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Am J Infect Control. 2014 Feb;42(2):106-10. doi: 10.1016/j.ajic.2013.07.019. Epub 2013 Dec 17.

Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.

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UCL Research Department of Infection and Population Health, University College London, London, United Kingdom. Electronic address:
NIHR King's Patient Safety and Service Quality Research Centre, King's College London, London, United Kingdom.
UCL Research Department of Infection and Population Health, University College London, London, United Kingdom.
Scottish Collaboration for Public Health Research and Policy, Medical Research Council, University of Edinburgh, Edinburgh, Scotland, United Kingdom.
UCL Medical School, University College London, London, United Kingdom.
Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.



Insufficient use of behavioral theory to understand health care workers' (HCWs) hand hygiene compliance may result in suboptimal design of hand hygiene interventions and limit effectiveness. Previous studies examined HCWs' intended, rather than directly observed, compliance and/or focused on just 1 behavioral model. This study examined HCWs' explanations of noncompliance in "real time" (immediately after observation), using a behavioral theory framework, to inform future intervention design.


HCWs were directly observed and asked to explain episodes of noncompliance in "real-time." Explanations were recorded, coded into 12 behavioral domains, using the Theory Domains Framework, and subdivided into themes.


Over two-thirds of 207 recorded explanations were explained by 2 domains. These were "Memory/Attention/Decision Making" (87, 44%), subdivided into 3 themes (memory, loss of concentration, and distraction by interruptions), and "Knowledge" (55, 26%), with 2 themes relating to specific hand hygiene indications. No other domain accounted for more than 18 (9%) explanations.


An explanation of HCW's "real-time" explanations for noncompliance identified "Memory/Attention/Decision Making" and "Knowledge" as the 2 behavioral domains commonly linked to noncompliance. This suggests that hand hygiene interventions should target both automatic associative learning processes and conscious decision making, in addition to ensuring good knowledge. A theoretical framework to investigate HCW's "real-time" explanations of noncompliance provides a coherent way to design hand hygiene interventions.


Behavioral theory; Noncompliance

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