Lowbury Lecture 2013. Cultural determinants of infection control behaviour: understanding drivers and implementing effective change.

Despite dealing with biomedical practices, infection prevention and control (IPC) is essentially a behavioural science. Human behaviour is influenced by various factors, including culture. Hofstede's model of cultural dimensions proposes that national cultures vary along consistent dimensions which can be grouped and scored as specific constructs. Studies have reported that three Hofstede constructs--power distance, uncertainty avoidance, and masculinity--show significant association with several key performance indicators relevant to IPC and antibiotic stewardship. In addition, national meticillin-resistant Staphylococcus aureus (MRSA) levels within Europe correlate well with general quality-of-care indices, including preventive strategies and patient rights. This suggests that IPC may be simply a microcosm of overall quality and safety standards within hospitals and countries. Effective improvement would therefore need to address underlying and embedded core cultural values relevant to patient safety and quality of care. Successful IPC strategies are likely to be those that are compatible with the cultural background where they are implemented. To this end, content analysis of many current IPC improvement tools identifies elements of strong compatibility with cultures that are low in uncertainty avoidance and power distance, and high in individualism and masculinity. However, this cultural combination is largely restricted to Anglo-Saxon countries, where most of the recent improvements in healthcare-associated infection (HCAI) incidence have taken place. There is a paucity of research on IPC behaviour change in different cultural backgrounds, especially countries that score high for power distance and/or uncertainty avoidance. This information is vital to inform IPC campaigns in these countries, which often show high HCAI prevalence.