Introduction
Hand hygiene (HH) is an important public health issue and a factor in the control of infectious pathogens. It remains the number one significant measure of preventing the spread of bacterial infections which are resistant to most antibiotics leading to nosocomial infections (Staats, Dai, Hofmann, & Milkman, 2017). In the past, HH was used as a cultural norm where the ancestors used it as a form of revoking moral evils and removal of physical dirt. Lal (2020) suggests that HH is a simple procedure to ignore in a public health sector by any healthcare worker or the staff. However, the compliance towards cleaning hands with soap and water, or the use of disinfectants such as alcohol hand rub in most specialized dental centers in the United Arab Emirates (UAE) are below the acceptable level.
For instance, a systematic review conducted by Seo et al. (2019) on the measure of the healthcare worker’s attitude towards the use of HH indicated compliance rate of below 50% in many of the researches. Similarly, another research conducted on the compliance of medical staff towards the HH showed an acquiescence rate of 47%. (Santosaningsih et al., 2017). Based on the research findings of these studies, it is evident that HH practices among healthcare workers, specifically, dental centers are on the worrying trends, unacceptable to the WHO minimum required levels. In this regard, such disregard to HH practices among healthcare and medical staff is the leading cause of dental-related infections such as tooth abscess, gingivitis, and periodontitis among others.
On day to day activities, healthcare workers make numerous decisions regarding the use of HH to provide patient-centered care to our patients. Consciously or unconsciously, the medical staff can resort to certain practices that are not evidence-based practices (EBPs). However, most clinical workers in healthcare programs utilize resources such as journals or individual experiences or judgments when handling critical infections in care settings.
However, it is a requirement in the medical field that healthcare practitioners evaluate and think critically about the decisions that they make to ensure the patient’s safety. In this regard, the uses of EBP; an approach in medical care where the healthcare staffs utilize the best available evidence to make decisions regarding clinical decisions, provide value, and develop practitioners’ expertise and awareness about various disease mechanisms.
Over the years, there have been great improvements in the compliance rates on the use of HH in the dental and medical fields. However, the existence of contentious issues in the handling of HH provides several challenges in the efforts to provide appropriate care to patients which minimize bacterial infections. Of great concern is the question of total compliance among the medical staff. Moreover, according to Phan et al. (2018), there is no particular intervention to the provision of compliance to HH. However, there is a need for multimodal programs that aim to improve medical compliance towards HH practice.
Problem Statement
Despite the current developments in the HH practice in most Specialized Dental Centers in UAE, there exists poor compliance of dental Practitioners towards hand washing using detergent and water or the decontamination through the use of hand sanitizers during dental care practices and tooth examinations. Notably, the dental staffs perceive that the use of gloves is the only perfect intervention to the control spread of dental infections in specialized dental clinics. Furthermore, most dental staffs argue that hand washing is a waste of time and a costly procedure compared to the use of gloves. Some dental care staffs also argue that hand washing interferes with the patient-nurse relationship, and should be disregarded as a key priority if there is the presence of gloves that reduce the risk of acquiring dental infections or any other healthcare-related diseases.
Goal and Objectives
The goal of this proposal is to appraise compliance of HH by the dental healthcare workers within 8 specialized dental clinics in UAE. This will be done following the guidelines provided by the WHO on HH Implementation multimodal improvement strategy and subsequently apply a change model (Intervention). This will encompass reversing the current trends on HH compliance rates reported from the previous years in most specialized dental clinics in UAE.
To accomplish this goal, two objectives have been established based on the risk of infections in the dental care units when compliance is below the accepted levels. First, the main objective is to reduce dental and health-related infectious among dental care patients in the 8 dental clinics in UAE. The second objective will aim to create awareness of the risk factors of non-compliance towards HH and train the hospital stakeholders on the proposed intervention.
Evidence Review
The application of HH in dental care clinics finds support from various literature materials. HH is an important healthcare practice in the prevention of healthcare-associated infections (HCAIS). The effects of nosocomial infections on both the patients and their families are the increased financial burden, long hospital stays, and increased mortality rates (Badia et al., 2017). However, an essential safety hazard, the application of multi-faceted intervention for HH has been deployed in various settings as an EBP. HCAIs contribute to the long-term disability with an increment in the resistance of microbes to antibiotics medications. In this regard, HCAIs caused as a result of poor compliance to HH implies an increased financial burden to healthcare systems.
