Improving hand hygiene practices in health care has been a major challenge for more than 160 years.1 Despite much evidence that hand hygiene practices are effective in preventing infection and reducing the spread of microbial resistance, the hand-cleaning behaviour of health care workers (HCWs) remains largely unchanged.2 Indeed, in almost all settings where it has been assessed, compliance with hand hygiene practices at appropriate times during the course of patient care has been less than 50%. But should HCWs carry all the blame? How do working conditions affect hand hygiene behaviour? Can behaviour change? If so, how much change in individual behaviour is necessary to reflect change at a group level? Is a major system change sufficient to transform practices? Is hand hygiene behaviour integrated into the theory of ecological perspective3 once change is targeted? What should the targets for improvement be? How far can HCWs be expected to modify their practices? How long will it take to succeed? How can behavioural change be sustained, if and when it is achieved? What does “success” mean in terms of hand hygiene promotion? What are the best indicators of success? How much local success is needed to predict more global achievements?

©The Medical Journal of Australia 2009 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377