European Journal of Dental Education ISSN 1396-5883
Does Special Care Dentistry undergraduate teaching improve dental student attitudes towards people with disabilities? C. Mac Giolla Phadraig1,2, J. H. Nunn1,2, O. Tornsey2 and M. Timms3 1 2 3
Trinity College Dublin,School of Dental Science, Dublin, Ireland, Department of Child and Public Dental Health, Dublin Dental University Hospital, Dublin, Ireland, Centre for Disability Studies, University College Dublin, Dublin, Ireland
keywords Special Care Dentistry; dental education; disability; attitude; dental student; curriculum. Correspondence Caoimhin Mac Giolla Phadraig Trinity College Dublin School of Dental Science Dublin Ireland Tel: +35316127337 Fax: +35316127298 e-mail: [email protected] Accepted: 8 May 2014 doi: 10.1111/eje.12110
Abstract Introduction: Undergraduate dental curricula increasingly aim to address student attitudes towards people with disabilities. This study reports the effectiveness of a comprehensive, blended learning Special Care Dentistry undergraduate programme to change attitudes towards people with disabilities. Methods: A validated psychometric instrument (ATDP-Form 0) was given as a course evaluation to third-year dental students in the Dublin Dental University Hospital over 3 years from 2010 to 2013, immediately before and after the delivery of a brief comprehensive curriculum in Special Care Dentistry. Results: From a population of 109 students, 100 (91.7%) pre-test and 83 (76.1%) retest responses were analysed. Mean score before the course, for all years, was 74.8 (SD = 14.7), compared with 76.8 (SD = 14.0) for all years after the course. Conclusions: Dental students in our study had neither particularly positive, or negative attitudes towards people with disabilities. There was no statistically significant difference in student attitudes before and after the educational intervention. This study, therefore, shows that a comprehensive undergraduate blended learning module, which aimed to improve attitudes towards people with disabilities, did not do so, using the described measures within the selected timeframe.
Introduction People with disabilities are not without hope. This hope does not centre on finding a “cure” for disabling conditions, but on the possibility of improving their quality of life through changes in existing attitudes. . . A Strategy for Equality (1)
Attitudes towards people with disabilities can influence many aspects of their lives, including their self-esteem, how they are treated by wider society, public policy and service provision (2). Attitudes represent a predisposition to respond favourably or unfavourably to an object, person or event (3), involving evaluation along dimensions such as good-bad, pleasant-unpleasant, worthy-unworthy, same-different (4). Our attitudes are known to influence our behaviour by shaping our intentions (5).
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 107–112
As part of a disabling society, the attitudes held by healthcare professionals may affect the care that people with disabilities receive (6–8). These attitudes may act as ‘powerful barrier(s) to equitable access to care for patients with. . .disabilities’. Poor provider attitudes along with a focus on the disability rather than the person may result in poorer outcomes such as withholding or providing inferior treatment, and neglecting general, preventive care (9). As such, improving attitudes are seen as crucial in the development of tomorrow’s healthcare professionals (10). Researchers recommend that academic institutions aim to modify healthcare students’ attitudes because fostering positive attitudes towards persons with disabilities could be linked to more vigorous efforts on their part (e.g. increased optimism, higher levels of motivation, more time spent on planning and providing services) to serve persons with disabilities (6).
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Across health sciences, curricula have been developed to improve attitudes towards people with disabilities amongst healthcare trainees (10–16). Within dentistry, as in medicine, many educators have attempted to change student attitudes through undergraduate curricula (17). Whilst the effects of education in Special Care Dentistry on dentist behaviour are perhaps mixed (18), direct contact with patients with disabilities at undergraduate level has been linked to better attitudes (19), and a greater likelihood that, as qualified dentists, trainees will treat people with disabilities more often (20–22). A growing body of guidance for developers of dental undergraduate curricula continues to focus on enhancing attitudes as a key outcome of learning for dental students (23–26). If curricula and teaching methods are to be effective in changing attitudes, there is a need for evaluation strategies involving validated instruments (7). In dentistry, it is recognised that psychometric measurement of dental student attitude can measure the effectiveness of undergraduate special care dental education (27). This study aimed to assess the effectiveness of a comprehensive blended learning Special Care Dentistry undergraduate programme using a validated psychometric tool.
Null hypothesis There will be no difference between mean ATDP scale scores for early clinical years’ dental students prior to and after training in Special Care Dentistry.
Methods This article reports the results of a course evaluation comparing repeat measures before and after a brief comprehensive curriculum in Special Care Dentistry delivered to third-year dental students in the Dublin Dental University Hospital over 3 years from 2010 to 2013. The Faculty of Health Sciences Research Ethics Committee of Trinity College Dublin granted ethical approval for this study.
