Attitudes and Practices of Dental Students in Providing Oral Health-Care Services to Underserved Rural Patients Attending Dental Institutions of Telangana, India.

INTRODUCTION: Attitude is a relatively enduring organization of beliefs around an object, subject, or concept, which predisposes one to respond in some preferential manner. It decides one's action. Dental students frequently come across underserved rural population and must have good attitudes toward them, so that the care delivered to them will be optimum. AIM: To assess the attitudes and practices of dental students in providing oral health-care services to underserved rural patients.
MATERIALS AND METHODS: A cross-sectional study was conducted among final-year Bachelor of Dental Surgery (BDS) students, interns, and postgraduate students who are involved in providing dental care in dental institutions of Telangana State, India. A 15-item, self-structured, pretested questionnaire was administered. Descriptive statistics were calculated using the Statistical Package for the Social Sciences (SPSS) software, version 20.0. Attitudes and practices of undergraduates and postgraduates were compared using paired t-test.
RESULTS: A total of 574 students participated in the study. Approximately 73.3% of the dental students agreed that they personally want to be involved in providing oral health care for the underserved and 27.1% students disagreed that underserved patients are subjects on whom they can train and expertise. Approximately 56.62% of dental students often asked patients about the expenses they bear for attending a single dental visit and 53.48% tried to minimize the number of appointments required for the patients. No significant difference was observed in attitudes between undergraduates and postgraduates.
CONCLUSION: Dental students had moderate attitude toward underserved patients but this was not reflected in their practices.

INTRODUCTION

In India, poor and marginalized form the major part of the population. Of the total of 1.21 billion population in India, the size of the rural population is 0.83 billion or 68.84% of the total population and approximately 25.7% of the rural population is below the poverty line.[1] Underserved is referred to a group of individuals who are provided with inadequate service.[2] Underserved are the ones with the greatest disease burden. This group has poor oral health status and most of the times, they are unable to afford basic and emergency health-care services.[3] Underserved people are at more risk of developing dental caries and periodontal diseases,[4] and consequently, of losing their teeth. This situation is in part related to poor access or no access to professional dental services. People on low incomes tend to present less often for preventive care,[5] to wait longer when a problem occurs, and consequently, to be more at risk of having teeth extracted.[6]

Even though the financial barrier is often paramount in accessing dental services, it is not the only issue.[4] An attitude of dental students toward underserved patients is a major concern. Attitude development is a complex and multifaceted issue. Studies on the effects of medical education on attitudes have found that students become less humanitarian, less willing to provide all services to those who have no ability to pay, and less willing to become involved in providing care to indigent population.[78] As they progress through their course of training, students become more focused on career goals and feel underserved patients will be those on whom they will often practice and improve their skills.[9]

Providing a positive educational environment where students can interact with patients may help them develop more positive attitudes toward patients with special needs.[1011] A study conducted by Dao et al.[12] found that more the education, dentists had received about providing care for patients with special needs, the better their attitudes and the more likely they were to provide services for these patients.[13] Many dental schools have incorporated community-based and service-learning programs into their curricula to expand care for underserved populations as well as educational experiences for students, and the outcomes of these programs seem promising. They provide opportunities for students to care for patients who are underserved.[1415]

Therefore, this study was designed to investigate the attitudes and practices of dental students in providing oral health-care services to underserved rural patients attending dental colleges of Telangana State, India.

MATERIALS AND METHODS

A cross-sectional study was conducted to assess the attitudes and practices of final-year Bachelor of Dental Surgery (BDS) students, interns, and postgraduates in providing oral health-care services to underserved rural patients. A total of 11 dental colleges are present in Telangana State, among them six are situated in urban areas and five are in rural areas. Of the five rural dental colleges, authorities of four gave permission to conduct the study. All the final-year BDS students, interns, and postgraduates who were present on the day of survey from the four dental colleges were included. Students who had direct interaction with patients and performed treatment procedures were eligible to participate in the study. All the undergraduate dental students who do not interact with patients, that is, first-, second-, and third-year BDS students and postgraduates from nonclinical department (i.e., oral and maxillofacial pathology) were excluded.

