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Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Improving hand hygiene behaviour among adolescents by a planning intervention a
b
a
cd
Guangyu Zhou , Tingting Jiang , Nina Knoll & Ralf Schwarzer a
Department of Educational Science and Psychology, Freie Universität Berlin, Berlin, Germany b
Wuhan No.2 Middle School, Students Counselling Center, Wuhan, Hubei Province, China c
Institute for Positive Psychology and Education, Australian Catholic University, Strathfield, Australia
Click for updates
d
Department of Clinical, Health, and Rehabilitation Psychology, University of Social Sciences and Humanities, Wrocław, Poland Published online: 16 Mar 2015.
To cite this article: Guangyu Zhou, Tingting Jiang, Nina Knoll & Ralf Schwarzer (2015): Improving hand hygiene behaviour among adolescents by a planning intervention, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1024138 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1024138
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Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1024138
Improving hand hygiene behaviour among adolescents by a planning intervention Guangyu Zhoua*
, Tingting Jiangb, Nina Knolla and Ralf Schwarzerc,d
a
Department of Educational Science and Psychology, Freie Universität Berlin, Berlin, Germany; Wuhan No.2 Middle School, Students Counselling Center, Wuhan, Hubei Province, China; c Institute for Positive Psychology and Education, Australian Catholic University, Strathfield, Australia; dDepartment of Clinical, Health, and Rehabilitation Psychology, University of Social Sciences and Humanities, Wrocław, Poland b
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(Received 7 September 2014; accepted 24 February 2015) To improve regular hand hygiene in adolescents, educational messages based on medical information have not been very successful. Therefore, a theory-guided self-regulatory intervention has been designed with a particular focus on planning strategies. A randomised controlled trial with 307 adolescents, aged 12–18 years, was conducted in high schools. The control group received educational hand hygiene leaflets, whereas the experimental group received a self-regulatory treatment which required them to generate specific action plans and coping plans. Three times during one month, both groups received verbal reminder messages about planning to wash their hands properly. At one-month follow-up, hand hygiene behaviour as well as planning to practise hand hygiene were higher in the self-regulation than in the education group (p < .01). Moreover, changes in planning levels operated as a mediator between experimental conditions and changes in behavioural outcomes. Teaching self-regulatory planning strategies may constitute a superior approach than educational messages to improve regular hand hygiene practice in adolescents. Keywords: hand self-regulation
hygiene;
adolescents;
action
planning;
coping
planning;
Introduction Interventions on hand hygiene have included non-hospital populations, such as school pupils, to decrease illness-related absenteeism by washing hands properly (Azor-Martínez et al., 2014; Correa et al., 2012; Lau et al., 2012; Nandrup-Bus, 2009). Didactic information on hand hygiene is the main principle used in previous educational interventions, which typically includes knowledge about infections transmitted by hands and how to prevent them by washing hands properly (Azor-Martínez et al., 2014; Cairncross, Shordt, Zacharia, & Govindan, 2005; Cole et al., 2012; Correa et al., 2012). Besides providing health knowledge, role models (Davis et al., 2013), social norms (Mackert, Liang, & Champlin, 2013), rewards (Bowen et al., 2007) and disgust emotion (Porzig-Drummond, Stevenson, Case, & Oaten, 2009) also were investigated. Primary outcomes of such studies are often the infection rates or school absenteeism, but little is known about the intervention’s active ingredients (e.g. self-regulatory components).
