (HLC), Protection Motivation Theory (PMT), Theory of Planned Behaviour (TPB) and the Self-Efficacy
Model (S-EM).
The Lowbury lecture: behaviour in infection control
Included in social modela Comment
All models Knowledge is a basic determinant to mount the individual
evaluation of threat and of expectancy that a given behaviour
can counteract/increase the threat
HBM PMT S-EM TPB Motivation is an early stage towards behaviour change. In this
stage, the individuals form a disposition (i.e. enact their self-
conceptions, revise their behaviour) either to comply with a
measure or to modify risk behaviours
PMT TPB S-EM The intention is based on attitude towards the behaviour,
perceived social pressure and perceived behavioural control,
with each predictor weighted for its importance in relation
with the behaviour and population of interest
HBM PMT S-EM This determinant seems not to strongly predict behaviour. It is
assumed to be a distal component of the process. It seems to be
important in the early phase of the decision-making process,
and it probably influences behaviour via its impact on
motivation and attitude
All models Influences behaviour via its strong impact on intention (TPB,
S-EM) or on motivation (PMT, HBM)
HLC PMT TBP S-EM The judgment is influenced by access to necessary resources
weighted by the perceived power of each factor to
facilitate/impede behaviour performance
TBP It is assumed that the total set of normative beliefs determine
the prevaili
ng subjective norm. A partner is defined as any individual who
can influence the individuals behaviour (a leader, an admired
colleague)
5
6 D. Pittet
Figure 5 Social models and cognitive determinants (see also Table III).
intervention strategies for modifying behaviour.
One way to improve understanding of motivation is
to identify the factors that define an individuals
behavioural intention. A leading theory that
explains intention is the Theory of Planned Beha-
viour.30 It defines intention by a persons attitude,
perceived social norm and perceived behavioural
control, and has been successfully applied to study
several categories of health-related behaviours.31
The attitude towards the behaviour is the
expression of ones positive or negative evaluation
of performing the behaviour. The perceived social
norm reflects a personal perception of the expec-
tations of others about the behaviour. Perceived
behavioural control reflects a personal perception
of the difficulty or ease with which the behaviour
could be adopted and is the consequence of
anticipated obstacles or impediments. The Theory
of Planned Behaviour has been used to test
intentions towards specific infection control
measures, such as understanding compliance with
hand hygiene recommendations,25 or physicians
intention to wear gloves during patient care.27 The
Theory of Planned Behaviour and the Self-Efficacy
Model are better predictors than most other social
cognitive models, but contain two major draw-
backs: the lack of assessment of threat and social
pressure (Figure 5).
Modelling human behaviour
Current models/theories that help to explain
human behaviour, particularly as it relates to health
education, can be classified on the basis of being
directed at the level of: (1) individual (intra-
personal); (2) inter-personal; and (3) community.
The social cognitive models mentioned previously
deal with individual determinants of behaviour.
Among the community level models (i.e. models of
community organization, Diffusion of Innovations
Theory, Organizational Change Theories, ecological
models) the Theory of Ecological Perspective (also
referred to as the Ecological Model of Behavioural
Change) can successfully result in behaviour change.
This theory is based on two key ideas: (1) behaviour is
viewed as being affected by and affecting multiple
levels of influence; and (2) behaviour both influences
and is influenced by the social environment. Levels of
influence for health-related behaviours and
conditions include intra-personal, inter-personal,
institutional and community factors, as well as
administrative support.
Intra-personal factors are individual character-
istics that influence behaviour such as knowledge,
attitudes, beliefs and personality traits. These are
contained in social cognitive models such as the
Health Belief Model, which proposes six constructs
that apply to the success of individual changes:
perceived susceptibility, perceived seriousness,
perceived benefits, perceived barriers, cues to
action and self-efficacy (Table III). Relationships
between these factors, and the balance between
perceived threats and net benefits are illustrated in
Figure 6.
Inter-personal factors include inter-personal
processes and primary groupsfamily, friends and
peersthat provide social identity, support and role
definition. HCWs can be influenced by or are
influential in their social environments. Behaviour
is often influenced by peer group pressure. The
Social Learning Theory states that people learn not
only through their own experiences, but also by
observing others actions and the results of those
actions, as well as through role modelling.32
Institutional factors to be considered to promote
change include the availability and easy access to
rules, policies, and as technical and informal
The Lowbury lecture: behaviour in infection control 7

