Abstract
This study aimed to identify factors influencing hand hygiene compliance among long-term care workers in long-term care facilities based on the theory of planned behavior (TPB). A cross-sectional survey was conducted with 133 long-term care workers from four long-term care facilities in Daegu Metropolitan City and Gyeongsangbuk-do, South Korea. Self-reported questionnaires assessed hand hygiene-related belief factors (behavioral, normative, and control beliefs), core TPB factors (attitude toward behavior, subjective norms, and perceived behavioral control), intention, and hand hygiene compliance. Descriptive statistics, t-tests, analysis of variance, Pearson correlation, and multiple regression analysis were performed. The mean scores for hand hygiene attitude, subjective norms, and behavioral intention exceeded the scale midpoint, whereas the scores for control beliefs and perceived behavioral control were relatively lower. Hand hygiene compliance was significantly correlated with behavioral beliefs (r=0.23, P=0.008), control beliefs (r=0.26, P=0.002), attitude toward behavior (r=0.18, P=0.038), perceived behavioral control (r=0.41, P<0.001), and intention (r=0.31, P<0.001). Multiple regression analysis identified perceived behavioral control (β=0.33, P=0.002) and intention (β=0.23, P=0.006) as significant predictors of compliance, explaining 19.1% of the variance (Adjusted R2=0.191). Perceived behavioral control and intention were identified as significant predictors of hand hygiene compliance. Interventions should not only enhance knowledge but also address structural and organizational factors to strengthen caregivers’ perceived control and translate intention into practice.
Keywords: Hand hygiene, Compliance, Caregivers, Aged, Theory of planned behavior
INTRODUCTION
South Korea became an “aging society” in 2000, when over 7% of citizens were aged 65 years and older, and a “super-aged society” in late 2024, when those over 65 comprised 20% of the population. The increase in the elderly population has raised the prevalence of geriatric diseases, increased physical dependence, and increased care burden among family members of older adults. This development underscores the growing importance of long-term care facilities for older adults who are unable to live independently. The introduction of the Long-term Care Insurance System in 2008 accelerated the expansion of such facilities and the related workforce. By the end of 2023, Korea reported over 6,000 long-term care institutions and more than 3 million caregivers working in long-term care settings.
Older adults in residential care are highly susceptible to infectious diseases due to declining immunity, cognitive impairment, and high comorbidity rates. Group living further compounds the risk, frequently resulting in infection clusters that impact morbidity, mortality, and quality of life (Veronese et al., 2025). Infection control must, therefore, be regarded as a central component of institutional long-term care to protect vulnerable older adults and optimize rehabilitation outcomes (Richards, 2002). Hand hygiene remains the most effective measure for preventing healthcare-associated infections. However, persistent lapses in hand hygiene among caregivers undermine infection prevention efforts, as hands represent the primary vector for cross-transmission (Allegranzi and Pittet, 2009). According to reports following the coronavirus disease 2019 pandemic, the infection fatality rate increases with age, particularly among adults aged 65 years and older (Levin et al., 2020). Moreover, long-term care facilities have been reported to have relatively limited professional healthcare personnel and infection control infrastructure compared with acute care hospitals (Festa et al., 2023), and their infection control guidelines and policies are often less systematic (Ye et al., 2015). Accordingly, the need for more rigorous infection prevention and control measures in resource- and personnel-limited long-term care facilities has been increasingly emphasized.
Despite its established importance, many previous studies on hand hygiene in elderly care facilities have focused merely on performance rates or outcomes, with limited assessment of the underlying psychological and social determinants of adherence. The theory of planned behavior (TPB) offers a robust model for understanding the formation of health-related behaviors, positing that behavioral intention—the most proximal predictor of action—is in turn shaped by one’s attitude toward the behavior, subjective norms, and perceived behavioral control (Ajzen, 1991). For long-term care workers, limited resources, sporadic education, and heavy workloads may interact with psychological determinants to hinder or facilitate hand hygiene compliance. Understanding these dynamics within the TPB framework is essential for designing effective, context-specific interventions to enhance hand hygiene behavior, ultimately supporting infection prevention, health promotion, and the safety of residents and caregivers within rehabilitation-oriented institutions.
This study investigated the components and determinants of hand hygiene compliance among caregivers in long-term care facilities using the TPB as an analytical framework. Specifically, it aimed to identify general and hand hygiene-related characteristics; examine levels of hand hygiene beliefs, core TPB constructs, compliance intention, and compliance; determine the differences in these factors according to demographic and hand hygiene-related characteristics; analyze the correlations among belief-related factors, core TPB constructs, compliance intention, and hand hygiene compliance; and identify the key factors influencing hand hygiene compliance.
