Dental assistants` knowledge, attitude and practices of infection prevention and control measures in South-African Oral Health Care Facilities

Thesis (Master of Health Sciences in Environmental Health) (M_HSEN) --Central University of Technology, 2023

Introduction: Due to the invasive nature of many dental procedures, the presence of blood, saliva, and intact mucous membranes and tissues are inevitable. Exposure to these substances that potentially contain pathogens puts oral health care workers (OHCWs), patients and significant others at risk of contracting infectious diseases. This lurking danger puts the obligation on each oral health care team (OHCT) member to ensure the utmost safety when providing oral health care (OHC) service to patients. The principal approach to attain safety within oral health care facilities (OHCFs) is to apply effective infection prevention and control (IPC) measures. Therefore, this study aimed to determine dental assistants’ knowledge, attitude, and practices (KAP) of IPC measures within OHCFs. Methods: A quantitative descriptive study was conducted at public OHCFs and within OHCFs under the management of a specific private health care service group, further referred to as private OHCFs. A validated questionnaire was used to collect data. A total of n = 197 dental assistants, of whom n = 76 were employed in the public sector, and n = 121 employed in the private sector, participated in the study. Of the total respondents, n = 84 were formally trained (FT), and n = 113 were in-service (IST) dental assistants. Results and discussion: IPC duties: Out of the fifteen (15) IPC tasks surveyed, more than 80% of the dental assistants were always responsible for performing twelve (12) of the IPC tasks. However, tasks such as preparing the clinical area, flushing the waterlines between patients, and changing the 3-in-1 tips after every patient were performed by less than 70% of the dental assistants. Significantly more dental assistants employed in the private sector were always responsible for the disinfection of working surfaces (p < 0.01), removing the local anaesthetic needles and ampules from the syringe and maintaining the clinical area (p=0.02). In contrast, significantly more IST dental assistants always flushed waterlines between patients (p < 0.01). Knowledge about IPC measures: A high percentage (81%) of dental assistants perceived their level of IPC knowledge as average and above. More than 80% were knowledgeable about aspects of infectious diseases and risks, sterilisation and disinfection, hand hygiene, personal protective equipment (PPE) and health care related waste. However, 77% of dental assistants were knowledgeable about aspects related to vaccination, and 62% of dental assistants were knowledgeable about aspects related to IPC training and continuous professional development. Dental assistants’ preferences for resources to obtain IPC information differed. In terms of IPC guidelines, less than 65% were aware of IPC guidelines, if it is available in their OHCFs, and were familiar with the content thereof. Significantly more private sector (p=0.001), and IST dental assistants (p=0.02), knew that IPC guidelines existed and were available within their OHCFs. Even though 89% of dental assistants were aware of transmitting Hepatitis B, HIV and TB within OHCFs, only 42% were knowledgeable about the possibility of transmitting prions within OHCFs. Furthermore, only 44% of dental assistants confirmed indirect contact as a disease transmission mode within OHCFs. Although dental assistants were aware of the risk of occupational exposure incidents (OEI), they were not knowledgeable about the correct management thereof. Furthermore, dental assistants lacked knowledge about the classification of endodontic instruments, mouth mirrors and dental handpieces; awareness about the vaccination against Hepatitis B was higher than that of Hepatitis A and Influenza. However, a misconception about the availability of a Hepatitis C vaccine exists among 74% of the dental assistants. Attitude towards IPC measures: More than 80% of dental assistants portrayed a positive attitude toward IPC training and continuous professional development, disinfection and sterilisation, infectious diseases and risks, vaccination, hand hygiene, personal protective equipment (PPE) and health care related (HCRW) management. Even though 90% agreed with the application of standard precautions to all patients, 43% of dental assistants indicated that they would consider changing their standard IPC routine when working on a patient with a known infectious disease, with significantly more respondents in the public sector who hold that stance (p=0.01). Furthermore, significantly more FT dental assistants portrayed a positive attitude towards the correct method to process orthodontic instruments. Significantly more FT dental assistants who portrayed a positive attitude towards Hepatitis B vaccination (p=< 0.01), vaccination against Influenza (p=0.01) and vaccination against Hepatitis C (p=0.01). Only 50% believed that protective clothing should always be used. However, less than 25% considered limited availability of PPE, comfortability of PPE, the time it takes to put on and remove PPE, the costs of PPE, patients fearing PPE and OHCWs being used to work without PPE as reasons that prevented them from wearing PPE. Practices of IPC measures: Overall, more than 70% of dental assistants reported acceptable practices in IPC training and continuous professional development, disinfection and sterilisation, infectious diseases and risks, vaccination, hand hygiene, personal protective equipment (PPE) and health care related waste (HCRW) management. However, the overall tendency was that significantly more dental assistants employed in the private sector confirmed performing the respective IPC practices. Dental assistants reported inadequate attendance of IPC training and ongoing professional development events, with only 40% receiving yearly IPC training within their respective OHCFs. Significantly more dental assistants in the private sector received IPC training when new IPC products and equipment arrived (p=0.01). On the other hand, more dental assistants in the public sector did not receive IPC training when new IPC equipment arrived (p=0.02). Factors that prevented dental assistants from attending CPD events were the cost of CPD events, unawareness of upcoming CPD events, and the date and time of the CPD event that clashed with their schedules. Significantly more FT dental assistants indicated that the costs of CPD events deterred them from attending the CPD events. Significantly dental assistants in the public sector were unaware of CPD events. Among the total dental assistants, 74% previously worked on a patient with a known infectious disease. A total of 48% once experienced an occupational exposure injury (OEI). The most common OEIs occurred during the instrument cleaning process (27%), as manual cleaning of instruments before sterilisation was done by 91% of the dental assistants. Splash into the eyes and face, and needle stick injuries were among the top OEI experienced. A further concern was that 37% of dental assistants who used cold/chemical sterilisation methods did not use a high-level disinfectant. Dental assistants' routine practices to clean dental handpieces require attention. Less than 40% run the dental handpiece for 20-30 seconds before removing it from the hose and disassembling it to reach the inner parts. Even though 88% confirmed being vaccinated against Hepatitis B, only 45% of the total respondents received all three Hepatitis B vaccination doses. Although visible hand hygiene instructions are available in 86% of OHCFs, only 67% of the dental assistants washed their hands before putting on gloves, and 77% always washed their hands after taking off their gloves and before leaving the clinical area. Furthermore, 60% did not use an alcohol-based hand sanitiser (ABHS) to supplement their hand hygiene practices. The average use of the individual PPE items across the listed procedures was 66% for gloves, 80% for masks, 5% for protective eyewear, and 50% for protective clothing. Regarding the use of PPE during different procedures, the tendency was that higher percentages of dental assistants used all the PPE items when assisting during surgical procedures, helping a patient with known infectious disease, and anticipating blood and splatter during procedures.