Table III Individual levels of influence. Knowledge, attitudes, beliefs and personal traits that influence behaviour (according to the
Health Belief Model)

Construct Definition Example from the infection control

arena (application to hand hygiene
practice)

Perceived susceptibility Self-opinion of the likelihood of Is the patient at risk of infection ?

acquisition of a disease
Perceived seriousness Self-opinion of how serious a Do nosocomial infections affect patient health ?
condition and its sequelae are
Cues to action Strategies to activate readiness to Personal experience Reminders at the
internal act workplace Easy access to hand hygiene agent
external Institutional promotion programme
Perceived benefits Self-opinion of the efficacy of the What is the impact of appropriate hand hygiene
advised action to reduce the risk or action to reduce the risk of cross-transmission?
seriousness of impact
Perceived barriers Self-opinion of the tangible and Would hand hygiene action damage my hands?
psychological costs of the advised Would it be time-consuming? Would it
action change my relationship with the patient?
Self-efficacy Confidence in self ability to take Would I be capable? Could I overcome
action difficulties?

Social pressure
Intention to perform action
The perceived social pressure to
engage or not engage in a behaviour
Individuals readiness to perform a
given behaviour
How do others (whom I admire) expect me to
perform? How compliant with hand hygiene are
my colleagues?
Do I intend to clean my hands?

structures that help to promote recommended Community factors are social networks and
behaviours. Responsibilities for each individual norms that exist either formally or informally
group of HCWs must be clearly recognized and between individuals, groups and organizations. For
defined. example, in the hospital, the community level

Figure 6 Relationship between intra-personal beliefs, perception and action.