MATERIALS AND METHODS
Participants
Participants were recruited through convenience sampling from four long-term care facilities located in Daegu Metropolitan City, South Korea. Study participants comprised long-term care workers who fully understood the purpose and methods of the research and voluntarily consented to participate. Sample size was calculated using G*Power 3.1.9.4 for multiple regression analysis with Cohen f2=0.25, a significance level (α) of 0.05, and statistical power of 0.90 (1−β). Based on these criteria, the minimum required sample size was estimated to be 109 participants. Considering the potential dropout rate, questionnaires were distributed to 147 individuals, with 133 valid responses included in the final analysis after excluding 14 incomplete or invalid responses.
TPB belief factors
Belief factors included behavioral, normative, and control beliefs, measured by the instrument developed by Whitby et al. (2006).
Behavioral beliefs
Twelve items rated on a 7-point Likert scale (“strongly disagree” =−3 to “strongly agree”=+3), with reverse scoring for negatively worded items. Scores ranged from −36 to +36; higher scores indicated more positive behavioral beliefs. Instrument reliability (Cronbach α): 0.80 (original), 0.82 (present study).
Normative beliefs
Four items rated on a 7-point Likert scale (−3 to +3), scores −12 to +12; higher values indicated greater social influence. Reliability (Cronbach α): 0.77–0.90 (original), 0.73 (present study).
Control beliefs
Four items rated on a 7-point Likert scale (−3 to +3), scores −12 to +12; higher scores reflected stronger self-regulatory beliefs regarding hand hygiene. Reliability (Cronbach α): 0.80 (original), 0.86 (present study).
Core TPB constructs
Core TPB constructs included attitude, subjective norms, perceived behavioral control, measured using the scale developed by O’Boyle et al. (2001).
Attitude
Eight items measured on 7-point semantic differential scales; higher scores represented a more positive attitude. Reliability (Cronbach α): 0.91 (original), 0.80 (present study).
Subjective norms
Two items on a 7-point Likert scale, total score −6 to +6; higher scores suggested greater perceived social pressure. Reliability (Cronbach α): 0.87 (original), 0.76 (present study).
Perceived behavioral control
Six negatively worded items on a 7-point Likert scale (−3 to +3, reverse coded); higher scores indicated greater self-efficacy in overcoming hand hygiene barriers. Reliability (Cronbach α): 0.80 (original), 0.89 (present study).
Hand hygiene compliance intention
Measured using five items from Whitby et al. (2006), rated on a 7-point Likert scale (“strongly disagree”=1 to “strongly agree” =7), with scores ranging from 5 to 35. Higher scores indicated stronger intention. Reliability (Cronbach α): 0.74 (original), 0.84 (present study).
Hand hygiene compliance behavior
Hand hygiene compliance was assessed using a self-report questionnaire based on the five World Health Organization-recommended moments for hand hygiene: before patient contact, after patient contact, before a clean/aseptic procedure, after exposure to body fluids, and after contact with the patient’s environment. Participants reported the frequency with which they performed hand hygiene in each situation, and compliance was expressed as a percentage of self-reported performed opportunities relative to recommended opportunities.
Data collection procedures
Data collection was conducted from June 3 to July 30, 2025, at four long-term care facilities in Daegu, Gyeongsangbuk-do, South Korea. Facilities received official letters requesting cooperation, with consent obtained from administrators and nurse managers following a study briefing. Participants were informed of the study aims, methods, and estimated completion time, as well as that they could withdraw at any time without penalty.
Data analysis
Data analysis was performed using IBM SPSS Statistics ver. 27.0 (IBM Co., USA). Descriptive statistics (frequency, mean, standard deviation) were used for participant and variable analysis. Differences among groups were evaluated using t-tests and one-way analysis of variance (ANOVA) with Scheffé post hoc tests. Pearson correlation coefficients assessed relationships among constructs. Multiple regression analysis was conducted to identify significant predictors of hand hygiene compliance behavior based on the TPB framework. Because this study’s primary purpose was exploratory identification of influencing factors rather than testing the full TPB structural model, simplified regression analyses were employed.
Ethical considerations
This study was approved by the institutional review board (IRB) of Gyeongkuk National University (IRB No. 1040191-202506-HR–021-01).
RESULTS
General and hand hygiene-related characteristics of participants
Among the 133 long-term care workers, most were female (n= 115, 86.4%). Participants in their 50s constituted the largest age group (n=69, 51.8%), whereas those aged 40 years or younger and those aged 60 years or older each accounted for 24.1% (n=32 each). Regarding work experience, 81 participants (60.9%) had worked for ≤3 years, while 52 (39.1%) had >3 years of experience. More than half reported having a religious affiliation (n=73, 54.9%). The most common educational level was high school graduation (n=62, 46.6%), followed by college education or higher (n=51, 38.4%) and middle school education or less (n=20, 15.0%). Most participants were married (n=119, 89.5%). Regarding the number of clients cared for, 47 participants (35.4%) were responsible ≥10 clients, while 43 (32.3%) each cared for ≤4 clients and 5–9 clients, respectively (Table 1).
Table 1.
