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J Dent Educ. 71(5): 646-654 2007
© 2007 American Dental Education Association
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Critical Issues in Dental Education

Students’ Opinions About Treating Vulnerable Populations Immediately After Completing Community-Based Clinical Experiences

Raymond A. Kuthy, D.D.S., M.P.H.; Keith E. Heller, D.D.S., Dr.P.H.; Katharine J. Riniker, D.D.S.; Michelle R. McQuistan, D.D.S., M.S.; Fang Qian, Ph.D.

Key words: attitude of health personnel, student comfort, extramural, willingness to treat, frail elderly, dental care for disabled

Submitted for publication 12/07/06; accepted 02/22/07


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
The purpose of this study was to analyze students’ perceptions of comfort and anticipated willingness to treat selected special needs and traditionally underserved populations immediately upon completion of community-based clinical assignments. The sample consisted of University of Iowa senior dental students who completed a questionnaire that asked, in part, about student comfort with and future willingness to treat twelve vulnerable population groups. With student comfort and future willingness to treat each group as dependent variables, logistic models were developed to determine whether there were significant associations between dependent variables and gender, graduation year, and students’ prior experience with these groups. Regression models indicate students’ prior experience is most often associated with comfort in treating the associated population group. Likewise, experience and comfort add different dimensions to perceived future willingness to treat almost all of the twelve groups. Student gender, graduation year from dental school, and community assignments influence only a few of these targeted population groups. This study provides empirical evidence concerning students’ perceptions about comfort with various vulnerable populations after completing their extramural rotations. Students were more comfortable treating certain population groups as well as more willing to consider including these groups in their future practices.

Community-based clinical experiences, sometimes referred to as extramural programs, help students to develop a broad understanding of the responsibilities they will have as dental professionals. Students observe and work with diverse social, cultural, and age groups and those who have medical, dental, personal, and other problems that are not often encountered within the predoctoral curriculum of U.S. dental schools. Moreover, these community-based experiences often expand students’ knowledge and technical capabilities, along with placing them in an environment that may present new and interesting challenges. Oftentimes, such facilities are either safety net health care providers (i.e., deliver a substantial level of care to the uninsured, Medicaid, or other vulnerable patients) or are dedicated to treating patients with specific needs (e.g., children and medically complex or mentally challenged patients). While community-based clinical experiences have been an integral part of the curriculum at many U.S. dental schools for a number of years,1 these experiences vary among institutions.2 There has been a resurgence of interest in these programs with the recent funding by the Robert Wood Johnson Foundation and the California Endowment of community-based education at fifteen U.S. dental schools that are participating in the dental pipeline project.3

Little data exist concerning students’ attitudes about community-based clinical education programs.4 Available data generally address either students’ overall satisfaction with a program5–7 or are specific to one group of individuals, such as those with mental retardation.8,9 While there is little information available about students’ perceptions subsequent to such external experiences, there is even less about the relationship between practitioners’ comfort with population groups and their future willingness to include these groups in their practices. Such information is important for community planning purposes, particularly when many of these groups are at higher risk for dental disease than the rest of the population.

The purpose of this study was to analyze dental students’ perception of comfort in treating selected special needs groups immediately after completion of these community-based assignments. Moreover, the researchers explore whether gender, graduation year, experience with each population group, and students’ comfort in treating these populations influence students’ anticipated willingness to treat these population groups once they graduate.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
The University of Iowa initiated a community-based clinical program in 1969.10 Since 1975, senior dental students have been required to participate in two consecutive, five-week community experiences. Students were appointed to each of two sites based on student preference (for either time during the academic year or site) and site availability. There were several in- and out-of-state affiliated programs including the dental school’s Special Care Program, which consists of an in-house, designated clinic where students primarily treat adults who are physically, cognitively, or mentally challenged, and the Geriatric Mobile Unit, which serves residents of several long-term care facilities in the surrounding community. Another site was Broadlawns Medical Center, a county public hospital in Des Moines, Iowa, that has a greater proportion of uninsured patients than elsewhere in the county. There were several other sites, such as community health clinics in Iowa and Colorado, a Veterans Affairs hospital, a children’s outpatient dental center, private practice preceptor-ships, Indian Health Service sites, and three overseas student exchange sites. While the preponderance of their time was spent providing clinical services, students were required to spend at least 15 percent of their time with other community experiences (e.g., group presentations, working with local social service employees).

On the final day of their two experiences, senior dental students gather for an all-day exit seminar to discuss their activities of the previous ten weeks. These seminars occur quarterly throughout the academic year, with time set aside during the activity for students to complete a course evaluation and survey. The findings presented here are for senior students who completed surveys over a thirteen-year period (i.e., graduated from 1992 through 2004).