*Corresponding author. Email: [email protected] © 2015 Taylor & Francis
2
G. Zhou et al.
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Planning as one of the well-established behaviour change techniques has been documented in various meta-analyses to be an effective self-regulatory skill to promote health-related behaviours (Adriaanse, Vinkers, De Ridder, Hox, & De Wit, 2011; Gollwitzer & Sheeran, 2006; Kwasnicka, Presseau, White, & Sniehotta, 2013). Previous studies confirming the role of planning skills have been found in trials on health behaviours, such as dietary behaviour (Lange et al., 2013), physical exercise (Luszczynska, 2006), dental flossing (Schüz, Sniehotta, Wiedemann, & Seemann, 2006), sunscreen use (Zhou, Zhang, Knoll, & Schwarzer, 2014), smoking prevention (Conner & Higgins, 2010) and reducing alcohol consumption (Armitage, 2009), but few in the domain of hand hygiene. Aims and hypotheses The objectives were to examine the effectiveness of a self-regulation intervention among Chinese adolescents and to identify the effects of planning on hand hygiene. It was hypothesised that the self-regulatory intervention would lead to a higher frequency of hand hygiene as well as higher levels of planning to wash hands properly compared to the common educational intervention. Moreover, it was expected that planning would mediate between experimental conditions and subsequent hand hygiene frequency. Method Participants and procedure Adolescent students were invited to a flu prevention programme and participation was voluntary. Of N = 372 recruited high school students from one central city in China, n = 307 remained in the analysis after excluding 58 students who had provided an invalid code and seven students with wounded hands. The final sample consisted of 134 (43.6%) female and 173 (56.4%) male students, with a mean age of 14.54 years, SD = 1.55, ranging from 12 to 18 years. At baseline (Time 1, T1), participants completed a questionnaire asking for demographic information, hand hygiene behaviour and planning. Following this assessment, they were randomised into an education group (n = 156) and a self-regulation group (n = 151). Then both groups received their treatment packages. During the following month, on three mondays, research assistants gave verbal reminder notices about hand hygiene to the education group and detailed instructions on how to plan hand hygiene to the self-regulation group. One month later (Time 2, T2), all participants were reinvited to the follow-up questionnaire (see Figure 1). They were debriefed after the second wave of data collection. All students and head teachers gave their informed consent for participation and the local department of health approved of the study. Measures All scales were administered at T1 and T2. Hand hygiene behaviour was assessed by three items from the Nordic Occupational Skin Questionnaire-2002 (NOSQ-2002) that asks about the frequency of hand washing using plain water, water and soap, or disinfectant (Susitaival et al., 2003). One item was worded: ‘During the last week, how many times a day did you wash your hands with
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Psychology, Health & Medicine
Figure 1.
3
CONSORT flow diagram.
soap and water?’. Response categories were ‘1: 0–2 times; 2: 3–4 times; 3: 5–6 times; 4: 7–9 times; 5: 10 or more times’. Cronbach’s α was .62 at T1 and .66 at T2. Planning was measured with six items (three for action planning and three for coping planning), adapted from Schwarzer (2008). Action planning was assessed by asking participants to evaluate to which extent they agreed with the affirmation that they had already made a concrete plan on when, where and how to wash hands, respectively. Coping planning was assessed by asking participants to rate to what extent they had made a concrete plan about what to do if something interfered with their goal of hand washing, e.g. if they were in a hurry and if there was no water or soap. Responses ranged from not at all true (1) to definitely true (4). Cronbach’s α for the combined planning scale was .86 at T1 and .89 at T2. Interventions In the education intervention group, participants received a leaflet adopted from the webpage of the Centers for Disease Control and Prevention (CDC, 2013). In terms of BCT, the leading components were BCT 4.1 (e.g. instruction on how to wash the hands properly) and BCT 5.1 (e.g. outcomes of washing hands) (Michie et al., 2013). In the self-regulation intervention, individuals were instructed to generate three action plans (BCT 1.2) and three coping plans (BCT 1.4) on hand hygiene in addition to reading the hand hygiene information (Michie et al., 2013).
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G. Zhou et al.
Table 1. Means and standard deviations of hand hygiene behaviour, planning as well as change scores in both groups. Time 1 Variable/group
M
SD F(1, 306)
Hand hygiene Self-regulation 2.29 .95 group Education group 2.15 .82
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Planning Self-regulation 2.77 .79 group Education group 2.63 .80
1.86
2.48
Change scores
Time 2 p
η2
M
SD
.17 .01 2.57 1.04 2.11
.79
.12 .01 2.91
.82
2.45
.79
F(1, 306) 19.72
25.61
p
η2
.00 .06
.00 .08
M
SD
.28 1.06 −.05
.77
.14
.77
−.18
.90
Results Randomisation check A MANOVA revealed no baseline differences across the study conditions regarding age and sex as well as hand hygiene planning (all p > .05, see Table 1). Intervention effects To examine the intervention effects, repeated-measures ANOVAs were conducted. For hand hygiene, there was a main effect for time, F(1, 305) = 4.83, p < .05, η2 = .02, indicating that overall behaviour had increased, and a main effect for
Figure 2.
Hand hygiene behaviour in the experimental conditions at two points in time.
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Psychology, Health & Medicine
Figure 3.
