J Dent Educ. 73(3): 303-310 2009
© 2009 American Dental Education Association
Critical Issues in Dental Education |
Impact of Community-Based Oral Health Experiences on Dental Students’ Attitudes Towards Caring for the Underserved
Jennifer S. Holtzman, D.D.S., M.P.H.;
Hazem Seirawan, D.D.S., M.P.H., M.S.
Key words: attitudes, oral health education, underserved populations, extramural dental programs
Submitted for publication 10/15/08;
accepted 12/22/08
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Abstract
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Dental students’ attitudes towards access to dental care for the underserved may be impacted by participation in community oral health promotion programs that target individuals in underserved communities. At the University of Southern California School of Dentistry, freshman dental students provide classroom oral health promotion and preventive dental care programs to underserved elementary school children. One hundred forty-four freshman dental students were surveyed three times during their freshman year—before, during, and after participation in these programs. The students’ attitudes about societal expectations, health professionals’ responsibility, access to care, and students’ personal efficacy to positively impact the need for expanded oral health care services for segments of the population were measured. Students reported positive attitudes in all categories throughout the study period. The students’ attitudes about societal expectations to care for the oral health of the underserved remained stable over the study period, but they became more uncertain of who should be responsible for fulfilling that obligation, who should receive that care, and their capability to provide this care while in dental school. These changes in attitude may reflect the students’ greater understanding of the complexity of the determinants of oral health as a consequence of their community education experiences.
The University of Southern California School of Dentistry (USCSD) has a long history of incorporating extramural experiential learning into its dental school program. Since 1991, freshman dental students have provided dental and fluoride treatment to children attending schools in the neighborhood near USC in two sequential programs, Doctors Out to Care (DOC) and the Neighborhood Mobile Dental Van Prevention Program (NMDVPP). Although the programs were designed to promote dental health, we wanted to understand if participation in this program increased the dental students’ sense of social responsibility, the sense of dentist/ student responsibility in caring for the underserved, the students’ feelings of self-efficacy, and their attitudes about an individual’s right to access dental care. Similar programs at other dental schools have been reported to positively influence student attitudes towards community service,1 increase their understanding of oral health disparities,2,3 increase their self-efficacy in providing care for diverse populations,1,2,4,5 and increase their motivation to concentrate on their coursework.6 Therefore, we posed this question for our study: Does the community-based oral health experience that our freshman dental students experience have a positive influence on the students’ beliefs that underserved populations have the right to dental care and that society and health professionals should take responsibility in providing this care? DOC and NMDVPP are the only outreach programs in our dental school designed for freshman students. Other outreach programs, designed for junior and senior students, provide comprehensive dental care for underserved children, the homeless, the elderly, and special populations in Southern California.
Since 2003, all freshman dental students at USC School of Dentistry have been required to participate in two oral health promotion programs during their freshman year: 1) the DOC program, in which students provide a series of classroom oral health promotion programs based on the National Institutes of Health curriculum "Open Wide Trek Inside" (OWTI), and 2) the NMDVPP, two half-day clinical rotations in which the students place dental sealants and provide topical fluoride for at-risk elementary school children in the USC neighborhoods. Each year in the DOC program, all freshman dental students conduct a community-based oral health needs assessment of one elementary school in the USC neighborhood. Students working in teams use the information they learn in the needs assessment to develop, in collaboration with classroom teachers, their own set of four forty-five-minute culturally and age-appropriate sessions, which the dental students then deliver. Students are given general goals (e.g., help the children understand the relationship among oral bacteria, plaque, and tooth decay) and are expected to use their creativity to develop the classroom interventions (e.g., games, plays, songs, or small group discussions).
All freshman dental students also participate in the NMDVPP, which consists of three parts over three consecutive weeks in trimester two and a fourth rotation in trimester three: 1) a problem-based case (trimester two); 2) a preclinical laboratory experience on how to place dental sealants (a week later in trimester two); 3) a half-day of clinical experience (a week following session two, also trimester two); and 4) a second half-day experience (trimester three). During these half-day clinical rotations, dental students discuss social and economic determinants of health in pre- and post-clinic sessions with both the community and individual children. Dental students examine the children using World Health Organization (WHO)7 criteria and determine their eligibility for sealants as described by the Association of State and Territorial Dental Directors Basic Screening Survey;8 their findings are verified by faculty members. Students provide dental sealants and topical fluoride to at-risk children in a "5th-wheel" trailer equipped with four dental operatories that is parked at an elementary school campus in the USC neighborhood. Dental students work in pairs sharing patients, alternating as operator and assistant, and providing dental sealants and topical fluoride. The students are asked to write reflections about one incident they found particularly meaningful during their NMDVPP rotation.
The protocol for this study (Figure 1
) was reviewed by, and satisfied the requirements of, the Institutional Review Board of the University of Southern California.