A pilot study was conducted to validate the data collection tool, which was formulated based on literature review and objectives of the study. Initially, it had 18 questions, which were segregated under two domains (i.e., attitudes and practices) and validated by a panel of oral health professionals (content validity ratio = 1). The questionnaire was tested for its reliability (Cronbach’s α = 0.7), and three questions had to be deleted after the pilot study.

The final questionnaire consisted of demographic data and 15 questions regarding attitudes and practices of dental students, which were used for data collection. Attitudes of students were addressed with six items, the responses were scaled using a three-point Likert scale (i.e., agree, uncertain, and disagree). Practices of dental students were addressed with nine items and responses were scaled using a three-point Likert scale (i.e., often, rarely, and never).

The study was conducted for two months in 2016. Ethical clearance was obtained from the institutional review board of Sri Sai College of Dental Surgery, Vikarabad (Ethical clearance letter ID: Ref no. 557/7/COMD/SSCDS/IRB-E/2016), and informed consent (verbal) was obtained from the students who were willing to participate before the study. The purpose of the study was explained to the dental students and only those who were willing to participate were given the questionnaires. Sufficient time was given to them to fill the questionnaires anonymously and it was collected back on the same day. Care was taken to prevent interaction among participants. Attitudes of students were addressed with six items, which included three positive statements and three negative statements. A correct answer, that is, agree for a positive statement was assigned a score of 3, uncertain was assigned 2, and disagree was assigned 1, and vice versa for negative statements. Similarly, practices were addressed with nine items with a score of 3, 2, and 1 for often, rarely, and never, respectively. Statistical analysis was carried out using descriptive statistics in the Statistical Package for the Social Sciences (SPSS) software, version 20.0, (IBM SPSS, Inc. Chicago, Illinois). Microsoft Word and Excel Pro version 2016 (computer software), (Redmond, Washington) were used to generate tables and figures. Attitudes and practices of undergraduates and postgraduates were compared using paired t-test. A P < 0.05 was considered to be statistically significant.

RESULTS

A total of 574 dental students participated in the study. The mean age of the study population was 23.5 ± 2.6 years.

Majority of the students were females (63.07%) and 36.93% were males. Among 574 students, 194 (33.79%) were final-year BDS students, 228 (39.72%) were interns, and 152 (26.48%) were postgraduate students.

Table 1 shows that majority of students have moderate attitudes toward underserved rural patients with mean score of 13.3 of 18. A total of 437 (76.1%) dental students conceded that underserved patients have the greatest disease burden, 482 (83.9%) dental students agreed that caring for the underserved and needy people and helping them is a noble endeavor, and 421 (73.3%) dental students felt that they personally want to be involved in providing care for the underserved patients. Approximately 233 (40.7%) participants admitted that the underserved patients are difficult to handle and more than half of the students (57.66%) felt that underserved patients neglect their health and only 38.3% of the dental students felt underserved are the subjects on whom they can train and expertise.

Table 1

Attitudes of dental students in providing oral health care to underserved rural patients attending dental institutions of Telangana, India

Attitude question	Agree N (%)	Uncertain N (%)	Disagree N (%)
Underserved suffer from the greatest disease burden	437 (76.1%)	106 (18.4%)	31 (5.4%)
Caring for the underserved and needy people and helping them is a noble endeavor	482 (83.9%)	84 (14.6%)	8 (1.39%)
I personally want to be involved in providing care for the underserved patients	421 (73.3%)	140 (24.3%)	13 (2.26%)
Underserved patients are the ones who are difficult to handle	233 (40.07%)	253 (44.07%)	88 (15.33%)
Underserved patients are the ones who neglect their health	331 (57.66%)	196 (34.14%)	47 (8.1%)
I feel underserved patients are subjects on whom I can train and expertise	223 (38.85%)	195 (33.97%)	156 (27.17%)