5
Changes in planning in the experimental conditions at two points in time.
group, F(1, 305) = 11.61, p < .01, η2 = .04. Moreover, a significant time × group interaction, F(1, 305) = 9.66, p < .01, η2 = .03 emerged, indicating that participants in the self-regulation group had benefited more than those in the education group (Figure 2). For the combined planning scores, there was a significant main effect for group, F (1, 299) = 15.23, p < .01, η2 = .05, and a significant time × group interaction, F(1, 305) = 11.32, p < .01, η2 = .04, indicating that participants in the self-regulation intervention formed more plans compared to those in the education intervention. However, there was no significant main effect for time, F(1, 305) = .23, p > .05, indicating that overall planning did not increase (Figure 3).
Figure 4. Mediation model with effects of experimental conditions (1 = self-regulation intervention, 0 = education intervention) via changes in planning on hand hygiene behaviour changes. Unstandardised solution; bootstrapped with 5000 resamples (N = 307) using the PROCESS macro (Hayes, 2013). Note: *p < .05; **p < .01.
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G. Zhou et al.
Mediation analysis To test mediation, planning change scores (T2 planning – T1 planning) were considered to serve as mediator between the condition and hand hygiene change scores (T2 behaviour – T1 behaviour). A path model yielded the expected results (Figure 4). The unstandardised indirect effect of treatment on hand hygiene changes via changes in planning was .07 (95% CI [.02, .14]).
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Discussion This study aimed at testing whether a brief planning intervention with three verbal reminders (boosters) would improve hand hygiene behaviour among adolescents. Results demonstrated that participants receiving the self-regulation intervention made more plans and washed their hands more often than those in the education group. This finding is in line with the study by Erasmus et al. (2010), who trained nurses to formulate action plans to perform hand hygiene behaviour. However, their study had only a small sample of 10 nurses. In the present study, the question whether planning operates as a facilitator of behaviour change was explored by a path model. It was found that planning served as the key ingredient of the intervention. This finding is consistent with a large body of literature, which shows that planning is assumed to mediate the effects of the intervention on subsequent behaviours (Hagger & Luszczynska, 2014). The present study adds to the literature mainly by introducing planning as a mediator, and thus, stimulating future research to include this self-regulatory skill as an intervention component. Planning is an alterable variable. It can be easily communicated to individuals with self-regulatory deficits. By simply teaching people how to generate detailed action plans and coping plans for critical situations, they can be empowered to apply such self-regulatory strategies for various domains, including hygiene behaviours. Researchers might want to implement planning for hand washing also beyond school settings, for example, in companies or hospitals. A limitation is that quite a few persons had to be excluded because of their invalid anonymous codes. Also, hand hygiene behaviour was self-reported, implying a risk of bias, as there is evidence documenting over-reporting of ‘correct’ behaviours (Vindigni, Riley, & Jhung, 2011). One could overcome this limitation by direct observation of hand hygiene behaviours. In sum, this study has confirmed the role of planning as a self-regulatory skill to attain behaviour change. Teaching planning strategies may constitute a superior approach than educational messages to improve regular hand hygiene practice in adolescents.
Disclosure statement No potential conflict of interest was reported by the authors.
ORCID Guangyu Zhou
http://orcid.org/0000-0003-2053-6737
Psychology, Health & Medicine
