Abstract
BackgroundHealthcare workers perform clinical behaviours which impact on patient diagnoses, care, treatment and recovery. Some methods of supporting healthcare workers in changing their behaviour make use of social norms by exposing healthcare workers to the beliefs, values, attitudes or behaviours of a reference group or person. This review aimed to evaluate evidence on (i) the effect of social norms interventions on healthcare worker clinical behaviour change and (ii) the contexts, modes of delivery and behaviour change techniques (BCTs) associated with effectiveness.MethodsSystematic review and meta-analysis of randomised controlled trials. Searches were undertaken in seven databases. The primary outcome was compliance with a desired healthcare worker clinical behaviour and the secondary outcome was patient health outcomes. Outcomes were converted into standardised mean differences (SMDs). We performed meta-analyses and presented forest plots, stratified by five social norms BCTs (social comparison, credible source, social reward, social incentive and information about others’ approval). Sources of variation in social norms BCTs, context and mode of delivery were explored using forest plots, meta-regression and network meta-analysis.ResultsCombined data from 116 trials suggested that social norms interventions were associated with an improvement in healthcare worker clinical behaviour outcomes of 0.08 SMDs (95%CI 0.07 to 0.10) (n = 100 comparisons), and an improvement in patient health outcomes of 0.17 SMDs (95%CI 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I2 of 85.4% (healthcare worker clinical behaviour) and 91.5% (patient health outcomes). Credible source was more effective on average, compared to control conditions (SMD 0.30, 95%CI 0.13 to 0.47, n = 7). Social comparison also appeared effective, both on its own (SMD 0.05, 95%CI 0.03 to 0.08, n = 33) and with other BCTs, and seemed particularly effective when combined with prompts/cues (0.33, 95%CI 0.22 to 0.44, n = 5).ConclusionsSocial norms interventions appeared to be an effective method of changing the clinical behaviour of healthcare workers and have a positive effect on patient health outcomes in a variety of health service contexts. Although the overall result is modest and variable, there is the potential for social norms interventions to be applied at large scale.Trial registrationPROSPERO CRD42016045718.
Highlights
Healthcare workers perform clinical behaviours which impact on patient diagnoses, care, treatment and recovery
Combined data from 116 trials suggested that social norms interventions were associated with an improvement in healthcare worker clinical behaviour outcomes of 0.08 Standard mean difference (SMD) (95%Confidence Interval (CI) 0.07 to 0.10) (n = 100 comparisons), and an improvement in patient health outcomes of 0.17 SMDs (95%CI 0.14 to 0.20) (n = 14), on average
Social comparison appeared effective, both on its own (SMD 0.05, 95%CI 0.03 to 0.08, n = 33) and with other Behaviour Change Technique (BCT), and seemed effective when combined with prompts/cues (0.33, 95%CI 0.22 to 0.44, n = 5)
Summary
Healthcare workers perform clinical behaviours which impact on patient diagnoses, care, treatment and recovery. Some methods of supporting healthcare workers in changing their behaviour make use of social norms by exposing healthcare workers to the beliefs, values, attitudes or behaviours of a reference group or person. Healthcare workers routinely perform behaviours in clinical settings which impact all aspects of patient care including diagnoses, treatment and recovery. We have defined a social norms intervention as one which seeks to change the clinical behaviour of a target healthcare worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. The target healthcare worker is the person at whom a social norms intervention is aimed, with a view to changing their clinical behaviour. Social norms interventions sometimes report a peer benchmark, such as the top 10% of the reference group or the average performance: the downside of the average approach is that the above-average performers will receive feedback suggesting that they are already performing better than their peers, and this may lead them to reduce their effort [5]
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