Challenges in Hand Hygiene Practice: Understanding Human Behavior Barriers

Abstract

 

Background:
Despite global awareness campaigns and the availability of sanitation infrastructure, hand hygiene compliance remains persistently low in both healthcare settings and the general public. Behavioral and cognitive barriers are often overlooked in hygiene promotion strategies.

Objective:
To investigate behavioral, cultural, and perceptual factors influencing hand hygiene compliance in healthcare workers and caregivers in low-resource primary health facilities.

Methods:
A mixed-methods study was conducted in 14 public primary health centers in rural France between May and September 2024. Observational audits of 211 healthcare workers (nurses, aides, physicians) were performed using the WHO “5 Moments” framework. Semi-structured interviews (n=52) explored beliefs, risk perceptions, social norms, and facility-level barriers. Quantitative compliance data were analyzed using chi-square and multivariable logistic regression.

Results:
Overall hand hygiene compliance was 41.6%. Compliance was significantly lower before patient contact (27.9%) versus after contact (54.3%, p < 0.001). Key behavioral barriers included perceived time pressure (reported by 68.2%), absence of immediate feedback (61.5%), and low perceived infection risk in routine tasks (44.8%). Workers with high workload (≥15 patients/shift) had 2.3 times lower odds of compliance (OR = 0.43; 95% CI: 0.31–0.59, p < 0.001). Qualitative themes revealed the impact of workplace culture and role modeling, especially among junior staff.

Conclusion:
Hand hygiene compliance is not solely a matter of availability—it is shaped by complex behavioral and organizational dynamics. Interventions that combine behavioral nudges, peer accountability, and targeted education may be more effective than infrastructure alone. Cultural tailoring and real-time feedback mechanisms should be central to future programs.