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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 41-46

Factors influencing hand hygiene among dental personnel at the outpatient clinic of a Tertiary Hospital in Indonesia


Coordinator of Committee of Quality, Safety, and Performance, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia

Date of Web Publication18-Jun-2019

Correspondence Address:
Dr Sylvia Fatridha Situngkir
Perumahan Jatinegara Indah Blok BE 1 No. 31, Jakarta Timur
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SDJ.SDJ_6_19

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  Abstract 

Background: Nosocomial infections are acquired during hospitalization, and they are strongly influenced by the healthcare workers' hand hygiene. Many factors can affect hand sanitation compliance, including healthcare worker's perception, profession, high workload, lack of time, access to hand washing materials, presence of skin irritation, team of healthcare workers, and knowledge regarding the importance of hand sanitation. Objective: The aim of this study was to determine the influence of individual factors (knowledge, perception, and profession), the availability of hand sanitation facilities, and the hand hygiene workload on the hand sanitation compliance among dental personnel. Method: This quantitative observational study involved 36 dentists and 14 dental hygienists at the outpatient dental clinic of the Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia, from July 2013 to January 2014. The data were obtained via observation and questionnaires, and it was analyzed using univariate and bivariate analyses (Chi-square test) and a multivariate analysis with a logistic regression. Result: There were no correlations between the knowledge (P = 0.086) or profession (P = 0.181) and the hand sanitation compliance. However, significant correlations were found between the hand sanitation compliance and the individual perception toward hand sanitation (P = 0.000), availability of hand sanitation facilities (P = 0.000), and hand hygiene workload (P = 0.029). Conclusion: The factors that influenced the dental personnel's compliance to the hand sanitation procedures at the outpatient dental clinic were the availability of the hand sanitation facilities and the individual perceptions of the dental personnel. However, further research is needed to determine the level of hand sanitation compliance when using hand rubs and liquid soap.

Keywords: Compliance, hand washing, nosocomial infections


How to cite this article:
Situngkir SF. Factors influencing hand hygiene among dental personnel at the outpatient clinic of a Tertiary Hospital in Indonesia. Sci Dent J 2019;3:41-6

How to cite this URL:
Situngkir SF. Factors influencing hand hygiene among dental personnel at the outpatient clinic of a Tertiary Hospital in Indonesia. Sci Dent J [serial online] 2019 [cited 2019 Jul 24];3:41-6. Available from: http://www.scidentj.com/text.asp?2019/3/2/41/260560


  Background Top


Patients being treated at a healthcare facility have an increased vulnerability to hospital-acquired infections that can occur as a result of their hospital stay, their decreased immunity level, and the condition of the hospital. Such infections are also known as nosocomial infections. These infections can increase the length of the hospital stay, risk of mortality, and overall treatment costs.[1] More than 1.4 million patients receiving hospital care worldwide suffer from nosocomial infections every year.[2] The overall cleanliness of the hospital can affect the occurrence of nosocomial infections, and previous research has shown that 25% of the medical equipment and 37% of the surfaces in dental units are contaminated.[3] This highlights the increased risk of contracting nosocomial infections as a result of receiving care in a dental unit.

One strategy for preventing and controlling the spread of nosocomial infections in a hospital is the implementation of awareness standards that break the chain of infection. The most effective approach for controlling the spread of infections is good hand hygiene.[1],[4],[5],[6] Previous research conducted in Africa has shown that only 21.7% of the respondents performed hand hygiene procedures before performing dental procedures.[3] This reflects the inadequate implementation of hand hygiene in a clinical setting.

According to the World Health Organization (WHO), there are various factors that influence the hand hygiene compliance among healthcare personnel, including an excessive workload, lack of time, distant or difficult to access cleaning solvents, presence of skin irritation, and healthcare worker's gender, perception, and profession.[7],[8] Other factors that influence the hand hygiene compliance are the healthcare worker's age and knowledge of the importance of good hand hygiene.[9]

The aim of this research was to identify the factors that influenced the compliance to hand sanitation among the dental personnel at the outpatient dental clinic of the Dr. Cipto Mangunkusumo National General Hospital (RSCM). It was hypothesized that certain individual factors, the availability of hand sanitation facilities, and a high hand hygiene workload would significantly influence the hand sanitation compliance among the dental personnel at the outpatient clinic.


