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Acta Odontológica Latinoamericana

versão On-line ISSN 1852-4834

Acta odontol. latinoam. vol.27 no.1 Buenos Aires maio 2014



Validation of an instrument to assess factors associated with adherence to standard precautions among dentists in primary healthcare


Patrícia H.V. Ribeiro1, Elucir Gir2, Claudia B. Santos2, Renata P. Ribeiro1, Miyeko Hayashida2, Silmara E. Malaguti-Toffano3, Adriana M. da Silva4

1 State University of Londrina, Londrina (PR), Brazil
2 School of Nursing of the University of São Paulo (USP - Ribeirão Preto), Ribeirão Preto (SP), Brazil
3 Federal University of São João del Rei (UFSJ) Divinópolis (MG), Brazil
4 Heart Hospital (HCOR), São Paulo (SP), Brazil

CORRESPONDENCE Dr. Patricia Helena Vivan Ribeiro Rua Paranagua, 199, Apto 1103. Londrina, PR. CEP: 86020-030, Brazil


Accidents with biological material are a reality in dental practice. The use of preventive measures such as the adoption of Standard Precautions (SP) is essential, thus this study aims to validate an instrument to check factors associated with adherence to SP among dentists. The scales of psychosocial and organizational factors that influence adherence to SP were the starting point. These scales have already been nationally validated for doctors and nurses. The instrument consisted of 49 items divided into five dimensions. The process of instrument validation involved the following steps: its adaptation for situations that pose risks to dentists; content and semantic analysis by a committee of judges, and application to dentists. The adapted instrument was applied to 224 dentists who provided primary healthcare in the north region of Parana State. After the application of scales, the psychometric properties were analyzed using the factor analysis technique and a reliability test. The factor analysis confirmed three domains: Obstacles to following standard precautions; Knowledge of occupational transmission of HIV and Safety climate. The reliability of the domains was considered adequate (Cronbach's alpha between 0.73 and 0.88.). The instrument demonstrated adequate psychometric properties to assess factors that influence adherence to SP among dentists.

Keywords: Validity; Reliability; Universal Precautions; Dentists.


Validação de um instrumento para avaliar os fatores associados a adesão às precauções padrão entre cirurgiões-dentistas da atenção básica

Os acidentes com presenca de material biologico sao uma realidade na pratica odontologica. A utilizacao de medidas preventivas como a adocao das Precaucoes Padrao (PP) e essencial, desta maneira este estudo tem como objetivo validar um instrumento para verificacao de fatores associados a adesao as PP, entre dentistas. Partiram-se das Escalas de Fatores Psicossociais e Organizacionais que Influenciam a Adesao as Precaucoes-Padrao, ja validadas nacionalmente para enfermeiros e medicos. O instrumento compos-se de 49 itens distribuidos em 5 dimensoes. O processo de validacao do instrumento seguiu as seguintes etapas: adaptacao do instrumento para as situacoes que envolvem riscos aos dentistas por meio da analise semantica e analise de conteudo, as quais foram realizadas por um comite de juizes. O instrumento adaptado foi para 224 dentistas que atuavam na Rede Basica de Saude na regiao Norte do Estado do Parana. Apos aplicacao das escalas foram analisadas as propriedades psicometricas atraves das tecnicas de analise fatorial e teste de confiabilidade. A analise fatorial confirmou tres dominios: Obstaculo para seguir as Precaucoes Padrao; Conhecimento da transmissao ocupacional do HIV e Clima de seguranca. A confiabilidade dos dominios foi considerada adequada (alfa de Cronbach entre 0,73 e 0,88). O instrumento demonstrou propriedades psicometricas adequadas para avaliar fatores de influencia na adesao as PP, entre dentistas.

Palavras chave: Validade; Confiabilidade; Precaucoes Padrao; Dentistas.



