Introduction
As a consequence of current population demographic trends, medical and dental practices are presented with increasing numbers of geriatric clients. Moreover, the elderly patient nowadays presents with increasing numbers of natural teeth and with complex treatment needs (ZITZMANN ET AL. 2007; SCHNEIDER ET AL. 2017). The situation is further complicated due the complex health and cognitive status of the elderly patient. The dental and medical curricula have accordingly started increasing their geriatric content (REUBEN ET AL. 1998). The aims of these measures are to somehow increase the awareness and the students’ knowledge and to accomplish a better understanding of the geriatric subjects. An additional focus however lies on implementing a positive attitude towards older persons along with the necessary care that needs to be rendered. More importantly, the geriatric modules in the dental curriculum will help the young students to be better experienced to treat the complex geriatric patient efficiently, confidently, and with quality care.
Discrimination due to age is not uncommon, especially in Europe (ABRAMS ET AL. 2011). Findings from the European Social Survey indicated that 57% of the participants find elders over 70 years to contribute very little to the society. The same survey also documented that 49% of the participants believe that the elders are a burden on the health care services. Studies indicated that the attitudes of health care professionals, including dentists, towards the elderly have ranged between moderately positive to even negative (BECK ET AL. 1979; FABIANO ET AL. 2005; WALDROP ET AL. 2006; DE VISSCHERE ET AL. 2009; NOCHAJSKI ET AL. 2009; NOCHAJSKI ET AL. 2011; ETTINGER 2012; MOREIRA ET AL. 2012). These findings are a cause for concern because these may well affect the treatment choices offered or deprived to the older patients (BOWLING 1999; ROBB ET AL. 2002). Therefore, it is important to cultivate an accepting and positive attitude in the minds of the students early in their medical or dental curriculum towards elders in order to foster an aspect of responsibility towards treating the elderly society. Hence, it is important to assess whether the modules of geriatric content in the current study curriculum are adequate to instill confidence in the young graduates to treat the complex elderly patient.
The aim of this questionnaire-based survey was to assess the attitudes of dental students on treating elderly patients. Therefore, the null hypothesis set for this survey was that, irrespective of the year of training, there would be no differences in the attitudes of the dental students towards the elderly patients. The secondary aim was to evaluate the opinions of the students on the adequacy of the geriatric modules present in their training curriculum and their confidence levels in hypothetically treating the elders unsupervised.
Materials and Methods
This Swiss nation-wide survey was conducted amongst the dental students from the Swiss universities of Basel, Bern, Geneva, and Zurich. The validated 14-item Geriatric Attitudes Scale (GAS-14, Table I) questionnaire (REUBEN ET AL. 1998), was reviewed by the cantonal ethics committee of Zurich [(Kantonale Ethikkommission Zürich (KEK ZH)] and they decided that an ethics approval was not required to conduct this survey (Basec-Nr.: Req-2019-00840) as it did not fall within the scope of the Human Research Act (HRA). Following the decision from KEK ZH, the respective ethics committees of Basel [Ethikkommission Nordwest- und Zentralschweiz (EKNZ)], Bern [Kantonale Ethikkkommission Bern (KEK Bern)], and Geneva [Commission Cantonale d’ethique de la Recherche (CCER)] were contacted and all authorities confirmed that an ethics approval was not required to conduct this survey.
Survey Questionnaires
The GAS-14 questionnaire had 14 items which were designed to evaluate the attitudes of health care providers/students towards older adults as well as in providing care for these individuals (Table I). The items were designed such that they are sensitive to detect changes in the attitudes of the students. Each of the questions had a 5-point Likert scale response type (1= strongly disagree, 2= somewhat disagree, 3= neutral, 4= somewhat agree, 5= strongly agree). The questions are either positively or negatively phrased with reversed response scores for the latter (i.e., 1 to 5, 2 to 4, 3 stays, 4 to 2, and 5 to 1). The scores for negatively phrased questions were reversed (nos. 2, 3, 5, 6, 8, 10, 11, 12, & 13) before being added to the scores of the positively-worded items to obtain a total score. A second questionnaire with 9 items related to students’ opinions on the current gerodontology modules in their study curriculum was also presented (Table I). This 9-item questionnaire also had a Likert scale response-type system. General demographic data about the participants such as: age, sex, nationality, country of origin, religion, marital status, accommodation status, whether they live with their parents or grandparents or both, were also collected.