% - percentage of study subjects N- number of study subjects

Table 2 shows the practices of dental students in providing oral health-care services to underserved rural patients. The majority of the dental students (75%) asked the patients about the distance they have travelled to attend an appointment and attempted to treat them on the first visit. Approximately 388 (67.59%) students asked patients about their socioeconomic status before treatment. Around 325 (56.62%) dental students asked the patients about their expenses for attending a single dental visit, 307 (53.4%) dental students felt they should try to minimize the number of appointments required for the patients and offer dental services regardless of an individual’s ability to pay. The majority of the students (75.43%) tried to stick to the appointment schedule in treating underserved patients. Approximately 476 (82.9%) dental students in their practice often tried to motivate underserved patients to maintain good oral health.

Table 2

Practices of dental students in providing oral health care to underserved rural patients attending dental institutions of Telangana, India

Practice question	Often N (%)	Rarely N (%)	Never N (%)
Do you treat a patient on his first visit?	440 (76.6%)	115 (20.03%)	19 (3.31%)
Do you assess the socioeconomic status of a patient prior to treatment?	388 (67.59%)	146 (25.43%)	40 (6.9%)
Do you consider the distance patient has traveled to attend an appointment?	430 (74.91%)	126 (21.95%)	18 (3.1%)
Do you ask patient about his expenses for attending a single dental visit?	325 (56.62)	196 (34.14%)	53 (9.23%)
Do you ask a patient about loss of his income for a single dental visit?	234 (40.7%)	222 (38.67%)	118 (20.55%)
Do you stick to the appointment schedule given to your patient?	433 (75.43%)	126 (21.95%)	15 (2.6%)
Do you try to minimize the number of appointments required by your patient?	307 (53.48%)	201 (35.01%)	66 (11.4%)
Do you offer dental services regardless of an individual’s ability to pay?	307 (53.4%)	210 (36.1%)	54 (9.6%)
Do you try to motivate underserved patients to maintain good oral health?	476 (82.9%)	74 (12.89%)	24 (4.18%)

% = percentage of study subjects, N = number of study subjects

Table 3 shows the comparison of attitudes of undergraduate and postgraduate dental students in providing oral health care to underserved rural patients attending dental institutions of Telangana, India. The mean attitude score of undergraduates and postgraduates was 13.27 ± 1.999 and 13.44 ± 1.663, respectively. No statistically significant difference was observed in attitudes of undergraduates and postgraduates (P = 0.340).

Table 3

Comparison of attitudes of undergraduate and postgraduate dental students in providing oral health care to underserved rural patients attending dental institutions of Telangana, India

Study year	N	Mean	SD	P value	t	df	95% Confidence interval of the difference
Undergraduates	422	13.27	1.999	0.340	–0.955	573	Lower	Upper
Postgraduates	152	13.44	1.663				–0.529	0.183

N = number of students, t = t-test statistic, SD = standard deviation, df = degree of freedom

Table 4 shows the comparison of practices of undergraduate and postgraduate dental students in providing oral health care to underserved rural patients attending dental institutions of Telangana, India. The mean practice score of undergraduates and postgraduates was 12.76 ± 2.515 and 12.32 ± 2.289, respectively. No statistically significant difference was observed in practices of undergraduates and postgraduates (P = 0.060).

Table 4

Comparison of practices of undergraduate and postgraduate dental students in providing oral health care to underserved rural patients attending dental institutions of Telangana, India

Study year	N	Mean	SD	P value	t	df	95% Confidence interval of the difference
Undergraduates	422	12.76	2.515	0.060	1.885	573	Lower	Upper
Postgraduates	152	12.32	2.289				–0.018	0.895

N = number of students, t = t-test statistic, SD = standard deviation, df = degree of freedom

DISCUSSION

Homeless, poor and patients in racial/ethnic minority groups may come under underserved.[15] They face considerable barriers in accessing dental care and have poorer oral health than the rest of the population.[1617] In addition, the perception of many dental students that these individuals are difficult to handle exacerbates the problem. Understanding these attitudes is important for dental educators, policymakers, and dental organizations that embrace the profession’s mission to protect and improve the oral health of the individual and society.[14]

This study was undertaken to assess the attitudes and practices of dental students toward underserved rural patients in Telangana, India. Primary outcomes, that is, when attitudes were assessed, dental students had moderate attitude scores and when practices of dental students were assessed, they were not in accordance with their attitudes. Secondarily, attitudes and practices of undergraduates and postgraduates were compared and no significant difference was found.