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access to comprehensive e-learning resources as well as small group online tutorials. Students were also paired and placed in three professional observation sessions each. The module began with a series of two 2-h introductory interactive lectures: one on disability issues, and another, an introduction to special care dentistry. The introductory lectures were designed to encourage reflection on students’ own attitudes towards people with disabilities and the effect of their own attitudes on people with disabilities, a process encouraged formatively throughout the curriculum. For example, attitudes that saw people with disabilities as people foremost were encouraged through the application of the biopsychosocial model of disability during these lectures. The attitude that all people with disabilities are best seen in specialist centres was addressed in the second introductory lecture by outlining the role of service structure, physical access and attitudes as barriers and facilitators in society and in the dental setting. Clinical attachments consisted of a variety of professional experiences including observing dental general anaesthetic for people with disabilities, attending screening sessions in residential and day service settings, assisting in dental oncology clinics, observing treatment in specialist dental facilities in rehabilitation and other hospitals, community clinics and disability institutions. Each student experienced three different settings, and the group as a whole shared their experiences formatively at regular feedback sessions. Dedicated contact time (including web-based contact) included one 3-h session per week over 7–9 weeks on this module as well as a 1-day experiential workshop on ageing. This was in addition to two introductory and one wrap-up lecture. Summative evaluation further encouraged reflection on students’ own attitudes and the attitudes of those with whom they had met through this experience through the production of a module diary, similar to an abridged logbook and extended case report with dummy referral letter for one patient seen from each student. Between the years 2011 and 2013, minor changes to curriculum and delivery were made, however, the overall structure described above was maintained.
Design Course evaluation using repeat measures collated over 3 years.
Intervention At pre-test, students had previous exposure to a minimum number of Problem-Based Learning sessions regarding Special Care Dentistry. This element of teaching was minor relative to the course described below. This section describes the educational intervention, which took place between pre-test and retest measures. A curricular module specific to Special Care Dentistry was provided to all third-year dental students in the third of three academic terms (Trinity Term) in Trinity College Dublin, over the 3 years tested. This module was developed from an initial undergraduate Special Care Dentistry education curriculum introduced to Dublin some time ago (28). This was a blended learning module involving lectures, experiential workshops and
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Data collection ATDP instruments were self-administered at each stage. Pre-test data were collected immediately before the first lecture of the programme. This normally occurred around mid-April of each of the 3 years studied. The instrument was circulated around the class, who were each year advised that it would serve primarily as a course evaluation and that this may be published. As such, it may be considered a direct measurement of attitudes, rather than indirect measurement where participants believe that data collection is for non-research purposes, which may give more accurate measurement of attitudes (6). Repeat data were collected immediately after completion of the curriculum at course review lectures or tutorials. This event was between 8 and 9 weeks following initial data collection. No other known education relating to the domains considered in this article was provided outside of this module during test intervals.
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Attitudes towards people with disabilities
TABLE 3. Mean ATDP score by year (Standard Deviation)1
Data collection instrument This study used the 20-item Attitudes Towards Disabled Persons Scale (ATDP-Form 0), developed by Yuker et al. (29) . This scale was selected given its robust psychometric properties and broad applicability. It is recognised as being valid and reliable and is the most widely used of the many psychometric scales testing attitudes towards people with disabilities (7). The ATDP scale assumes that if individuals with disability are seen as different from people without disability they may therefore be seen as inferior (30, 31). Therefore, attitudes are considered positive where respondents do not see difference between people with disabilities and those without disabilities.
Analysis Data were transformed according to Yuker’s original scoring before summative index scores were collated (31). Means and standard deviations for each year were calculated using SPSS (V.19; IBM Corp., Armonk, NY) before and after training. Aggregates over the 3 years were also calculated. Cronbach’s alpha measured internal consistency. Independent samples Student’s t test was used to compare pre-test and retest scores by year and aggregate.
Results Sample and flow The population is described by gender and year in Table 1. The mean age in years was 22 (SD = 3) in 2011, 22 (SD = 4) in 2012 and 21 (SD = 2) in 2013. From a population of 109 students, 100 (91.7%) pre-test and 83 (76.1%) retest responses were analysed. The number of students from each year who undertook the evaluation is described in Table 2.
ATDP scores Overall, ATDP scores ranged from 33 to 106 with a mean of 75.7 (SD = 14.4). As a measure of reliability, Cronbach’s alpha
2011 2012 2013 Total
Pre-test
Retest
75 73 76 75
74 78 81 77
(15) (13) (16) (15)
(14) (16) (16) (14)
1 Using independent samples Student’s t test, no difference was statistically significant.
was 0.75 for all returned scales. Mean score before the course, for all years was 74.8 (SD = 14.7), compared with 76.8 (SD = 14.0) for all years after the course. Differences per year are reported in Table 3. What it shows is that in 2011, 2012 and 2013, there was no statistically significant difference in pretest and retest measure. Marginal means are represented in Fig. 1.
Discussion Dental students in our study had neither particularly positive nor negative attitudes towards people with disabilities (mean score at pre-test = 74.8, SD = 14.7) . Yuker specifies that raw scores are only relevant when compared with norms (31). In the case of Yuker’s original psychometric analyses, mean scores ranged from 72.8 (SD = 15.5) to 75.4 (SD = 13.5) amongst groups without disabilities (31). Therefore, dental students’ attitudes were similar to other groups without disabilities. However, attitudes towards people with disabilities have generally improved since this original work (32). More recent research has shown that dentists have worse attitudes towards people with disabilities compared with other student groups (25, 33). Using the ATDP (Form 0) as a useful comparison, our population generally had similar results to other healthcare students and professionals (9). As an example, similar mean scores have been found amongst nursing (M = 78.4, SD = 8.5) and medical students (M = 77.8, SD = 7.6) (34). In comparison with other Irish populations, our scores were lower than
TABLE 1. Study population (%)
Population Gender Female Male
2011
2012
2013
Total
40 (36.7)
33 (30.3)
36 (33.0)
109 (100)
23 (57.5) 17 (42.5)
22 (66.7) 11 (33.3)
24 (66.7) 12 (33.3)
69 (63.3) 40 (36.7)
TABLE 2. Study samples (Valid %)
Pre-test n Retest n
2011
2012
2013
Total
40 (40.0) 39 (43.8)
30 (30.0) 20 (22.5)
30 (30.0) 24 (27.0)
1001 892
1
Representing a response rate of 91.7% at pre-test. Representing a response rate of 76.1% at retest. n = Sample.