Despite the high risk of contracting HCAIs from poor compliance for HH is a global issue, the healthcare burden remains unknown because of the challenges of collecting consistent diagnostic data. However, on a global scale, it is approximated that at least 722000 patients in 2011 contracted the HCAIs of which 75000 died (Haverstick et al., 2017). For instance, in countries such as England, the attitude towards the time-related barrier to using HH leads to the transmission of HCAI by hospitalized patients (Sadule-Rios & Aguilera, 2017).
Conversely, in countries such as Africa, factors such as poor hygiene, shortage of basic needs such as water, poor sanitation, overpopulation, and challenging social amenities immensely elevates the risk of being infected by HCAIs (Ataiyero, Dyson, & Graham, 2019). In developing countries, the burden of managing HCAIs contributes to a greater percentage of the general healthcare budget as well as the countries’ economies.
During the non-compliance towards HH, both the patients and the healthcare staff have an equal chance of contracting HCAIs, thus increased infection rates. For instance, the transmission of Angola’s Marburg viral hemorrhagic fever played a key role in its outbreak (Nyakarahuka et al., 2017). Another good example is the nosocomial gathering coupled with the high rate of transmission among healthcare workers in China was established with severe acute respiratory syndrome (SARS) (Pan et al., 2020).
Similarly, because of poor disinfection procedures due to a lack of appropriate training, many healthcare workers were infected during the influenza pandemic (Ma et al., 2020). Notably, HCAIs are significant patient safety hazards that also contribute to severe harm to patients. Fortunately, most of the harms reported because of HCAI are avoidable with the application of the universal implementation of HH improvement methods.
Moreover, several studies investigating disease outbreaks have proposed a relationship between the rate of acquiring infection and HH. Precisely, Karkar (2016) examining the link between infection and overpopulation or understaffing of hospitals and their consistency to compliance to HH, indicated a direct relation between understaffing (meaning more work resulting in reduced attention to basic hospital control measures) and the transmission of bacteria. Therefore, HH is a key component in all healthcare systems because it controls and protects individuals against HCAIs and the risk of acquiring multi-resistant microbes.
Proposed Intervention
The preceding evidence review acknowledged that the application of HH in specialized dental centers may be an effective, acceptable, and cost-friendly strategy in achieving the first objective of the intervention. The research review also determined that peer-based training programs may achieve the second objective. Therefore, the proposed intervention will comprise of two working constituents. First, it will implement HH in the seven specialized dental clinics using the HH proposed intervention of “Automated Vending machine” with an alarm for monitoring non-compliance.
According to Karkar (2016), an automated vending machine (dispensers) surpasses the need for stakeholder’s supervision and is recognized to lower the huge workload because of understaffing. The second section of the suggested intervention will be the provision of a peer-led training program regarding HCAI and transmission risks with regards to poor compliance with the use of HH and the proposed intervention. The optimal design and time frame for the proposed intervention and training program will be a by-weekly educational workshop with evaluation of post-intervention done every 3 weeks.
Methodology
Study Design, Sampling and Participants
A descriptive mixed method approach will be applied to this project. A simple survey will be disseminated randomly among the 8 specialized dental care units; namely Dubai Specialized dental center, Sharjah, Khorfakkan, Kalba, Ajman, Fujurah, Rasalkahimah, and Umalquain, with an approximate (N= 96) dental staffs. The quantitative part of the study will examine the “how many” and the “how often” to determine the frequency of handing washing behavior as indicated by Green and Norris (2015).
The qualitative section of the study will encompass staff HH compliance. A voluntary group will be requested to contribute to a random questionnaire on the impact of the HH training program via simple text messages. The survey will examine questions and responses on perception, frequency, proposed intervention training, and the attitude towards the automated vending machine. In essence, the questionnaire will assess HH knowledge which will be delivered through SurveyMonkey to all the dental healthcare practitioners at the seven specialized dental clinics. A blinded, randomized study will be conducted on a voluntary group to examine the impact of the intervention post-test and post-survey.
Theoretical Perspective
Numerous researches have evaluated interventions to promote HH compliance. Still, there are only countable EBP recommendations on prime interventions for HH. According to Belela-Anacleto et al. (2019), the behavioral theory approach provides a better comprehension of the external obstacles and facilitators to HH compliance by healthcare practitioners. Hartley, Hong, and Elowitz (2020) established a rise in compliance rate in healthcare related communication is high when using text Surveys as reminders for events. Therefore, the framework that will be used is the socio-behavioral cognitive theory to improve the healthcare practitioners’ HH activity and alter the negative prevailing attitude towards HH.
Possible Types and Sources of Data
The current total dental care staff at the 8 specialized dental clinics in UAE is 96. The ideal sample size for this research study should consist of 100% of dental healthcare practitioners in the proposed intervention (N= 96). A randomized sample of the dental practitioners will receive the HH text messaged training, which is predicted to be approximately 50 or ~ 60% of the 96 dental clinicians.