8 D. Pittet
would be the ward. 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. Public policy factors include
local policies that regulate or support practices
for disease prevention, control and management.
The institutional administration must openly
support the creation of a multidisciplinary task
force to address the problem of infection cross-
transmission within the ward or the hospital. By
this, it mandates representative members of the
multidisciplinary institutional team to come
together to identify the problem and to develop
strategies to resolve it, endorses the choices and
options taken, and mobilizes the hospital resources
needed to implement the strategies.
There are only few reports of the possible
application of the Theory of Ecological Perspective
to the field of infection control. Curry and Cole33
reported their experience in the medical and
surgical intensive care units in a large teaching
hospital experiencing an increased patient
colonization rate with vancomycin-resistant enter-
ococci (VRE). Their intervention consisted of a
multifaceted approach of the problem that
considered the five levels of influence (individual,
inter-personal, institutional, community and
administrative factors). They implemented in-
service education and developed references,
policies and programmes directed at each of the
five levels of influence. The Health Belief Model and
the Social Learning Theory were employed for
intervention, and behaviour change was based on
role modelling, observation learning and vicarious
reinforcement. The authors observed a significant
decrease in the number of patients with surveil-
lance cultures and clinical isolates positive for VRE
within six months in both intensive care units, and
the benefit seemed to persist even two years later.
Application to hand hygiene behaviour
Semmelweis intervention
Ignaz F. Semmelweis (1818 1865) pioneered hand
hygiene in medicine when trying to control the
spread of puerperal fever caused by Streptococcus
pyogenes. In 1846, he observed that women whose
babies were delivered at the First Clinic of the
Lying-In Womens Hospital of the General Hospital
(Allgemeines Krankenhaus) in Vienna consistently
had a higher mortality than those who were
delivered in the Second Clinic.34 He also noted
that physicians and medical students who went
directly from the autopsy room to the obstetrics
ward had a disagreeable odour on their hands
despite washing their hands with soap and water
upon entering the delivery room. Furthermore,
when Semmelweis learned of the death of his friend
and colleague Kolletschka, professor of forensic
science, after a scalpel cut while working on a
cadaver, he postulated that the high rate of
puerperal fever was caused by cadaverous par-
ticles transmitted from the autopsy to the delivery
room via the hands of students and physicians, and
that his friend had died from the same disease
process. As of May 15, 1847, Semmelweis insisted
that students and physicians scrub their hands in a
chlorinated lime solution before every patient
contact. The fever deaths promptly declined in
the First Clinic, and remained low thereafter.
Today, Ignaz Semmelweis is considered as the
father of hand hygiene and his intervention a
model of epidemiology-driven infection prevention
strategy.
But Semmelweis brilliant, radical insight that
the lack of hand hygiene was causing patient
infections and deaths was not well received. His
colleagues greeted his paper with jeers and a
scathing attack on his character. They simply
refused to believe that their own hands were the
vehicle for disease spread. Semmelweis hospital
contract was not renewed and he left Vienna and
returned to Hungary where he made exactly the
same observation in a lying-in clinic, but again was
dismissed. He finally was committed to an insane
asylum, where he died miserably. As commented in
1924 by the French writer and physician Louis-
Ferdinand Ce line in his doctoral thesis The Life and
Work of Semmelweis, il semble que sa de cou-
verte depassa les forces de son ge nie. Ce fut, peut-
e
tre, la cause profonde de tous ses malheurs (it
would seem that his discovery went beyond the
force of his genius. This was, perhaps, the under-
lying cause of all his ills).35
How can we explain Semmelweis failure to
convince his colleagues and collaborators? Impor-
tantly, despite the fact that he had a full under-
standing of the disease process and was absolutely
correct with the intervention he had proposed,
Semmelweis failed in many regards to apply basic
principles of social sciences for a successful change
in behaviour. He first failed to explain the theory of
germ transmission because knowledge was insuffi-
cient at that time and, also, because he did not
The Lowbury lecture: behaviour in infection control
implement an education-based intervention. His
decision was typically autocratic, made solely by
himself as attending physician, and with no attempt
to consult the opinion of subordinates. Even worse,
his vision conflicted with the beliefs of his chief,
Professor Johann Klein, acting director of the
maternity clinic of the Allgemeines Krankenhaus.36
Semmelweis imposed the use of a chlorine solution
that was the perfect antimicrobial agent, available
almost at the bedside, extremely active, but
unfortunately quite strong for HCWs hands.
Although the perceived seriousness of puerperal
fever was high, HCWs opinion of the efficacy of the
advised action to reduce the risk of death was
dubious, as well as perceived benefits and barriers
to action. Thus, most of the cognitive determinants
were not considered in the planning and conducting
of Semmelweis intervention. Furthermore, Sem-
melweis failed for a long time to publish the
complete observation he made; he was also quite
hesitant to speak in public, and irritated many
colleagues when he finally produced his work.36
Hand hygiene promotion appears thus as a
perfect example of the difficulty in changing
HCWs behaviour and, importantly, ensuring the
sustainability of such a change.
Modern hand hygiene promotion strategies
Education is one of the cornerstones of improve-
ment in hand hygiene practices.37,38 Educational
programmes need to address issues such as avail-
ability and awareness of guidelines for hand
hygiene; potential risks of transmission of micro-
organisms to patients; potential risks of HCW
colonization or infection acquired from the patient;
knowledge about indications for hand hygiene
during daily patient care; awareness of the very
low average compliance with hand hygiene prac-
tices of most HCWs; and recognition of opportu-
nities for hand hygiene associated with high risk of
cross-transmission. Teaching must emphasize mor-
bidity, mortality and costs associated with nosoco-
mial infections, and emphasize the epidemiological
evidence for the definitive impact of improved hand
hygiene on nosocomial infection and resistant
organism transmission rates. Thus, knowledge,
attitudes, beliefs and personal traits that influence
behaviour (Table III) all interact in the process of
hand hygiene behaviour. Coaching should also focus
on the appropriateness, efficacy and understanding
of the use of hand hygiene and skin care protection
agents. Finally, education is also part of the
strategies in which active participation in hand
hygiene promotion at the individual and insti-
tutional levels, as well as enhancement of individ-
9
ual and institutional self-efficacy, is enforced.
Guidelines for hand hygiene in healthcare settings
include a list of specific elements that should be
considered for inclusion in educational and motiva-
tional programmes for its successful promotion.37
Some of these targets are clearly related to the
institution and would require a system change in
most hospitals with the need to involve senior
management support and commitment.37,39 44
Table IV lists factors that can influence compliance
with hand hygiene according to their level of
influence from the Theory of Ecological Perspec-
tive.
In many hospitals, a system change would
probably be necessary to replace a hand hygiene
agent (in particular when associated with increased
costs), promote and facilitate skin care for HCWs
hands, and introduce monitoring and regular per-
formance feedback of hand hygiene compliance.
Some changes are sometimes difficult to manage, or
would probably be even more difficult to introduce
in most hospitals. These include securing the active
participation for hand hygiene promotion at indi-
vidual and institutional level, and administrative
sanction or rewarding associated with hand hygiene
behaviour.37,38,45 Doctors compliance with hand
hygiene is usually low, but can improve. Salemi
et al.46 observed that personal encounters, in
particular direct meetings with an infectious
disease colleague, and videotaped presentations
to a lesser degree, had a greater impact on
physician compliance compared with e-mail remin-
ders. Whether objective demonstration of hand
contamination occurring during routine patient
care activities might be a helpful component of
successive educational programmes remains to be
further tested.47 Good role models are also import-
ant:19,38 a consultant who washes or rubs his/her
hands when appropriate will encourage junior staff
to follow this example; unfortunately, the reverse
is true too! We identified risk factors for non-
compliance and assessed beliefs and perceptions
associated with hand hygiene among doctors at our
institution.24 Individual observation of doctors
hand hygiene practices during routine patient care
with documentation of relevant risk factors, and
self-report questionnaire to measure beliefs and
perceptions were conducted. Compliance averaged
57% and varied markedly across medical specialties.
In multivariate analysis, compliance was associated
with the awareness of being observed, the belief of
being a role model for other colleagues, a positive
attitude towards hand hygiene after patient con-
tact, and easy access to alcohol-based hand rub
solution. Conversely, high workload, activities
associated with a high risk of cross-transmission,
 10
Table IV Factors associated with hand hygiene compliance classified according to their level of influence from the Theory of Ecological Perspective

