Hand Hygiene Among General Practice Dentists
A Survey of Knowledge, Attitudes and Practices
Ronnie Myers, DDS,
Elaine Larson, RN, PhD,
Bin Cheng, PhD,
Aaron Schwartz, DDS, MPH,
Keith Da Silva, DDS and
Carol Kunzel, PhD
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ABSTRACT
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Background. Hand hygiene (HH) is a primary practice used to reduce the risk and spread of infection. The authors conducted a study to examine the self-reported knowledge, attitudes and practices of general practice dentists (GPDs) regarding HH and factors associated with HH and skin condition.
Methods. The authors mailed a four-page closed-ended questionnaire to a random sample of active GPDs drawn from a list supplied by the New York State Dental Association. The authors classified eight GPDs as ineligible, leaving a net sample of 352. They received 234 responses, for a response rate of 66 percent.
Results. At the start of the practice day, 71 percent of GPDs often/almost always/always washed with soap but never/almost never disinfected with an alcohol-based hand sanitizer. Twenty-two percent often/almost always/always washed with soap and disinfected with alcohol-based hand sanitizers. GPDs with good/excellent knowledge of the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings were more likely to report acceptable HH behavior. Approximately one-third of GPDs had limited/ moderate knowledge of the CDC HH guideline.
Conclusions. Most GPDs use soap and water for HH frequently, and a smaller number of GPDs use alcohol-based hand sanitizers for HH frequently. Results show that 25 percent of GPDs or fewer maintain inadequate HH. Knowledge of the CDC HH guideline needs to be heightened.
Practice Implications. Further education of the dental community is warranted to improve HH compliance, efficacy of HH practices and skin health.
Key Words: Practice guidelines; professional practice; dentists; hand washing; infection controlAbbreviations: CDC: Centers for Disease Control and Prevention • GPD: General practice dentist • HH: Hand hygiene • NYSDA: New York State Dental Association
For more than a century, health care providers’ hands have been recognized as major reservoirs of pathogens that may cause clinical infections. Washing hands with soap and water has been the primary method of hand cleansing. In 2002, however, the Centers for Disease Control and Prevention (CDC) published Guideline for Hand Hygiene in Health-Care Settings, which included several new evidence-based practices such as an alcohol-based hand sanitizer to replace traditional hand washing for all patient contacts except if hands are visibly soiled.1 Although the CDC hand hygiene (HH) guideline was published more than five years ago, the extent to which dental practitioners are aware of it and the extent to which alcohol-based hand sanitizers are used by general practice dentists (GPDs) in the practice setting are unknown. While we have been able to find data on GPDs’ knowledge, attitudes and practices regarding HH in Iran, Brazil and Canada,2–5 we have been unable to find data from the United States. Hence, we conducted a study to examine the self-reported knowledge, attitudes and practices of GPDs with regard to HH and to identify factors associated with their HH practices and the condition of their hands.
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SUBJECTS, MATERIALS AND METHODS
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Sample.
We collected data by using a mail survey of active GPDs in New York state. We drew a random sample (n = 360) from a list of GPDs supplied by the New York State Dental Association (NYSDA). NYSDA has a membership of 14,000 dentists, which is 76 percent of the practicing dentists in New York state. The sampling frame included members of NYSDA who were listed as nonretired GPDs. Of the initial total sample, we excluded eight potential subjects who were ill, deceased, retired or did not self-identify their primary professional activity as the practice of dentistry and themselves as GPDs, leaving a net sample of 352 GPDs. We received 234 responses, resulting in a response rate of 66 percent.
Instrument.
Using a four-page closed-ended questionnaire, we asked subjects to describe the basic characteristics of their practice settings, their HH practices, the HH products they use, the condition of the skin on their hands, their attitudes toward HH practices and their adherence to HH guidelines. We also asked subjects to assess their knowledge in this area.
We modeled the attitudinal measurement portion of the four-page instrument after tools originally developed by Cabana and colleagues.6–8 In a systematic literature review, Cabana and colleagues8 identified six categories of barriers to physicians’ adherence to practice guidelines: lack of familiarity or awareness, lack of agreement with guidelines in general or with specific guideline recommendations, lack of outcome expectancy, lack of self-efficacy, lack of motivation, or external barriers such as patient or environmental factors. We based the tool used in our study on this empirical evidence and used it to measure GPDs’ attitudes toward a variety of barriers to complying with HH guidelines. Subjects rated their attitudes by using a four-point Likert scale, on which 1 was equated with "strongly agree" and 4 equated with "strongly disagree." The items were reverse scored where necessary, so that a higher score represented more a negative attitude. Larson9 reported the initial psycho-metric evaluation of the attitude instrument previously.