  Method Top


A total of 50 dental personnel were involved in this study, including 36 dentists and 14 dental hygienists out of the 48 dentists and 14 dental hygienists who worked at the outpatient dental clinic. Twelve dentists were unable to participate in the study because they were on maternity or educational leave or they were stationed at an external healthcare facility (not in the RSCM). Research began after receiving ethical clearance (KE/FK/563/EC) from the Medical and Health Research Ethics Committee of the Faculty of Medicine at Gadjah Mada University. This research was conducted from July 2013 to January 2014 at the outpatient dental clinic of the RSCM, which is a center for patient referrals in Jakarta, Indonesia.

The data were obtained using a modified version of the structured questionnaire from the WHO (translated into the Indonesian language), which was used to identify the subjects' knowledge and perceptions regarding hand sanitation, the hand hygiene workloads, and the hand sanitation facilities available. The questionnaire was distributed by the primary author, and it was filled out independently by each of the respondents [Table 1].
Table 1: Structured questionnaire from the World Health Organization

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In addition, the participants' knowledge regarding hand sanitation was evaluated using a 15-point questionnaire that included questions about whether the subjects knew that the hand sanitation policy of the RSCM was based on the International Patient Safety Goals of the Joint Commission International. It also included questions regarding whether each subject had knowledge of the following: hand sanitation is used to reduce nosocomial infections; nosocomial infections can occur as a result of hospital care; patients and their families should be educated regarding their hand hygiene, facilities required for hand sanitation, and when and how to perform hand hygiene. The perception section of the questionnaire asked about the following: whether the dental personnel considered a nosocomial infection to be a risk to the patient's clinical condition; whether the effectiveness of hand sanitation is reducing nosocomial infections; if hand sanitation facilities, instructions, education, and posters affected their hand sanitation compliance; if the healthcare personnel were compliant with the hand hygiene policy; and if their compliance to hand sanitation required conscious effort. The hand hygiene workload section asked the dental personnel questions regarding the following: overtime; the number of patients treated and if it exceeded the daily quota; if there were patients who were not treated due to time constraints; whether they educated their patients regarding hand sanitation and their compliance to hand hygiene. Finally, the facilities section asked whether the hand sanitation facilities at the outpatient dental clinic were readily available and ready-to-use when required.

The dependent variable for this study was compliance, which was determined using an observation checklist with a score of 1 for using the correct method and duration and a score of 0 if the hand hygiene method and duration were incorrect. The dental personnel were considered to be compliant with the implementation of the hand sanitation procedures if the method and duration of the hand sanitation were performed correctly 100% of the time at every opportunity for hand hygiene. The dependent and independent variables of this study are described in [Table 2].
Table 2: Research variable measurements

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For this research, the quantitative data were analyzed using the Statistical Package for the Social Sciences (version 16.0; SPSS Inc., Chicago, IL, USA). The following analyses were conducted:

  1. Univariate analysis: Individual analyses of the independent and dependent variables using a frequency distribution table
  2. Bivariate analysis: Correlations between dependent and independent variables using a Chi-square analysis with a confidence interval of 95% (P < 0.05)
  3. Multivariate analysis: Post hoc analysis that identified the associations between the dependent and independent variables using a logistic regression analysis with a confidence interval of 95% (P < 0.05).



  Result Top


Respondent characteristics

Fifty subjects were involved in this research, including nine males and 41 females. A total of 58% of the respondents were 18–40 years old, while the remaining were older than 40 years old. The profession distribution among the respondents was as follows: 72% were dentists and 28% were dental hygienists.

Univariate analysis

The distribution of the respondents' knowledge and perceptions regarding hand sanitation, their professions, the hand sanitation facilities, the hand sanitation workload, and their compliance to hand sanitation is shown in [Table 3].
Table 3: The distribution of the respondents' knowledge and perceptions

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Bivariate analysis

To identify the relationships between the independent variables (knowledge, perception, profession, hand sanitation facilities, and hand sanitation workload) and the dental personnel's compliance to hand sanitation, a Chi-square test with a significance level of 95% was used. [Table 4] shows the results of the bivariate analysis.
Table 4: Cross tabulation of personnel perception and hand hygiene compliance in the dental clinic

