The first section of all questionnaires was identical both for visitors and patients. It included information about the purpose of the study, instructions, and demographic questions. The questionnaires for the visitors included two items about their typical hand hygiene behavior in a hospital. The two items assessed whether they usually sanitize their hands (a) before and (b) after contact with a patient on a 5-point scale adopted from previous research [47] ranging from 1 (always) to 5 (rarely). These two moments were chosen as the dependent variable because they are suggested in the literature [14]. Moreover, one of the hospitals in which the survey was conducted placed these indications in their guidelines for visitors.

The patient questionnaire included eight items about patients’ typical hand hygiene behavior at the hospital at the following moments: (a) after entering and (b) before leaving the patient room, (c) before eating, (d) after using the restroom, (e) before and after touching wounds or medical devices, (f) before and after contact with mucous membranes, (g) after coughing or sneezing, and (h) before entering a high-risk area such as an intensive care unit. These eight indications were selected as the dependent variable because they are suggested in the literature [12]. Again, one of the hospitals in which the survey was conducted placed these indications in their guidelines for patients. The behavioral variables were assessed on a 6-point scale ranging from 1 (always) to 6 (never). The sixth option was included in the patient survey after a few participants in the precursor visitor survey mentioned there should be a never answer option.

All questionnaire items afterward varied depending on the theoretical model. The structure of the patient and visitor questionnaires was the same but adjusted for the target group. S1 Table includes the constructs of each questionnaire, example items, numbers of items included in each scale, scale means and standard errors, Cronbach’s alphas, and inter-item correlation for each scale and target group.

There is no standardized TPB-questionnaire because the theory’s author recommends constructing a new set of questions suitable for the specific behavior and population of interest. Therefore, our TPB-questionnaire was constructed according to a manual, as suggested in the literature [53]. All items were developed in English to match the manual’s recommendations, and we used forward and backward translation to maintain conceptual equivalence of the questionnaire in German. All items were pre-tested with 21 people from the general public to ensure comprehensibility and face-validity and were modified when necessary. The instrument used among visitors included 42 TPB-items and the one used among patients contained 67 TPB-items. To ensure construct validity, a Confirmatory Factor Analysis (CFA) was performed for each target group to ensure that all items included in the scales to measure the TPB model's latent variables had at least a standardized factor loading of 0.40. Items with lower standardized factor loadings were dropped, leaving 18 TPB-items among visitors and 45 among patients. The data fit well with the original four-factor TPB structure.

The items for the HAPA-questionnaire were adopted from the PSYGIENE project’s HAPA-survey [54], which they had pre-tested by an independent institute. We reached out to the corresponding authors to gain access to the original German items and adjusted the questions to fit our target group and behavior. All items were pre-tested with 15 people. The visitor questionnaire contained 35 HAPA-items and the patient questionnaire contained 50 HAPA-items. Again, a CFA was performed for each target group to ensure that all items included in the scales to measure the latent variables of the HAPA models have at least a standardized factor loading of 0.40. According to the CFAs, risk perception did not load onto a single factor but should be separated into perceived likelihood and perceived severity. Among visitors, the items for the perceived likelihood variable did not load well on a factor. Therefore, we selected the most representative item to include in the model. Additionally, outcome expectancies had to be divided into positive and negative outcome expectancies, while all self-efficacy items loaded on a single factor among both groups. The resource- and inverted-barrier-items did not load on a single factor, and the barrier-items also did not load well on a separate factor. Therefore, the barriers-construct was dropped in both groups. In total, 25 items among visitors and 42 among patients were used to build the HAPA scales. The data fit sufficiently well with the suggested HAPA structure.

Finally, the items for the TDF-survey were adopted from a questionnaire to investigate the barriers and levers to healthcare workers’ hand hygiene behavior based on the TDF [49]. The authors developed and validated the TDF-instrument in iterative, multistep processes. Their questionnaire combined the knowledge and skills domains and dropped the nature of behavior domain. We adjusted the items to fit our target sample and behavior and used forward and backward translation to produce a German version. All items were pre-tested with 19 people from the general public. The visitor instrument consisted of 39 TDF-items, and the patient survey included 58 TDF-items. Again, CFAs for each target group were performed to ensure that all items included in the scales to measure the latent variables in the TDF models have at least a standardized factor loading of 0.40. Items with lower standardized factor loadings were dropped leaving 31 TDF-items for visitors and 46 items for patients. Among visitors, the items to measure the environmental context and resources domain did not load well on a factor; therefore, we selected the most representative item to include in the model. Overall, the data fit sufficiently well with the suggested 10-factor structure.

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