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References Adriaanse, M. A., Vinkers, C. D., De Ridder, D. T., Hox, J. J., & De Wit, J. B. (2011). Do implementation intentions help to eat a healthy diet? A systematic review and meta-analysis of the empirical evidence. Appetite, 56, 183–193. doi:10.1016/j.appet.2010.10.012 Armitage, C. J. (2009). Effectiveness of experimenter-provided and self-generated implementation intentions to reduce alcohol consumption in a sample of the general population: A randomized exploratory trial. Health Psychology, 28, 545–553. doi:10.1037/a0015984 Azor-Martínez, E., Gonzalez-Jimenez, Y., Seijas-Vazquez, M. L., Cobos-Carrascosa, E., Santisteban-Martínez, J., Martínez-López, J. M., … Gimenez-Sanchez, F. (2014). The impact of common infections on school absenteeism during an academic year. American Journal of Infection Control, 42, 632–637. doi:10.1016/j.ajic.2014.02.017 Bowen, A., Ma, H., Ou, J., Billhimer, W., Long, T., Mintz, E., … Luby, S. (2007). A clusterrandomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools. The American Journal of Tropical Medicine and Hygiene, 76, 1166–1173. Cairncross, S., Shordt, K., Zacharia, S., & Govindan, B. K. (2005). What causes sustainable changes in hygiene behaviour? A cross-sectional study from Kerala, India. Social Science & Medicine, 61, 2212–2220. Centers for Disease Control and Prevention. (2013). Saving lives. Protecting people.TM Retrieved from http://www.cdc.gov/handwashing/ Cole, E. C., Hawkley, M., Rubino, J. R., Crookston, B. T., McCue, K., Dixon, J., … Kim, J. (2012). Comprehensive family hygiene promotion in peri-urban Cape Town: Gastrointestinal and respiratory illness and skin infection reduction in children aged under 5. South African Journal of Child Health, 6, 109–117. Conner, M., & Higgins, A. R. (2010). Long-term effects of implementation intentions on prevention of smoking uptake among adolescents: A cluster randomized controlled trial. Health Psychology, 29, 529–538. doi:10.1037/a0020317 Correa, J. C., Pinto, D., Salas, L. A., Camacho, J. C., Rondón, M., & Quintero, J. (2012). A cluster-randomized controlled trial of handrubs for prevention of infectious diseases among children in Colombia. Revista Panamericana de Salud Pública, 31, 476–484. Davis, T. P., Wetzel, C., Avilan, E. H., Lopes, C. D. M., Chase, R. P., Winch, P. J., & Perry, H. B. (2013). Reducing child global undernutrition at scale in Sofala Province, Mozambique, using care group volunteers to communicate health messages to mothers. Global Health: Science and Practice, 1, 35–51. Erasmus, V., Kuperus, M. N., Richardus, J. H., Vos, M. C., Oenema, A., & Van Beeck, E. F. (2010). Improving hand hygiene behaviour of nurses using action planning: A pilot study in the intensive care unit and surgical ward. Journal of Hospital Infection, 76, 161–164. doi:10.1016/j.jhin.2010.04.024 Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes. Advances in Experimental Social Psychology, 38, 69–119. doi:10.1016/S0065-2601(06)38002-1 Hagger, M. S., & Luszczynska, A. (2014). Implementation intention and action planning Interventions in health contexts: State of the research and proposals for the way forward. Applied Psychology: Health and Well-Being, 6(1), 1–47. doi:10.1111/aphw.12017 Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: The Guilford Press. Kwasnicka, D., Presseau, J., White, M., & Sniehotta, F. F. (2013). Does planning how to cope with anticipated barriers facilitate health-related behaviour change? A systematic review. Health Psychology Review, 7, 129–145. doi:10.1080/17437199.2013.766832 Lange, D., Richert, J., Koring, M., Knoll, N., Schwarzer, R., & Lippke, S. (2013). Self-regulation prompts can increase fruit consumption: A one-hour randomised controlled online trial. Psychology & Health, 28, 533–545. doi:10.1080/08870446.2012.751107 Lau, C. H., Springston, E. E., Sohn, M. W., Mason, I., Gadola, E., Damitz, M., & Gupta, R. S. (2012). Hand hygiene instruction decreases illness-related absenteeism in elementary schools: A prospective cohort study. BMC Pediatrics, 12, 52. doi:10.1186/1471-2431-12-52 Luszczynska, A. (2006). An implementation intentions intervention, the use of a planning strategy, and physical activity after myocardial infarction. Social Science and Medicine, 62, 900–908.