Besides questions pertaining to their comfort in treating and future willingness to treat (after graduation) twelve different vulnerable populations, the survey asked about students’ gender, race, and experience in dealing with these different populations. The twelve patient groups included (in the order that they appear on the questionnaire) the following: low income; frail elderly; homebound; medically complex; mentally compromised; homeless; drug users; other ethnic groups; Title XIX eligible (Medicaid); HIV+/AIDS; jailed; and non-English speaking. Comfort was measured using a five-point Likert style scale (5=no problem; 4=OK; 3=some concern; 2=rather not; and 1=will not treat). Prior patient experience with the associated population group and anticipated willingness to treat patient groups beyond graduation were categorized dichotomously (Yes/No). Data were entered into an Excel spreadsheet and then converted to SAS (version 9) for analysis. This project was approved by the University of Iowa Institutional Review Board.

Skewness of univariate frequency statistics determined that, for statistical analyses, comfort for each population group could be collapsed dichotomously into YES=comfortable (representing either no problem or OK) and NO=not completely comfortable (representing some concern, rather not, or will not treat).

Approximately three-quarters of the students were assigned to Special Care (SC) and Broadlawns Medical Center (BMC) because of additional space availability and supervision at these sites, respectively. Thus, four community-based site combinations were created: Special Care and Broadlawns Medical Center (SC+BMC); SC and some other program besides BMC (SC+Other); BMC and some other program besides SC (BMC+Other); and two assignments other than SC and BMC (Other only).

Bivariate analysis and logistic regression models were performed to determine important variables related to comfort in treating and future willingness to treat for each of the twelve vulnerable groups. This study assessed students’ gender, year of graduation, past experience with each group, and combinations of community-based student site assignments towards comfort in treating and future willingness to treat by initially analyzing differences between groups using either chi square statistic or the Cochran-Mantel-Haenszel test when there were more than two categories. If individual cell sizes were very small (i.e., less than 5), then the Fisher’s exact test was used for the bivariate analysis. All bivariate results that demonstrated statistical differences (p ≥ 0.1) were included in the model building for the multiple logistic regression final models. If there were no statistically significant bivariate findings within that population group who met this criterion, then no regression model was developed. Variables were entered into models using stepwise regression, followed by forward and backward selection methods (p<0.05) to determine the best statistical approach for determining factors associated with comfort in treating and future willingness to treat the respective population group. Subsequently, the possibility of statistical interaction was examined.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
From 1992 through 2004 there were 852 senior students who participated in community-based clinical experiences at the University of Iowa. Of 726 students (85.2 percent) who returned the voluntary survey on the final day of their assignments, 65.3 percent were male, and 44.9 percent participated between 1992 and 1998. The number of students who participated at each community-based program combination were as follows: SC+BMC, 373; SC+Other, 247; BMC+Other, 67; and Other only, 21). Table 1Go displays mean and median scores for comfort with treating each population group and percentage of students who were comfortable, had any experience, and were willing to treat these groups subsequent to graduation. Mean comfort ratings ranged from 3.7 (HIV+/AIDS) to a high of 4.7 (low income and other ethnic group) on a 5-point scale. When comfort was collapsed dichotomously, comfort towards treating groups varied from 55.3 (HIV+/AIDS) to 96.5 (low income and other ethnic group) percent.


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  		Table 1. Post-extramural survey of Iowa senior students concerning comfort, treatment experience, and willingness to treat underserved populations in the future (N=726)
 
Tables 2Go and 3Go display logistic regression models for each group with comfort and perceived future willingness to treat, respectively. Low-income, mentally compromised, and other ethnic groups failed to achieve statistically significant differences among predictor variables (Table 2Go), while four groups (medically complex, homeless, drug user, and Medicaid) only had one predictor variable that demonstrated statistical significance. For instance, female students were 1.91 times more likely to be comfortable with Medicaid patients as were males.


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  		Table 2. Logistic regression model for comfort with each of the selected underserved populations (N=726)
 

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  		Table 3. Logistic regression model for willingness to treat each of the selected underserved populations after graduation (N=726)
 
Four regression models had two predictor variables influencing student comfort level, with prior experience being associated with each model. Regression models for homebound and HIV+/AIDS were also associated with graduation year, whereas the frail elderly were also associated with program assignments and jailed was associated with the student’s gender. For example, male students were 2.17 times more likely to be comfortable treating inmates than female students, while students with experience with inmates were 2.66 times more likely to be comfortable treating the incarcerated than those having no experience.

Three predictor variables influenced the non-English-speaking regression model. Students who graduated between 1992 and 1998 were 1.92 times more likely to be comfortable in treating non-English-speaking patients compared to those who graduated between 1999 and 2004. Those students who had experience with non-English-speaking patients were 2.20 times more likely to be comfortable with them than students having no experience, and students participating in Other only programs were 2.70 times more likely to be comfortable in treating non-English-speaking patients than those who were in an SC+BMC rotation. No evidence of two-way interactions was found for any logistic models relating to comfort with these population groups.