Properly taken preventive measures against accidents work effectively, particularly in professional environments1,2. Therefore, government agencies have systematically established regulations such as the adoption of Standard Precautions (SP) for healthcare providers3,4.
Even with adherence to standard precautions and the routine use of appropriate barriers to ensure protection against most microorganisms, healthcare providers are at risk of accidents involving potentially contaminated blood and body fluids, and of acquiring blood-borne infections1,3 .
The adoption of SP is considered an effective tool in the strategy for preventing contamination and transmission of infectious agents among patients and healthcare providers5-7. However, failures in these precautions have been found to cause high incidence rates of work accidents caused by exposure to body fluids and sharp objects5-8.
The adherence to safety measures by dentists has been shown to be frail, as dental practice by nature involves a wide range of potentially harmful agents such as constant aerosol formation with saliva and/or blood and handling sharp materials in a small field of view, considerably increasing the risk of accidents and contamination 8-11. Thus, the adoption of preventive measures is essential.
A review of the literature in search of information about non-compliance with SP by healthcare providers found that the abovementioned factors may go beyond the individual issue. Some authors report that adherence to SP may be associated with individual factors such as occupation, working hours, and level of knowledge of SP, as well as to psychosocial factors such as fear and work-related stress, and to organizational factors such as organizational security climate and participation in training12-14. In this sense, the role of dentists in primary care as members of a multidisciplinary team and the fact that they belong to an organization with distinctive work features favor the evaluation of these factors. In the United States, discussions of the 'Model of Adherence to Universal Precautions13 and the 'Model of Work System14 have extrapolated individual issues as factors responsible for the adoption of safe behavior, since organizational issues are present and have a relevant role. In the Model of Adherence to Universal Precautions, the aspects of influence are divided into individual, psychosocial and organizational factors, while in the Model of work system, adherence may be influenced by individual and organizational factors, and also by workrelated factors.
A Brazilian study used the Models of Adherence to Universal Precautions and the Model of Work System as a theoretical basis and proposed the 'Explanatory Model of Adherence to Standard Precautions' by validating the scales12 among doctors and nurses, and identified four categories of factors that can influence adherence: knowledge of risks and preventive measures; assessment of occupational risk and the effectiveness of prevention; barriers and interference in work performance; organizational aspects such as structure and managerial support.
Thus, the aim of this study was to adapt and validate an instrument to check factors associated with adherence to SP among dentists.


This is a methodological study that aims to adapt and analyze the structure and reliability of factors in psychometric scales that have already been translated and culturally adapted to our environment12: Knowledge of occupational transmission of HIV (8 items) and Risk perception (5 items), which include individual factors; Obstacles to SP (7 items), which comprises work-related factors; Safety climate (17 items), which includes organizational factors; and Adherence to SP (13 items). The scales are of the Likert type, with five response options in a progressive sequence from one to five points (1 to 5).
As the original instrument was developed to be applied to doctors and nurses, it had to be adapted to situations involving risks to dentists. This was done in the following two steps:

Step One - Instrument adaptation
In this stage, the original instrument was presented to five dentists who worked both as teachers and in their private practices. They were asked to evaluate the items on the scale, identifying any situations/procedures that are not usual in dental practice and should be modified. Then they suggested other procedures performed by dentists, which involved the same risk as the items to be replaced. Five dentists could suggest up to three procedures.

Step Two - Content analysis The instrument developed in Step One (Instrument Adaptation), with the items to be replaced and the three suggested options, was analyzed regarding content. Five dentists and nurses who were experts on the subject and proposed method were invited to participate by choosing the item that best represented the situation being substituted. If they considered that none of the three suggested options was right for the situation, they could suggest another. Adjustments were made and a corrected version of the instrument was prepared.

Instrument validation
The participant population consisted of all dentists (N=224) who worked in the Primary Healthcare System in six counties in the north of Parana. The eligibility criteria were to be providing direct patient care and being active in the dental profession throughout the period of data collection. Dentists who were on vacation, on leave, or in administrative leadership positions were excluded. Data were collected from July to November 2008. The researcher applied the instrument at pre-established times at the workplaces of the survey participants. All participants signed a Consent Form. The study was approved by the Ethics Committee of the Universidade Estadual de Londrina under No. 279/07. The study followed national and international standards of ethics in research involving human beings. To evaluate the construct validity of the adapted version, exploratory factor analysis was performed using the method of principal components and varimax rotation among the instrument items which were grouped into five factors, with the criterion to exclude any which had factor loadings less than or equal to 0.3015, 16. The reliability analysis was verified by the means of internal consistency of scale items, measuring the coefficient of Cronbach's alpha. Alpha values between 0.70 and 0.90 were considered appropriate17, 18.


Instrument adaptation
Semantic and content analyses were made by experts in the subject and the proposed methodology. There was 100% agreement among judges regarding the withdrawal and/or modification of suggested items.

Instrument validation
A total of 224 dentists participated in the instrument validation. There were more females (63.8%) and 75.4% were aged 30-49 years, with average age 40 years. 51.3% had 11 - 20 years' experience in the profession, and had been working at the institution for less than 10 years (50.4%), for 40 hours a week on average (Table 1). Initially, Item 12 of the dimension called 'Adherence to SP' was deleted because 100% of the participants provided the same answer to it, leaving the instrument with 48 items.

Table 1: Sociodemographic characteristics (n=224).

