Fourth-Year Dental Students’ Perceived Barriers to Providing Tobacco Intervention Services

Methods

The study was approved by the Institutional Review Board (IRB) at the University of Iowa. A survey based on previous studies^{19–21,24–33} was developed that included eighteen main questions with eighty-seven statements. Informal pilot-testing was conducted with seven soon-to-be-graduating fourth-year dental students (May 2008) for content and organization of questions and time taken to complete the survey, after which appropriate revisions were made. All incoming fourth-year dental students (N=70) were invited to participate in the cross-sectional study during their July 2008 academic orientation. Completing then turning in the survey was considered to constitute consent.

The main dependent variable was “perceived barriers to the provision of tobacco intervention service.” This was a composite variable that was defined as the sum of the scores from 1 to 5 for each of fourteen statements, with a possible range from 14 (low barriers) to 70 (high barriers). There were twelve independent variables, most of which were created as composite scores (see Table 1⇓). A social desirability scale³² was included since the survey included self-reported responses from the students and there was no way of knowing whether the students actually provided cessation services or had favorable attitudes related to cessation services or were instead giving socially desirable responses.

Data analyses were conducted using SAS (SAS 9.1. for Microsoft Windows, Cary, NC, SAS Institute, 2004). Tests of normality and internal consistency were conducted. The nonparametric Wilcoxon rank-sum, Kruskal-Wallis, and Spearman correlation tests were used for bivariate analyses, as the data were not normally distributed. Multivariable linear regression models with a stepwise algorithm were used to identify factors associated with barriers concerning provision of tobacco intervention services. Bivariate associations with p<0.20 were considered statistically significant due to the small sample size and exploratory nature of the study, and were included for initial entry into the linear regression model. Those variables with p-values <0.05 were retained in the final model.

Results

Sixty-eight of the seventy eligible students completed the survey (97 percent response rate). Table 2⇓ presents the demographic characteristics of respondents, as well as their current practices and anticipated attitudes related to providing tobacco intervention services in the future. The mean age was 26.4 years, 66 percent were male, 6 percent were current tobacco users, and 21 percent were former users. Thirty-four percent of the students reported providing tobacco intervention services for two minutes, followed by 25 percent for three minutes, 22 percent for less than or equal to one minute, and 19 percent for four or more minutes.

The responses for five knowledge statements related to oral and systemic effects of smoking (agree and strongly agree categories combined, data not shown) were in the range of 38 percent to 99 percent. Highest agreements for combined strongly agree and agree responses were reported related to the statements “smoking is associated with chronic heart disease” (99 percent), “smoking is associated with delayed wound healing” (97 percent), and “smoking is associated with implant failure” (82 percent). However, only 38 percent correctly agreed or strongly agreed with the statement “smoking is associated with necrotizing ulcerative gingivitis,” and 52 percent correctly disagreed or strongly disagreed (this statement was reverse-coded) with the statement “smokers have greater bleeding on probing than nonsmokers.”

The responses for the four attitude statements related to dental professionals’ provision of tobacco intervention services (agree and strongly agree categories combined, data not shown) were in the range of 81 to 92 percent. Ninety-two percent of the respondents strongly agreed or agreed that “dentists have an important role to play in tobacco cessation,” and 84 percent strongly agreed or agreed that “dental professionals should set a good example by not using tobacco.”

Table 3⇓ presents information on students’ behaviors with their patients in the clinic. For example, 81 percent of students reported asking about tobacco use status for more than 50 percent of their patients in the past year. In contrast, none of the students prescribed tobacco cessation medications for their patients.

Students perceived many barriers to providing tobacco intervention services (see Table 4⇓). For each of the fourteen individual barriers, at least 47 percent of the responding students reported having it as a barrier (sometimes, about half the time, often, or almost always; see last column of Table 4⇓). Similarly, at least 19 percent reported each of the individual barriers about half the time or more. There was substantial variation across barriers in the percentages reporting sometimes, about half the time, often, and almost always. The most commonly perceived barriers (reported at least sometimes) were patients’ resistance to tobacco intervention services (96 percent), inadequate time available for tobacco intervention services (96 percent), forgetting to give tobacco intervention counseling (91 percent), inadequate knowledge about nicotine replacement drugs (75 percent), and inadequate skills in providing tobacco intervention services (75 percent). When only the almost always category was considered, the highest response of 21 percent was obtained for patient resistance.