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Mackert, M., Liang, M. C., & Champlin, S. (2013). “Think the sink:” Preliminary evaluation of a handwashing promotion campaign. American Journal of Infection Control, 41, 275–277. doi:10.1016/j.ajic.2012.03.023 Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., … Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46, 81–95. Nandrup-Bus, I. (2009). Mandatory handwashing in elementary schools reduces absenteeism due to infectious illness among pupils: A pilot intervention study. American Journal of Infection Control, 37, 820–826. doi:10.1016/j.ajic.2009.06.012 Porzig-Drummond, R., Stevenson, R., Case, T., & Oaten, M. (2009). Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests. Social Science and Medicine, 68, 1006–1012. doi:10.1016/j.socscimed.2009.01.013 Schwarzer, R. (2008). Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology, 57(1), 1–29. doi:10.1111/j.14640597.2007.00325.x Schüz, B., Sniehotta, F. F., Wiedemann, A., & Seemann, R. (2006). Adherence to a daily flossing regimen in university students: Effects of planning when, where, how and what to do in the face of barriers. Journal of Clinical Periodontology, 33, 612–619. doi:10.1111/j.1600051X.2006.00967.x Susitaival, P., Flyvholm, M. A., Meding, B., Kanerva, L., Lindberg, M., Svensson, A., & Olafsson, J. H. (2003). Nordic occupational skin questionnaire (NOSQ-2002): A new tool for surveying occupational skin diseases and exposure. Contact Dermatitis, 49, 70–76. doi:10.1111/j.0105-1873.2003.00159.x Vindigni, S. M., Riley, P. L., & Jhung, M. (2011). Systematic review: Handwashing behaviour in low-to middle-income countries: Outcome measures and behaviour maintenance. Tropical Medicine & International Health, 16, 466–477. doi:10.1111/j.1365-3156.2010.02720.x Zhou, G., Zhang, L., Knoll, N., & Schwarzer, R. (2014). Facilitating sunscreen use among Chinese young adults: Less-motivated persons benefit from a planning intervention. International Journal of Behavioral Medicine. doi:10.1007/s12529-014-9458-7
Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Improving hand hygiene behaviour among adolescents by a planning intervention a
b
a
cd
Guangyu Zhou , Tingting Jiang , Nina Knoll & Ralf Schwarzer a
Department of Educational Science and Psychology, Freie Universität Berlin, Berlin, Germany b
Wuhan No.2 Middle School, Students Counselling Center, Wuhan, Hubei Province, China c
Institute for Positive Psychology and Education, Australian Catholic University, Strathfield, Australia
Click for updates
d
Department of Clinical, Health, and Rehabilitation Psychology, University of Social Sciences and Humanities, Wrocław, Poland Published online: 16 Mar 2015.
To cite this article: Guangyu Zhou, Tingting Jiang, Nina Knoll & Ralf Schwarzer (2015): Improving hand hygiene behaviour among adolescents by a planning intervention, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1024138 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1024138
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1024138
Improving hand hygiene behaviour among adolescents by a planning intervention Guangyu Zhoua*
, Tingting Jiangb, Nina Knolla and Ralf Schwarzerc,d
a
Department of Educational Science and Psychology, Freie Universität Berlin, Berlin, Germany; Wuhan No.2 Middle School, Students Counselling Center, Wuhan, Hubei Province, China; c Institute for Positive Psychology and Education, Australian Catholic University, Strathfield, Australia; dDepartment of Clinical, Health, and Rehabilitation Psychology, University of Social Sciences and Humanities, Wrocław, Poland b
Downloaded by [FU Berlin] at 09:21 09 July 2015
(Received 7 September 2014; accepted 24 February 2015) To improve regular hand hygiene in adolescents, educational messages based on medical information have not been very successful. Therefore, a theory-guided self-regulatory intervention has been designed with a particular focus on planning strategies. A randomised controlled trial with 307 adolescents, aged 12–18 years, was conducted in high schools. The control group received educational hand hygiene leaflets, whereas the experimental group received a self-regulatory treatment which required them to generate specific action plans and coping plans. Three times during one month, both groups received verbal reminder messages about planning to wash their hands properly. At one-month follow-up, hand hygiene behaviour as well as planning to practise hand hygiene were higher in the self-regulation than in the education group (p < .01). Moreover, changes in planning levels operated as a mediator between experimental conditions and changes in behavioural outcomes. Teaching self-regulatory planning strategies may constitute a superior approach than educational messages to improve regular hand hygiene practice in adolescents. Keywords: hand self-regulation
hygiene;
adolescents;
action
planning;
coping
planning;
Introduction Interventions on hand hygiene have included non-hospital populations, such as school pupils, to decrease illness-related absenteeism by washing hands properly (Azor-Martínez et al., 2014; Correa et al., 2012; Lau et al., 2012; Nandrup-Bus, 2009). Didactic information on hand hygiene is the main principle used in previous educational interventions, which typically includes knowledge about infections transmitted by hands and how to prevent them by washing hands properly (Azor-Martínez et al., 2014; Cairncross, Shordt, Zacharia, & Govindan, 2005; Cole et al., 2012; Correa et al., 2012). Besides providing health knowledge, role models (Davis et al., 2013), social norms (Mackert, Liang, & Champlin, 2013), rewards (Bowen et al., 2007) and disgust emotion (Porzig-Drummond, Stevenson, Case, & Oaten, 2009) also were investigated. Primary outcomes of such studies are often the infection rates or school absenteeism, but little is known about the intervention’s active ingredients (e.g. self-regulatory components).