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The risk ratio for the relationship between the knowledge and the compliance with hand sanitation was 3.7, which showed that the level of accuracy was poor, with a significance level of P > 0.05. Moreover, the risk ratio for the relationship between the profession and the compliance with hand sanitation was 1.94. The confidence interval indicated a higher level of precision; however, the dentists were not found to be more compliant to the hand hygiene principles than the dental hygienists (P > 0.05). In contrast, the risk ratio for the relationship between the personnel's perceptions and the compliance with hand sanitation was 12.3. The P value obtained was <0.05, which showed that the personnel with good perceptions had tendencies toward being compliant to implementing the hand hygiene principles, although the degree of the increase in the compliance could not be determined due to the wide 95% confidence interval of 1.77–85.41. This weakness may have been the result of the small sample size.

The statistical analysis revealed that the availability of the hand sanitation facilities influenced the compliance with hand sanitation (P < 0.05) although the difference in the degree of the compliance could not be determined due to the wide confidence interval of 1.6–78.5. Similarly, the hand hygiene workload did not influence the compliance with hand sanitation as shown by the wide confidence interval with a P > 0.05. In addition, the risk ratio analysis showed that the personnel with high hand hygiene workloads were 3.4 times more compliant to the hand sanitation principles than those with average workloads.

Multivariate analysis

To identify the individual factors that affected the compliance with hand sanitation the most (the availability of the hand sanitation facilities and the hand sanitation workload) in the implementation of the hand sanitation principles at the dental clinic, a logistic regression test with a significance level of 95% was used. Five variables were analyzed regarding their relationships to the compliance with hand sanitation, including the variables with P < 0.25 in the bivariate analysis. The logistic regression analysis identified the variables among the individual factors (knowledge, perception, and profession), the availability of hand sanitation facilities, and the hand hygiene workload that affected the implementation of the hand sanitation principles the most [Table 5].
Table 5: Logistic regression analysis of the independent variables: knowledge, perception, profession, and hand sanitation facilities and workload; and its effects on hand hygiene compliance among the personnel (dentists and dental hygienists) at the dental clinic

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The statistical analysis revealed that the profession, hand hygiene workload, and knowledge regarding hand hygiene did not influence the subjects' compliance with the hand sanitation procedures. In contrast, the perceptions regarding hand sanitation and the availability of the hand sanitation facilities affected the compliance with the hand sanitation procedures. These results are similar to those obtained in the bivariate analysis, which strengthens the relationships between these two factors and the compliance to hand sanitation among the dental personnel.


  Discussion Top


This study reveals that 82% of the respondents had a good knowledge of hand sanitation, 58% had a good perception of hand sanitation, 70% had a high hand sanitation workload, and 60% of the facilities exhibited high standards. Overall, the compliance to the hand sanitation procedures among the dental personnel at the outpatient dental clinic at the RSCM was only 36%. When compared to the results of studies conducted in other countries, where only 21.7% of the clinicians washed their hands before performing procedures, this result was relatively higher.[3] However, when considering the fact that the nosocomial infection risk increases significantly with noncompliance to hand hygiene procedures, the dentists and dental hygienists still need to improve their hand washing compliance.[7]

The level of knowledge regarding hand sanitation among the dental personnel was lower in this study by approximately 4% when compared to previous research.[3] This difference may not be significant, but it does reveal a disparity because the knowledge regarding hand sanitation was lower at the RSCM, while the level of implementation was higher. This is supported by the study results showing that the knowledge of the dental personnel did not influence their compliance to the hand sanitation procedures. Similarly, the healthcare personnel's professions (dentist or dental hygienist) were not related to their hand sanitation compliance. This shows that the factors that influence the hand sanitation compliance are not limited to individuals from one profession; therefore, they may be generalized among all of the healthcare workers at the outpatient dental clinic. In addition, any recommendations and methods for improving compliance may be implemented among all of the personnel at the clinic. However, further research involving other outpatient clinics at the RSCM and in other hospitals is required to identify whether similar results are found prior to implementing any hospital-wide approach for improving the hand sanitation compliance. Another factor that did not influence the compliance to hand sanitation was the hand sanitation workload; therefore, any resources for hand sanitation compliance improvements should be applied to the other influential factors.