The possible range for the barrier composite score was from 14 to 70. For the purpose of statistical analysis, the Likert scale was redefined from 0 to 4, such that the sum of the scores for fourteen questions could range from 0 to 56. Then, the minimum, median, and maximum scores were 4, 16, and 43, respectively.

Concerning the adequacy of specific tobacco intervention topics covered over the past three years at the University of Iowa College of Dentistry (data not shown), the combined responses related to covered moderately well and covered very well ranged from 20 to 93 percent and were highest for “review of oral tobacco-related diseases” (93 percent) and “review of general tobacco-related diseases” (90 percent). However, less than 50 percent reported that the curriculum adequately addressed strategies for dealing with a student’s own tobacco use, strategies for becoming involved in community-based tobacco control programs, and developing a comprehensive tobacco intervention program in a clinical setting.

In general, students reported that the tobacco cessation curriculum was adequate (data not shown). Ninety-three percent of the respondents felt that the topics were relevant, and 96 percent felt the topics were current. Nonetheless, only 55 percent of the students reported feeling prepared to provide intervention services based on the curriculum.

When asked about the most valuable methods to teach the tobacco intervention curriculum, 91 percent of the responding students reported that didactic lectures were a valuable method of learning tobacco intervention, followed by web-based learning (83 percent), problem-based learning (79 percent), CD-ROM instruction (68 percent), and objective structured clinical examination (OSCE) (67 percent) methods.

Fifty-three of the sixty-eight students responded to the open-ended question related to their views about grading dental students on didactic and clinical work related to tobacco intervention services. Almost 47 percent reported that students should be graded on didactic work only, followed by 36 percent who reported that students should be graded on didactic as well as clinical work, 8 percent who reported that students should be graded on clinical only, and 6 percent who reported that students should not be graded on didactic or clinical work.

Twenty-six of the sixty-eight students responded to the open-ended question about their suggestions concerning the college’s tobacco intervention curriculum and services. Almost 31 percent reported that they needed more clinical experience, and 23 percent reported that they needed more information related to nicotine replacement therapy use. Seven students (less than 1 percent) made these comments: “patients mostly see different dental students each time, thus difficult to do follow-up and loss of clinic time as well,” “do not move to clinical grading,” “best learning method is to watch tobacco cessation instructor provide cessation services,” “provide free nicotine samples to students so that they can prescribe it to patients,” “overbearing to patients,” and “patient resistance.”

The students reported that faculty members from the Department of Periodontics (71 percent) followed by the Departments of Oral Diagnosis, Oral Pathology, and Oral Radiology and Medicine (49 percent) encouraged them to provide tobacco intervention services during their third year more than 50 percent of the time. However, they reported very low responses for the Departments of Endodontics (0), Orthodontics (0), Pediatric Dentistry (1 percent), Prosthodontics (3 percent), Oral and Maxillofacial Surgery (16 percent), and Operative Dentistry (26 percent).

Table 5⇓ summarizes the bivariate associations (p<0.20) between the independent variables and the dependent barrier composite variable. The predictor variable “level of guidance received from the faculty of the Department of Pediatric Dentistry at the individual patient level” was not considered for further analysis due to the large number of missing values. The social desirability scale data were not significantly associated with any of the barrier (p=0.93), attitude (p=0.49), or behavior (p=0.92) composite scores. As a result the social desirability data were also not considered for further analysis. Overall, eight variables showed a bivariate association (p<0.20) with the barrier composite variable; thus, they were included for consideration in the development of the final regression model.

Two predictor variables showed statistically significant associations with the dependent variable-barrier composite score. The composite scores representing the adequacy of the tobacco intervention curriculum coverage of specific topics related to tobacco intervention (ten statements asked regarding specific topics, p=0.003) and the perceived importance by the students of incorporating OSCEs into the curriculum for learning tobacco intervention (p=0.02) were found to be significantly (p<0.05) associated with the barrier composite score in the final linear regression model (see Table 6⇓). The coefficient of −0.52 indicated that the barrier composite will decrease by 0.52 units for one unit increase in the composite score related to the adequacy of tobacco intervention curriculum while controlling for the other variable in the model. The barrier composite score was 5.94 units higher for students who reported that learning tobacco intervention through an OSCE was moderately valuable compared to students who reported it was not valuable at all. However, there was not a significant difference in the barrier composite score between the students who reported somewhat and not valuable at all for learning tobacco intervention through an OSCE.