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Methods
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Freshman students (Class of 2009) were surveyed about their attitudes toward access to dental care, society’s and health professionals’ responsibility to care for the underserved, and their personal efficacy to provide care for the underserved. Surveys were conducted at three time points: 1) during students’ September 2005 orientation week to dental school before any community experiences (baseline); 2) at the end of December 2005, after half of the students had completed the DOC program and the other half had not; and 3) in October 2006, after both groups had completed the DOC program and their two NMDVPP rotations (Figure 1
).
The "Attitudes Toward Health Care" instrument (Figure 2), originally designed for medical students,9 was used after being adapted for dental use by replacing medical with dental references. The instrument’s content validity was assessed by a panel of six USCSD dental educators who have experience partnering with the community and designing community rotations and were aware of the goals of the USC program to improve the students’ attitudes about the underserved and providing dental care for the community. All of the panel members agreed that the questions were necessary and important. No other measures of the instrument’s validity or reliability were conducted for internal inconsistency or test-retest reliability. The instrument consisted of two sets of questions. The first set requested demographic information (age, gender, race, years of school, urban or rural residence until age eighteen); details of the student’s community and volunteer activities both before and during dental school; and how the dental student was paying for school and his or her anticipated debt level at graduation. The second set of questions consisted of twenty-three statements: six on societal expectation, eight on dentist/student responsibility, four on personal efficacy, and five on access to care. Students evaluated statements on a five-point Likert scale with 1 indicating strong disagreement with the statement and 5 strong agreement.
In September 2005, program staff assigned all dental students, in teams of four, to thirty-six elementary school classrooms grades one through five at a school in East Los Angeles. Half of the students (eighteen teams) completed their classroom interventions (DOC program) by December 2005. In January 2006, all students completed the questionnaire a second time. The remaining students then started their classroom interventions, which were completed by May 2006. From January to August (trimesters two and three), all students were assigned in groups of sixteen, consistent with USCSD academic scheduling, to the NMDVPP rotations.
Descriptive statistics from the questionnaire were generated for all study variables. The outcome variables were the overall sum of scores of the questions in the instrument and the sum of scores in distinct groups of questions representing four domains: societal expectation, dentist/student responsibility, personal efficacy, and access to care. Independent variables were age, race, living in rural areas, and the size or source of the student’s debt projected at the end of dental school. Attempts to transform variables to normality were performed. General linear models were used to quantify the association between the outcome and the independent variables.
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Results
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The study response rates were 95.1 percent, 97.2 percent, and 88.9 percent for the three administrations of the dental version of the Attitudes Toward Health Care instrument, respectively. At baseline, the students averaged 24.6 years of age (range from twenty-one to forty-one years); females comprised 35.6 percent of the sample; 13.9 percent of the dental students lived in rural areas before the age of eighteen years; and more than half of the students (69.3 percent) lived in suburbs. Most students (95.6 percent) had volunteered for community work before their enrollment in dental school. The vast majority of the students (84.3 percent) had borrowed money to support their dental education, 26.9 percent had some type of parental support, and 6.0 percent had some type of scholarships. Students projected an average debt at the end of dental school of $249,064, ranging from 0 to $570,000 (Table 1).
At baseline, the students scored 91.1 (SD=8.3) points out of a maximum 115 on the instrument. Maximum scores reflected what a student would score if he or she recorded the strongest possible "idealistic" attitudes: society has an obligation to make dental care available for everyone. The average student score was 22 out of a possible maximum of 30 in the societal expectation component of the instrument and 33.1 out of a possible 40 in the dentist/student responsibility component. Students averaged 17.5 points in personal efficacy. A score of 20 would have indicated that the student strongly believed that he or she has the ability to play a significant role in providing care for the needy. The students averaged 18.5 points concerning access to care. A score of 25 would have indicated a student’s belief that individuals should have an unlimited right to access dental care. None of these scores were different by age, gender, living in rural areas, or the size or source of the student’s debt (Table 2). Although statistically insignificant, the average female student score (92.8 mean) was higher than that of the males (90.0). Students who had previously volunteered for community work responded more idealistically than those who did not volunteer, as indicated in the dentist/student responsibility and personal efficacy components (33.2 vs. 30.5 [p=0.045] and 17.6 vs. 15.8 [p=0.01], respectively).
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Table 2. Attitude scores by sociodemographic characteristics of freshman dental students (baseline), by mean (standard deviation)
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The students’ attitudes changed over the course of the study period, decreasing from an overall mean score of 91.1 when they entered the dental school to a mean of 85 at the end of their first year (p<0.001) (Table 3). Two-thirds of the students (68 percent) scored lower (less idealistic) on the instrument in the second administration (p=0.0003) than in the first, when only half of the dental students had participated in the DOC program. There were no statistically significant differences between students who had participated in the DOC program and those who had not. Approximately two-thirds of the students showed a further reduction in idealistic attitudes between the second and the third administrations of the instrument, after all the students had completed both the DOC and NMDVPP rotations.
Table 4 details the effects of the students’ sociodemographic factors on their scores in univariate mixed model analyses. Older students were more likely to score lower than younger students. For each additional year of age, students scored 0.5 points less idealistic overall (p=0.01). Students with no parental financial support were more likely to score higher on personal efficacy (p<.05) than students who reported parental assistance in paying for dental school.