Two of the most influential factors for the hand hygiene compliance at the outpatient dental clinic at the RSCM were the healthcare personnel's perceptions and the availability of the hand hygiene facilities. However, previous studies have shown contrasting results in which the hand hygiene perception did not influence the hand hygiene implementation.[10] Various factors may be responsible for this difference, including the different locations in which the studies were conducted; for example, previous studies included the entire healthcare facility, while this study was limited to the outpatient dental clinic. Moreover, this difference highlights the fact that hand hygiene compliance may be influenced by different factors in each department of a healthcare facility. As a result, it is recommended that a hospital-wide study be done before the implementation of any improvement strategies. However, an approach to improve the perception of healthcare personnel at the outpatient dental clinic of the RSCM can be implemented to increase the clinic's compliance to the hand hygiene practices.

One factor that influenced the hand sanitation compliance was the availability of the hand sanitation facilities. This is a clear result because if facilities do not fulfill the required standards, hand sanitation procedures cannot be effectively implemented. Similar results have also been seen in previous studies.[3],[11] Therefore, to reduce the occurrence of nosocomial infections, one strategy that can be implemented to improve the hand sanitation compliance must be conducted by the hospital management, who can ensure that hand sanitation facilities are readily available and ready-to-use.


  Conclusion Top


Investigating the various factors that influence hand sanitation compliance helps to identify the underlying issues that need to be resolved. These factors may vary between healthcare facilities; therefore, the results from specific studies can provide areas of improvement that must be investigated, but they may not necessarily be generalized to all healthcare facilities. In this study, the perceptions of the dental personnel regarding hand sanitation and the availability of the hand sanitation facilities were two factors that significantly influenced the compliance with the hand sanitation procedures. Therefore, some interventions can be focused on the hospital management to ensure the availability of the hand sanitation facilities. Moreover, interventions directed at influencing the perceptions of the dental personnel may help to improve their compliance to the hand sanitation procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Darmadi. Nosocomial Infections: The Problem and Control. Jakarta: Penerbit Salemba Medik; 2008. p. 2-4.  Back to cited text no. 1
    
2.
Frost and Sullivan. Hospital Acquired Infection – Trends across Europe. Liechtenstein: Sicherheit Im Op; 2010 Available from: http://www.sicherheitimop.at/documents/FrostSullivanHospitalInfectionsTrendsacrossEuropeJuni2010.pdf. [Last accessed on 2012 Nov 12].  Back to cited text no. 2
    
3.
Mehtar S, Shisana O, Mosala T, Dunbar R. Infection control practices in public dental care services: Findings from one South African province. J Hosp Infect 2007;66:65-70.  Back to cited text no. 3
    
4.
Gould DJ, Chudleigh J, Drey NS, Moralejo D. Measuring handwashing performance in health service audits and research studies. J Hosp Infect 2007;66:109-15.  Back to cited text no. 4
    
5.
Gould DJ, Drey NS, Moralejo D, Grimshaw J, Chudleigh J. Interventions to improve hand hygiene compliance in patient care. J Hosp Infect 2007;2:CD005186.  Back to cited text no. 5
    
6.
Smith A, Carusone SC, Loeb M. Hand hygiene practices of health care workers in long-term care facilities. Am J Infect Control 2008;36:492-4.  Back to cited text no. 6
    
7.
Wibowo T, Parisihni K, Haryanto D. Protection of dentists to break the chain of cross-infection. PDGI 2009;58:6-9.  Back to cited text no. 7
    
8.
World Health Organization. Prevention of Hospital Acquired Infections: A Practical Guide. Switzerland: World Health Organization; 2009. Available from: http://www.who.int/csr/resources/publications/whocdscsreph 200212.pdf. [Last accessed 2012 Nov 12].  Back to cited text no. 8
    
9.
Cantrell D, Shamriz O, Cohen MJ, Stern Z, Block C, Brezis M, et al. Hand hygiene compliance by physicians: Marked heterogeneity due to local culture? Am J Infect Control 2009;37:301-5.  Back to cited text no. 9
    
10.
Szabó R, Böröcz K, Nagy O, Takács M, Szomor KN. Hand hygiene perception among health care workers in Hungarian hospitals: Prior to a nationwide microbiological survey. Acta Microbiol Immunol Hung 2013;60:55-61.  Back to cited text no. 10
    
11.
Marjadi B, McLaws ML. Hand hygiene in rural Indonesian healthcare workers: Barriers beyond sinks, hand rubs and in-service training. J Hosp Infect 2010;76:256-60.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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