2
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 107–112
Fig. 1. Mean ATDP scores per year and as a total, compared with published norms (31).
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previously reported ATDP scores (35). This latter group were recognised as returning especially high responses, giving rise to the theory that Irish respondents’ scores may be higher on this test. Our study does not support this. Overall ATDP scores for dental students in this study were similar both before (mean = 74.8 SD = 14.7) and after training (mean = 76.8, SD = 14.0). The results from this study would indicate that a brief, comprehensive undergraduate blended learning module, which aimed to improve attitudes towards people with disabilities, was not successful in doing so, using the described measures within the selected timeframe. From year to year, little improvement was seen, despite incremental changes to the delivery of this module to address previous years’ perceived shortcomings, based on formal feedback sessions with students at the close of this module and review by course providers. Logically, these changes should have lead to increasing impact over time if training was effective. Our results indicate that these improvements were largely ineffectual in changing attitudes in this instance and more radical review may be necessary. The lack of improvement in ATDP score is surprising, given that undergraduate healthcare curricula and specific disability awareness programmes have been shown to be effective at improving attitudes, using this metric. Amongst nursing students, interventions have lead to increased ATDP scores over time (14, 36). Amongst nurses’ aides, as little as a lecture and case-based discussions have been shown to lead to changes in ATDP scores, even in small samples (37). Medical students too have been shown to significantly increase their ATDP scores, along with other indices of attitudes, where curricula were directed specifically towards promoting empathy. Again, this was designed using a short intervention, based on 16 individuals with disabilities sharing their experiences of healthcare, delivered by DVD and incorporating artistic expression (12). In dentistry, no studies have used the ATDP (Form 0) to measure the impact of curricula on attitudes, so direct comparisons with previously cited research is difficult. Results using various other measures in longitudinal studies are mixed. Whilst older studies showed a failure of curricula to improve attitudes amongst dental students (38, 39), a number of other studies show effectiveness (26, 40, 41). Considering attitude change, effective curricula may involve a diverse range of teaching methods. Examples include a 1-year clinical and didactic curriculum for dental hygiene students (40), a short lecture series augmented with case presentations for fourth year dental students (26), and a mixture of lectures, group discussion, screening and fluoride varnish provision for patients with disabilities (41). The ATDP scale assumes that some people perceive individuals with disability as being different from and thus inferior to people without disability (30, 31). It was selected to measure outcomes for this evaluation as it is the most widely used attitudinal scale in this field of research and has robust psychometric properties (7). However, it also has significant shortcomings, as used in this study. First, this scale uses a unidimensional singlescore method to measure generalised attitude. This limits the depth of understanding we can gain from the application of such a scale, which perhaps reflects the failure of this scale to mirror the multidimensional theoretical nature of attitudes – that is the 110
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cognitive, affective and behavioural dimensions of attitudes (42). Second, we selected a measure of general dispositions towards people with disabilities applicable to the general population, to measure effectiveness of our curriculum in increasing the likelihood of specific behaviours, such as making reasonable accommodation to treat oral disease amongst people with disabilities. According to Ajzen’s Theory of Planned Behaviour, attitudes only predict behaviour when they are specifically related to the specific behaviours in question, or conversely as general as the general behaviours of interest (5). There is a possibility that a more specific scale measuring specific attitudes may have led to different findings. Ideally, for our purposes, a situation-specific scale with robust psychometric qualities, applicable across disability types and in keeping with current concepts of disability, would best meet our needs in assessing the effectiveness of curricula in the dental setting. Specific scales, focusing on dental students or dentists and their interactions with people with ID or physical disabilities, have been developed for this use (19, 27). The DSATHS scale specifically assesses attitudes of dental students (and latterly dental hygiene and social policy students) towards with physical disabilities only (19, 25, 40, 43). Whilst it has been found to be valid and reliable, it is less frequently used than the scale of Yuker (7). The scale developed by Bedi et al. has also been used amongst dentists and dental care professionals, on a limited basis (44, 45). Given that these scales measure attitudes more specifically relevant to dental students and their behaviours, our research team have decided to include one of these scales (27), with minor modification, for future course evaluation in Trinity College Dublin. We have also started collecting other demographic data on parameters that are associated with attitudes towards people with disabilities, such as previous exposure to disability, gender and age (9).