Procedures.
The institutional review board at Columbia University Medical Center, New York City, reviewed and approved the study’s protocol and materials. We mailed questionnaires in October and November 2006. The first mailing included a personalized cover letter addressed to each prospective subject, a self-addressed stamped envelope for subjects to use to return the completed questionnaire, a copy of the questionnaire and a $5 honorarium. A personalized reminder letter was sent approximately six weeks later to prospective subjects who had not yet responded to the first mailing. We determined who these people were by means of anonymous numbering of surveys. We sent all mailings by first-class mail.
Data analysis.
We used frequencies to describe the basic characteristics of the sample: the character of their practices, their demographics, their HH practices, the condition of the skin on their hands, their attitudes toward HH, and their familiarity with HH guidelines. We developed composite measures of hand condition, HH behavior and attitude toward HH practices. We determined that GPDs had good skin condition if they reported little or no redness, blotching, rash, abrasions or fissures, dryness, itching, burning or soreness on both sides of their dominant hands. We categorized them as having acceptable behavior if they reported often/almost always/always using either soap with at least 15 seconds of washing time or an alcohol-based hand sanitizer before beginning to provide care, between patients and after removing their gloves. We rated GPDs as having a positive attitude toward HH if their average score for each item (after reversing the coding of some of the items) was less than or equal to 1.79, the overall median.
We examined associations between GPDs’ HH behavior and their knowledge of the CDC HH guideline and between HH behavior and their attitude toward HH by using two-way tables and 
2 tests. We also assessed associations between GPDs’ skin condition and their behavior in dental practice, their knowledge of the CDC HH guideline (dichotomized as good/excellent versus limited/moderate), their length of time in dental practice (26 years or more versus less than 26 years), their affiliation status (affiliated with hospital/educational institution or not), whether they received any postgraduate education, number of hours per week they practiced dentistry (more than 35 hours or 35 hours or less), number of patients they saw weekly (more than 40 patients or 40 patients or fewer) and their attitude toward HH (positive versus negative) by using two-way tables and 2 tests. We conducted analyses by using the statistical software packages SPSS, Version 12 (SPSS, Chicago) and SAS, Version 9.1 (SAS, Cary, N.C.). We considered P values of .05 or less to be statistically significant.
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RESULTS
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The subjects were distributed widely on the basis of their years in practice. A total of 48 subjects (21 percent) had practiced 15 years or less, 68 (30 percent) had practiced from 16 to 25 years, 61 (27 percent) had practiced from 26 to 35 years, and 47 (21 percent) had practiced for more than 35 years (Table 1
). The subjects were predominantly male (188 subjects [84 percent]). Ninety-five subjects (41 percent) spent more than 35 hours per week in direct patient care; 129 subjects (55 percent) saw more than 40 patients per week.
A total of 113 subjects (53 percent) were solo practitioners, 103 (49 percent) had two or more hygienists in their offices, and 149 (66 percent) had two or more dental assistants in their offices. A total of 117 subjects (52 percent) had completed formal postdoctoral programs that were defined as a general practice experience. Forty-seven subjects (20 percent) were affiliated with a hospital or educational institution.
With respect to caring for their hands, 181 of 227 subjects who responded (80 percent) reported using latex gloves. Approximately two-thirds of subjects (155 of 224 subjects who responded [69 percent]) answered that they primarily used powder-free gloves. A total of 180 of 229 subjects who responded (79 percent) reported wearing gloves more than five hours each day, and 56 of the 234 subjects (24 percent) reported using alcohol-based hand sanitizers in their primary practice setting. Antimicrobial soap was the most commonly used product in the practice setting, with 202 of 234 subjects (86 percent) using it. In total, 210 of 234 subjects who responded (90 percent) used either antimicrobial soap or alcohol-based hand sanitizers in their primary practice settings.
Results in Table 2 refer to GPDs’ self-reported HH behaviors. Fourteen subjects (6 percent) reported they never/almost never wash their hands with soap or disinfect with an alcohol-based hand sanitizer at the start of the practice day. One hundred sixty-five subjects (71 percent) often/almost always/always washed with soap but never/almost never disinfected with an alcohol-based hand sanitizer at the start of the day. In contrast, two subjects (1 percent) often/almost always/ always disinfected with an alcohol-based hand sanitizer but never/almost never washed with soap. Fifty-one subjects (22 percent) often/almost always/always washed with soap or disinfected with an alcohol-based hand sanitizer. Similar patterns of combined soap and alcohol-based hand sanitizer usage occurred between patients and after glove removal. In instances involving interruptions of patient care, a larger proportion of subjects (56 [25 percent]) reported they never/almost never wash their hands or disinfect with an alcohol-based hand sanitizer before regloving and resuming patient care.
Figure 1 shows that 176 of 232 subjects who responded (76 percent) and 172 of 231 subjects who responded (74 percent), respectively, reported washing their hands for 15 seconds or more before the first patient in the morning and before the first patient after lunch. Between patients, however, fewer subjects (142 of 231 who responded [62 percent]) reported they washed their hands for 15 seconds or more.
One hundred twenty-two of 223 subjects who responded (55 percent) reported having had instances of hand irritation. In addition, they were asked about the current condition of their skin, as shown in Figure 2. With regard to hand appearance, intactness and sensation, 79 to 85 percent of subjects reported having normal skin condition. The most problematic area with respect to hand condition was amount of moisture; 91 of 228 subjects who responded [40 percent]) reported having normal moisture, and 137 of 228 subjects who responded (60 percent) reported having dry skin.
Regarding their knowledge of the association between HH and infection control, 210 of 232 subjects who responded (91 percent) indicated that their knowledge of HH was good/excellent (Figure 3). Regarding their knowledge of the CDC HH guideline, 153 of 229 subjects who responded (67 percent) responded that their knowledge was good/excellent, and a similar number and percentage of subjects (143 [61 percent]) responded that their knowledge concerning where to obtain information about the CDC HH guideline was good/excellent.
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Figure 3. Assessment of hand hygiene knowledge level. CDC Hand Hygiene Guideline: Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings.1
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We also asked subjects about their attitudes toward statements concerning HH. Almost all subjects agreed that HH prevented the spread of infection, with 178 (76 percent) strongly agreeing that it prevents the spread of infection to patients and 178 (77 percent) strongly agreeing that it prevents the spread of infection to their families (Table 3, page 954). A slightly lower number of subjects (160 [71 percent]) strongly agreed that HH prevents the spread of infection to themselves. Concerning the necessity for HH in relation to perceived risk, strong agreement with the following statements was expressed by 2 to 4 percent of responding GPDs: "Bacteria on my hands are harmless" (2 percent), "I seldom have contact with infectious patients" (3 percent) and "There is a low risk of acquiring infection from my patients" (4 percent).
With respect to the implications of HH for their skin condition (Table 3
), 9 percent of subjects strongly agreed that HH products were detrimental to their skin, 11 percent strongly agreed that frequent HH was detrimental to their skin, and 10 percent strongly agreed that the condition of their hands was likely to worsen if they followed the recommendations of the CDC HH guideline. In regard to three potential barriers—busyness, priority setting and access to supplies—five subjects (2 percent) strongly agreed that they often were too busy for HH and that other patient needs take priority over HH. One hundred two subjects (45 percent) strongly agreed that they have access to the necessary supplies and equipment to use the CDC HH guideline recommendations.
Among GPDs with good/excellent knowledge of the CDC HH guideline, 71 percent reported having acceptable HH behavior, while among those with limited/moderate knowledge, 49 percent reported having acceptable HH behavior (P < .01). Among those with a positive attitude toward HH, 75 percent reported having acceptable HH behavior, while among those with a negative attitude, 53 percent reported having acceptable HH behavior (P < .01). GPDs who had good/excellent knowledge of the CDC HH guideline are significantly more likely to have good skin condition (P = .05) (Table 4, page 955) than were those with limited/ moderate knowledge. GPDs not affiliated with a hospital or an educational institution also were more likely to have good skin condition (P = .04) than were those who were affiliated with a hospital or educational institution. GPDs with a positive attitude toward statements on HH were more likely to have good skin condition than were those with a negative attitude (P < .01).
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DISCUSSION
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Dentistry has a responsibility to adhere to scientifically accepted and evidence-based principles of infection control. In the United States, the profession includes approximately 150,000 dentists, 90,000 registered dental hygienists, 175,000 dental assistants and 43,000 dental laboratory technicians.10 It also includes dental students, postdoctoral trainees and hospital residents. Furthermore, there are thousands of other support personnel who are not directly involved in patient care but who may be exposed to potentially infectious agents.
