Title: The impact of social norms interventions on clinical behaviour change among health workers: protocol for a systematic review.
Funder: Department of Health and Social Care

Abstract: Background Health professionals routinely carry out behaviours which impact on patient diagnoses, care, treatment and recovery. Many of these behaviours have clear guidelines on best practice including: ordering of diagnostic tests; appropriate prescription of antibiotics; regular recall of patients with long-term conditions; hand-washing; choice of wound dressings. Health professionals face challenges in following evidence-based professional practice. Some methods of persuading health professionals to change their behaviour rely on social influence behaviour change techniques (BCTs). Examples include: telling a GP the antibiotic prescribing rates of neighbouring GPs in comparison to their own rate, or informing hospital staff that the ‘top 10’ most frequent hand-washers will have their names displayed in a staff newsletter. Aim We will examine the impact of social influence interventions on clinical behaviour change among health professionals, addressing two research questions: 1. What is the effect of social influence interventions on the clinical behaviour of health professionals, and resulting patient outcomes? 2. Which contexts, modes of delivery and behaviour change techniques are associated with health professional clinical behaviour change? Methods The study design is a systematic review and meta-analysis, including randomised controlled trials where the participants are healthcare professionals. Our scoping exercise suggests there will be approximately 135 articles and 93 unique trials. We will include social influence interventions, which we define as behaviour change techniques (BCTs) that rely on peer or social influences, highlighting social norms. The BCT Taxonomy v1 is a list of behaviour change techniques, compiled by consensus between international experts in behavioural science. We will include the following BCTs in the review , as defined in the BCT taxonomy v1: social comparison; information about others’ approval; credible source; social incentive; social reward. Searches will be undertaken in MEDLINE, EMBASE, CINAHL, British Nursing Index, ISI Web of Science, PsychInfo and Cochrane trials, without restriction on dates. One reviewer will independently screen titles and abstracts, excluding any that are clearly ineligible, with a second reviewer independently screening a sample of 20%. Two reviewers will independently screen all the full texts, extract data, and assess risk of bias, using a data extraction form based on the Effective Practice and Organisation of Care (EPOC) form. The primary outcome measure will be ‘compliance with desired behaviour.’ We will convert any observed measure of health professional behaviour into a standardised mean difference between groups, e.g. the mean number of times a behaviour was performed per professional. Analysis To assess the effect of social influence on the behaviour of health professionals we will perform random effects meta-analysis and present forest plots, stratified by BCT. We will explore sources of variation using meta-regression and may use multi-component-based network meta-analysis to explore which forms of social influence are more likely to be effective, if our data meet the necessary requirements. We will disseminate the research to academics, health professionals and members of the public. We will use the findings from the review to plan future research on the use of social influence with health professionals.

Lay abstract: Health professionals routinely carry out behaviours which impact on patient diagnoses, care, treatment and recovery. For example, reducing the number of unnecessary antibiotics prescribed by General Practitioners (GPs) can limit antibiotic resistance. Encouraging hospital staff to wash their hands more often can reduce the spread of infection. It may be possible to reduce waste by persuading community nurses to avoid the use of expensive wound dressings when cheaper alternatives are known to work just as well. Some methods of persuading health professionals to change their behaviour rely on social or peer influences. Examples include social comparison, social incentive and credible source. Social comparison is when a person is encouraged to perform a particular behaviour by being told about what other people do: e.g. a GP may be told how many times their colleagues prescribed antibiotics in the previous month, compared to their own prescription rate. Social incentive is when a person is promised a reward for performing a particular behaviour: e.g. hospital staff may be informed that the ‘top 10’ most frequent hand-washers will have their names displayed in a staff newsletter. Credible source is sending a message from a well-respected person in support of the behaviour: e.g. a nurse may be sent a letter from the chief nursing officer supporting a particular wound dressing. In this project we aim to find out whether or not social influence techniques are effective ways of encouraging healthcare staff to carry out desired behaviours. We will also explore which types of social influence, if any, are most useful. To do this we will do a thorough search for research studies that have looked at these questions. From our preliminary searches we estimate we will include around 100 studies in the review. We will carefully read the reports of these studies and assess the quality of the research methods used. We will take information from these studies and combine their results (using statistical analysis where suitable). The review will take one year to complete. We expect to publish the results of our research project in a leading medical journal and to present the findings to medical and patient communities. Interested public representatives will be asked to help us communicate the findings effectively. This research will help managers in the health service to plan effective strategies to influence the behaviour of health professionals. This will lead to benefits for patients including improved healthcare and increased patient safety. We will use the findings from the review to plan future research on the use of social influence with health professionals.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE