A step-wise approach towards introduction of an alcohol based hand rub, and implementation of front line ownership- using a, rural, tertiary care hospital in central India as a model

Megha Sharma, Rita Joshi, Harshada Shah, Ragini Macaden, Cecilia Stålsby Lundborg

Appropriate hand hygiene is a gold standard to combat healthcare associated infections (HAIs). The World Health Organization (WHO) has recommended alcohol based hand rub (ABHR) as the most effective tool to maintain hand hygiene. In resource poor settings commercially available ABHR is not "economically accessible". The objectives of this study were to assess the acceptability of, and to build confidence for an in-house prepared (based on WHO guidelines) alcohol based hand rub among healthcare workers (HCWs) using a rural, tertiary care hospital in central India as an example. A series of activities were developed and conducted based on the Precede-Proceed model, the Trans Theoretical model of behaviour change, Front line ownership and Social marketing. A modified WHO-ABHR formulation, the 'test product' and 'WHO product evaluation form' were used for self assessment of acceptability of the 'test product'. Confidence building activities, as finger tip culture, visual portrayal method and handmade posters, were used in high-risk wards for HAIs, to build confidence for the 'test product' in removing transient flora from the hands. A locally developed feedback from was used to evaluate the impact of the activities conducted. Overall 183 HCWs were enrolled for the assessment of the 'test product' (130- doctors and 53 nurses). Out of these 83% (108/130) doctors and 94% (50/53) nurses were satisfied with the 'test product'. The confidence building activity was conducted with 116 participants (49 doctors). After single use of the 'Micro Kavach', overall a significant reduction was observed for the CFUs on the blood agar plates (0.77 Log(10), p < 0.001). A complete reduction (100%) in colony forming units on incubated blood agar plates was seen for 13% (15/116) participants. Eighty two percent (95/116) participants expressed their confidence in the 'test product'. The self reported acceptance level for the 'test product' was high. The use of finger tip culture coupled with the visual portrayal was perceived as a convincing and highly effective way to develop confidence in HCWs. Thus, is the foremost step towards successful introduction of ABHR and can be seen as a model for similar settings.