KNOWLEDGE, ATTITUDE AND PRACTICE OF HAND HYGIENE AMONG DENTISTS AS A PREVENTION METHOD FROM COVID-19 IN AL QASSIM REGION, KINGDOM OF SAUDI ARABIA: A CROSS-SECTIONAL STUDY

1 Lecturer, Department of Preventive Dentistry, College of Dentistry in Ar Rass, Qassim University, Kingdom of Saudi Arabia 2 Lecturer, Department of Preventive Dentistry, College of Dentistry in Ar Rass, Qassim University, Kingdom of Saudi Arabia 3 Assistant Professor, Department of Preventive Dentistry, College of Dentistry in Ar Rass, Qassim University Conflicts of Interest: Nil Corresponding author: Dr Nader M. Elsayed Marei DOI: https://doi.org/10.32553/ijmsdr.v4i9.672 Abstract: Aim: To assess the knowledge, attitude and practices of hand washing among dentists in Al Qassim Region, Saudi Arabia. Materials and Method: A descriptive cross-sectional study was carried out by use of a self-administered questionnaire. The questionnaire was based on WHO`s “Five Moments of Hand Hygiene Questionnaire” with a few notable changes. Statistical Analysis: Statistical Package for Social Sciences (SPSS) version 16 was used to analyze data. Results were displayed as counts and percentages. Results: The level of knowledge of Hand Hygiene (HH) was found high in 52% and moderate in 37% of the participants, when in the attitude levels the majority of the participants i.e. 88% had high level of attitude and was moderate in 7% of respondents. Level of practices of Hand Hygiene was high in 61%, moderate in 37% and almost none (1.4%) of our participants were found with a low level of practices. Conclusion: The population under study scored high on attitude when compared to practices and knowledge scores were the least. These points to the need for interventions for improving knowledge through regular workshops and continuing education. Since knowledge does not automatically translate into practices, emphasis on HH compliance must be laid. Planned interventions to improve compliance must be multidimensional which considers and includes administrative support, clinic ergonomics and design, timely HH supplies, periodic educational programs, reminders, process surveillance and employee feedback to achieve sustained improvements.

Hospital-associated virus transmission has been suspected in up to 29% of health care workers (HCW). COVID-19 can also be transmitted from patient to patient and hence HCW must remain vigilant. 5 While the global pandemic is spreading, one of the easiest, effective, and economical ways to prevent the spread of the virus is by practicing good hand hygiene. 4 HCWs including dentists are the most common agent that transmit most hospital infections (healthcare-related infections) from one patient to another Hand Hygiene (HH) is effectively achieved by washing hands with soap and water or an alcohol gel. 6 In these times of COVID-19 pandemic, wherein we know that infected subjects with and without clinical signs of the disease may transmit the virus, Dentistry is at the greatest risk of infection. As we work in close proximity of the portals of entry for the virus namely mouth and nose and due to the production of aerosol during treatment and in the constant presence of saliva. 7 The assessment of knowledge, practices, and attitude of HCWs may also help to identify factors that influence their HH compliance allowing for planning to overcome any barriers to its implementation. colleges and hospitals in Al Qassim region. The study was approved by the ethical committee of the institution with the approval code DRC/005FA/20 and conducted from March to June 2020 using a self-administered WHO`s "Five Moments of Hand Hygiene Questionnaire" to collect data with a few notable changes to assess the knowledge of dentists in view of the COVID-19 pandemic. We used another self-administered questionnaire to assess Attitude and Practices, utilizing 5 and 6 questions respectively.
The questionnaire consisted of 27 questions arranged in four sections. The first section was concerned with the general data of the participants (6 questions). The second section was concerned with the participants knowledge about HH (10 questions). The third section was related to participants attitude about HH (5 questions). All the questions in this section were about the proper rules, information, and sufficient training about HH. The final section included six questions about the reported practices of the participants in preventing the spread of infection and how to deal with the pandemic COVID-19.
The questionnaire was checked by two subject experts for its validity and was found satisfactory. A pilot study was conducted on 20 faculty members for the questionnaire reliability on two different days, one week in between. A Kappa test demonstrated a reliability coefficient of 0.88 indicating almost perfect reliability.
A list of dentists was obtained from the health affairs in Al Qassim region (N=355).
The study included all dentists practicing in Al Qassim region whose email IDs were available except interns. The questionnaire was also shared on the dentists` groups on WhatsApp to increase the response rate. We used a Convenience sampling technique and all submitted responses were included in the study.
An implicit consent was included at the beginning of the questionnaire. All participants were informed about the study purpose and reassured regarding the confidentiality of their individual responses.
The population size of all dentists in Al Qassim region is 355.
The sample size (n) was calculated according to the formula: n = [z2 * p * (1 -p) / e2] / The sample size (with finite population correction) was equal to 185. A total of 137 completed questionnaires were received, giving a response rate of 74.05%.
Statistical Package for Social Sciences (SPSS) version 16 was used to analyze the study data (Chi-square test was used to analyze the questions while ANOVA test was used to analyze the domains). Results were displayed as counts and percentages.