Most of the times, these patients are unable to afford basic and emergency health-care services, their lack of health literacy, and the perception of health professionals that underserved are difficult to handle might lead to increased disease burden in poor and homeless. In this study, majority of the dental students (76.1%) agreed underserved patients have the greatest disease burden. The possible reason for this finding could be that students felt underserved are provided with inadequate health-care services, poor sanitation, poor dietary intake, and financial barriers to avail health care. In this study, majority (83.9%) of the dental students acknowledged “caring for the underserved and needy people and helping them is a noble endeavor.”

Similarly, in a study conducted by Garfinkle et al.,[15] majority of the participants agreed that they entered dentistry to help people who are in need of oral care. The attitude in students may be due to the idealism they have, to serve the underserved and needy.

Approximately 73.3% of dental students conceded that they personally want to be involved in providing care for the underserved patients. This finding is in contrast to a study conducted by Robben et al.,[18] where only half of the study subjects and 37% of dentists agreed to treat underserved patients. Here, in this study, students clearly valued giving back to their respective communities and held more idealistic values.

Lack of awareness about oral health among underserved patients might negatively affect dental students’ sense of building rapport with their patients and having successful patient–dentist relationship.[19] In this study, approximately 40.7% of subjects felt underserved patients are difficult to handle. Similarly, in a study conducted by Phlypo et al.,[20] dental students encountered problems when treating patients with poor oral health literacy, the less they enjoyed treating these patients, the less likely they intended to provide care for them in the future. Ultimately, these challenges could interfere with dental students’ level of comfort when providing care to the underserved.

It is interesting to note that approximately 38.3% of the dental students felt underserved are the subjects on whom they can train and expertise. Such attitudes can be a major deterrent in the way dental care is provided. Recognizing dental students’ perceptions of the underserved and guiding them at an early stage of their dental career can help in the provision of better dental care.

Increasing students’ awareness through community participation about social and financial determinants of poor oral health may aid them to appreciate the value of their professional contributions in providing care for underserved and medically indigent population.[2122] In our study, it is interesting to note that majority of the dental students responded that they tried to assess patients’ socioeconomic status before treatment. Students felt that assessing the socioeconomic status may guide to plan treatment accordingly.

In spite of their willingness to serve the needy, approximately half of the participants did not bother to ask patients about their expenses and loss of income for attending a single dental visit. This type of practice by students may be due to varied reasons such as their busy schedule, limited hours of clinical postings, or a lack of empathy toward poor patients. It is encouraging to note that approximately 53.4% of dental students were willing to offer dental services regardless of an individual’s ability to pay. This finding is in contrast to a study conducted by McFarland et al.,[23] where students showed relatively less positive attitudes to volunteering services to underserved patients. Here, in this study, students are moderately positive as they felt underserved are deprived of services because of financial barriers. In this study, approximately 53.4% of participants tried to minimize the number of appointments required for the patients as the students felt decreasing the appointments may reduce the expenses of patients for attending an appointment.

The various factors that change students’ attitudes and behaviors over a period were not assessed in this study. Another limitation of this study is that relatively positive attitudes of students could have been related to a social desirability effect: students might have provided answers they thought were best so they would not appear judgmental.

CONCLUSION

In this study, students were found to have moderate attitudes toward underserved patients but this was not reflected in their practices. Students’ attitudes and practices toward underserved patients can be improved by promoting empathy through curricular efforts and focusing directly on role modeling. Service-learning coupled with critical reflection exercises is considered a promising means toward reaching these goals. Community-based education is one major opportunity to create a deeper understanding of these issues. Being exposed to experiences in the community allows dental students to develop more positive values and competence concerning treating underserved patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.