Background
Hand hygiene is one of the most effective attempts to control nosocomial infections, and is performed by washing hands with antimicrobial soap and water, and/or by rubbing with alcohol-based antiseptic solutions (ABAS) [
1,
2]. Several publications have appeared in recent years documenting the importance of hand hygiene to prevent and to control the spread of healthcare-associated infections, and there has been a growing interest in this topic [
1‐
3].
The first evidence for the benefits of hand hygiene, implemented by Semmelweis in 1847, demonstrated that cleansing contaminated hands with antiseptic agents was more effective than hand washing with soap and water to reduce healthcare-associated transmission of microorganisms. Today, it is widely accepted that washing hands with antimicrobial soap and water in cases where hands are visibly contaminated with proteinaceous material, including patients’ blood or other body fluids is the best practice. In cases where the hands are not visibly soiled, the use of alcohol based hand rubs for routine hand hygiene in clinical situations is an effective and preferred choice [
4,
5]. The World Health Organization (WHO) recommends that hand hygiene should be performed basically in five situations, including (i) before contact with patients, (ii) immediately before aseptic procedures, (iii) immediately after contact with patient’s body fluids, (iv) after contact with patients, and (v) after touching any object or furniture in the patient’s surroundings [
6]. Despite the compliance level of healthcare workers (HCWs) should be 100% in all five moments, described by the WHO, it is still poor worldwide and thought that the negative attitudes and lack of motivation of HCWs, and increased workload are the major contributors of low compliance [
7]. A comprehensive review on hand hygiene studies by the WHO indicates that the average baseline compliance level of HCWs is 38.7% (ranging from 5 to 89%) [
6]. Additionally, in a recent systematic review by Luangasanatip et al. [
3], this level can be as low as 34% among HCWs.
Soaps are detergent-based products, and although plain soaps have cleaning activity, they lack the efficacy to remove many hazardous pathogens from the hands of HCWs [
8]. On the other hand, alcohols denature proteins, and alcohol solutions containing 60–95% alcohol are the most effective against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens (e.g., MRSA and VRE),
mycobacterium tuberculosis and various fungi. As reported by Boyce and Pittet [
5] alcohol solutions effectively reduces bacterial count on the hand within 30 s of application. Therefore, hand rubbing with ABAS is the preferred hand hygiene procedure. Its main advantages over soap and water include (i) a higher level of antimicrobial efficacy, (ii) faster usage time, and (iii) easier availability at the point of care [
6,
9].
In recent years, multi-criteria decision analysis (MCDA) methods, including the Multi-Attribute Utility Theory (MAUT) and the Analytic Hierarchy Process (AHP), have gained popularity in a wide range of fields of healthcare, in which a number of criteria must be taken into account while making crucial decisions. Previous reports indicate that the MAUT method has been successfully applied to solving numerous healthcare associated problems, such as formulary management in a health system, planning of emergency medical services, decision making in delivery of epidural analgesia during labor and in flu vaccination, and the treatment of streptococcal sore throat, rheumatic fever, schizophrenia and cancer [
10‐
18]. Another MCDA technique, the AHP method, on the other hand, has been utilized in distinct applications of healthcare, including diagnosis, treatment, priority setting, healthcare management and health technology evaluation [
19‐
25].
Given the substantial contribution of hand hygiene, a simple and low-cost action, to preventing and controlling the spread of healthcare-associated infections, the evaluation of the choice of hand hygiene agents among the infectious diseases and clinical microbiology (IDCM) specialists is crucial. So far, a number of studies have investigated the criteria that influence the hand hygiene preference of the IDCM specialists [
7,
26‐
28]. To date, however, there is no available study exploring the priorities among these criteria and the most preferred hand hygiene alternative with MCDA approaches yet. Herein, we evaluated for the first time the best hand hygiene preference of the IDCM specialists with commonly used MCDA techniques, the MAUT and the AHP. To that end, we collected expert opinions via face-to-face interviews, and then modeled these opinions with MCDA methods. We observed that rubbing the hands with ABAS had the highest total utility value, and was the alternative contributing the most to the goal of choosing the best hand hygiene method of the IDCM specialists. The detailed theoretical background of the MAUT and the AHP methods are given in the methods section.
Discussion
In this study, we utilized the MAUT and the AHP methods to investigate the factors affecting hand hygiene preference of the IDCM specialists, and determined their best choice for the most favorable way to prevent nosocomial infection among HCWs. Hand hygiene in healthcare settings is commonly implemented in two ways; disinfecting hands with an antiseptic agents and washing hands with soap and water. Previous studies comparing hand hygiene by hand rubbing with an ABAS and hand washing with antiseptic soap clearly proved that hand hygiene with hand rubbing procedure was the most appropriate way to reduce the bacterial contamination and to increase hand hygiene compliance [
27,
40‐
42]. In a randomized controlled trial during daily nursing sessions, it was presented that reduction in bacterial contamination was significantly higher with hand rubbing than hand washing (83% vs 58%;
p = 0.0012), and hand rubbing with an ABAS was preferred to hand washing due to its rapid action and accessibility [
26]. Therefore, it has been regarded that hand hygiene by rubbing with ABAS is faster and more effective than that of by washing hands with soap and water [
6]. The concurrent evaluation of the decision models established in our study suggests, consistent with previous findings, that the best choice of the IDCM specialists for hand hygiene is ABAS with the highest priority and utility. Our study has also revealed that “efficiency” is the most important factor influencing the preference of hand hygiene. This finding agrees with the results offered by Girou et al. in [
26], suggesting that HCWs usually prefer the most effective method.
HCWs have a tendency to overestimate their own compliance [
28] and their hand washing habits differ in the five moments of hand hygiene [
7,
30,
41]. For example, HCWs potentially prefer to protect themselves rather than patients therefore the reported hand hygiene rates are higher for after patient contact than that of before [
7,
28]. In our pairwise comparisons of the AHP method, we found that “efficiency” was less important than “dry and cracked skin” criterion in terms of the hand hygiene alternatives. However, when our criteria list being ranked by their priorities, “efficiency” and “dry and cracked skin” were the most and the least important criteria, respectively. These findings were not surprising, and consistent with earlier researches [
7,
28] that HCWs more likely to tend to give priority to protecting themselves and their health. On the other hand, the implication of “efficiency” by IDCMs may be interpreted as a real belief and the evidence of their compliance to hand hygiene to protect their patients since it has long been known that the rubbing the hands with ABAS is more efficient than washing the hands with soap and water. However, this reality does not replace with another truth. Because the ABAS without glycerin, as a humectant, can be harmful for the hands and cause dry and cracked skin. This might be one of the reasons why the effectiveness of hand hygiene is less important when considered the efficiency and the harmful effect of ABAS together.
Although the MCDA methods do not have a clear superiority to each other, the two most commonly used techniques, the MAUT and the AHP, have been particularly preferred in this study [
19,
43]. Given the strengths of the AHP, unlike to other approaches, it is a powerful tool in terms of (i) evaluating the priorities of expert opinions with pairwise comparisons, (ii) demonstrating uncertain and conflicting opinions as numerical values, (iii) combining decisions among experts from different or similar expertise, and (iv) having objectivity and reliability for weight calculation [
24,
44,
45]. Additionally, the systematic literature review study of Schmidt et al. [
22] reported that there was no precise rule for the number of experts involved in the AHP studies, and the method generally did not require large number of experts. The review of 121 AHP studies revealed that the number of experts can be range from 1 to 1300 (
\( \overline{x} \)=109) [
22]. Besides, the MAUT method is substantially successful in the assessment of risk preferences, taking uncertainty into account, and changing the formula easily when new attributes or factors are added [
12,
44]. Therefore, we believe that the MAUT and the AHP methods suit appropriately to resolve the research question that we focused on in this study.
Another point worth discussing is that the IDCM specialists working in the same institution may tend to make similar decisions with one another. In order to achieve the most accurate result in our decision models, we have been paid a special attention to reach the experts working in different hospitals and institutions. Therefore, the opinions included in the study were collected, as far as possible, from the experts working in different institutions. However, experts who share their views on daily practice in hand hygiene routines, still serve in the same geographical region, and this may be a limitation of our decision models. To overcome such a possible limitation, we plan to develop a web-based application, which aggregates the opinions of the IDCM specialists, as the next step of our research. In this way, we believe we will be able to perform much more comprehensive decision analysis and to understand the attitudes of the IDCM specialists towards hand hygiene more deeply.