*Corresponding author. Email: [email protected] © 2015 Taylor & Francis
2
G. Zhou et al.
Downloaded by [FU Berlin] at 09:21 09 July 2015
Planning as one of the well-established behaviour change techniques has been documented in various meta-analyses to be an effective self-regulatory skill to promote health-related behaviours (Adriaanse, Vinkers, De Ridder, Hox, & De Wit, 2011; Gollwitzer & Sheeran, 2006; Kwasnicka, Presseau, White, & Sniehotta, 2013). Previous studies confirming the role of planning skills have been found in trials on health behaviours, such as dietary behaviour (Lange et al., 2013), physical exercise (Luszczynska, 2006), dental flossing (Schüz, Sniehotta, Wiedemann, & Seemann, 2006), sunscreen use (Zhou, Zhang, Knoll, & Schwarzer, 2014), smoking prevention (Conner & Higgins, 2010) and reducing alcohol consumption (Armitage, 2009), but few in the domain of hand hygiene. Aims and hypotheses The objectives were to examine the effectiveness of a self-regulation intervention among Chinese adolescents and to identify the effects of planning on hand hygiene. It was hypothesised that the self-regulatory intervention would lead to a higher frequency of hand hygiene as well as higher levels of planning to wash hands properly compared to the common educational intervention. Moreover, it was expected that planning would mediate between experimental conditions and subsequent hand hygiene frequency. Method Participants and procedure Adolescent students were invited to a flu prevention programme and participation was voluntary. Of N = 372 recruited high school students from one central city in China, n = 307 remained in the analysis after excluding 58 students who had provided an invalid code and seven students with wounded hands. The final sample consisted of 134 (43.6%) female and 173 (56.4%) male students, with a mean age of 14.54 years, SD = 1.55, ranging from 12 to 18 years. At baseline (Time 1, T1), participants completed a questionnaire asking for demographic information, hand hygiene behaviour and planning. Following this assessment, they were randomised into an education group (n = 156) and a self-regulation group (n = 151). Then both groups received their treatment packages. During the following month, on three mondays, research assistants gave verbal reminder notices about hand hygiene to the education group and detailed instructions on how to plan hand hygiene to the self-regulation group. One month later (Time 2, T2), all participants were reinvited to the follow-up questionnaire (see Figure 1). They were debriefed after the second wave of data collection. All students and head teachers gave their informed consent for participation and the local department of health approved of the study. Measures All scales were administered at T1 and T2. Hand hygiene behaviour was assessed by three items from the Nordic Occupational Skin Questionnaire-2002 (NOSQ-2002) that asks about the frequency of hand washing using plain water, water and soap, or disinfectant (Susitaival et al., 2003). One item was worded: ‘During the last week, how many times a day did you wash your hands with
Downloaded by [FU Berlin] at 09:21 09 July 2015
Psychology, Health & Medicine
Figure 1.
3
CONSORT flow diagram.
soap and water?’. Response categories were ‘1: 0–2 times; 2: 3–4 times; 3: 5–6 times; 4: 7–9 times; 5: 10 or more times’. Cronbach’s α was .62 at T1 and .66 at T2. Planning was measured with six items (three for action planning and three for coping planning), adapted from Schwarzer (2008). Action planning was assessed by asking participants to evaluate to which extent they agreed with the affirmation that they had already made a concrete plan on when, where and how to wash hands, respectively. Coping planning was assessed by asking participants to rate to what extent they had made a concrete plan about what to do if something interfered with their goal of hand washing, e.g. if they were in a hurry and if there was no water or soap. Responses ranged from not at all true (1) to definitely true (4). Cronbach’s α for the combined planning scale was .86 at T1 and .89 at T2. Interventions In the education intervention group, participants received a leaflet adopted from the webpage of the Centers for Disease Control and Prevention (CDC, 2013). In terms of BCT, the leading components were BCT 4.1 (e.g. instruction on how to wash the hands properly) and BCT 5.1 (e.g. outcomes of washing hands) (Michie et al., 2013). In the self-regulation intervention, individuals were instructed to generate three action plans (BCT 1.2) and three coping plans (BCT 1.4) on hand hygiene in addition to reading the hand hygiene information (Michie et al., 2013).
