Abstract:

Maintaining optimal hand hygiene is an important strategy for infection control and prevention. However, how to increase adherence to hand hygiene practices has been a major challenge to prevent infectious diseases and reduce hospital acquired infections (HAIs), especially in the critical period of COVID-19 epidemic regular prevention and control. There are great differences in the effectiveness between different hand hygiene behavior intervention strategies, and the best hand hygiene intervention practice is still in development and requires further investigation. In order to develop intervention strategies for health care researchers and practitioners, the current research systematically summarizes hand hygiene behavior intervention strategies from the perspective of “nudge” for the first time. Traditional hand hygiene interventions are usually based on knowledge sharing and health education, which only produce weak or modest effects on hand hygiene practices. Recent research in behavioral science provides insights for developing effective behavioral interventions to optimize hand hygiene practices by helping people form better hand hygiene habits. Traditional intervention strategies tend to rely on people’s ability to engage in rational thinking and the availability of cognitive resources, that is, encouraging people to reflect on their hand hygiene behaviors and enhance their handwashing motivation in a rational and conscious way. The influences of external environmental factors are rarely taken into account in traditional intervention strategies. Similarly, the role of personal psychological factors is often ignored, so this kind of hand hygiene intervention strategy often shows limited effectiveness and low sustainability. In addition, there are many other common obstacles such as limited accessibility of hand hygiene products, people's overconfidence in their immune system to prevent infection, inertia, and habitual forgetting. Many research results show that even if traditional intervention strategies can increase risk awareness of poor hand hygiene and enhance hand washing intention in the target population, they may not lead to effective behavior changes in hand hygiene. Inspired by the research from behavioral sciences, researchers have tried to promote experiential, unconscious, and automatically triggered hand hygiene behavior through interventions of specific psychological or external environmental factors, so as to help people overcome the gap between hand washing intention and behaviors. Based on different influential mechanisms, hand hygiene nudging strategies can be classified into four categories and nine subordinate categories, including providing decision information (simplifying information, providing feedback, and harvesting the impact of social norms), optimizing decision options (simplifying options and making original options more attractive), influencing decision structure (increasing the accessibility and visibility of favorable options), and reminding decision direction (direct reminder and environmental hint). Previous studies have shown that behavioral science-based hand hygiene interventions, in general, achieved positive effects at a fairly low cost, which are worthy of further application. However, there are still many disputes concerning ethics and effectiveness for nudging intervention. Among these disputes, the two points often mentioned are whether nudging limits the decision-makers' freedom of independent choice and damages their ability of independent choice. These two disputes may have a relatively small impact on hand hygiene promotion, and the form of nudging intervention is more easily accepted by the public, which may be due to the fact that handwashing behavior essentially has a certain degree of “injunctive norm” tendency (i.e., the vast majority of people agree with maintaining hand hygiene). In addition, previous research on hand hygiene nudging intervention also has many limitations, including low accuracy of the evaluation criteria, sustainability, and generalizability of nudging strategies. Further research is warranted to develop more effective hand hygiene nudging interventions and apply them to diverse social contexts. The effectiveness of multi-facet nudging strategies has also been confirmed in hand hygiene practices, suggesting that another future research direction is to construct a hand hygiene nudging strategy classification system similar to the Behavior Change Technique (BCT) taxonomy, so as to design multi-facet nudging strategies for promoting hand hygiene in a specific social context. Based on China's national conditions, traditional hand hygiene intervention strategies such as health education cannot be completely abandoned. This kind of comprehensive new model of “traditional intervention + nudging strategies” and the personalization and specialization of nudging intervention strategies might be the focus of hand hygiene behavior promotion intervention in the future. However, there is still a lack of hand hygiene nudging intervention in Chinese sociocultural contexts. Another direction for future research is to carry out such nudging interventions in hospitals, schools, communities, and other public places based on the theory of behavioral change, so as to contribute to the prevention and control of infectious diseases and improve public health.

Key words: hand hygiene, disease prevention, infection control, health behavior change, behavior intervention, behavior public health