Levels of influence Factora Susceptibility to modification Susceptibility to behaviour change Tool for change

Individual
Being a doctor No Yes Education Motivation
Male gender No Yes Education
Skin irritation and dryness associated with the use of hand Yes Yes Education System
hygiene agents
Activities with high risk of cross-transmission Yes Yes Education System
High number of indications for hand hygiene per hour of No Yes Education System
patient care
Wearing gowns/gloves No Yes Education
Patient needs take priority Yes Yes Education System Motivation
Hand hygiene interferes with HCWpatient relationship Yes Yes Education Motivation
Low risk of acquiring infection from patients No Yes Education
Belief that glove use obviates the need for hand hygiene Yes Yes Education
Lack of knowledge of guidelines/protocols Yes Yes Education System Motivation
Lack of availability of guidelines/protocols Yes Yes System
Not thinking about hand hygiene/forgetfulness Yes Yes Education System Motivation
Scepticism about the value of hand hygiene Yes Yes Education Motivation
Disagreement with recommendations/indications for hand Yes Yes Education Motivation
hygiene
Inter-personal
Understaffing/overcrowding No Yes System
Patient needs take priority Yes Yes Education System Motivation
Not thinking about hand hygiene/forgetfulness Yes Yes Education System Motivation
No role model from colleagues or superiors No Yes Education Motivation
Lack of active participation in hand hygiene promotion at Yes Yes Education Motivation
individual or institutional level
Lack of institutional priority for hand hygiene No Yes System Motivation
Institutional
Skin irritation and dryness associated with the use of hand Yes Yes System
hygiene agents
Working in critical care No Yes Education System
High number of indications for hand hygiene per hour of No Yes Education System
patient care
Sinks are inconveniently located/shortage of sinks Yes Yes Education System
Lack of soap, paper, towel Yes Yes System
HCW is too busy, has insufficient time for hand hygiene Yes Yes System
Lack of knowledge of guidelines/protocols Yes Yes Education System Motivation
Lack of availability of guidelines/protocols Yes Yes System