Translation
The geriatric attitudes scale was translated according to the Medical Outcomes Trust criteria (1997). The questionnaire was translated from English to French and German. Then it was back-translated from French and German to English and adjusted where necessary. The questionnaires were reviewed and checked for any problems in comprehension. If any such problems were encountered, appropriate corrections were made accordingly.
Participants
The survey included the dental students in Switzerland. The participation was completely voluntary and responses were anonymous. The questionnaires were printed out, then manually handed over to the students in a classroom session (Bern, Geneva and Zurich) and supervised by one investigator from the respective dental school, who observed that the questionnaires were completed properly. Any doubts (if any) that arose during the completion of the questionnaire, were clarified by the supervising investigator. All efforts were made to ensure that a maximum participation was achieved. The students in each of the academic years at each university dental school were informed by proper communication channels beforehand and were requested to participate. The manual distribution of the questionnaires in the classrooms were aimed to achieve this end. Due to the COVID-19 lockdown restrictions, University of Basel administered the questionnaires electronically to the students.
Statistical Analysis
Responses collected from the GAS questionnaire were scored; means and standard deviations (SD) were calculated. The calculated means were verified for normal distribution. ANOVA and post hoc tests (LSD test) were applied with the level of significance set at ?=0.05. Ancillary analyses were conducted to study the influence of the demographic parameters on the GAS scores. Participants’ demographic information and the responses from the second questionnaire were reported descriptively. All statistical analyses were performed using SPSS statistical software (version 25.0, IBM Incorporated, NY, USA).
Results
A total of 305 out of 385 (response rate: 79.2%) dental students (mean age: 25.8±4.0yrs) from the four Swiss university dental schools participated in this survey. The participants’ demographic characteristics are shown in Table II. The participants from Bern did not respond to the demographics section of the questionnaire. However, no demographic differences were observed between the participating centers in terms of participant number (p=0.498), age (p=0.394), sex (p=0.320), nationality (p=0.954), origin (p=0.828), religion (p=0.053), marital status (p=0.666), and their living status (p=0.219). The borderline significance in the religion status could have been influenced by the non-responders from Bern.
The mean GAS scores of the students categorized by the year of training for each participating center is reported in Table III. The overall mean GAS scores of the participants were 3.5±0.4, 3.6±0.4, 3.4±0.4, and 3.5±0.4 for Basel, Bern, Geneva and Zurich, respectively with no significant difference between the participating centers [F(3, 300)=2.266, p=0.081]. There was no significant overall difference between the three training years [F(2, 301)=1.884, p=0.154] with all centers combined. For individual centers, there were no significant overall difference between the three years (Table III), except for Basel where the GAS scores of the participants of the 3rd year students revealed a significantly lower GAS score than the 5th year students (p=0.029; p-value: post-hoc LSD test; Table III). Demographic parameters did not significantly influence the GAS scores of the participants (Table IV).
Responses to specific questions related to the geriatric dentistry curriculum, confidence and preference in treating the elderly patients is reported in Table V (Fig. 1). 78.7% of the students agreed that geriatric dentistry was an important aspect of the dental education. 47.2% agreed that the current geriatric program in their dental education was adequate while 40.7% were of neutral opinion. With respect to their confidence in hypothetically independently treating elderly patients, 43.6% agreed and 32.8% were of neutral opinion. The majority of the respondents (83.9%) agreed that they would like hands-on experience in treating the elderly patients during their dental education. For the preference of treatment setting, 38.1%, 16.4%, and 15.4% of the respondents preferred to treat the elders in a clinic-, hospital-, and nursing home- setting, respectively. The majority of the respondents (81.7%) agreed that mobile dental clinics are a good solution for elders with no access to dental care.
Discussion
This study was conducted to evaluate the attitudes of undergraduate dental students on elderly patients. Ageism is a widespread phenomenon in our society where youth and beauty are stereotypes often associated with success, social status, intelligence and popularity with others (DONIZETTI 2019; WEBER ET AL. 2019). The process of ageing is progressive, general and irreversible. Apart from functional limitations, it applies visible changes in a person’s physiognomy and physical appearance, but it applies also to psychosocial and behavioral aspects (DZIECHCIAZ & FILIP 2014). The World Health Organization (WHO) defined the phenomenon of ageism as, “the stereotyping and discrimination against individuals or groups on the basis of their age” (WHO, 2015). It seems particularly prevalent in western societies (ABRAMS ET AL. 2011), whereas other cultures appreciate and even worship their seniors for their wisdom and experience.