In 2002, the CDC published Guideline for Hand Hygiene in Health-Care Settings.1 In 2003, the CDC released Guidelines for Infection Control in Dental Health-Care Settings.11 Although the CDC HH guideline was published first, the CDC dental infection control guidelines are distributed more widely in dentistry. Both of these documents have implications for oral health care providers’ HH practices. The dental infection control guidelines include a list of areas of concern that were not addressed in previous recommendations for dentistry, including HH products and surgical hand asepsis. Although the dental infection control guidelines are scientifically based on the CDC HH guideline, the recommendations are somewhat different. For example, the CDC HH guideline encourages the use of alcohol-based hand sanitizers. The dental infection control guidelines, however, place no more emphasis on the use of alcohol-based products than on the use of soap and water. In fact, alcohol-based products are presented as an alternative method. It is possible and even probable that most dental health care personnel are more familiar with or only familiar with the dental infection control guidelines. In some instances, people who say they have limited/moderate knowledge of the CDC HH guideline may believe that they have good/excellent knowledge of the dental infection control guidelines.
HH in dental practice is one of the most important parts of the infection-control process and is the single most important activity performed to reduce the risk of transmitting micro-organisms from provider to patient. Microflora that inhabits the skin can be classified as transient or resident. Transient microflora colonizes the superficial layers of the skin and can be removed easily during routine hand washing. It also is the type of microflora that is transmitted most often when providing care directly to patients and is associated most frequently with health care–associated infections. Resident microflora is adherent and associated with the deeper layers of the skin, is most resistant to removal with HH and is less likely to be associated with health care–associated infections.
The selection of HH methods depends on factors such as the type of procedure to be performed, the persistence of decontamination and the potential risk of spreading infection. Gloves—which often are thought to be a completely effective barrier that protects health care providers and prevents the spread of microorganisms—have microscopic imperfections. Hence, gloves can give providers a false sense of security. According to the CDC,12 the use of gloves reduces the risk of contamination 70 to 80 percent, helps prevent cross-contamination and helps protect patients and providers. Although wearing gloves offers a means of protection, it also creates a warm, moist environment in which organisms can proliferate. This situation results in a large increase in the amount of transient microflora, so HH is essential to eliminate transient microflora and decrease resident microflora, even when gloves are worn.
Our data show that 69 to 93 percent of GPDs use soap and water for HH frequently and 21 to 25 percent use alcohol-based hand sanitizers for HH frequently. In addition, approximately one-third of the GPDs indicate that they have limited/moderate knowledge of the CDC HH guideline. Adequate hygiene with traditional hand washing requires a considerable amount of time and does not provide as rapid and effective bactericidal activity as does an alcohol-based hand sanitizer.13,14 The use of alcohol-based hand sanitizers, however, was not emphasized in the dental infection control guidelines, which may account, in part, for their low usage among GPDs. Even in our survey, the results show that 6 to 25 percent of providers maintain inadequate HH.
Barriers to HH and to adhering to practice guidelines that were identified by other health care professionals were reported less often among the GPDs in our survey. In contrast to the barriers expressed by other health care professionals, most GPDs reported that they were not too busy for HH, that they often saw patients with infections, that they were at considerable risk of acquiring infection, and that they had access to the requisite supplies to use for following the CDC HH guideline. Other health care professionals have reported for years that these types of barriers are deterrents to HH and to adhering to practice guidelines.15–18 On the other hand, 84 percent of subjects in our survey stated that they agree or strongly agree that they are comfortable with their current HH practices, regardless of guidelines. Overall, our findings indicate that GPDs report generally positive attitudes toward HH, that ways to improve HH practices of a relatively small group of practitioners need to be found, and that knowledge of the CDC HH guideline needs to be heightened.
We found two factors that were associated significantly with subjects’ rating their skin condition as poor. First, subjects who were less familiar with the CDC HH guideline were more likely to report that their hands were in poor condition. Results of other studies have demonstrated that HH with an alcohol-based product is associated with significantly healthier skin.13,19–21 The second factor associated with subjects’ rating their skin condition as poor was their being affiliated with a hospital or educational institution. Although this finding may seem surprising at first, it may be due to the GPDs’ seeing a higher volume of patients in a hospital or academic setting, which can require frequent HH or wearing gloves more often.
We also found two factors that were associated significantly with subjects’ acceptable HH behavior. First, those with good/excellent knowledge of the CDC HH guideline were more likely to report acceptable behavior. The second factor associated with acceptable HH behavior was having a positive attitude toward HH. These findings are consistent with established theories of social behavior22 that suggest that people are more likely to perform certain behaviors when they feel there are benefits, or positives, associated with them and when they feel competent with respect to them. Attention to issues involving the dissemination and implementation of HH guidelines within the profession is warranted.