Variables
The research will measure the association between two variables. Data will be composed of two diverse features, such as the rate of hand washing and the education of the dental practitioners, and then the association will be established. With the help of a probability concept, the study will evaluate if an occurrence is conjointly exclusive and then a foreseeable prototype can be created. The independent variables comprise such features as demographics of sex and age, year of practice, while dependent variables consist of the rate of patient contacts, frequency of using hand wash, how participants interact with the simple text messages training, the replies received from the survey, and the HH test. Finally, the study will evaluate the association between data sets using the correlation coefficient. The occurrence will be assessed if it is reciprocally exclusive and then the foundation for use of a predictive strategy can be formed.
Data Collection and Data Analysis
The survey design will entail the application of the simple SurveyMonkey along with a HH questionnaire. The survey questions will be sent to study participants via SurveyMonckey through email after collecting study emails from the research participants. The survey will seek responses regarding individual demographics profiles such as age, gender, year of dental school completion, and year of dental clinic placement at the specialized dental facilities; what methods of HH were previously used: washing hands with soap and water, alcohol-based sanitizer, or gloves. The rate of patient interaction, washing of contacts places after care, the frequency per day on average does an individual sanitize. The data collection process will take up to a maximum of 3 months since the training is also scheduled to be conducted within the same time frame.
Probability Theory
Different events and subsets will be applied in this study methodology based on probability theory. Mani (2017) stipulates the probability theory with the use of sets and subsets to understand the mutual inclusive and exclusive events in a research study is critical. In this case, the first event (P1); the dental practitioners will sanitize their hands before and after coming into contact with a patient, and (P2) event, composed of subsets, (P2a) and (P2b) events posits that the training program on the proposed intervention and the rate of HH and the second event, the year of dental practitioners residency and rate of HH are mutually exclusive. (P3) The occurrence which postulates that simple text note on HH training will lead to arise in the degree of HH practice; with all events being mutually exclusive.
Data Analysis
Data which will be recorded from the survey and questionnaires will manually be entered in datasheets. Chi-square tests will be applied to evaluate whether the disparity in compliance will be statistically important amongst the dental healthcare practitioners such as dentists and nurses and the various specialized dental clinics. A logical regression method will be utilized to cross-examine whether their working association between compliance and text messages and training reminders post-survey and post-training. Data will be analyzed using the standard SPSS version 10 and STATA version 9.
Results and Strategy
Table 1: Frequency of compliance with HH by dental healthcare Practitioners.
Multi-Faceted Intervention Strategy
An advocacy training mediation is envisioned to construct a multimodal workable HH program. This platform is a model of applying three steps to cultivating quality in clinical care settings and three other steps to constantly creating awareness which embraces using raw information, comprehending the 80-20 rule, and attaining a consensus within the medical team (Brown, 2016). In addition, the strategy ensures verdicts from leaders are used to ascertain that the implemented change model moves the team from failure through creation and management of satisfactory processes, and certification through inspecting and auditing findings. Therefore, through training, the change strategy is predicted to gain traction among dental practitioners, which has minimal chances of failure.
Strengths
Vibrant leadership will be the driving force in the research study in the Oral health board and the minister for public health. Moreover, UAE’s well-established policies and healthcare designations, and managerial hierarchy are of great strength to the project. The application of WHO promoted alcohol-based hand rubs is an evidence-based practice and strategy, which overcome such constraints as understaffing in specialized dental centers and poor compliance rates to HH because the sanitizers can be dispersed independently to dental staff for their portability and carriage or when positioned at the point of patient’s care. The major benefit is that its application is well pertinent to such conditions as two or more patients sharing the same bed location, or patient’s families being invited to support in healthcare provision.
Limitations
The maintenance of the implementation change model, with approximately new policies and recommendations coupled with recommended follow-ups through text messages will provide a challenge. Coordinating the eight specialized dental clinics with their stakeholders will also prove to be a limiting factor. The sustainability of resources allocated for the project is a key limiting factor as they depend on the durability of the research study. Besides, although WHO evidence-based strategies are gradually being instigated in such countries as UAE, inadequate government support and surveillance networks limit the successful application of HH. Furthermore, insufficient hand washing amenities in most specialized dental clinics such as sinks and running water are a major constraints to implementation HH.