When the significance level for retention in the final model was relaxed to p<0.20 (data not shown in the table), three variables were found to be significantly associated with a greater barrier composite score (more barriers). They were less reported adequacy of tobacco intervention curriculum coverage of specific topics related to tobacco intervention (β =−0.31, p=0.11), greater perceived importance by the students of incorporating an OSCE into the curriculum for learning tobacco intervention (β =5.53 for moderately valuable category vs. not valuable at all; overall p=0.03), and less reported agreement regarding overall tobacco curriculum assessment composite (three statements asked regarding adequacy, currency, and preparedness, β =−1.22, p=0.06).

Discussion

The main emphasis of our study was to assess perceived barriers related to tobacco intervention services and factors associated with barriers related to tobacco intervention services. No U.S. dental student studies have focused primarily on perceived barriers, and very few studies^19,21,24 have addressed even in a minimal way perceived barriers related to tobacco intervention services. The null hypothesis that “there are no barriers reported by fourth-year dental students concerning provision of tobacco intervention services” was rejected, since each of the barrier-related statements for the current study was reported as a barrier to providing tobacco intervention services. Besides the barriers “lack of time” and “patient resistance” identified by earlier studies,^19,21,24 “lack of skills,” “lack of nicotine replacement therapy knowledge,” and “forgetting to give tobacco intervention counseling” were also identified as commonly perceived barriers in our study.

The most commonly (sometimes or more) reported barriers were patients’ resistance to tobacco intervention services and inadequate time available for providing intervention services, at 96 percent each. Patients’ resistance to tobacco intervention services was also reported as one of the barriers in previous studies.^19,21,24 However, a greater proportion of the students in our study reported this as a barrier compared to Yip et al.¹⁹ It is possible that traditional (without the emphasis on the Stages of Change model) or prescriptive approaches²⁸ followed by dental students are contributing to some of the patient resistance and, therefore, the perceived barrier. Thus, students need to be informed that patients often resist traditional health education, but may respond better to a health behavior change approach. Motivational Interviewing (MI) approaches have been proven to be effective for behavior change in patients.^34–36 It also has been found that identifying the patient’s stage of change related to tobacco cessation is critical to avoid patient-related barriers.³⁷ In the future, students could be reminded to identify each patient’s stage of change and consider use of MI approaches when advising their patients in clinics.

Although a previous study of dental hygiene students²⁴ found “inadequate time available for providing intervention services” not to be a significant barrier, our study did find concerns about time available. The clinical protocol in our study was based on the American Dental Hygienists’ Association’s Ask, Advise, Refer model, an adaptation of the U.S. Public Health Service Clinical Guideline’s 5As: Ask, Advise, Assess, Assist, Arrange. Thus, following our protocol, students only had to Ask and document tobacco use, Advise, and Refer to quitlines, without having to Assess, Assist, or Arrange follow-ups with the patients. These steps should certainly take students less time than those using the traditional 5As approach to tobacco cessation. However, students have to perform dental procedures in the limited time allotted to them. Since they are typically slow and have many step checks along the way, lack of time could have been a perceived barrier to providing consistent cessation services. As a result, to overcome this barrier students should be encouraged to provide cessation services when possible during their clinical appointments, perhaps during “down time,” such as the time when students are waiting for their instructors to arrive to their dental chair to provide a step check.

The third most commonly reported barrier (91 percent) in our study was “forgetting to provide tobacco cessation services.” A similar finding was identified in an Australian study of medical practitioners.³⁸ To help overcome this barrier, students could be reminded of providing cessation services when they are oriented to each dental department clinic for performing patient-related activities. Having appropriate policies in all the dental clinics to use reminders, instructions, checklists, and faculty support for providing cessation should address this barrier.

The fourth most commonly reported barrier (75 percent) was “inadequate skills to provide tobacco intervention services.” A study of Australian dental students reported a similar finding.³⁰ This barrier could be reduced by providing students with more opportunities to practice and apply the knowledge gained through their didactic lectures (i.e., provide more clinical experiences).¹⁸ Also, use of standardized patients or OSCE techniques could be useful in improving skills related to the 5As of cessation.^39–42

The other barrier reported by 75 percent of the respondents in our study was “inadequate knowledge regarding nicotine replacement drugs,” which is much higher than that reported in a study of fourth-year medical students.⁴³ To overcome this barrier, perhaps a training approach similar to that used by Seidman et al.⁴⁴ could be used to include pharmacists at the dental school to show students various tobacco cessation medications and provide instructions regarding these medications. This could help the students understand the medications’ indications, advantages, adverse effects, and contraindications. If students are taught about and supplied with nicotine gums, patches, and lozenges, they will be likely to feel more responsible and prepared to make correct decisions in providing these medications to their patients interested in quitting. Making students write tobacco cessation prescriptions in the class using various patient scenarios could also improve their knowledge regarding tobacco cessation medications.⁴⁵

No previous study has reported factors associated with barriers related to tobacco cessation services performed by dental students. However, one study of Canadian dental private practitioners⁴⁶ assessed some factors associated with intervention services. The authors of that study found that all females and dental hygienists were more likely to report “patient resistance” and “fear of alienating patients” as significant barriers compared to all males and dentists, while the males and dentists were more likely to report “lack of reimbursement” as a significant tobacco cessation barrier. However, when overall barrier composite scores were created and compared, there were no significant differences by gender or provider type.

Our study found two factors to be significantly associated with tobacco cessation barriers in the final model. Barriers decreased as the students reported greater adequacy of coverage in the tobacco intervention curriculum over the previous three years. The importance of having a specific tobacco cessation curriculum has been emphasized in the literature.^10–12 However, the reporting of fewer barriers among students who reported OSCEs as a less favorable method is an unexpected finding. The OSCE has been used successfully in training medical students in improving their communication skills.⁴¹ The teaching methods investigated in our study included web-based education, didactic education, use of CD-ROM instruction, and problem-based learning. The first three methods feature instruction in tobacco intervention without any patient interaction or clinical experiences. Problem-based learning, which also does not include patient interaction, uses group efforts to address cases or problems associated with tobacco cessation. On the other hand, OSCE techniques usually have stations with lab materials, casts, radiographs, or patients (simulated or standardized). The students rotate to the stations and are graded either by their instructors or standardized patients. It is possible that the students in our study were not prepared to be graded clinically, since they mentioned that they wanted clinical experiences but did not prefer to be graded clinically. Our students are required to complete examinations using OSCEs in the Department of Pediatric Dentistry, so they know about this teaching method. Another possibility could be that students believed their patients’ readiness to quit would be used as a final outcome for grading their counseling skills. Besides, if OSCEs were used, the students probably would be required to perform all the 5As, counsel their patients, come up with treatment plans, and address patient concerns, which they would not be required to do otherwise.

Overall, the students in our study reported favorable attitudes related to tobacco cessation and generally favorable responses for the knowledge-related questions, except for two questions. Concerning behaviors related to tobacco cessation, students reported favorable responses for all the steps (Ask and document tobacco use, Advise, and Refer patients) that they are required to do in the dental clinics, except for referrals to quitlines. The implementation of referral to the quitline began at the University of Iowa College of Dentistry two years ago. Thus, the students in this study were probably not fully experienced with it to the degree that future cohorts will be. Faculty members could remind the students to refer their tobacco-using patients to quitlines after completion of the required dental procedures for that day in the dental clinic. Also, the students could be advised to provide tobacco cessation materials and quitline information to those patients who are assessed as willing to quit during the next few months.

There are several other possible factors concerning reduced reporting of specific tobacco cessation behaviors. First, if the question in our survey had been changed from “I prescribed tobacco cessation medications to patients” to “I recommended tobacco cessation medications to patients,” it could have changed the number of positive responses. This is important because students could have recommended medications that are available over-the-counter or could have recommended medications but referred the patient to the faculty member for a prescription since some have to be prescribed by the faculty due to legal requirements. Secondly, Geller et al.⁴⁷ have suggested that, because few patients are willing to actually quit, students have limited opportunities to Assist, Arrange follow-ups, or even Refer patients to quitlines. Thus, there could have been drops in percentages reporting Assist, Arrange follow-ups, or Refer procedures. In other words, Ask, Advise, and Assess are “practitioner-driven procedures,” while Assist, Arrange follow-ups, or Refer are largely “patient-driven procedures.” Consequently, having tobacco-using patients who are willing to consider quitting (or simulating such experiences) is essential to providing adequate clinical experiences for students. Thirdly, students would be less likely to have continuity of follow-up with their patients and complete the 5A steps since they rotate through various department clinics throughout the year. Lastly, there are significant differences between the behaviors of arranging follow-up visits and referring patients to quitlines. Even if the students rotate into multiple department clinics, they could still arrange recall visits in a setting that uses all the 5As of cessation. For our setting, which utilizes an Ask and document, Advise, and Refer approach, students could ask and document tobacco use, advise on quitting, and refer to quitlines and/or counseling for each patient at each visit. The behavior-related findings suggest that, besides receiving didactic instruction concerning the 5As of tobacco cessation behaviors, the students should know the specific University of Iowa College of Dentistry tobacco cessation behavior protocol. Both of these two protocols (the 5As or the Ask and document, Advise, and Refer to quitlines approach) ultimately aim to assist patient cessation.