Data analysis
The factor structure of the scale was verified, in which the 48 items proposed to comprise the instrument were subjected to exploratory factor analysis and distributed in five factors. The rotated component matrix showed that nine had a factor loading of less than 0.3. According to the previously established criteria, it was decided to exclude these items.
An instrument reduced to 39 new items was obtained and a new factor analysis was performed, with grouping into five factors and verification of factor loadings. Considering the results in which the method of principal components was used after varimax rotation, the internal consistency of each domain was verified in accordance with Cronbach's alpha. Factors number four and five were excluded because their alpha was considered non-significant (below 0.70). After instrument validation for application to dentists, 27 items were retained, confirming the following theoretical constructs: a) Obstacles to SP (Cronbach's alpha=0.760) with 4 items; b) Knowledge of occupational transmission of HIV (Cronbach's alpha=0.732) with 6 items; c) Safety climate (Cronbach's alpha=0.885) with 17 items: Fig. 1 shows the steps followed for instrument validation and the composition of the items in each of them. After all the methodological steps were completed, the final version of the 'Scale for assessment of factors associated with adherence to standard precautions among dentists' was considered by the authors to be finalized, as shown in Table 2.

Fig. 1
: Steps after the process of instrument validation.


Table 2: Scale for 'Assessment of Factors Associated to Adherence to Standard Precautions among Dentist'.


In order for an assessment tool to be used in another culture with the same psychometric properties it must undergo a rigorous, systematic process of adaptation. The cultural adaptation of an assessment tool is only considered valid if its psychometric properties are confirmed, and this is only possible after the instrument is subjected to empirical analyses in order to demonstrate its reliability and validity19.
Psychometric tests are essential components for assessing or achieving cultural equivalence of the instruments17. According to Fayers and Machin 17 this phase is critical because the equivalence of a measure can only be demonstrated through analysis of these psychometric properties and their consistency with the original questionnaire. Therefore, validity and reliability should be evaluated17.
Content validity of an instrument verifies the ability of items to represent adequately all aspects of the content to be addressed by the instrument. As it is based on a trial, a committee of judges (experts in the subject) shall consider how appropriate the items are15. In this analysis, the judges should be experts in the area of the construct, because their task is to consider/assess whether or not the items refer to the point or subject in question. An agreement of at least 80% among judges can serve as a decision criterion on the relevance of the item and the point or subject to which it theoretically relates16.
In this study there was 100% agreement among judges regarding the withdrawal or modification of suggested items. Construct validity can be checked by factor analysis, which is the best known method for investigating the dependence of a set of response variables in relation to a smaller number of latent variables. This type of analysis is normally used when there is interest in the behavior of a variable or in groups of variables and their correlation with others of interest16.
Reliability is another important step in validating an instrument, as it refers to the consistency with which an instrument measures the attribute; in other words, it is the quality of the test scores that suggests that they are consistent enough and free enough from measurement errors to be useful16, 19- 21. The smaller the variation produced by the instrument on repeated measurements of an attribute, the greater its reliability.
Although there are several techniques for verifying internal consistency, the most frequently used in the literature is the Cronbach's alpha coefficient. Internal consistency ranges from 0 to 1 and the higher the reliability coefficient, the more accurate the measure is, but values between 0.70 and 0.90 are considered acceptable. Values below 0.70 are considered insufficient, and above 0.90 may indicate redundancy of items16. In this process, after items were grouped according to the values of factor loadings, internal consistency was verified according to Cronbach's alpha statistic and factors number four and five were excluded as they presented an alpha considered not significant (below 0.70).
It was confirmed that after the instrument was subjected to validation so that it could be applied to dentists, 27 items were maintained, confirming the following theoretical constructs: Obstacles to SP, with 4 items; Knowledge of occupational transmission of HIV, with 6 items and Safety climate, with 17 items. In comparison to the original scale, after being adapted to our environment12, only the Safety climate scale remained the same. Three items were removed from the Obstacles to SP scale and one item was removed from the Knowledge of occupational transmission of HIV scale.
It is important to emphasize that for its validation, the instrument was applied to dentists who worked in the Primary Healthcare system, which limits the application of the scale to this context. Therefore, it cannot be generalized, since the issue of 'Safety climate' in the context of primary healthcare has many specificities that differ from a private practice where the dentists is usually independent and directly responsible for management. This situation could also be observed as a limitation in study by Palese at al22.


After the validation process, in relation to the psychometric properties, construct validity and reliability were confirmed.

The 48 items initially proposed to compose the instrument underwent exploratory factor analysis by the principal components method, which confirmed five factors in the beginning. However some items were excluded because their factor loading was lower than 0.3.
The 39 remaining items subjected to a new factor analysis were kept and grouped into five factors. Verification of the reliability and internal consistency of items with two dimensions showed that Cronbach's alpha was below 0.7 and they were excluded (Adherence to SP and Risk perception). Thus, the adapted instrument after the validation process was composed of 29 items in three domains, namely:
Obstacles to SP, with 4 items (a=0.76);
Knowledge of occupational transmission of HIV, with 6 items (a=0.73);
Safety climate, with 17 items (a=0.88).