Characteristics and hand hygiene-related factors of the participants (N=133)
| Variable | No. (%) |
|---|---|
| Sex | |
| Female | 115 (86.4) |
| Male | 18 (13.6) |
|
| |
| Age (yr) | |
| ≤40s | 32 (24.1) |
| 50s | 69 (51.8) |
| ≥60s | 32 (24.1) |
|
| |
| Work experience (yr) | |
| ≤3 | 81 (60.9) |
| ≥3 | 52 (39.1) |
|
| |
| Religion | |
| Yes | 73 (54.9) |
| No | 60 (45.1) |
|
| |
| Education level | |
| Below middle school | 20 (15.0) |
| High school graduate | 62 (46.6) |
| Above college graduate | 51 (38.4) |
|
| |
| Marital status | |
| Married | 119 (89.5) |
| Unmarried | 14 (10.5) |
|
| |
| No. of patients | |
| ≤4 | 43 (32.3) |
| 5–9 | 43 (32.3) |
| ≥10 | 47 (35.4) |
|
| |
| Experience with hand hygiene education (within 3 yr) | |
| Yes | 115 (86.4) |
| No | 18 (13.6) |
|
| |
| Hand hygiene guidelines | |
| Yes | 130 (97.7) |
| No | 3 (2.3) |
Regarding hand hygiene-related characteristics, 115 caregivers (86.4%) had received hand hygiene education in the past 3 years. Most respondents (n=114, 85.7%) rated the need for hand hygiene education as high, with a mean score of 4.23±0.76 on a 5-point scale. Moreover, nearly all participants (n=130, 97.7%) reported that hand hygiene guidelines were available in their workplace (Table 1).
Levels of hand hygiene TPB belief factors, core TPB constructs, intention, and compliance behavior
All measured hand hygiene constructs had mean scores above the scale midpoint. Among the belief subdomains, normative beliefs demonstrated the highest mean score (2.32±0.69), followed by behavioral beliefs (2.14±0.71) and control beliefs (0.45±1.61). For the core constructs, the mean scores were 2.07±1.02 for attitude toward behavior, 1.85±1.25 for subjective norms, and 1.26± 1.51 for perceived behavioral control. The mean score for hand hygiene compliance intention was 5.98±0.95 on a 7-point scale, and the mean hand hygiene compliance behavior rate was 60.65%± 20.22% (Table 2).
Table 2.
Descriptive statistics of observed variables (N=133)
| Variable | Mean±SD | Min | Max | Skewness | Kurtosis |
|---|---|---|---|---|---|
| TPB belief factors | 1.84±0.74 | −0.60 | 3.00 | −0.59 | 0.03 |
| Behavioral beliefs | 2.14±0.71 | −0.50 | 3.00 | −1.01 | 1.28 |
| Normative beliefs | 2.32±0.69 | 0.25 | 3.00 | −0.72 | −0.25 |
| Control beliefs | 0.45±1.61 | −3.00 | 3.00 | −0.08 | −0.98 |
|
| |||||
| Core TPB constructs | 1.74±0.94 | −1.38 | 3.00 | 0.04 | −0.79 |
| Attitude | 2.07±1.02 | −3.00 | 3.00 | −1.62 | 3.99 |
| Subjective norms | 1.85±1.25 | −3.00 | 3.00 | −1.51 | 2.69 |
| Perceived behavioral control | 1.26±1.51 | −3.00 | 3.00 | −0.75 | −0.39 |
|
| |||||
| Intention of hand hygiene | 5.98±0.95 | 1.80 | 7.00 | −1.81 | 4.85 |
|
| |||||
| Hand hygiene behavior (%) | 60.65±20.22 | 20.00 | 100.00 | 0.04 | −0.79 |
| Contact with patient | 65.69±25.08 | 0.00 | 100.00 | 0.06 | −1.21 |
| Cleaning & aseptic procedure | 62.16±28.18 | 0.00 | 100.00 | 0.06 | −1.17 |
| Contact with pollutants | 56.67±28.19 | 0.00 | 100.00 | 0.10 | −1.00 |
| After touching patient surrounding | 58.07±28.07 | 0.00 | 100.00 | 0.14 | −1.09 |
SD, standard deviation.
Differences in hand hygiene-related variables by participant characteristics
Differences in hand hygiene TPB belief factors, core TPB factors, compliance intention, and compliance behavior according to participant characteristics were examined using independent t-tests and one-way ANOVA. Female participants had significantly higher behavioral belief scores than male participants (t=−2.58, P= 0.011). According to the number of clients per caregiver, significant differences were observed in behavioral beliefs (F=3.46, P= 0.034), control beliefs (F=4.38, P=0.014), attitude (F=3.98, P=0.021), and subjective norms (F=8.15, P<0.001). Post hoc analysis indicated that caregivers responsible for five to nine clients had significantly higher scores for control beliefs, attitude, and subjective norms than those caring for four or fewer clients. Subjective norms also differed significantly according to hand hygiene education experience (F=3.60, P=0.030).