Results
The demographic details of participants are presented in Table (1). About 64% of our participants were male and 36% were females. A majority of them were faculty at various universities (72.99%) with 13 (9.49%) being employed at hospitals and another 24 (17.52%) who were in Private dental practices.  between the groups (P = 0.771) This confirms the high level of knowledge of the participants. When questioned regarding the main route of crosstransmission of germs between patients in a health-care facility, majority of the participants from the University (47%) and governmental hospitals group (76.92%) rightly recognized the hazards of not following hand hygiene, but 50% among the private clinics group were more concerned regarding contaminated surfaces with no significant differences between the groups. (P = 0.129)

Discussion
Like all other HCWs, Dentists have a moral responsibility to follow the protocols of HH which are evidence based. However, it is also the responsibility of employers to provide updated information regarding HH and eliminate any barriers to its implementation. The present study was performed to evaluate knowledge, attitude and practices of dentists regarding. HH When questioned about formal training in hand hygiene in the last 3 years, it is alarming to note only 30%, 41.67% and 46.1% recalled receiving any such training in universities, private and governmental sector respectively with no significant differences between the groups (P = 0.189) When we enquired regarding any additional training or information in view of the COVID-19 pandemic, a majority of the respondents attributed the same to self directed learning with 17 (70%) of dentists in private clinics, 64 (64%) in universities and 4 (30.77%) in governmental hospitals. Governmental hospitals benefitted by employer bulletins to about 53% and another 15% were provided by orientation programs by the employers. These findings point to a robust system of knowledge transfer in governmental institutions in updating the knowledge of their employees. It is also pertinent to note here that self directed learning also makes use of literature which are prepared and widely disseminated in public domains using the Internet and social media by the governmental bodies such as Ministry of Health. Alcohol based hand rubs are routinely used by 64 (64%), 17 (70.83%) and 8 (61.54%) among dentists from Universities, private clinics and governmental hospitals. This is encouraging as CDC guidelines also recommend the use of Alcohol hand sanitizers. Since hand sanitizers provide rapid convenient hand hygiene, a case for their availability and accessibility in dental clinics must be made to reduce cross contamination. 8 When discussing main routes of cross-transmission of potentially harmful germs between patients in a healthcare facility, majority of dentists correctly agreed that contaminated hands were responsible at 76.9%, 47% for Dentists at hospitals and Universities. However, in the private sector more dentists were concerned about contaminated surfaces 12 (50%) than about transmission through contaminated hands at 9 (37%).
When asked if Hospital environment could be a source of COVID-19, about 95 % (n=23) of dentists in private and 91% (n=91) in Universities answered in the affirmative. However, this number was 61% (n=80) for dentists in governmental sector. This comparison between the groups was highly significant. (P = 0.003) We believe this is because dentists at governmental hospitals are more aware of the stringent adherence to infection control protocols applied in their hospitals and this is responsible for their enhanced confidence regarding the safety of the hospital environment.
Twenty seconds is the least amount of time necessary to sterilize hands using alcohol to eliminate most germs in your hands and it was rightly mentioned by dentists from governmental, university and private clinics at 100%, 69% and 45% respectively. When compared between the groups, this was highly significant with a P = 0.020.
When asked if hand rub was more convenient to hand washing, 47 (47%), 5 (20.83%) and 4 (30.77%) of dentists in governmental, private and academic institutions respectively agreed. Dentists in governmental hospitals showed greater preference for hand rubs followed by those in academic institutions which was highly significant (P = 0.038) Saito H demonstrated improved HH practices even in resource limited settings when alcohol-based hand rub was provided along with HH education. 9 Lotfinejad et al. (2020) demonstrated the efficacy of alcohol-based hand rubs on inactivated enveloped viruses, including coronaviruses, recommending solutions with a minimum of 60% ethanol for hand hygiene. 10 It is heartening to note that 92 (92%) of dentists at universities and 20 (80.33%) of dentists at private clinics and 13 (100%) at governmental hospitals also made the distinction between the need to wash hands with soap and water as against the use of a hand sanitizer in certain clinical situations. All dentists (100%) across the three study groups regularly disinfected or washed hands before and after touching the patient.
Majority of the dentists surveyed had sufficient information regarding HH and were committed to it. It is encouraging to note that governmental hospitals emphasized the importance of handwashing to their new recruits (84.62%).
Our study found that all dentists in government hospitals perform hand hygiene before and immediately after contact with a patient. While it was 88% for dentists at Universities and 91.6% for those in private practices and 100% for governmental hospitals (P = 0.476) . These rates of compliance are high compared to certain other studies. Thivichon-Prince, 2014 11 compared compliance of HH Among Educators and Students and noted educators had a higher compliance rate 63.7% compared to the students at 35.8%.