Limitations Any consideration of the results of this article must acknowledge some shortcomings in design. This article is based on anonymous data primarily collected as part of course evaluation. This limits the richness of analysis. For example, we cannot pair data from pre-test to retest, which limits our statistical analyses. This also introduces bias. We cannot differentiate the sample, which responded from the population, as we do not know who within the sample responded at either stage. We are therefore open to selection bias, affecting external validity. Having said that, response rates were high at both stages in this study. Additionally, scores were stable within years. These factors may mitigate some concern from the methodological weaknesses described above. Finally, we cannot precisely measure the impact of gender and other background parameters upon the results, which is considered good practice (6). Perhaps most importantly, we focus our intention on attitude in this evaluation, whilst it is acknowledged that the impact of attitudes on behaviour is variable across situation, context and time (46). Perhaps this is due to the complex interaction of attitudes and other psychosocial factors, which influence behaviour (5). Notably, other studies showing no improvement in attitudes towards people with disabilities saw increasing confidence and intention to treat people with ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 107–112
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disabilities in attitude-stable dental student samples (38, 39). The authors recognise a need to follow-up graduates at a later stage in their professional career to test the stability of ATDP scores and more recently adopted measures and most importantly correlate attitudes with independent measures of behaviour towards people with disabilities. The academic year 2013/2014 represents the first opportunity for educators in this field of Special Care Dentistry undergraduate dental education to implement and measure the impact of new internationally agreed guidance on curriculum design (20). This guidance recognises the importance of addressing student attitudes as a means of preparing future professionals for positive professional behaviours. We at Trinity College Dublin/ Dublin Dental University Hospital integrated this guidance into our curriculum and have re-organised the delivery of training in this field to meet these commonly agreed learning outcomes. Given these changes, it is ever more important to continue to measure outcomes to ensure quality and accountability in special care dental education.
Conclusion Dental students should be aware that their attitudes can subtly affect their behaviours, potentially leading to enablement or disablement for people with disabilities. Dental educators should acknowledge this in their efforts, through the curriculum to modify attitudes held by graduates. Our study showed fairly average levels of attitude towards people with disabilities amongst 3 years of dental students in Ireland. The curriculum taught up to 2013 in Trinity College Dublin was not associated with greatly improved dental attitudes. We need to change how we measure and teach changes in attitudes for dental students. The adoption of changes in curriculum along international standards and a broadening of our outcome measures may be successful in doing so.
Acknowledgements The authors would like to thank the students and staff involved in this study, particularly Dr. Alison Dougall and those who allow our students to attend their clinics year after year to gain vital experience. The authors also appreciate the award of a student summer scholarship to one author, granted by GSK, Ireland.
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6 Antonak RF, Livneh H. Measurement of attitudes towards persons with disabilities. Disabil Rehabil 2000: 22: 211–224. 7 Lam W, Gunukula S, McGuigan D, Isaiah N, Symons A, Akl E. Validated instruments used to measure attitudes of healthcare students and professionals towards patients with physical disability: a systematic review. J Neuroeng Rehabil 2010: 7: 55. 8 Roush SE. Health professionals as contributors to attitudes toward persons with disabilities. A special communication. Phys Ther 1986: 66: 1551–1554. 9 Satchidanand N, Gunukula SK, Lam WY, et al. Attitudes of healthcare students and professionals toward patients with physical disability: a systematic review. Am J Phys Med Rehabil 2012: 91: 533–545. 10 Byron M, Dieppe P. Educating health professionals about disability: ‘attitudes, attitudes, attitudes’. J R Soc Med 2000: 93: 397–398. 11 Symons A, McGuigan D, Akl E. A curriculum to teach medical students to care for people with disabilities: development and initial implementation. BMC Med Educ 2009: 9: 78. 12 Miller SR. A curriculum focused on informed empathy improves attitudes toward persons with disabilities. Perspect Med Educ 2013: 2(3): 114–125. 13 Seccombe JA. Attitudes towards disability in an undergraduate nursing curriculum: the effects of a curriculum change. Nurse Educ Today 2007: 27: 445–451. 14 Thompson TL, Emrich K, Moore G. The effect of curriculum on the attitudes of nursing students toward disability. Rehabil Nurs 2003: 28: 27–30. 15 Yamamoto K, Randall M, Takeda M, Leelamanit W. Attitudes of medical students towards persons with mental disorders: a comparative study between Japan and Thailand. Psychiatry Clin Neurosci 1996: 50: 171–180. 16 Estes JP, Deyer CA, Hansen RA, Russell JC. Influence of occupational therapy curricula on students’ attitudes toward persons with disabilities. Am J Occup Ther 1991: 45: 156–159. 17 Holder M, Waldman HB, Hood H. Preparing health professionals to provide care to individuals with disabilities. Int J Oral Sci 2009: 1: 66–71. 18 Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ 2004: 68: 23–28. 19 Lee M, Sonis A. An instrument to assess dental students’ attitudes toward the handicapped. Spec Care Dentist 1983: 3: 117–123. 20 Smith G, Rooney S, Nunn J. Provision of dental care for special care patients: the view of Irish dentists in the Republic of Ireland. J Ir Dent Assoc 2010: 56: 80–84. 21 Chavez EM, Subar PE, Miles J, Wong A, Labarre EE, Glassman P. Perceptions of predoctoral dental education and practice patterns in special care dentistry. J Dent Educ 2011: 75: 726–732. 22 Vainio L, Krause M, Inglehart MR. Patients with special needs: dental students’ educational experiences, attitudes, and behavior. J Dent Educ 2011: 75: 13–22. 23 Nunn J, Boyle C, Thompson S, Wilson K. Developing an undergraduate curriculum in special care dentistry. J Disabil Oral Health 2005: 6: 3–15. 24 Dougall A, Thompson SA, Faulks D, Ting G, Nunn J. Guidance for the core content of a Curriculum in Special Care Dentistry at the undergraduate level. Eur J Dent Educ 2014: 18: 39–43. 25 Coyle C, Saunderson W, Freeman R. Dental students, social policy students and learning disability: do differing attitudes exist? Eur J Dent Educ 2004: 8: 133–139. 26 Delucia LM, Davis EL. Dental students’ attitudes toward the care of individuals with intellectual disabilities: relationship between instruction and experience. J Dent Educ 2009: 73: 445–453.