The availability of hand hygiene guidelines in the workplace was associated with higher normative belief scores (t=2.78, P= 0.006). Moreover, perceived necessity of hand hygiene education was significantly associated with behavioral beliefs (F=11.77, P< 0.001), normative beliefs (F=7.36, P=0.001), control beliefs (F= 12.27, P<0.001), and subjective norms (F=4.99, P=0.006). No significant differences were identified according to age, work experience, religion, education, marital status, or workload (Table 3).
Table 3.
Differences in hand hygiene TPB belief factors, core TPB constructs, intention, and behavior according to the participant’s general characteristics and hand hygiene-related factors (N=133)
| Variable | TPB belief factors | Core TPB constructs | Intention to perform hand hygiene | Hand hygiene behavior | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||||||||
| Behavioral beliefs | Normative beliefs | Control beliefs | Attitude | Subjective norms | Perceived behavioral control | |||||||||||
|
|
|
|
|
|
|
|
|
|||||||||
| Mean±SD | t/F (P) | Mean±SD | t/F (P) | Mean±SD | t/F (P) | Mean±SD | t/F (P) | Mean±SD | t/F (P) | Mean±SD | t/F (P) | Mean±SD | t/F (P) | Mean±SD | t/F (P) | |
| Sex | −2.58 (0.011) | 0.20 (0.839) | 0.57 (0.573) | 0.56 (0.573) | −0.33 (0.745) | −0.59 (0.559) | −0.12 (0.909) | 1.91 (0.058) | ||||||||
| Male | 1.69±0.60 | 2.36±0.59 | 0.68±1.66 | 2.21±0.78 | 1.75±1.11 | 1.04±1.61 | 5.96±0.76 | 0.70±0.19 | ||||||||
| Female | 2.19±0.70 | 2.32±0.71 | 0.42±1.61 | 2.05±1.05 | 1.87±1.27 | 1.29±1.50 | 5.99±0.98 | 0.60±0.20 | ||||||||
|
| ||||||||||||||||
| Age (yr) | 0.69 (0.502) | 2.51 (0.085) | 2.31 (0.103) | 0.57 (0.568) | 0.73 (0.486) | 1.98 (0.142) | 1.07 (0.346) | 2.31 (0.103) | ||||||||
| ≤40s | 2.12±0.55 | 2.14±0.78 | 0.27±1.63 | 1.96±0.87 | 1.63±1.48 | 1.21±1.53 | 6.09±0.91 | 0.60±0.18 | ||||||||
| 50s | 2.09±0.78 | 2.31±0.69 | 0.29±1.59 | 2.15±0.85 | 1.91±1.19 | 1.07±1.54 | 5.87±1.00 | 0.58±0.20 | ||||||||
| ≥60s | 2.27±0.68 | 2.52±0.58 | 0.98±1.58 | 1.99±1.45 | 1.97±1.14 | 1.71±1.36 | 6.13±0.88 | 0.67±0.22 | ||||||||
|
| ||||||||||||||||
| Work experience (yr) | −0.87 (0.385) | 0.18 (0.856) | −1.27 (0.208) | −0.99 (0.322) | −0.70 (0.482) | −0.41 (0.681) | 0.41 (0.681) | 0.46 (0.648) | ||||||||
| ≤3 | 2.10±0.76 | 2.33±0.72 | 0.31±1.73 | 2.00±1.11 | 1.80±1.40 | 1.22±1.54 | 6.01±1.00 | 0.61±0.21 | ||||||||
| >3 | 2.21±0.62 | 2.31±0.66 | 0.66±1.41 | 2.18±0.87 | 1.94±0.99 | 1.33±1.47 | 5.94±0.88 | 0.60±0.19 | ||||||||
|
| ||||||||||||||||
| Religion | 0.59 (0.554) | −0.43 (0.668) | −0.42 (0.675) | 0.16 (0.874) | −0.53 (0.599) | 1.38 (0.170) | 0.64 (0.524) | 1.48 (0.141) | ||||||||
| Yes | 2.17±0.73 | 2.30±0.67 | 0.39±1.68 | 2.08±1.14 | 1.80±1.17 | 1.42±1.51 | 6.03±1.01 | 0.63±0.19 | ||||||||
| No | 2.10±0.69 | 2.35±0.73 | 0.51±1.54 | 2.05±0.87 | 1.92±1.35 | 1.06±1.49 | 5.93±0.88 | 0.58±0.22 | ||||||||
|
| ||||||||||||||||