D. Pittet
Not thinking about hand hygiene/forgetfulness Yes Yes Education System Motivation
No role model from colleagues or superiors No Yes Education Motivation
 The Lowbury lecture: behaviour in infection control
Table IV (continued)
Levels of influence Factora Susceptibility to modification Susceptibility to behaviour change Tool for change

Lack of active participation in hand hygiene promotion at Yes Yes Education System Motivation
institutional level
Lack of institutional priority for hand hygiene No Yes System Motivation
Lack of administrative sanction of non-compliers/rewarding Yes Yes System Motivation
of compliers
Lack of institutional safety climate Yes Yes System Motivation

Community
Hand hygiene interferes with HCW-patient relationship Yes Yes Education Motivation
Scepticism about the value of hand hygiene Yes Yes Education Motivation
Lack of scientific information of definitive impact of Yes Yes Education
improved hand hygiene on infection rates

Administrative
Sinks are inconveniently located/shortage of sinks Yes Yes System
Lack of soap, paper, towel Yes Yes System
HCW is too busy, has insufficient time for hand hygiene Yes Yes System
Understaffing/overcrowding No Yes System
Not thinking about hand hygiene/forgetfulness Yes Yes System
Lack of availability of guidelines/protocols Yes Yes System
Lack of active participation in hand hygiene promotion at Yes Yes System Motivation
institutional level
Lack of institutional priority for hand hygiene No Yes System Motivation
Lack of administrative sanction of non-compliers/rewarding Yes Yes System Motivation
of compliers
Lack of institutional safety climate Yes Yes System Motivation
a
Factor refers to both observed and self-reported risk factors for the lack of compliance with recommended hand hygiene practices as documented in several studies in the literature
and adapted from references.37 39,45

11
12
and certain technical medical specialties, surgery,
anaesthetics, emergency medicine and intensive
care medicine, were risk factors for non-compli-
ance. We concluded that doctors compliance with
hand hygiene is associated with work and system
constraints, as well as knowledge and cognitive
factors. At the individual level, strengthening a
positive attitude towards hand hygiene and reinfor-
cing the conviction that each individual can
influence the group behaviour may improve com-
pliance among doctors.
Successful strategies to improve infection con-
trol practices result from their multidimensional
aspect. Based on behavioural theories and reported
experiences, multimodal intervention strategies
have more chance of success than single
approaches or promotion programmes focusing on
one or two elements alone.23,37 40,48 Similarly,
social models that include several levels of cogni-
tive determinants have more chance of success in
explaining changes in behaviour. Studies are
needed to assess the key determinants of infection
control practices and behaviour promotion among
the different populations of HCWs, to develop
methods to secure senior management support,
and to implement and evaluate the impact of the
different components of multimodal programmes
to promote optimal infection control practices.
Acknowledgements
The author thanks members of the Infection Control
Programme at the University of Geneva Hospitals
who have been involved in research and insti-
tutional projects related to hand hygiene epide-
miology and promotion since 1994, and Rosemary
Sudan for editorial assistance. He is also grateful to
Professor WH Seto for useful discussion and reading
of the final version of the manuscript.
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