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27 Bedi R, Champion J, Horn R. Development of an attitudinal scale for dental personnel in the provision of care for people with learning disabilities. J Disabil Oral Health 2000: 1: 26–30. 28 Nunn J. An outreach programme in special care dentistry – the pitfalls. Bristol: Private correspondence delivered to the British Society for Disability and Oral Health Teacher’s Group, 2005. 29 Yuker HE, Block J, Younng J. The measurement of attitudes toward disabled persons. Albertson, NY: Human Resources Centre, 1966. 30 Yuker H, Block J, Campbell W. A scale to measure attitudes disabled persons. Human Resources Study (No. 5). Albertston, New York: Human Resources, 1960. 31 Yuker H, Block J, Younng J. Measurement of attitudes toward disabled persons [Online], 1970. Available: http://files.eric.ed.gov/ fulltext/ED044853.pdf [Accessed 30/04/2014]. 32 Hannon F. Literature review on attitudes towards disability: national disability authority. Dublin: NDA, 2007. 33 O’Donnell D. Use of the SADP for measurement of attitudes of Chinese dental students and dental surgery assistants toward disabled persons. Spec Care Dentist 1993: 13: 81–85. 34 Tervo RC, Palmer G, Redinius P. Health professional student attitudes towards people with disability. Clin Rehabil 2004: 18: 908–915. 35 Timms M, McHugh S, O’Carroll A, James T. Assessing impact of disability awareness training using the Attitudes Towards Disabled Persons Scale (ATDP–Form 0). Int J Rehabil Res 1997: 20: 319–323. 36 Oermann MH, Lindgren CL. An educational program’s effects on students’ attitudes toward people with disabilities: a 1-year followup. Rehabil Nurs 1995: 20: 6–10. 37 Lehman JJ, Vargo JW. The effects of an in-service program upon the attitudes of nursing aides. Can J Occup Ther 1979: 46: 105–108.
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38 Kinne RD, Stiefel DJ. Assessment of student attitude and confidence in a program of dental education in care of the disabled. J Dent Educ 1979: 43: 271–275. 39 Udin RD, Kuster CG. The effect of clinical experience on the attitudes and confidence of senior dental students toward treating children with handicapping conditions. Spec Care Dentist 1986: 6: 70–73. 40 Loiacono C, Muzzin KB, Guo IY. Dental hygiene students’ attitudes toward treating individuals with disabilities. Probe 1996: 30: 220– 224. 41 Mohebbi SZ, Chinipardaz Z, Batebi A. Effectiveness of training senior dental students on oral health care for disabled patients. Eur J Dent Educ 2014 Feb 4.: doi: 10.1111/eje.12090. [Epub ahead of print]. 42 Findler L, Vilchinsky N, Werner S. The multidimensional attitudes scale toward persons with disabilities (MAS): construction and validation. Rehabil Couns Bull 2007: 50: 166–176. 43 Stoltenberg JL, Walker PO. Student dental hygienists’ and dental hygiene educators’ attitudes toward the handicapped. J Dent Hyg 1989: 63: 117–123. 44 Bedi R, Champion J, Horn R. Attitudes of the dental team to the provision of care for people with learning disabilities. Spec Care Dentist 2001: 21: 147–152. 45 AlSarheed M, Bedi R, Hunt NP. Attitudes of dentists, working in Riyadh, toward people with a sensory impairment. Spec Care Dentist 2001: 21: 113–116. 46 Fazio R. How do attitudes guide behavior. In: Sorrentino R, Higgins E, eds. Handbook of motivation and cognition: foundations of social behavior. vol. 1. New York: The Guilford Press, 1986: 204–243.
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Does Special Care Dentistry undergraduate teaching improve dental student attitudes towards people with disabilities? C. Mac Giolla Phadraig1,2, J. H. Nunn1,2, O. Tornsey2 and M. Timms3 1 2 3
Trinity College Dublin,School of Dental Science, Dublin, Ireland, Department of Child and Public Dental Health, Dublin Dental University Hospital, Dublin, Ireland, Centre for Disability Studies, University College Dublin, Dublin, Ireland
keywords Special Care Dentistry; dental education; disability; attitude; dental student; curriculum. Correspondence Caoimhin Mac Giolla Phadraig Trinity College Dublin School of Dental Science Dublin Ireland Tel: +35316127337 Fax: +35316127298 e-mail: [email protected] Accepted: 8 May 2014 doi: 10.1111/eje.12110
Abstract Introduction: Undergraduate dental curricula increasingly aim to address student attitudes towards people with disabilities. This study reports the effectiveness of a comprehensive, blended learning Special Care Dentistry undergraduate programme to change attitudes towards people with disabilities. Methods: A validated psychometric instrument (ATDP-Form 0) was given as a course evaluation to third-year dental students in the Dublin Dental University Hospital over 3 years from 2010 to 2013, immediately before and after the delivery of a brief comprehensive curriculum in Special Care Dentistry. Results: From a population of 109 students, 100 (91.7%) pre-test and 83 (76.1%) retest responses were analysed. Mean score before the course, for all years, was 74.8 (SD = 14.7), compared with 76.8 (SD = 14.0) for all years after the course. Conclusions: Dental students in our study had neither particularly positive, or negative attitudes towards people with disabilities. There was no statistically significant difference in student attitudes before and after the educational intervention. This study, therefore, shows that a comprehensive undergraduate blended learning module, which aimed to improve attitudes towards people with disabilities, did not do so, using the described measures within the selected timeframe.