1. Wicker S, Rabenau HF. Occupational exposures to bloodborne viruses among German dental professionals and students in a clinical setting. Int Arch Occup Environ Health 2010;83:77-83.         [ Links ]

2. Malaguti-Toffano SE, Santos CB, Canini SR, Galvao MT, Brevidelli MM, Gir E. Adherence to standard precautions by nursing professionals in a university hospital. Acta Paul Enferm 2012;25:401-407.         [ Links ]

3. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Health Care Infection Control Practices Advisory Committee. 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Am J Infect Control 2007;35:S65-164.         [ Links ]

4. Puttaiah R, Miller K, Bedi DR, Shetty S, Almas K, Tse E, Kim BO, Youngblood D, Minquan D Comparison of knowledge, attitudes and practice of dental safety from eight countries at the turn of the century. J Contemp Dent Pract 2011;12: 1-7.         [ Links ]

5. Brevidelli MM, Cianciarulo TI. Niveis de adesao as precaucoes- padrao entre os profissionais medicos e de enfermagem de um hospital universitario. Online Braz J Nurs 2006; 5. URL:         [ Links ]

6. Campins M, Torres M, Varela P, Lopez Clemente V, Gasco A, de la Prada M, Espuga M, Tapias G, Pena P, Hermosilla E, Otero S, Bastida T, Sanz P, Maria Bayas J, Serra C.l. Needlestick injuries in health care workers: analysis of non preventable risk factors through standard precautions. Med Clin (Barc) 2009;132:251-258.         [ Links ]

7. Gershon RR, Pearson JM, Sherman MF, Samar SM, Canton AN, Stone PW. The prevalence and risk factors for percutaneous injuries in registered nurses in the home health care sector. Am J Infect Control 2009;37:524-533.         [ Links ]

8. Harte JA. Standard and transmission-based precautions: an update for dentistry. J Am Dent Assoc 2010;141:572-581.         [ Links ]

9. Moore D, Gamage B, Bryce E, Copes R, Yassi A; BC Interdisciplinary Respiratory Protection Study Group. Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines. Am J Infect Control 2005;33:88-96.         [ Links ]

10. Garcia LP, Blank VLG. Prevalencia de exposicoes ocupacionais de cirurgioes-dentistas e auxiliares de consultorio dentario a material biologico. Cad. Saude Publica 2006;22: 97-108.         [ Links ]

11. Barlean L, Dnil I, Balcos C, Saveanu I, Balan A. Preventive attitudes towards infection transmission in dental offices in North-East Romania. Rev Med Chir Soc Med Nat Iasi 2012;16:1209-1212.         [ Links ]

12. Brevidelli MM, Cianciarullo TI. Fatores psicossociais e organizacionais na adesao as precaucoes-padrao. Rev Saude Publica 2009;43:907-916.         [ Links ]

13. Dejoy DM, Murphy LR, Gershon RM. The influence of employee, job⁄task, and organizational factors on adherence to universal precautions among nurses. Int J Ind Ergon 1995;16:43-55.

14. Gershon RM, Karkashian CD, Grosch JW, Murphy LR, Escamilla-Cejudo A, Flanagan PA, Bernacki E, Kasting C, Martin L.. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control 2000;28:211-221.         [ Links ]

15. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000;25:3186-3191.         [ Links ]

16. Pasquali L. Psicometria. Rev Esc Enferm. USP 2009;43: 992-999.         [ Links ]

17. Fayers PM, Machin D. Quality of life assessment, analysis and interpretation. England. John Wiley, 2007.

18. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, Bouter LM, de Vet HC. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 2007;60:34-42.         [ Links ]

19. Queiroz FA, Pace AE, Santos CB. Adaptacao cultural e validacao do instrumento Diabetes - 39 (D-39): versao para brasileiros com diabetes mellitus tipo 2 - fase 1. Rev Latino- Am Enfermagem 2009;17:708-715.         [ Links ]

20. Urbina S. Fundamentos da testagem psicologica. Porto Alegre, Brazil: Artmed.2007.

21. Bordoni N, Ciaravino O, Zambrano O, Villena R, Beltran- Aguilar E, Squassi A. Early childhood oral health impact scale (ECOHIS) translation and validation in Spanish language. Acta Odontol Latinoam 2012;25:270-278.         [ Links ]

22. Palese A, Dante A, Tonzar L. The N2N instrument to evaluate healthy work environments: an Italian validation. Int Arch Occup Environ Health 2014;87:217-228.         [ Links ]

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