Effects of social norm feedback on adherence to clinical practice guidelines among healthcare workers and its characteristics in behavior change techniques: A systematic review and meta-analysis

Abstract

Background

Poor adherence to clinical practice guidelines among healthcare workers could have negative impacts on the effectiveness of care, patient health outcomes, and healthcare costs. Social norm feedback can be an essential means of achieving the intended intervention goals by providing information to the intervention target regarding the values, attitudes, or behaviors of the reference group or individual. However, there is a lack of consensus on the effectiveness of social norm feedback in improving adherence to clinical practice guidelines among healthcare workers. Therefore, this systematic review aimed to assess the effects of social norm feedback on adherence to clinical practice guidelines among healthcare workers and its characteristics in behavior change techniques.

Methods

Searches of PubMed, Web of Science, Cochrane Central Register of Controlled Trials (via CENTRAL), EMBASE (via OVID), MEDLINE (via OVID), and Scopus were preformed to identify peer-reviewed studies published until February 29, 2024. Randomized controlled trials reporting social norm feedback interventions (social comparison, information about others' approval, credible source, social reward, and social incentive) to support compliance with clinical practice guidelines were included. The risk of bias of individual studies was assessed using the Cochrane Risk of Bias 2.0 tool and the certainty of evidence was rated using the GRADE method. Pooled data were analyzed in Stata 17.0 using a random effects model meta-analysis.

Results

A total of 31 articles (30 studies) were identified. Fifteen behavior change techniques were tested in the included studies. The three most commonly used behavior change techniques in clinical practice guidelines were social comparison, feedback on the outcome of behavior, and social support. A meta-analysis showed that social norm feedback appeared to be an effective strategy to improve adherence to clinical practice guidelines among healthcare workers, with a rate difference (RD) of 0.04 (95 % confidence interval [CI] 0.02–0.06). Credible source (RD 0.12, 95 % CI 0.06–0.19) and multiple social norms behavioral change techniques (RD 0.05, 95 % CI 0.04–0.06) seemed effective when combined with other behavioral change techniques, compared to the control condition. The certainty of evidence across the outcomes ranged from very low to high based on the GRADE approach.

Conclusion

Social norm feedback appears to be an effective method for improving adherence to clinical practice guidelines among healthcare workers. This review provides a broad understanding of how social norm feedback can be applied to improve adherence of healthcare workers to clinical practice guidelines, ultimately improving patient health and quality of care.

Trial registration: PROSPERO CRD42023411582.