Only the dependent variables of homeless and jailed failed to demonstrate any statistically significant differences for regression models concerning students’ perceived future willingness to treat these groups. All other willingness to treat models included comfort with each respective population as a statistically significant predictor (Table 3Go).

Four perceived future willingness to treat regression models were also associated with experience. Students having prior experience were 1.83, 5.78, 3.73, and 2.26 times more likely and those comfortable were 4.67, 2.67, 2.25, and 1.68 times more likely to be willing to treat frail elderly, mentally compromised, drug users, and HIV+/AIDS patients, respectively.

In addition to students’ comfort level, prior experience and community-based assignments also influenced their perceived future willingness to treat medically complex patients. Students with experience were 5.85 times more likely to be willing to treat medically complex patients than those with no experience; those who were comfortable with medically complex patients were 1.86 times more likely to be comfortable in treating medically complex patients than those who were not comfortable; and students participating in Other only programs were 2.70 times more likely to be willing to treat medically complex patients than those who were assigned to both Special Care and Broadlawns Medical Center.

Future willingness to treat logistic regression models for low income, Medicaid, and non-English-speaking patients were associated with four predictors, along with experience and comfort as a common statistically significant variable. Student graduation year was a statistically significant predictor for Medicaid patients, whereas students’ community-based assignment predicted perceived future willingness to treat low-income patients. Students who graduated between 1999 and 2004 were 1.54 times more likely to be willing to treat non-English-speaking patients than those who graduated in 1992 through 1998; those having experience were 3.46 times more likely to be willing to treat non-English-speaking patients than those having no experience; students comfortable with non-English-speaking patients were 2.77 times more likely to be willing to treat non-English-speaking patients than those not comfortable; and students participating in Other only experiences were 3.57 times more likely to be willing to treat non-English-speaking patients than those participating in SC+BMC.

Other ethnic groups were influenced by all predictor variables. A two-way interaction was found between those having experience and student graduation year for other ethnic groups (p=0.0011). Regardless of student graduation year, there were significant associations between experience and willingness for treating other ethnic groups, with p-values 0.0018 and <0.0001, respectively. However, students who graduated between 1999 and 2004 and those who had no experience in treating other ethnic groups had higher percentages of willingness to treat other ethnic groups (36.4 percent) than those who graduated between 1992 and 1998 and who had no experience (9.3 percent).


   Discussion
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 Abstract
 Methods
 Results
 Discussion
References
 
In general, students’ experiences working with a specific population appear to have a positive impact on comfort level. There were two exceptions (low income and other ethnic groups), each of which had a very high level of student comfort (96.5 percent). In addition, there were no statistically significant differences for students’ experiences with either medically complex or mentally compromised patients. Possibly, at this stage of their education such conditions still interject some relative confusion with both treatment planning and clinical treatment procedures.

When controlling for other predictor variables, student program assignments impacted their comfort with frail elderly, medically complex, and non- English-speaking patients. As anticipated, the Special Care program provided students with a wide array of adults with various medical conditions. Interestingly, those who participated at Other only locations were more comfortable with non-English-speaking patients. Since many of these sites required additional student logistical planning because the student was the only one from the University of Iowa there, possibly these students may have a more adventurous and worldly view than their peers.

Students graduating between 1999 and 2004 expressed a greater comfort with HIV+/AIDS patients, which could possibly indicate a greater knowledge about the disease as well as a greater likelihood that they personally know an individual with the disease. Females had a greater comfort with Medicaid patients, whereas males had a greater comfort with jailed patients. Speculation about either of these latter findings may relate to compassion by females for those least able to afford care, especially children, and the possibility that even though males may not relish working with incarcerated patients, they may have more physical self-assurance than females with this group.

Comfort and experience were common predictor variables for future willingness to treat logistic regression models. These empirical findings confirm the assertion that comfort is associated with willingness to work with specific population groups. Likewise, experience with a population group adds an additional positive dimension beyond comfort. Future research should explore more in-depth reasons for the relationship among experience, perceived comfort, and willingness to care for certain populations, so that educators may properly mentor students about incorporating these groups into their practices.

Other predictor variables were also associated with willingness to treat, but the findings were targeted to specific groups. Adjusting for other predictor variables, students who participated in Other only community-based programs had a more favorable attitude toward including low-income, medically complex, other ethnic groups, and non-English-speaking groups into their practices when compared to those who participated in the combination of Special Care and Broadlawns Medical Center. There may be some self-selection bias that reflects the personality type of individuals who request the Other only rotations. These findings are also tempered because of the relative imbalance in the number of students who participated in Other only versus SC+BMC groups. Moreover, there may be many other reasons besides those noted here for why individuals have more or less favorable attitudes toward certain population groups.

