Handwashing as a socially co-produced practice: an analysis through cultural-historical activity theory.

INTRODUCTION: Handwashing is widely promoted as a key preventive behavior in public health; however, its historical development reflects a complex interplay of cultural, religious, and scientific influences that remain insufficiently theorized in the literature. This study examines the evolution of handwashing practices through the lens of Cultural-Historical Activity Theory, aiming to conceptualize handwashing as a product of interacting activity systems rather than a purely biomedical behavior. METHODS: Drawing on a historical research design, we synthesized evidence from diverse cultural traditions, major religious texts, and the development of medical science from ancient civilizations to the modern era. RESULTS: The analysis identified three interrelated activity systems (cultural, spiritual-religious, and medical-scientific) each characterized by distinct objects, norms, tools, and meanings that shaped handwashing practices over time. We show that persistent tensions and misalignments between these systems have influenced both the diffusion and the inconsistent adoption of handwashing practices in contemporary settings. CONCLUSION: These findings suggest that current public health approaches, which predominantly emphasize knowledge and infrastructure, may overlook the historically embedded, symbolic, and normative dimensions of hygiene behavior. We argue that integrating cultural and religious logic into hand hygiene interventions can enhance their effectiveness and sustainability. Reconceptualizing handwashing as a socially and historically co-produced practice offers a more comprehensive framework for designing context-sensitive public health strategies.