Conclusion
The use of HH in the prevention of HCAIs has shown a gradual improvement because of increased compliance rate over time, based on the foregoing literature review. However, few modifications are necessary to ensure a 100% compliance rate, thus control of infectious pathogens causing disease. In this regard, the use of an Automated Vending Machine that ensures dispensing of small drops of sanitizer with alarm for monitoring compliance rates among healthcare practitioners has been proposed. This intervention is vital in ascertaining that the transmission of HCAIs is gradually reduced to the acceptable minimum levels of the WHO guidelines.
Conversely, the theoretical framework indicates that change models and multi-faceted intervention strategies are as important in guaranteeing adherence to the proposed intervention and increased compliance rate for a positive impact. If the intervention proves to be of benefit, then further work is needed to ensure that the intervention is institutionalized as a healthcare policy in UAE.
References
Ataiyero, Y., Dyson, J., & Graham, M. (2019). Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review. American Journal of Infection Control, 47(5), 565-573.
Badia, J. M., Casey, A. L., Petrosillo, N., Hudson, P. M., Mitchell, S. A., & Crosby, C. (2017). Impact of surgical site infection on healthcare costs and patient outcomes: A systematic review in six European countries. Journal of Hospital Infection, 96(1), 1-15.
Belela-Anacleto, A. S., Kusahara, D. M., Peterlini, M. A. S., & Pedreira, M. L. (2019). Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study. Australian Critical Care, 32(1), 21-27.
Brown, B. (2016). 3 steps to prioritize clinical improvement in healthcare. Healthcatalyst. Web.
Green, J. A., & Norris, P. (2015). Quantitative methods in pharmacy practice research. In B. Zaheer-Ud-Din (Ed.), Pharmacy Practice Research Methods (pp. 31-47). Springer International Publishing.
Hartley, B. R., Hong, C., & Elowitz, E. (2020). Communication in neurosurgery: The tower of Babel. World Neurosurgery, 133, 457-465.
Haverstick, S., Goodrich, C., Freeman, R., James, S., Kullar, R., & Ahrens, M. (2017). Patients’ hand washing and reducing hospital-acquired infection. Critical care nurse, 37(3), 1-8.
Karkar, A. (2016). Hand hygiene in haemodialysis units. Open Access Library Journal, 3(8), 1. Web.
Lal, B. S. (2020). Back to basics: Understanding hand hygiene and quarantine. International Journal for Innovative Research in Multidisciplinary Field, 6(4), 245-251.
Ma, Q. X., Shan, H., Zhang, H. L., Li, G. M., Yang, R. M., & Chen, J. M. (2020). Potential utilities of mask‐wearing and instant hand hygiene for fighting SARS‐CoV‐2. Journal of Medical Virology, 92(5), 1567–1571.
Mani, A. (2017). Probabilities, dependence and rough membership functions. International Journal of Computers and Applications, 39(1), 17-35.
Nyakarahuka, L., Ojwang, J., Tumusiime, A., Balinandi, S., Whitmer, S., Kyazze, S.,… & Borchert, J. (2017). Isolated case of Marburg virus disease, Kampala, Uganda, 2014. Emerging Infectious Diseases, 23(6), 1001.
Pan, Y., Liu, H., Chu, C., Li, X., Liu, S., & Lu, S. (2020). Transmission routes of SARS-CoV-2 and protective measures in dental clinics during the COVID-19 pandemic. American Journal of Dentistry, 33(3), 129-134.
Phan, H. T., Tran, H. T. T., Tran, H. T. M., Dinh, A. P. P., Ngo, H. T., Theorell-Haglow, J., & Gordon, C. J. (2018). An educational intervention to improve hand hygiene compliance in Vietnam. BMC Infectious Diseases, 18(1), 116.
Sadule-Rios, N., & Aguilera, G. (2017). Nurses’ perceptions of reasons for persistent low rates in hand hygiene compliance. Intensive and Critical Care Nurs., 42(1), 17-21.
Santosaningsih, D., Erikawati, D., Santoso, S., Noorhamdani, N., Ratridewi, I., Candradikusuma, D.,… & Voor, A. F. (2017). Intervening with healthcare workers’ hand hygiene compliance, knowledge, and perception in a limited-resource hospital in Indonesia: A randomized controlled trial study. Antimicrobial Resistance & Infection Control, 6(1), 23.
Seo, H. J., Sohng, K. Y., Chang, S. O., Chaung, S. K., Won, J. S., & Choi, M. J. (2019). Interventions to improve hand hygiene compliance in emergency departments: A systematic review. Journal of Hospital Infection, 102(4), 394-406.
Staats, B. R., Dai, H., Hofmann, D., & Milkman, K. L. (2017). Motivating process compliance through individual electronic monitoring: An empirical examination of hand hygiene in healthcare. Management Science, 63(5), 1563-1585.