Introduction People with disabilities are not without hope. This hope does not centre on finding a “cure” for disabling conditions, but on the possibility of improving their quality of life through changes in existing attitudes. . . A Strategy for Equality (1)
Attitudes towards people with disabilities can influence many aspects of their lives, including their self-esteem, how they are treated by wider society, public policy and service provision (2). Attitudes represent a predisposition to respond favourably or unfavourably to an object, person or event (3), involving evaluation along dimensions such as good-bad, pleasant-unpleasant, worthy-unworthy, same-different (4). Our attitudes are known to influence our behaviour by shaping our intentions (5).
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 107–112
As part of a disabling society, the attitudes held by healthcare professionals may affect the care that people with disabilities receive (6–8). These attitudes may act as ‘powerful barrier(s) to equitable access to care for patients with. . .disabilities’. Poor provider attitudes along with a focus on the disability rather than the person may result in poorer outcomes such as withholding or providing inferior treatment, and neglecting general, preventive care (9). As such, improving attitudes are seen as crucial in the development of tomorrow’s healthcare professionals (10). Researchers recommend that academic institutions aim to modify healthcare students’ attitudes because fostering positive attitudes towards persons with disabilities could be linked to more vigorous efforts on their part (e.g. increased optimism, higher levels of motivation, more time spent on planning and providing services) to serve persons with disabilities (6).
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Across health sciences, curricula have been developed to improve attitudes towards people with disabilities amongst healthcare trainees (10–16). Within dentistry, as in medicine, many educators have attempted to change student attitudes through undergraduate curricula (17). Whilst the effects of education in Special Care Dentistry on dentist behaviour are perhaps mixed (18), direct contact with patients with disabilities at undergraduate level has been linked to better attitudes (19), and a greater likelihood that, as qualified dentists, trainees will treat people with disabilities more often (20–22). A growing body of guidance for developers of dental undergraduate curricula continues to focus on enhancing attitudes as a key outcome of learning for dental students (23–26). If curricula and teaching methods are to be effective in changing attitudes, there is a need for evaluation strategies involving validated instruments (7). In dentistry, it is recognised that psychometric measurement of dental student attitude can measure the effectiveness of undergraduate special care dental education (27). This study aimed to assess the effectiveness of a comprehensive blended learning Special Care Dentistry undergraduate programme using a validated psychometric tool.
Null hypothesis There will be no difference between mean ATDP scale scores for early clinical years’ dental students prior to and after training in Special Care Dentistry.
Methods This article reports the results of a course evaluation comparing repeat measures before and after a brief comprehensive curriculum in Special Care Dentistry delivered to third-year dental students in the Dublin Dental University Hospital over 3 years from 2010 to 2013. The Faculty of Health Sciences Research Ethics Committee of Trinity College Dublin granted ethical approval for this study.
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access to comprehensive e-learning resources as well as small group online tutorials. Students were also paired and placed in three professional observation sessions each. The module began with a series of two 2-h introductory interactive lectures: one on disability issues, and another, an introduction to special care dentistry. The introductory lectures were designed to encourage reflection on students’ own attitudes towards people with disabilities and the effect of their own attitudes on people with disabilities, a process encouraged formatively throughout the curriculum. For example, attitudes that saw people with disabilities as people foremost were encouraged through the application of the biopsychosocial model of disability during these lectures. The attitude that all people with disabilities are best seen in specialist centres was addressed in the second introductory lecture by outlining the role of service structure, physical access and attitudes as barriers and facilitators in society and in the dental setting. Clinical attachments consisted of a variety of professional experiences including observing dental general anaesthetic for people with disabilities, attending screening sessions in residential and day service settings, assisting in dental oncology clinics, observing treatment in specialist dental facilities in rehabilitation and other hospitals, community clinics and disability institutions. Each student experienced three different settings, and the group as a whole shared their experiences formatively at regular feedback sessions. Dedicated contact time (including web-based contact) included one 3-h session per week over 7–9 weeks on this module as well as a 1-day experiential workshop on ageing. This was in addition to two introductory and one wrap-up lecture. Summative evaluation further encouraged reflection on students’ own attitudes and the attitudes of those with whom they had met through this experience through the production of a module diary, similar to an abridged logbook and extended case report with dummy referral letter for one patient seen from each student. Between the years 2011 and 2013, minor changes to curriculum and delivery were made, however, the overall structure described above was maintained.
Design Course evaluation using repeat measures collated over 3 years.
Intervention At pre-test, students had previous exposure to a minimum number of Problem-Based Learning sessions regarding Special Care Dentistry. This element of teaching was minor relative to the course described below. This section describes the educational intervention, which took place between pre-test and retest measures. A curricular module specific to Special Care Dentistry was provided to all third-year dental students in the third of three academic terms (Trinity Term) in Trinity College Dublin, over the 3 years tested. This module was developed from an initial undergraduate Special Care Dentistry education curriculum introduced to Dublin some time ago (28). This was a blended learning module involving lectures, experiential workshops and
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Data collection ATDP instruments were self-administered at each stage. Pre-test data were collected immediately before the first lecture of the programme. This normally occurred around mid-April of each of the 3 years studied. The instrument was circulated around the class, who were each year advised that it would serve primarily as a course evaluation and that this may be published. As such, it may be considered a direct measurement of attitudes, rather than indirect measurement where participants believe that data collection is for non-research purposes, which may give more accurate measurement of attitudes (6). Repeat data were collected immediately after completion of the curriculum at course review lectures or tutorials. This event was between 8 and 9 weeks following initial data collection. No other known education relating to the domains considered in this article was provided outside of this module during test intervals.