4
G. Zhou et al.
Table 1. Means and standard deviations of hand hygiene behaviour, planning as well as change scores in both groups. Time 1 Variable/group
M
SD F(1, 306)
Hand hygiene Self-regulation 2.29 .95 group Education group 2.15 .82
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Planning Self-regulation 2.77 .79 group Education group 2.63 .80
1.86
2.48
Change scores
Time 2 p
η2
M
SD
.17 .01 2.57 1.04 2.11
.79
.12 .01 2.91
.82
2.45
.79
F(1, 306) 19.72
25.61
p
η2
.00 .06
.00 .08
M
SD
.28 1.06 −.05
.77
.14
.77
−.18
.90
Results Randomisation check A MANOVA revealed no baseline differences across the study conditions regarding age and sex as well as hand hygiene planning (all p > .05, see Table 1). Intervention effects To examine the intervention effects, repeated-measures ANOVAs were conducted. For hand hygiene, there was a main effect for time, F(1, 305) = 4.83, p < .05, η2 = .02, indicating that overall behaviour had increased, and a main effect for
Figure 2.
Hand hygiene behaviour in the experimental conditions at two points in time.
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Psychology, Health & Medicine
Figure 3.
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Changes in planning in the experimental conditions at two points in time.
group, F(1, 305) = 11.61, p < .01, η2 = .04. Moreover, a significant time × group interaction, F(1, 305) = 9.66, p < .01, η2 = .03 emerged, indicating that participants in the self-regulation group had benefited more than those in the education group (Figure 2). For the combined planning scores, there was a significant main effect for group, F (1, 299) = 15.23, p < .01, η2 = .05, and a significant time × group interaction, F(1, 305) = 11.32, p < .01, η2 = .04, indicating that participants in the self-regulation intervention formed more plans compared to those in the education intervention. However, there was no significant main effect for time, F(1, 305) = .23, p > .05, indicating that overall planning did not increase (Figure 3).
Figure 4. Mediation model with effects of experimental conditions (1 = self-regulation intervention, 0 = education intervention) via changes in planning on hand hygiene behaviour changes. Unstandardised solution; bootstrapped with 5000 resamples (N = 307) using the PROCESS macro (Hayes, 2013). Note: *p < .05; **p < .01.
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Mediation analysis To test mediation, planning change scores (T2 planning – T1 planning) were considered to serve as mediator between the condition and hand hygiene change scores (T2 behaviour – T1 behaviour). A path model yielded the expected results (Figure 4). The unstandardised indirect effect of treatment on hand hygiene changes via changes in planning was .07 (95% CI [.02, .14]).
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Discussion This study aimed at testing whether a brief planning intervention with three verbal reminders (boosters) would improve hand hygiene behaviour among adolescents. Results demonstrated that participants receiving the self-regulation intervention made more plans and washed their hands more often than those in the education group. This finding is in line with the study by Erasmus et al. (2010), who trained nurses to formulate action plans to perform hand hygiene behaviour. However, their study had only a small sample of 10 nurses. In the present study, the question whether planning operates as a facilitator of behaviour change was explored by a path model. It was found that planning served as the key ingredient of the intervention. This finding is consistent with a large body of literature, which shows that planning is assumed to mediate the effects of the intervention on subsequent behaviours (Hagger & Luszczynska, 2014). The present study adds to the literature mainly by introducing planning as a mediator, and thus, stimulating future research to include this self-regulatory skill as an intervention component. Planning is an alterable variable. It can be easily communicated to individuals with self-regulatory deficits. By simply teaching people how to generate detailed action plans and coping plans for critical situations, they can be empowered to apply such self-regulatory strategies for various domains, including hygiene behaviours. Researchers might want to implement planning for hand washing also beyond school settings, for example, in companies or hospitals. A limitation is that quite a few persons had to be excluded because of their invalid anonymous codes. Also, hand hygiene behaviour was self-reported, implying a risk of bias, as there is evidence documenting over-reporting of ‘correct’ behaviours (Vindigni, Riley, & Jhung, 2011). One could overcome this limitation by direct observation of hand hygiene behaviours. In sum, this study has confirmed the role of planning as a self-regulatory skill to attain behaviour change. Teaching planning strategies may constitute a superior approach than educational messages to improve regular hand hygiene practice in adolescents.
Disclosure statement No potential conflict of interest was reported by the authors.
ORCID Guangyu Zhou
http://orcid.org/0000-0003-2053-6737
Psychology, Health & Medicine
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