One should consider an HH protocol that will be effective and efficient. The HH method depends on several factors. The time of HH performance and the HH agent to be used should depend on the procedure to be performed, the persistence of decontamination needed and the potential risk of spreading infection (Table 5). At the time of routine hand washing or whenever hands are visibly soiled, HH should consist of using soap and water for a minimum of 15 seconds. In the performance of routine procedures that normally do not involve entering a sterile surgical site, the use of an alcohol-based hand sanitizer that is at least 60 to 95 percent ethanol or isopropanol is more efficient than hand washing and may be appropriate when hands are not visibly soiled. These routine procedures would include the majority of general dental procedures such as conducting oral examinations and placing restorations and surgical procedures with a low risk of causing infectious transmission. Critical surgical procedures that routinely penetrate a normally sterile site require the elimination of the transient microflora and a reduction in the resident microflora because these procedures carry a much higher risk of transmitting infectious bacteria. The clinician can accomplish this surgical antisepsis before donning sterile gloves by using soap and water followed by an alcohol-based hand sanitizer with persistent activity or by using antimicrobial soap and water.
Study limitations.
Although the response rate was high for a mailed survey (66 percent), as with all voluntary surveys, there is likely to be some nonresponse bias. Furthermore, the data were self-reported, and subjects may have responded in a socially desirable manner. The fact that the survey was anonymous likely mitigated that bias to a large extent. In addition, we restricted the study sample to GPDs in active practice in one state. We are not aware, however, of study findings demonstrating that HH practices among health care professionals vary geographically. The CDC HH guideline in question is intended to be implemented nationally, and GPDs are held to the same standards of HH practice regardless of location.
Finally, we restricted the sample to NYSDA members. The group we surveyed indicated inadequacies in maintaining appropriate HH even though it was a self-reported survey. We do not know of any reason to speculate that members of NYSDA would adhere to higher or lower standards of HH, thereby necessitating a reinterpretation of the main findings of our study. We suspect that the fact that New York state mandates infection control continuing education every four years for licensed oral health care professionals levels differences, if any, between members and non-members. The fact that such continuing education regulations exist in New York state, with the aim of heightening awareness and appropriate practice of HH protocols, suggests that our study does not overstate the breadth or scope of possible HH inadequacies. A representative national survey of dental practitioners, encompassing GPDs in states with and those without continuing education mandates, is an appropriate next step to review HH practices further.
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CONCLUSIONS
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In health care, HH is one of the most important links in the infection-control process and is considered the single most important activity to reduce the risk and spread of infection. To our knowledge, this is the first study that provides a comprehensive assessment of the HH practices and beliefs of GPDs in the United States. In general, the GPDs in our study reported attitudes toward HH that were positive, but their familiarity with the CDC HH guideline was not uniformly good/excellent. On the basis of our study results, we found that it is important to standardize guidelines for GPDs to increase their knowledge, as well as to create a practical guide to improve the HH process and guideline compliance. Further education of the dental community is warranted to improve HH compliance, improve efficacy of HH practices and improve skin health.
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FOOTNOTES
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Dr. Myers is an associate dean for Clinical Affairs, College of Dental Medicine, Columbia University, 630 W. 168th St., New York, N.Y. 10032, e-mail "rm36{at}columbia.edu". Address reprint requests to Dr. Myers.
Dr. Larson is a professor of pharmaceutical and therapeutic research, an associate dean for research, Columbia University School of Nursing, and a professor of epidemiology, Columbia University Mailman School of Public Health, New York City.
Dr. Cheng is an assistant professor, Department of Biostatistics, Columbia University Mailman School of Public Health, New York City.
Dr. Schwartz is a pediatric dental resident, Department of Pediatric Dentistry, Lutheran Medical Center, Department of Dentistry, Brooklyn, N.Y.
Dr. Da Silva is a pediatric dental resident, Division of Pediatric Dentistry, College of Dental Medicine, Columbia University, New York City.
Dr. Kunzel is an associate professor of clinical dental community health, College of Dental Medicine, and an associate professor of clinical sociomedical sciences, Mailman School of Public Health, Columbia University, New York City.
Disclosure. None of the authors reported any disclosures.
The authors thank Derek Hou, a student at Columbia College, New York City, for his participation in the review of study findings during a 2007 summer internship with Dr. Kunzel.
The authors thank Dr. Ira Lamster, dean, College of Dental Medicine, Columbia University, New York City, for his support of this research effort.
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ABSTRACT
SUBJECTS, MATERIALS AND METHODS
