Behavioral Mechanism Of Hand Hygiene Among Healthcare Workers Based On Intrinsic Motivation

[Purpose]Hand hygiene is a key measure to prevent and control healthcare-associated infections and the global coronavirus disease 2019(COVID-19)pandemic.However,hand hygiene behavior among healthcare workers(HCWs)is not satisfactory,which is a complex behavior involving various factors,not readily understood and explained.The intrinsic motivation of HCWs is key to hand hygiene behavior,but insufficient attention is paid to it.Moreover,psychology and behavioral theories are a promising way to explore the factors and underlying mechanism of hand hygiene behavior.Therefore,this study aimed to construct the mechanism model of hand hygiene behavior among HCWs based on the intrinsic motivation and other related theories.It may help understand and improve HCWs’ hand hygiene behavior,strengthen infection prevention and control,to ultimately improve the medical care quality and safety.[Methods](1)The literature review and focus group discussion method were used to define the conceptual connotation of hand hygiene intrinsic motivation,determine the variables included in the mechanism model of HCWs’ hand hygiene behavior with intrinsic motivation as the core variable,and propose hypotheses about the relationships between these variables.Then the theoretical framework model of hand hygiene behavior mechanism was constructed.(2)The literature review and focus group discussion method were used to develop item pool of intrinsic motivation,extrinsic motivation and execution about hand hygiene behavior.The expert scoring and pilot survey were both used to select items to form a formal questionnaire.Questionnaire method was used to collected7275 valid questionnaires from HCWs in second and third level hospitals.Hand hygiene behavior was measured by self-e reported compliance with the six indicators:WHO’s "five moments" and "after taking off the gloves".The above items were all evaluated on a Likert 5-point scale.Exploratory factor analysis(EFA),confirmatory factor analysis(CFA)and internal consistency reliability test(Cronbach’s alpha)were used to test the reliability and validity of the measurement tools regarding handhygiene intrinsic motivation,extrinsic motivation and execution.(3)Structural equation model(SEM)was used to construct the empirical model of hand hygiene behavioral mechanism among HCWs based on intrinsic motivation.Multiple indicators and multiple causes(MIMIC)model was adopted to observe the effects of HCWs’ personal characteristics,hand hygiene knowledge,and the availability of hand hygiene facilities and supplies on the empirical model.Multi-group structural equation model was constructed to further test the robustness of the mechanism model of hand hygiene behavior of HCWs,with age,professional title and hospital level as grouping variables.[Results](1)“Definition and measurement tool of hand hygiene intrinsic motivation”:The hand hygiene intrinsic motivation refers to that HCWs perform hand hygiene autonomously in order to satisfy their expectations,which is due to the recognition of the intrinsic value and significance of hand hygiene,rather than the existence of external factors.A measurement tool of hand hygiene intrinsic motivation was developed,including the 5 dimensions(self-protection,patient protection,value recognition,professional responsibility,self-efficacy)and 18 items.Second-order CFA showed that the measurement model of intrinsic motivation had a good fit index(TLI=0.975,CFI=0.979,RMSEA=0.057,SRMR=0.041),and the factor loading of each item was above 0.6.The Cronbach’s alpha of the overall measurement tool was0.900,and the Cronbach’s alpha of each dimension was between 0.771 and 0.907.(2)“Extrinsic motivation measurement tool of hand hygiene”: The extrinsic motivation measurement tool contained a single dimension and 6 items.CFA showed a good model fit index of the measurement tool(TLI=0.999,CFI=0.999,RMSEA=0.071,SRMR=0.010),and the factor loading of each item was above 0.6.The Cronbach’s alpha of the overall measurement tool was 0.927.(3)“Execution measurement tool of hand hygiene”: The execution measurement tool included 4 dimensions(objective understanding,work implementation,resource integration,reflection and improvement)and 16 items.Second-order CFA showed a good model fit index of the measurement tool(TLI=0.983,CFI=0.987,RMSEA=0.078,SRMR=0.023),and the factor loading of each item was above 0.7.The Cronbach’s alpha of the overall measurement tool was0.946,and the Cronbach’s alpha of each dimension was between 0.908 and 0.949.(4)“HCWs’ hand hygiene behavior level”: The average score of overall hand hygiene behavior was 4.41±0.57.The hand hygiene behavior after body fluid exposure got the highest score(4.83±0.46),and hand hygiene behavior before patient contact got the relatively lowest score(3.80±1.00).The scores of hand hygiene behavior at other moments ranged from 4.36 to 4.53.