Determinants of hand hygiene behavior.

Sustaining hand hygiene behavior change requires addressing a range of behavioral determinants. Behavioral determinants are factors that influence behavior. Determinants for hand hygiene behavior include social norms, affiliation, enabling technologies/infrastructure, nurture, disgust, perceived susceptibility and perceived severity of diseases. The Handwashing Handbook groups these determinants into reflexive, habitual factors (such as culture, environmental cues, and nudges) and more reflective, conscious decision-making factors (such as knowledge and emotional motivators).


Enabling technologies are a critical determinant for hand hygiene behavior. Undoubtedly, it is not possible to maintain good hand hygiene without the necessary facilities. However, in a study surveying 29 countries in Sub-Saharan Africa, Endalew et al. (2022) determined that 66.16% of handwashing facilities lacked either water or soap. Access to facilities and supplies cannot be neglected, but it is not the only determinant for hand hygiene behavior.

Emotional motivators, such as the feeling of affiliation, nurture, or disgust are also crucial factors for hand hygiene behavior. One such example is from a study which assessed the impact of the Mum’s Magic Hands resource in promoting handwashing among mothers in humanitarian settings (White et al., 2022). The storyboard features a mother and her efforts to care for her daughter and instill good handwashing habits despite their difficult emergency context. This resource uses the emotional motivators of nurture and group affiliation to capture the effect of positive social factors and motivate handwashing. Through its touching and engaging images, the storyboard presents handwashing as a crucial part of a mother’s care for her children. These innate motivators can move mothers to action even in emergency contexts where other pressing needs seem more urgent.

The presence of role models is also a notable factor for hand hygiene behavior. A cross-sectional study done in Ethiopia by Berhanu et al. (2022) found that students with strong handwashing role models were 4.41 times more likely to wash their hands as compared to students who did not have strong role models. Another study by Ahmadipour et al. (2022) identified improper behavioral patterns of supervisors among one of the main barriers to handwashing among health care workers in Iran. The study found that healthcare workers mirrored the practices of head doctors and nurses, admitting to underestimating the importance of handwashing because of the noncompliance of their supervisors.

Managers and supervisors play a large role in setting the norms for hand hygiene practices. Their own behaviors as role models can either reinforce or undermine the training that health workers receive regarding hand hygiene. Interventions should empower supervisors in their positions as role models as a mechanism for social norm change in healthcare environments. The same is true in public settings. A study by Akter et al. (2022) on the barriers and facilitators of a COVID-19 intervention demonstrated that influential community members can act as role models to influence hand hygiene behavior.

Decades of research show us the need to better understand our target audience and the key factors that influence their hand hygiene behavior. Good behavior change programming goes beyond knowledge and education, rather good program design understands the barriers and enablers of hand hygiene behavior to develop effective, context-specific interventions.