Cross-level associations of individual behavioral factors and institutional infection prevention capacity with self-reported hand hygiene performance in long-term care hospitals: a multicenter cross-sectional study

Hand hygiene (HH) is a core measure for preventing healthcare-associated infections; however, HH performance remains suboptimal in long-term care hospitals (LTCHs). Prior studies have often examined individual- or institutional-level factors separately, leaving it unclear whether institutional Infection Prevention and Control (IPC) capacity modifies the associations between individual behavioral factors and self-reported HH performance. This multicenter study identified Theoretical Domains Framework (TDF)-based behavioral factors of HH performance among nursing staff in LTCHs and tested cross-level moderation by institutional IPC capacity, assessed using the World Health Organization Infection Prevention and Control Assessment Framework (IPCAF). We conducted a cross-sectional survey with 220 nursing staff members at 11 LTCHs in South Korea. At the individual level, the TDF-based factors were assessed using the Barriers and Levers to Hand Hygiene Instrument. At the institutional level, IPC capacity was assessed using the IPCAF. Linear mixed models with hospital random intercepts were used to estimate mutually adjusted associations between TDF domains and self-reported HH performance, and to assess cross-level interactions with IPCAF. Memory and Attention (β = 0.402, p < 0.001) and Beliefs about Capability (β = 0.250, p = 0.003) were independently associated with self-reported HH performance. The IPCAF was not directly associated with self-reported HH performance; however, it significantly modified the associations of Beliefs about Consequences (FDR-adjusted p = 0.032), and Motivation and Goals (FDR-adjusted p = 0.021) with self-reported HH performance. Descriptive stratified analyses suggested that these associations for Beliefs about Consequences and Motivation and Goals were more pronounced in higher-IPCAF facilities. These exploratory findings suggest that memory and attention processes and self-efficacy were consistently associated with HH performance across institutional contexts. Additionally, the behavioral relevance of motivational and belief-related factors appeared to be context-sensitive, varying as a function of institutional IPC capacity. These findings highlight the need for context-sensitive multilevel strategies that strengthen core individual behavioral targets while accounting for IPC capacity in LTCHs.