There are significant differences among the number and content of tobacco intervention topics covered didactically and clinically across U.S. dental schools.^16,45 Based on our findings, we recommend that a standardized tobacco intervention curriculum be developed that covers key topics didactically and clinically, as well as accounts for cultural differences. Also, dental schools probably would be more active in providing cessation services if school accreditation depended on having implementation of a tobacco intervention curriculum and students’ being required to demonstrate competence. Similar suggestions to improve tobacco cessation curricula⁴⁸ and tobacco cessation competencies⁴⁹ have been mentioned in the medical literature. The findings from our study also can be used to inform future efforts for providing consistent tobacco intervention training in private practices or community health care settings.

The strengths of this study include a thorough assessment of the barrier component and the variables associated with barriers to tobacco intervention services. This is one of the few studies to have assessed students who had a tobacco intervention curriculum spread out over their predoctoral dental education, although with only five total core hours. The cross-sectional study design allowed data collection that was relatively easy, inexpensive, and less time-consuming. The response rate was high, so it avoided major nonresponse bias. Limitations of the study include a small convenience sample size and inability to establish causality of barriers since it was a cross-sectional study. Additionally, this study relied on self-reported data collection, so results could be affected by intentional deception, poor memory, or misunderstanding of questions. It should also be noted that the composite variables were not from validated tools, could have missed other important information, and used unweighted summative scores. The study findings are specific to incoming fourth-year dental students at the University of Iowa. Thus, the results should not be generalized.

Additional studies with larger, more diverse samples (i.e., more dental schools participating and greater diversity by race/ethnicity) should be conducted in order to better assess factors associated with dental students’ perceptions of barriers to tobacco intervention services. A thorough assessment of patient-related factors will also help dental educators understand such barriers to tobacco intervention services. Performing chart audits and documenting tobacco cessation steps would confirm whether students are providing cessation services and to what extent. Furthermore, standardized patients could be used to improve tobacco cessation counseling skills of dental students. Lastly, it would be useful to assess the dental faculty in order to understand whether faculty members are comfortable guiding students in cessation services and providing these services themselves and whether it is feasible to incorporate and provide these services in the various dental departments.

Conclusions

This study found that greater reported adequacy of tobacco intervention curriculum coverage over the previous three years was associated with lower perceived barriers to tobacco intervention services by early fourth-year dental students. Although the majority of students reported that the tobacco curriculum included relevant and current information, there were gaps in the perceived coverage of specific topics most relevant to clinical application (i.e., strategies for how to become involved in community-based programs, addressing dental students’ own tobacco use, and how to develop a comprehensive tobacco intervention program in clinical settings). In addition, the students reported being much less prepared to actually provide intervention services compared to their reporting of the quality of didactic training they received. Thus, both enhanced simulated and actual clinical experiences are recommended in order to facilitate dental students’ learning of effective intervention services.

Currently, several tobacco cessation curricular changes are being implemented at the University of Iowa College of Dentistry in order to emphasize application of cessation services, and several additional research studies are under way. A similar study is being conducted with the first-year students to assess factors associated with willingness to receive training; these first-year students will be surveyed again in their fourth year. Also, additional data will be collected after several years when the study’s fourth-year students are established in practice. In addition, a pilot study concerning using the Ask, Advise, and Refer to quitline approach is being conducted in five eastern Iowa dental practices to assess whether this approach would be feasible for dental practices overall in providing increased levels of cessation services.