How Behavior Change Interventions Can Be a Key to Improving Hygiene in Healthcare

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by the BASICS Team

 The 100&Change competition has challenged us to think critically and creatively about developing a solution that tackles one of the world’s most forgotten problems: healthcare-acquired infections (HAIs). BASICS was designed to catalyze and support transformative changes in how healthcare staff practice good hygiene in order to reach dramatic reductions in HAIs across national heath systems, saving lives, reducing antibiotic use and freeing up much-needed resources.

There are many reasons why following effective hygiene protocols can be difficult for healthcare staff in low-resource settings, such as lack of sanitation infrastructure and clean water and broken supply chains that fail to deliver needed materials. These physical barriers present one set of challenges – changing health workers’ longstanding habits and practices are another.  Overcoming these challenges requires work at all levels, from influencing very personal behaviors to national health policies.

How do we realize such a bold ambition – reducing HAIs by half in four demonstration countries to start, and then scaling to other high-burden countries – when our solution relies on individual and group behavior change in a diversity of settings?

One of our key strategies is to ensure that healthcare staff feel truly invested in the BASICS approach, and are actively engaged in a process that works for their social, cultural and socio-economic reality, and other important factors related to behavioral change.

The BASICS’ framework is grounded in the proven Behavior Centered Design approach. Developed and refined over a decade by scientists at the London School of Hygiene and Tropical Medicine, it combines evolutionary and environmental psychology with the best marketing practices to create imaginative and provocative behavior change interventions.

Once BASICS launches, we will begin with in-depth formative research, which consists of participatory methods inspired by anthropology, psychology and other behavioral and social sciences. This will help us understand the individual, social, and cultural drivers of the infection prevention control behaviors that BASICS is designed to change.

These insights will then be used to tailor BASICS to the local context. This will maximize both individual and institutional acceptability and adoption of changes.

BASICS partners Save the Children, London School and WaterAid have already used the approach in one of BASICS’ four demonstration countries –Cambodia. This experience will help to give BASICS a firm fooothold there, and inform work in the three other demonstration countries of  Bangladesh, Nigeria and Tanzania.

In Cambodia, we found that many people believe that if their hands don’t look soiled, that means they’re clean. Open defecation is also socially accepted, especially when there’s abundant open space.

Save the Children has, over the past six years, run the NOURISH program, which targeted behaviors in health, water, sanitation and hygiene and agriculture. The impact of the changed behaviors is very significant, including a 75 percent drop in open defecation in the program areas.

WaterAid and the London School, in partnership with the National Institutes of Public Health and 17 Triggers, recently used Behavior-Centered Design to develop a novel intervention to improve hand hygiene compliance among Cambodian midwives.

They identified the personal, institutional and cultural drivers of hygiene practices and are now testing a model that combines traditional infection prevention control training, emotional messaging that reinforces midwives’ desire to provide quality care to mothers and newborns and environmental cues to trigger hand hygiene at key moments.

Midwives’ compliance with good hand hygiene practices during childbirth will be measured later this year. These learnings will be very useful once we implement BASICS in the country.

In Bangladesh, we’re very excited about the impact of our programs addressing HAIs. When we started, there were quality standards for infection prevention in place, but they were simply not complied with. Staff were not adequately trained, supplies were limited at best, and there were no systems in place to ensure that healthcare facilities practiced effective hygiene.

We had to also address the widespread use of traditional, but harmful, practices like applying cow dung or corrosive mustard oil to a newborn’s umbilical cord. We were successful in helping staff to transition to the use of chlorhexidine through guidelines, training and the development of effective supply chains.

It was a long process, but it worked. Some 85,000 healthcare staff in 64 districts were trained. Independent monitors found that 86 percent of healthcare staff were proficient in the use of chlorhexidine. They also found great improvements in the sanitizing of medical equipment such as bag masks and suction devices.

As we’ve seen in Cambodia, Bangladesh and in many other countries, sustainable behavior change is possible at both the individual and institutional levels. BASICS will draw upon hard evidence and our collective eperiences to advance this bold solution in health facilities and across national health systems.