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Attitudes towards people with disabilities
TABLE 3. Mean ATDP score by year (Standard Deviation)1
Data collection instrument This study used the 20-item Attitudes Towards Disabled Persons Scale (ATDP-Form 0), developed by Yuker et al. (29) . This scale was selected given its robust psychometric properties and broad applicability. It is recognised as being valid and reliable and is the most widely used of the many psychometric scales testing attitudes towards people with disabilities (7). The ATDP scale assumes that if individuals with disability are seen as different from people without disability they may therefore be seen as inferior (30, 31). Therefore, attitudes are considered positive where respondents do not see difference between people with disabilities and those without disabilities.
Analysis Data were transformed according to Yuker’s original scoring before summative index scores were collated (31). Means and standard deviations for each year were calculated using SPSS (V.19; IBM Corp., Armonk, NY) before and after training. Aggregates over the 3 years were also calculated. Cronbach’s alpha measured internal consistency. Independent samples Student’s t test was used to compare pre-test and retest scores by year and aggregate.
Results Sample and flow The population is described by gender and year in Table 1. The mean age in years was 22 (SD = 3) in 2011, 22 (SD = 4) in 2012 and 21 (SD = 2) in 2013. From a population of 109 students, 100 (91.7%) pre-test and 83 (76.1%) retest responses were analysed. The number of students from each year who undertook the evaluation is described in Table 2.
ATDP scores Overall, ATDP scores ranged from 33 to 106 with a mean of 75.7 (SD = 14.4). As a measure of reliability, Cronbach’s alpha
2011 2012 2013 Total
Pre-test
Retest
75 73 76 75
74 78 81 77
(15) (13) (16) (15)
(14) (16) (16) (14)
1 Using independent samples Student’s t test, no difference was statistically significant.
was 0.75 for all returned scales. Mean score before the course, for all years was 74.8 (SD = 14.7), compared with 76.8 (SD = 14.0) for all years after the course. Differences per year are reported in Table 3. What it shows is that in 2011, 2012 and 2013, there was no statistically significant difference in pretest and retest measure. Marginal means are represented in Fig. 1.
Discussion Dental students in our study had neither particularly positive nor negative attitudes towards people with disabilities (mean score at pre-test = 74.8, SD = 14.7) . Yuker specifies that raw scores are only relevant when compared with norms (31). In the case of Yuker’s original psychometric analyses, mean scores ranged from 72.8 (SD = 15.5) to 75.4 (SD = 13.5) amongst groups without disabilities (31). Therefore, dental students’ attitudes were similar to other groups without disabilities. However, attitudes towards people with disabilities have generally improved since this original work (32). More recent research has shown that dentists have worse attitudes towards people with disabilities compared with other student groups (25, 33). Using the ATDP (Form 0) as a useful comparison, our population generally had similar results to other healthcare students and professionals (9). As an example, similar mean scores have been found amongst nursing (M = 78.4, SD = 8.5) and medical students (M = 77.8, SD = 7.6) (34). In comparison with other Irish populations, our scores were lower than
TABLE 1. Study population (%)
Population Gender Female Male
2011
2012
2013
Total
40 (36.7)
33 (30.3)
36 (33.0)
109 (100)
23 (57.5) 17 (42.5)
22 (66.7) 11 (33.3)
24 (66.7) 12 (33.3)
69 (63.3) 40 (36.7)
TABLE 2. Study samples (Valid %)
Pre-test n Retest n
2011
2012
2013
Total
40 (40.0) 39 (43.8)
30 (30.0) 20 (22.5)
30 (30.0) 24 (27.0)
1001 892
1
Representing a response rate of 91.7% at pre-test. Representing a response rate of 76.1% at retest. n = Sample.
2
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 107–112
Fig. 1. Mean ATDP scores per year and as a total, compared with published norms (31).