Students who graduated between 1999 and 2004 expressed a greater willingness to treat other ethnic groups, Medicaid, and non-English-speaking patients, controlling for other predictor variables. Hopefully, such willingness will have an impact in addressing a much more diverse U.S. population. Likewise, female dental students expressed a greater willingness to provide future care for low-income, other ethnic groups, and Medicaid patients. With an increase in the percentage of female dentists, this could have a potential positive effect on oral health care availability and accessibility for such groups.

There are a myriad of reasons why students may or may not have positive attitudes toward select population groups. Others have studied health professional students’ attitudes toward many of these individuals groups (e.g., elderly,11,12 HIV+/AIDS,13,14 disabilities15,16), but there are scarce data that compare students’ attitudes about various patient groups concurrently. Our research thus provides baseline data.

Effective clinical educational programs need to go beyond mere minimum exposure to various populations.17–19 Intensive clinical experience, especially in an environment that provides oversight and guidance, allows students to develop a greater degree of comfort and provides the foundation for mainstreaming these populations into dental offices.8,20 However, such programs must include clear goals and objectives so that students can appreciate and understand how social and cultural influences can be integrated into their educational and professional lives. Future research needs to link comfort toward a population group and actual incorporation of these individuals into their practices. This connection is critical for those individuals who are most susceptible to oral diseases. While ability and comfort in treating such patients may be achievable, it is critical to translate ability into reality (i.e., inclusion of these traditionally underserved populations into existing and new dental practices).

Student perceptions about community-based clinical experiences have oftentimes been reported only in aggregate form.6,7,21,22 Most research indicates that the overall effect of such experiences has been favorable. However, additional research with more refined quantitative and qualitative methods will assist educators in making this an even better experience.23,24 A recent national survey of senior dental students provides considerable aggregate descriptive data concerning community-based dental education,25 while others have explored determinants for improving students’ ability to provide care to various racial, ethnic, and culturally diverse groups.26 However, more extensive research concerning community-based programmatic outcomes is needed, so that educational planners can develop more refined programs to provide care for those who most need it.

There are several limitations to these findings. First, this dental school has had a long-standing program. Thus, findings may not be generalizable to other institutions. However, this study provides recent data concerning several population groups, and there is very little information concerning student interactions with some of these groups. Second, since student evaluations were voluntary (with 85 percent participation), we do not know if those students who did not complete forms are similar to their colleagues in comfort and future willingness to treat these populations. Third, validity of this instrument may be of concern because of the breadth of populations included. However, this may also be a strength because it provides a possibility for direct comparisons among groups. Further analysis is warranted concerning whether students are "comfortable" with all patients or if there are particular population groups in which educators need to develop other methods to help increase comfort levels. Fourth, individuals from one population group may also be members of more than one other population group. However, the researchers did not specifically ask students to take such possibilities into account. An argument could be made to keep these categories separate as highlighted by the differences between low-income and Medicaid patients, since Medicaid patients would be a subcategory of low-income families who are eligible for medical and dental services. Fifth, an unbalanced number of students in each of four community-based assignment categories may have impacted the stability of the statistical findings. Sixth, each student self-defined "experience," "comfort," and "willingness" to treat; thus, there is a need for future refinement of the survey instrument, without losing the rich data bank that already exists. Seventh, this study linked comfort and perceived future willingness to treat certain population groups at only one specific point in time. Thus, this research doesn’t address actual behavior toward these population groups once students begin to practice.

This research provides a comparison of predictors that may influence how students perceive certain population groups that have traditionally had difficulty accessing dental care. Future research should follow students after graduation to determine whether these population groups have been incorporated into practices. Such information would be quite useful for planning community-based, student educational opportunities, while instilling a higher degree of professionalism for future practitioners by encouraging inclusion of traditionally underserved groups into their practices.


   Acknowledgments
 
The authors wish to acknowledge Howard Field, emeritus faculty, who previously served as director of extramural programs at the University of Iowa.


   Footnotes
 
Dr. Kuthy is Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; Dr. Heller was Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry at the time of his death; Dr. Riniker practices clinical dentistry in Dubuque, Iowa, and worked with this research team while a dental student; Dr. McQuistan is Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry; and Dr. Qian is Adjunct Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry. Direct correspondence to Dr. Raymond A. Kuthy, University of Iowa College of Dentistry, N337-2 DSB, Iowa City, IA 52242-1010; 319-335-7201 phone; 319-335-7187 fax; raymond-kuthy{at}uiowa.edu. No reprints will be available.

This project was supported, in part, by NIH/NIDCR T32 DE14678 and Dows Student Research Award, University of Iowa College of Dentistry.


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