| Educational level | 1.50 (0.228) | 2.31 (0.103) | 0.12 (0.891) | 1.71 (0.190) | 2.61 (0.077) | 1.44 (0.240) | 0.12 (0.890) | 0.60 (0.550) | ||||||||
| Below middle school | 2.12±0.85 | 2.10±0.75 | 0.30±1.61 | 1.85±1.07 | 1.85±1.11 | 1.65±1.29 | 6.08±0.93 | 0.62±0.20 | ||||||||
| High school | 2.04±0.76 | 2.27±0.69 | 0.50±1.75 | 1.99±1.17 | 1.61±1.30 | 1.34±1.58 | 5.96±0.99 | 0.62±0.22 | ||||||||
| University or higher | 2.27±0.55 | 2.47±0.65 | 0.44±1.46 | 2.25±0.78 | 2.15±1.20 | 1.01±1.49 | 5.97±0.93 | 0.58±0.18 | ||||||||
|
| ||||||||||||||||
| Marital status | 0.52 (0.610) | 0.10 (0.919) | −0.80 (0.433) | −0.12 (0.907) | 0.33 (0.748) | 0.06 (0.956) | −0.06 (0.950) | −0.22 (0.826) | ||||||||
| Married | 2.15±0.73 | 2.32±0.70 | 0.42±1.66 | 2.06±1.05 | 1.87±1.19 | 1.26±1.53 | 5.98±0.91 | 0.61±0.20 | ||||||||
| Unmarried | 2.08±0.45 | 2.30±0.68 | 0.70±1.17 | 2.10±0.75 | 1.71±1.73 | 1.24±1.34 | 6.00±1.28 | 0.62±0.22 | ||||||||
|
| ||||||||||||||||
| No. of patients† | 3.46 (0.034) | 2.39 (0.095) | 4.38† (0.014) b>a | 3.98† (0.021) b>a | 8.15† (<0.001) b>a | 1.69 (0.189) | 1.00 (0.371) | 0.24 (0.784) | ||||||||
| ≤4a | 1.91±0.73 | 2.13±0.77 | −0.09±1.64 | 1.72±1.14 | 1.31±1.32 | 0.91±1.50 | 5.86±0.94 | 0.60±0.22 | ||||||||
| 5–9b | 2.28±0.69 | 2.42±0.65 | 0.90±1.43 | 2.31±0.86 | 2.29±0.87 | 1.45±1.35 | 5.94±1.15 | 0.60±0.18 | ||||||||
| ≥10c | 2.23±0.66 | 2.40±0.63 | 0.53±1.64 | 2.16±0.98 | 1.95±1.32 | 1.40±1.63 | 6.14±0.74 | 0.62±0.21 | ||||||||
|
| ||||||||||||||||
| Educational experience† | 0.71 (0.492) | 0.35 (0.704) | 0.03 (0.975) | 0.29 (0.750) | 3.60† (0.030) a,b>c | 0.62 (0.540) | 0.42 (0.677) | 0.83 (0.441) | ||||||||
| Yesa | 2.17±0.71 | 2.32±0.71 | 0.45±1.68 | 2.09±1.05 | 1.88±1.25 | 1.32±1.54 | 6.01±0.92 | 0.61±0.20 | ||||||||
| Nob | 1.94±0.74 | 2.37±0.60 | 0.48±1.17 | 1.93±0.87 | 2.03±0.85 | 0.93±1.27 | 6.07±0.65 | 0.61±0.18 | ||||||||
| Don’t knowc | 2.03±0.10 | 2.00±0.00 | 0.25±1.09 | 1.79±0.58 | 0.00±2.00 | 0.72±1.42 | 4.67±2.52 | 0.46±0.24 | ||||||||
|
| ||||||||||||||||
| Hand hygiene guidelines | 1.42 (0.291) | 2.78 (0.006) | 0.57 (0.567) | −0.03 (0.979) | 0.26 (0.795) | 1.27 (0.205) | 1.08 (0.284) | 1.51 (0.134) | ||||||||
| Yes | 2.17±0.67 | 2.35±0.68 | 0.46±1.62 | 2.07±1.03 | 1.86±1.26 | 1.28±1.49 | 6.00±0.96 | 0.61±0.20 | ||||||||
| No | 0.94±1.49 | 1.25±0.43 | −0.08±1.59 | 2.08±1.01 | 1.67±1.15 | 0.17±2.02 | 5.40±0.69 | 0.43±0.10 | ||||||||
|
| ||||||||||||||||
| Need for education of hand washing | 11.77† (<0.001) a,c>b | 7.36† (0.001) c>b | 12.27† (<0.001) a,c>b | 0.16 (0.848) | 4.99† (0.008) c>b | 0.50 (0.606) | 0.77 (0.464) | 0.39 (0.679) | ||||||||
| Lowa | 2.88±0.06 | 3.00±0.00 | 2.63±0.18 | 2.31±0.97 | 2.50±0.00 | 2.25±1.06 | 6.80±0.28 | 0.70±0.14 | ||||||||
| Averageb | 1.45±0.66 | 1.78±0.59 | −1.10±1.20 | 1.96±0.85 | 1.00±0.90 | 1.12±1.57 | 5.92±0.58 | 0.63±0.22 | ||||||||
| Highc | 2.23±0.66 | 2.39±0.68 | 0.64±1.54 | 2.08±1.05 | 1.97±1.26 | 1.26±1.51 | 5.98±1.00 | 0.60±0.20 | ||||||||
TPB, theory of planned behavior; SD, standard deviation.
