Capability, opportunity, and motivation: a structural equation model of hand hygiene behavior based on the COM-B...

Healthcare-associated infections (HAIs) present a major threat to patient safety worldwide. While hand hygiene is the primary defense against HAIs, compliance among healthcare workers (HCWs) remains inadequate, highlighting a persistent "know-do" gap. The COM-B (capability, opportunity, motivation-behavior) model offers a robust theoretical framework for understanding this behavior, yet its complex mediating pathways-particularly through structural equation modeling-remain underexplored in hand hygiene research.

This study aimed to assess the utility of the COM-B model in explaining hand hygiene behavior among HCWs in China, specifically quantifying the direct effects of capability, opportunity, and motivation on behavior and testing their indirect relationships through mediated pathways.

A cross-sectional study was conducted in a Chinese tertiary hospital, recruiting 1,722 HCWs. Data were collected on demographic characteristics and hand hygiene behaviors using validated questionnaires based on the COM-B framework. Structural equation modeling (SEM) was employed to examine the direct and mediated effects of capability, opportunity, and motivation on hand hygiene behavior.

The final COM-B model demonstrated acceptable fit (CFI = 0.917, TLI = 0.903, RMSEA = 0.115). Motivation (β = 0.434, p < 0.001) and opportunity (β = 0.324, p = 0.013) had significant positive direct effects on behavior. Capability exhibited a significant negative direct effect on behavior (β = -0.217, p = 0.013), but its indirect effects via opportunity alone (β = 0.199, p = 0.017) and via the serial mediation of opportunity and motivation (β = 0.205, p = 0.001) were significant and positive. Capability primarily enhanced motivation by fostering the perception of opportunity (capability→opportunity: β = 0.842, p < 0.001; opportunity→motivation: β = 0.769, p < 0.001).

This study validates the applicability of the COM-B model in understanding hand hygiene behavior among Chinese HCWs. Motivation is the core direct driver of behavior, while environmental opportunity acts as a critical bridge linking capability to behavior. The negative direct effect of capability suggests that isolated training interventions may have limited effectiveness without concurrent environmental support. Therefore, improving hand hygiene compliance requires multifaceted strategies that simultaneously bolster capability, optimize opportunity, and cultivate motivation.