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Table 4. Univariate analyses of the effects of sociodemographic characteristics on students’ attitudes during the study course, by parameter (standard deviation)
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Discussion
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The findings indicate that our group of freshman dental students started dental school with very idealist attitudes about oral health care for the under-served and remained so throughout their first year. At baseline, most of the students believed that all individuals have a right to dental care though some limitations should exist and that society has an obligation to provide dental care. Students thought dentists should provide at least some free care for the needy and that as dental students they had an obligation to care for the needy. Students who had previously volunteered for community work scored significantly higher in these categories, indicating a stronger commitment to providing care than those who had not previously volunteered in the community. This difference may reflect the volunteers’ perception of their own ability to impact the community, their ability to act as an agent of change, and a stronger sense of their obligation to do so. Older students were more likely to score lower on the survey, indicating less idealism than younger students. Students who reported that they received no financial support from parents felt more capable of impacting the oral health of the underserved even as dental students, perhaps reflecting greater self-confidence.
We expected that our dental students would remain idealistic or increase their commitment to providing oral health care access based on previous studies.1–4,10,11 Our study found that, by the end of their freshman year, students’ attitudes still reflected a high degree of social responsibility and care for the underserved, but, as a group, they felt less certain about several issues: that every person has a right to access dental care regardless of ability to pay; that health professionals have the responsibility to fulfill those needs; and that, as dental students, they were capable of providing care for the underserved that would make a difference in the lives of these individuals. Although these changes in attitude were small, they were statistically significant. Dental students’ belief that society is responsible for providing dental care for the underserved did not change over the study period, but students seemed less clear on how those needs should be addressed, which may reflect their greater understanding of the complexity of the social and economic determinants of oral health as a consequence of their experiences in the programs described.
Although not as dramatic, our results exhibit a pattern somewhat similar to the findings of Sherman and Cramer,12 who used the Jefferson Scale of Physician Empathy and found a significant drop in empathy during the first year of dental school. Sherman and Cramer hypothesized that this drop, similar to what medical students experience after their initial contact with patients and regardless of race, marital status, or age, may reflect that dental schools encourage dental students to focus on requirements rather than the needs and values of their patients. Unlike Sherman and Cramer, we do not believe that our findings reflect a drop in the empathy of our students, but think these results may indicate a greater understanding of the breadth and complexity of the problem of access to care for the underserved. Our students were consistent in their belief in societal expectations (which may indicate a degree of empathy), but less certain of how best to address the problem by the end of their first year in dental school. The lower scores for personal efficacy at the end of the year may reflect dental students’ increasing awareness of their own limitations as well as the enormity of the problem.
It is possible that our baseline surveys are biased and the initial scores in idealism were erroneously high. Students during the orientation process may have responded to questions about their attitudes as they felt they should respond rather than admit their true attitude, which was perhaps less idealistic. It is possible that dental students no longer felt compelled to provide what they felt was the "correct" answer when they completed the questionnaire for the second and third times. However, even after one year our students reported a very high level of social consciousness and concerns for the underserved.
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Conclusions
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Our study found that USC dental students had a strong positive attitude related to providing dental care for the underserved. During the first year of dental school, students’ perceptions of their societal responsibility to provide care for the underserved remained stable. However as they progressed, students became less certain of who should be responsible for fulfilling those obligations and providing the care, who should receive the care, and their own capability as dental students to address the problem of dental care for the underserved. Though these changes in attitude were small, they were statistically significant. These findings appear to indicate that community-based experiences in the freshman year at USCSD in the DOC and NMDVPP programs do not positively influence students’ attitudes towards caring for the underserved. More research needs to be conducted to determine if our results reflect students’ greater understanding of the complexity of providing dental care for the underserved.
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Acknowledgments
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Our thanks to Dr. Jane Weintraub and Dr. Kathy Atchison in the conceptualization of this project and Dr. Stuart Gansky for his wise counsel. We are greatly indebted to Dr. Roseann Mulligan for her support of the authors and the DOC and Sealant van programs. We would like to thank Dr. Mina Habibian for assistance in adapting the "Open Wide Trek Inside" curriculum for the DOC program.
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Author Information
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Dr. Holtzman is Assistant Professor, Clinical Dentistry, Division of Health Promotion, Disease Prevention, and Epidemiology, School of Dentistry, University of Southern California; Dr. Seirawan is Research Assistant Professor, Division of Health Promotion, Disease Prevention, and Epidemiology, School of Dentistry, University of Southern California. Direct correspondence and requests for reprints to Dr. Jennifer S. Holtzman, University of Southern California, School of Dentistry, Office of Community Health Programs, 3305B South Hoover Street, Bldg. A, Room A-120, Los Angeles, CA 90089-7001; 213-740-1098 phone; 213-740-5597 fax; Jennifer.holtzman{at}usc.edu.
This study was conducted by the principal investigator in partial fulfillment of the requirements of the Dental Public Health residency program at the University of California, San Francisco, supported by HRSA training grant D13HP30009.
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Abstract
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