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previously reported ATDP scores (35). This latter group were recognised as returning especially high responses, giving rise to the theory that Irish respondents’ scores may be higher on this test. Our study does not support this. Overall ATDP scores for dental students in this study were similar both before (mean = 74.8 SD = 14.7) and after training (mean = 76.8, SD = 14.0). The results from this study would indicate that a brief, comprehensive undergraduate blended learning module, which aimed to improve attitudes towards people with disabilities, was not successful in doing so, using the described measures within the selected timeframe. From year to year, little improvement was seen, despite incremental changes to the delivery of this module to address previous years’ perceived shortcomings, based on formal feedback sessions with students at the close of this module and review by course providers. Logically, these changes should have lead to increasing impact over time if training was effective. Our results indicate that these improvements were largely ineffectual in changing attitudes in this instance and more radical review may be necessary. The lack of improvement in ATDP score is surprising, given that undergraduate healthcare curricula and specific disability awareness programmes have been shown to be effective at improving attitudes, using this metric. Amongst nursing students, interventions have lead to increased ATDP scores over time (14, 36). Amongst nurses’ aides, as little as a lecture and case-based discussions have been shown to lead to changes in ATDP scores, even in small samples (37). Medical students too have been shown to significantly increase their ATDP scores, along with other indices of attitudes, where curricula were directed specifically towards promoting empathy. Again, this was designed using a short intervention, based on 16 individuals with disabilities sharing their experiences of healthcare, delivered by DVD and incorporating artistic expression (12). In dentistry, no studies have used the ATDP (Form 0) to measure the impact of curricula on attitudes, so direct comparisons with previously cited research is difficult. Results using various other measures in longitudinal studies are mixed. Whilst older studies showed a failure of curricula to improve attitudes amongst dental students (38, 39), a number of other studies show effectiveness (26, 40, 41). Considering attitude change, effective curricula may involve a diverse range of teaching methods. Examples include a 1-year clinical and didactic curriculum for dental hygiene students (40), a short lecture series augmented with case presentations for fourth year dental students (26), and a mixture of lectures, group discussion, screening and fluoride varnish provision for patients with disabilities (41). The ATDP scale assumes that some people perceive individuals with disability as being different from and thus inferior to people without disability (30, 31). It was selected to measure outcomes for this evaluation as it is the most widely used attitudinal scale in this field of research and has robust psychometric properties (7). However, it also has significant shortcomings, as used in this study. First, this scale uses a unidimensional singlescore method to measure generalised attitude. This limits the depth of understanding we can gain from the application of such a scale, which perhaps reflects the failure of this scale to mirror the multidimensional theoretical nature of attitudes – that is the 110
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cognitive, affective and behavioural dimensions of attitudes (42). Second, we selected a measure of general dispositions towards people with disabilities applicable to the general population, to measure effectiveness of our curriculum in increasing the likelihood of specific behaviours, such as making reasonable accommodation to treat oral disease amongst people with disabilities. According to Ajzen’s Theory of Planned Behaviour, attitudes only predict behaviour when they are specifically related to the specific behaviours in question, or conversely as general as the general behaviours of interest (5). There is a possibility that a more specific scale measuring specific attitudes may have led to different findings. Ideally, for our purposes, a situation-specific scale with robust psychometric qualities, applicable across disability types and in keeping with current concepts of disability, would best meet our needs in assessing the effectiveness of curricula in the dental setting. Specific scales, focusing on dental students or dentists and their interactions with people with ID or physical disabilities, have been developed for this use (19, 27). The DSATHS scale specifically assesses attitudes of dental students (and latterly dental hygiene and social policy students) towards with physical disabilities only (19, 25, 40, 43). Whilst it has been found to be valid and reliable, it is less frequently used than the scale of Yuker (7). The scale developed by Bedi et al. has also been used amongst dentists and dental care professionals, on a limited basis (44, 45). Given that these scales measure attitudes more specifically relevant to dental students and their behaviours, our research team have decided to include one of these scales (27), with minor modification, for future course evaluation in Trinity College Dublin. We have also started collecting other demographic data on parameters that are associated with attitudes towards people with disabilities, such as previous exposure to disability, gender and age (9).
Limitations Any consideration of the results of this article must acknowledge some shortcomings in design. This article is based on anonymous data primarily collected as part of course evaluation. This limits the richness of analysis. For example, we cannot pair data from pre-test to retest, which limits our statistical analyses. This also introduces bias. We cannot differentiate the sample, which responded from the population, as we do not know who within the sample responded at either stage. We are therefore open to selection bias, affecting external validity. Having said that, response rates were high at both stages in this study. Additionally, scores were stable within years. These factors may mitigate some concern from the methodological weaknesses described above. Finally, we cannot precisely measure the impact of gender and other background parameters upon the results, which is considered good practice (6). Perhaps most importantly, we focus our intention on attitude in this evaluation, whilst it is acknowledged that the impact of attitudes on behaviour is variable across situation, context and time (46). Perhaps this is due to the complex interaction of attitudes and other psychosocial factors, which influence behaviour (5). Notably, other studies showing no improvement in attitudes towards people with disabilities saw increasing confidence and intention to treat people with ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 107–112
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disabilities in attitude-stable dental student samples (38, 39). The authors recognise a need to follow-up graduates at a later stage in their professional career to test the stability of ATDP scores and more recently adopted measures and most importantly correlate attitudes with independent measures of behaviour towards people with disabilities. The academic year 2013/2014 represents the first opportunity for educators in this field of Special Care Dentistry undergraduate dental education to implement and measure the impact of new internationally agreed guidance on curriculum design (20). This guidance recognises the importance of addressing student attitudes as a means of preparing future professionals for positive professional behaviours. We at Trinity College Dublin/ Dublin Dental University Hospital integrated this guidance into our curriculum and have re-organised the delivery of training in this field to meet these commonly agreed learning outcomes. Given these changes, it is ever more important to continue to measure outcomes to ensure quality and accountability in special care dental education.
Conclusion Dental students should be aware that their attitudes can subtly affect their behaviours, potentially leading to enablement or disablement for people with disabilities. Dental educators should acknowledge this in their efforts, through the curriculum to modify attitudes held by graduates. Our study showed fairly average levels of attitude towards people with disabilities amongst 3 years of dental students in Ireland. The curriculum taught up to 2013 in Trinity College Dublin was not associated with greatly improved dental attitudes. We need to change how we measure and teach changes in attitudes for dental students. The adoption of changes in curriculum along international standards and a broadening of our outcome measures may be successful in doing so.
Acknowledgements The authors would like to thank the students and staff involved in this study, particularly Dr. Alison Dougall and those who allow our students to attend their clinics year after year to gain vital experience. The authors also appreciate the award of a student summer scholarship to one author, granted by GSK, Ireland.
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