Scheffé test.
Correlations among hand hygiene TPB belief factors/core TPB constructs, intention, and compliance behavior
Hand hygiene compliance behavior was positively correlated with behavioral beliefs (r=0.23, P=0.008), control beliefs (r=0.26, P=0.002), attitude (r=0.18, P=0.038), perceived behavioral control (r=0.41, P<0.001), and hand hygiene compliance intention (r=0.31, P<0.001). These findings indicate that more favorable beliefs and attitudes, stronger perceived behavioral control, and greater intention to perform hand hygiene were positively associated with compliance behavior (Table 4).
Table 4.
Correlation among participants’ hand hygiene TPB belief factors, core TPB constructs, intention, and behavior (N=133)
| Variable | TPB belief factors | Core TPB constructs | Intention of hand hygiene | Hand hygiene behavior | ||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| Behavioral beliefs | Normative beliefs | Control beliefs | Attitude | Subjective norms | Perceived behavioral control | |||
| TPB belief factors | ||||||||
| Behavioral beliefs | 1 | |||||||
| Normative beliefs | 0.53 (<0.001) | 1 | ||||||
| Control beliefs | 0.55 (<0.001) | 0.37 (<0.001) | 1 | |||||
|
| ||||||||
| Core TPB constructs | ||||||||
| Attitude | 0.25 (0.003) | 0.01 (0.911) | 0.41 (<0.001) | 1 | ||||
| Subjective norms | 0.34 (<0.001) | 0.34 (<0.001) | 0.25 (0.004) | 0.11 (0.209) | 1 | |||
| Perceived behavioral control | 0.47 (<0.001) | 0.17 (0.045) | 0.53 (<0.001) | 0.45 (<0.001) | 0.05 (0.578) | 1 | ||
|
| ||||||||
| Intention of hand hygiene | 0.26 (0.002) | 0.25 (0.004) | 0.07 (0.415) | 0.05 (0.589) | 0.34 (<0.001) | 0.24 (0.006) | 1 | |
|
| ||||||||
| Hand hygiene behavior | 0.23 (0.008) | 0.14 (0.099) | 0.26 (0.002) | 0.18 (0.038) | 0.08 (0.361) | 0.41 (<0.001) | 0.31 (<0.001) | 1 |
Values are presented as r (P-value).
TPB, theory of planned behavior.
Factors influencing hand hygiene compliance behavior
Multiple regression analysis identified perceived behavioral control (β=0.33, P=0.002) and hand hygiene compliance intention (β=0.23, P=0.006) as significant predictors of hand hygiene compliance behavior. The explanatory power of the model was 19.1% (adjusted R2=0.19), and the overall regression model was statistically significant (F=7.3, P<0.001). Regression assumptions were tested prior to analysis. Normality and homoscedasticity of residuals were assessed using residual plots and were found to be satisfactory. Diagnostic statistics supported the adequacy of the model, with variance inflation factor values below 2.0 (range, 1.12–1.77) and a Durbin–Watson statistic of 1.88, indicating no serious multicollinearity or autocorrelation concerns. Influential cases were examined using Cook distance, and no influential outliers were detected (Table 5).
Table 5.
Factors influencing participants’ hand hygiene behavior (N=133)
| Variable | Hand hygiene behavior | ||||||
|---|---|---|---|---|---|---|---|
| B | SE | β | t | P-value | Tolerance | VIF | |
| Behavioral beliefs | −0.01 | 0.03 | −0.04 | −0.35 | 0.725 | 0.618 | 1.62 |
| Control beliefs | 0.01 | 0.01 | 0.09 | 0.90 | 0.371 | 0.560 | 1.79 |
| Attitude | −0.002 | 0.02 | −0.01 | −0.09 | 0.930 | 0.756 | 1.32 |
| Perceived behavioral control | 0.04 | 0.01 | 0.33 | 3.23 | 0.002 | 0.589 | 1.70 |
| Intention of hand hygiene | 0.05 | 0.02 | 0.23 | 2.79 | 0.006 | 0.893 | 1.12 |
| Adjusted R2=0.191, F=7.3, P≤0.001 | |||||||
B, unstandardized coefficient; SE, standard error; VIF, variance inflation factor.
DISCUSSION
This study, grounded in the TPB, examined factors influencing hand hygiene compliance among long-term care workers in South Korea. The findings provide evidence on the cognitive, social, and perceived control determinants of infection prevention behavior in long-term care settings. The demographic profile of participants was consistent with prior research on long-term care workforces, where female and middle-aged caregivers predominate. This reflects the gendered structure of caregiving occupations and highlights the need for tailored educational strategies that align with the experiential learning needs of this group. Simulation-based and practice-oriented training approaches may be particularly effective in strengthening behavioral competence and self-efficacy in infection control practices (Pillemer et al., 2020).