(5)“Empirical model of the hand hygiene behavioral mechanism of HCWs:The SEM results showed that intrinsic motivation had a direct positive impact on HCWs’ hand hygiene behavior(b=0.149,P<0.001),while intrinsic motivation also indirectly promoted hand hygiene behavior through positively affected execution(b =0.640,P<0.001).The execution had a direct positive effect on hand hygiene behavior(b=0.476,P<0.001).The extrinsic motivation can indirectly improve hand hygiene behavior by promoting intrinsic motivation(b =0.121,P<0.001)and execution(b =0.107,P<0.001).However,extrinsic motivation may not directly improve hand hygiene behavior as it was significantly negatively correlated with hand hygiene behavior(b=-0.118,P<0.001).The whole model showed a good fit index(TLI=0.975,CFI=0.977,RMSEA=0.049,SRMR=0.057).The MIMIC model showed that age,professional title,hospital level,training,hand hygiene knowledge and availability of hand hygiene facilities and supplies were significant factors of the SEM model(P<0.05).After controlling for these covariates,the relationships between intrinsic motivation,extrinsic motivation,execution and hand hygiene behavior remained unchanged.The multi-group SEM results showed that the six path coefficients of hand hygiene behavior mechanism among HCWs of different age,professional title,and hospital level were all significant except for the path coefficient from extrinsic motivation to execution in the high-level professional title group,and just that path coefficients of different groups were not identical.[Conclusions]HCWs’ intrinsic motivation of hygiene intrinsic motivation is constituted of 5dimensions,which are self-protection,patient protection,value recognition,professional responsibility and self-efficacy.Although HCWs reported generally goodhand hygiene behavior,it still needs to be improved as there were great differences in scores at different hand hygiene moments.HCWs’ hand hygiene behavior was mainly driven by intrinsic motivation,and it can also be improved through the improvement of execution.The extrinsic motivation may not directly lead to good hand hygiene behavior.However,if the external motivation can play a role in promoting hand hygiene behavior when it can be transformed into the HCWs’ intrinsic motivation or execution.This study revealed the key role of intrinsic motivation and provided a scientific basis for understanding and improving HCWs’ hand hygiene behavior from the perspective of intrinsic motivation.And it also enlightened that when we carried out management work or interventions regarding hand hygiene in the future,we should consider their possible impact on HCWs’ hand hygiene intrinsic motivation and execution,and pay attention to the changes of their intrinsic motivation and execution.[Innovation and Deficiency]This is the first study to construct the measurement tools and empirical model of HCWs’ hand hygiene behavior mechanism based on intrinsic motivation and other related theories,and including closely related variables such as extrinsic motivation and execution in the model.(1)This was the first study to construct a measurement tool of hand hygiene intrinsic motivation with good reliability and validity,including 18 items in 5dimensions(self-protection,patient protection,value recognition,professional responsibility and self-efficacy),which enriched the tools for scientific research and clinical management on hand hygiene behavior.At the same time,it also expanded the research field of intrinsic motivation.(2)This study constructed the empirical model of HCW’s hand hygiene behavior mechanism for the first time,with focusing on HCWs’ intrinsic motivation.It revealed that the intrinsic motivation was the key driver of HCWs’ hand hygiene behavior,and the intrinsic motivation not only had a direct effect on hand hygiene behavior,but also had an indirect effect on hand hygiene behavior through positively affecting execution.This study also revealed that if the extrinsic motivation can be transformed into HCWs’ intrinsic motivation or execution,it can improve hand hygiene behavior.The present study has enriched the theoretical researches on the influencing factors of hand hygiene behavior,increased the exploration of HCWs’ hand hygiene intrinsic motivation,and deepened the understanding of the behavioral mechanism of HCWs’ hand hygiene.This study has some limitations.First,this was a cross-sectional study,and it is difficult to directly infer the causal relationships between intrinsic motivation,extrinsic motivation,execution,and hand hygiene behavior.Second,self-reported hand hygiene behavior may be overestimated due to the social desirability and recall bias.Third,the sample came from one province of China,which may limit the generalization of our results.