In another study by El Adawi, it was seen that less respondents wash their hands before gloving (27%) when compared to after de-gloving (73.9%). Also, the numbers for hand hygiene after torn gloves at 69.6%, contaminated hands (83.5%), prior to lunch (89.6%) and after use of the wash room was (86.1%). This may be a matter of inadequate personal hygiene. 12 Hsin-Chung Cheng et al 13 also recorded low compliance of HH at 34.7% for general procedures compared to 92.8% during oral surgery services. The study recommended education and continuous monitoring to improve handwashing compliance with emphasis on correct handwashing technique.
Hand hygiene is a decisive measure for reducing COVID 19 transmission. It is crucial to perform thorough HH before and after contact with patients, non disinfected surfaces and equipment. In particular, a protocol consisting of 5 HH opportunities (2 before and 3 after treatment) was recommended to reinforce HH compliance. 14 In our study, all participants agreed HH posters around washing areas will help improve compliance When questioned regarding the greatest barrier to apply HH in your practices, 69% of dentists in governmental hospitals mentioned time constraints due to busy schedule. The dentists in private sector believed there was the need for reminders (50%). Similar results were observed in another study 12 where 40% cited lack of time and another 36% said they were forgetful. There is a definite case for reminders near washing areas to improve compliance. A study by Eliana Dantas 15 conducted on dental students reported inadequate infrastructure such as sinks and lack of consumables undermining the observance of HH practices. Lack of supplies or costs are not barriers in our study.
Interesting reviews on HH in Sub Saharan Africa, barriers to HH compliance were classified as individual or institutional barriers. Some of the institutional barriers mentioned included lack of access to infection control policy and infrastructural deficits. Such a demarcation allows for accountability in the process so interventions can be more focused. 16 Lack of motivation on the part of hospital administrators is also a barrier to compliance. 17 Monitoring of HH can also be considered to improve compliance. Our study used self reporting as a method of data collection. Direct observation, measurement of usage of hand hygiene products and electronic HH monitoring which are capable of tracking HH Compliance of individual workers may also be utilized. 18 We need to focus on not just compliance but also the technique for HH to ensure it is optimal.
An observational study to confirm HH compliance reported an overall compliance of 22%. Compliance was better after patient contact at 42.8%. Hand rubbing was performed in 47% of the possible 202 HH actions. This study reported lack of visual reminders for hand hygiene, no HH compliance monitoring and more importantly lack of performance feedback to HCWs which may help motivate them. 19 All dentists confirmed the COVID-19 pandemic has made them more conscious regarding HH with 96% of dentists in Universities and 100% across the other two groups. It is also note worthy that a high percentage of dentists surveyed feel regular training will help reinforce the message of hand hygiene. These findings are consistent with El Adawi et al who reported more than half (57.4%) desired more information regarding hand hygiene. 12 The mean score for Knowledge was the highest for Dentists at governmental hospitals at 7.23, followed by those in universities and private clinics at 7.06 and 6.64 respectively (P = 0.358). In the attitude category private clinics scored higher (3.391) compared to dentists at governmental hospitals (3.53) and Universities 3.52 (P =0.263). The highest mean score for practices was recorded for dentists at governmental institutions (5.07) followed by dentists at private clinics (4.608) and universities (4.591). However, the differences between groups was not statistically significant (P =0.225) When we consider the level of knowledge for the entire study population, a majority had high levels of knowledge at 52.6% (n=72) 37.2% (n=51) displayed moderate levels of knowledge and 10.2% (n= 14) displayed low levels of knowledge. When we describe attitude 88% (n=121) showed high levels of attitude with 7% showing moderate and 5% showing low level of attitude. For practices of Hand Hygiene 61% (n=84) was High with 37.23% (n=72) and 1.46% (n=2) showing moderate and low levels respectively.

Limitations
The study used self-reporting for data collection which had inherent disadvantages such as recall bias and response bias. We tried to overcome response bias by assuring confidentiality of individual responses and data security.

Recommendations
There is a need for regular programs to reinforce the message of hand hygiene and thereby improve compliance.
Reminders around the wash areas highlighting the five moments of hand hygiene and proper techniques for the same will ensure optimal HH.

Conclusion
The population under study scored high on attitude when compared to practices and knowledge scores were the least. These points to the need for interventions for improving knowledge through regular workshops and continuing education. Since knowledge does not automatically translate into practices, emphasis on HH compliance must be laid. Further longitudinal studies with electronic or observational reporting will help better understand and eliminate barriers to HH. In these times of the COVID-19 pandemic, the importance of HH cannot be overstated. Planned interventions to improve compliance must be multidimensional which considers and includes administrative support, clinic ergonomics and design, timely HH supplies, periodic educational programs, reminders, process surveillance and employee feedback to achieve sustained improvements.