Overall, participants demonstrated relatively positive attitudes toward hand hygiene, strong subjective norms, and high behavioral intention. However, perceived behavioral control and control beliefs were comparatively lower. This indicates that while motivation and awareness are present, environmental and practical constraints may limit consistent execution of hand hygiene behavior. Similar patterns have been reported in previous studies, where intention did not always translate into behavior due to contextual barriers such as workload and resource limitations (O’Boyle et al., 2001; Pittet et al., 2004; Whitby et al., 2006). The lower perceived behavioral control observed in this study suggests that caregivers’ ability to perform hand hygiene is strongly influenced by structural and organizational conditions. In long-term care settings, time pressure, staffing shortages, and limited access to hygiene resources may reduce perceived control over behavior (Haenen et al., 2022). These findings highlight that improving knowledge alone is insufficient, and that organizational-level interventions are essential to support sustained compliance (Allegranzi et al., 2013; Pittet, 2001).
Significant differences were observed in behavioral beliefs according to gender, with female caregivers demonstrating higher scores. This is consistent with previous findings reporting greater infection prevention awareness among female healthcare workers (Goerig et al., 2018). However, behavioral performance remains strongly dependent on institutional conditions, suggesting that organizational support may play a more decisive role than individual attitudes alone (Lankford et al., 2003). Caregivers with moderate workloads (five to nine clients) demonstrated higher control beliefs, attitudes, and subjective norms compared to those with lower workloads. This may indicate that moderate exposure to caregiving responsibilities increases awareness of infection risk and reinforces compliance-related norms. However, excessive workload may lead to fatigue and reduced adherence, suggesting a potential nonlinear relationship that warrants further investigation (Erasmus et al., 2010).
Educational exposure and the presence of workplace hand hygiene guidelines were associated with stronger normative beliefs and subjective norms. This supports prior evidence that institutional policies and training programs reinforce perceived social expectations and professional responsibility regarding infection prevention (Whitby et al., 2006). Such interventions act not only as knowledge enhancers but also as organizational signals that shape behavioral norms. In contrast, demographic variables such as age, education, religion, marital status, and general work experience were not significantly associated with hand hygiene constructs. This suggests that behavioral compliance is more strongly influenced by modifiable organizational and environmental factors than by stable personal characteristics.
Correlation analysis showed general consistency with the TPB framework proposed by Ajzen (1991), with behavioral beliefs, control beliefs, attitudes, perceived behavioral control, and intention all positively associated with hand hygiene compliance. Among these, perceived behavioral control showed the strongest relationship with behavior, followed by behavioral intention. This finding aligns with TPB assumptions and reinforces the importance of self-efficacy and environmental facilitation in health behavior performance (Yue and Pan, 2025).
The strong role of perceived behavioral control suggests higher compliance when caregivers perceive adequate time, resources, and institutional support. This highlights the importance of reducing environmental barriers rather than focusing solely on motivational interventions. Practical improvements such as accessible hand hygiene stations, adequate staffing, and workflow optimization are essential for sustained behavioral change. Although intention significantly predicted behavior, the explanatory power of the model remained modest, reflecting the well-known intention-behavior gap. This indicates that strong intention alone is insufficient to ensure consistent compliance when structural constraints exist (Afework and Tamene, 2025; Ferreira et al., 2026). Therefore, continuous organizational reinforcement and monitoring are necessary to bridge this gap. The overall explanatory power of the TPB model (adjusted R2=0.19) is consistent with previous research in health behavior and infection control, where moderate predictive power is commonly observed (Pittet et al., 2004; Sax et al., 2007). This suggests that while TPB is useful, additional factors beyond cognitive constructs may also influence behavior in long-term care environments.
Hand hygiene behavior is likely shaped by a broader combination of individual, organizational, and systemic factors, including leadership support, staffing adequacy, emotional exhaustion, institutional safety culture, and infrastructure availability. Future research should integrate these variables into expanded behavioral models to improve explanatory power. From a methodological perspective, while regression analysis identified significant predictors, it does not capture the full causal pathways proposed in TPB. Future studies should employ structural equation modeling to examine relationships among beliefs, attitudes, intentions, and behavior more comprehensively.
This study has important practical implications. Organizational strategies should prioritize improving perceived behavioral control by addressing workload distribution, staffing levels, and accessibility of hygiene resources. Infection prevention training should move beyond knowledge delivery to include simulation-based learning, feedback systems, and peer-supported behavioral reinforcement. Additionally, institutional policies should formally recognize long-term care workers as key agents in infection prevention systems. The strength of this study lies in its focus on long-term care workers, an underresearched population in infection control literature. By examining both intention and actual behavior, the study provides a more complete understanding of hand hygiene performance in real-world care environments. However, limitations should be acknowledged. The use of a cross-sectional design limits causal inference, and self-reported behavior may introduce recall and social desirability bias. Moreover, the sample was regionally limited, restricting generalizability. Future research should adopt longitudinal and interventional designs, incorporate organizational and psychological variables, and explore technology-based interventions such as digital monitoring systems and behavioral nudges to improve compliance.
In conclusion, perceived behavioral control and behavioral intention were identified as key determinants of hand hygiene compliance among long-term care workers. Sustainable improvement in infection prevention requires not only individual motivation but also strong organizational and environmental support systems that enable consistent behavioral execution in long-term care settings.
Footnotes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
ACKNOWLEDGMENTS
The authors received no financial support for this article. This study was conducted as a part of a master’s thesis.
REFERENCES
- Afework A, Tamene A. Uncovering the obstacles: a comprehensive analysis of barriers to hand hygiene adherence among healthcare providers: a systematic review. BMC Infect Dis. 2025;25:502. doi: 10.1186/s12879-025-10924-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Processes. 1991;50:179–211. [Google Scholar]
- Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, Memish Z, Urroz O, Richet H, Storr J, Donaldson L, Pittet D. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis. 2013;13:843–851. doi: 10.1016/S1473-3099(13)70163-4. [DOI] [PubMed] [Google Scholar]
- Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73:305–315. doi: 10.1016/j.jhin.2009.04.019. [DOI] [PubMed] [Google Scholar]
- Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31:283–294. doi: 10.1086/650451. [DOI] [PubMed] [Google Scholar]
- Ferreira JMG, Marra VS, Generoso JR, Tudino CH, Hsieh MK, Pardo I, Campagnoli PS, Ceccon LE, Celeghini PD, Zancopé BB, Possebon MP, Tavares LMD, Seabra BCDS, Perencevich EN, Goto M, Edmond MB, Marra AR. Quality of hand hygiene performance: A systematic literature review. Am J Infect Control. 2026;54:192–209. doi: 10.1016/j.ajic.2025.08.025. [DOI] [PubMed] [Google Scholar]
- Festa N, Katz-Christy N, Weiss M, Lisk R, Normand SL, Grabowski DC, Newhouse JP, Hsu J. Nursing home infection control strategies during the COVID-19 pandemic. J Am Geriatr Soc. 2023;71:2593–2600. doi: 10.1111/jgs.18402. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Goerig T, Dittmann K, Kramer A, Diedrich S, Heidecke CD, Huebner NO. Infection control perception and behavior: a question of sex and gender? results of the AHOI feasibility study. Infect Drug Resist. 2018;11:2511–2519. doi: 10.2147/IDR.S178922. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Haenen A, de Greeff S, Voss A, Liefers J, Hulscher M, Huis A. Hand hygiene compliance and its drivers in long-term care facilities; observations and a survey. Antimicrob Resist Infect Control. 2022;11:50. doi: 10.1186/s13756-022-01088-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis. 2003;9:217–223. doi: 10.3201/eid0902.020249. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Levin AT, Hanage WP, Owusu-Boaitey N, Cochran KB, Walsh SP, Meyerowitz-Katz G. Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications. Eur J Epidemiol. 2020;35:1123–1138. doi: 10.1007/s10654-020-00698-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- O’Boyle CA, Henly SJ, Duckett LJ. Nurses’ motivation to wash their hands: a standardized measurement approach. Appl Nurs Res. 2001;14:136–145. doi: 10.1053/apnr.2001.24412. [DOI] [PubMed] [Google Scholar]
- Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020;324:25–26. doi: 10.1001/jama.2020.9540. [DOI] [PubMed] [Google Scholar]
- Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis. 2001;7:234–240. doi: 10.3201/eid0702.010217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004;141:1–8. doi: 10.7326/0003-4819-141-1-200407060-00008. [DOI] [PubMed] [Google Scholar]
- Richards C. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc. 2002;50:570–576. doi: 10.1046/j.1532-5415.2002.50128.x. [DOI] [PubMed] [Google Scholar]
- Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67:9–21. doi: 10.1016/j.jhin.2007.06.004. [DOI] [PubMed] [Google Scholar]
- Veronese N, Ragusa FS, Hajek A, Stubbs B, Smith L, Barbagallo M, Dominguez LJ, Fontana L, Soysal P, Sabico S, Al-Daghri NM. Long-term impact of physical activity on mortality in adults with multimorbidity: a 12-year cohort longitudinal study from the survey on health, ageing and retirement in Europe. J Cachexia Sarcopenia Muscle. 2025;16:e13695. doi: 10.1002/jcsm.13695. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Whitby M, McLaws ML, Ross MW. Why healthcare workers don’t wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol. 2006;27:484–492. doi: 10.1086/503335. [DOI] [PubMed] [Google Scholar]
- Ye Z, Mukamel DB, Huang SS, Li Y, Temkin-Greener H. Healthcare-associated pathogens and nursing home policies and practices: results from a national survey. Infect Control Hosp Epidemiol. 2015;36:759–766. doi: 10.1017/ice.2015.59. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yue J, Pan H. Enhancing hand hygiene compliance in healthcare settings: a long time intervention study. Front Public Health. 2025;13:1588336. doi: 10.3389/fpubh.2025.1588336. [DOI] [PMC free article] [PubMed] [Google Scholar]