The results of the present study confirm that the attitudes of the Swiss dental students towards elderly patients were on an acceptable level, but improvements in attitude were still possible and desirable. Interestingly, there were no differences between the participants irrespective of progressive training. Demographic factors did not influence their attitude confirming previous reports (WILSON & HAFFERTY 1980; STEVENS & PEARLMAN 1987; FIELDS ET AL. 1992). Hence, based on the findings of this survey the null hypothesis cannot be rejected. Previous studies have suggested that with advanced training, the attitude towards elders progressively improves (REUBEN ET AL. 1998). A study from Chile reported on neutral perceptions of ageing in students, whereas the attitude of faculty members was significantly more positive (LEON ET AL. 2013). The exposition to elderly persons seems to foster a positive attitude. The introduction of an “aging panel” where undergraduate students were exposed to elderly persons, and were able to ask questions, seemed also to diminish ageism (WESTMORELAND ET AL. 2009). One participant stated: “The Council of Elders provided a new and refreshing insight on the geriatric patient. Not only did they alert us to their concerns, but they helped us visualize some of our own. I feel this session will help me in future interactions with patients”. An evaluation of the appreciation of a brief rotation in a long-term care (LTC) facility of undergraduate students and again, the exposure to the elders was rated very positively (MACENTEE ET AL. 2005). In a German study, 463 dental students were exposed to institutionalized elders within the context of their undergraduate training, and the results confirmed changes towards a more positive attitude, although the effect was small (NITSCHKE ET AL. 2015). Therefore, it could have been expected that the GAS score from this study will increase along with the training years. Interestingly, the present results are not confirmative of this phenomenon, except for a non-significant trend in the pooled results, with Basel presenting the most obvious trend.
A possible explanation for this non-significant tendency is a lack of sufficient number of participants. Post-hoc power analysis (effect size = 0.246, ? err prob=0.05) revealed a power of 1-? err prob = 0.417 for the current survey. In order to achieve a power of 95%, a sample size of 429 students per study group was required, a sample size difficult to obtain in Switzerland at a given point in time, as the number of dental students/academic year/university is small. Nevertheless, the survey was nationally representative as all the university dental schools in Switzerland participated, and therefore the results may be considered representative for the country. Another possible explanation would be to speculate if the geriatric curricula in the four universities were dissimilar. However, the current curriculum of gerodontology followed in the Swiss universities is based on the catalogue of learning objectives from the Federal Office of Public Health. All four Swiss universities prepare their students to recognize and treat dental problems of patients with disabilities, of aging patients and of patients with systemic illnesses according to their individual needs and oral hygiene abilities. In particular, conditions as dementia, xerostomia, polypharmacy, malnutrition, anticoagulation, walking disability as well as hearing and visual impairment are being discussed in detail throughout numerous lectures during master courses, case reviews and work shadowing. Practical training is provided either over the course of the prosthetic clinical curriculum or during visits and examinations of acute or long-term geriatric patients in hospitals and residential care homes. Hence this speculation can be overruled. Previous studies evaluating the attitudes towards geriatric patients have published mixed findings; some report positive outcomes (HOLTZMAN ET AL. 1981; PERROTTA ET AL. 1981; FIELDS ET AL. 1992; CHUA ET AL. 2008; NOCHAJSKI ET AL. 2011), while others indicate no effects (FIELDS ET AL. 1992; WOOD & MULLIGAN 2000).
The overall mean GAS score of the students was 3.5±0.4 (range: min=1.79, max=4.36) which is in a position above neutral opinion and towards a positive attitude. Furthermore, the mean scores of the individual centers for any of the academic years did not fall below 3. This indicated that the attitudes of the students towards the elders were already quite good, albeit improvement would still be possible.
Another aspect that might have influenced the evaluation of the attitudes could have been the questionnaire itself. The GAS questionnaire was originally developed for medical residents in the United States and not a purpose-built ageism questionnaire for dental students. Therefore, this may have been not been sensitive enough for a true detection of attitudes. However, the GAS is considered a robust ageism questionnaire with sound psychometric characteristics (REUBEN ET AL. 1998). The instrument does not harbor a floor or a ceiling effect, and can demonstrate an adequate internal consistency reliability (NUNNALLY 1978). Moreover, the translation of this questionnaire was performed in accordance to the principles outlined by the Medical outcomes trust criteria (1997), and hence the process could be considered as robust. Perhaps the use of a specifically validated ageism questionnaire for dental students in Switzerland may have detected the attitudes more precisely, however such a questionnaire does not currently exist for Switzerland and this speculation need to be validated by future research. Conversely, the results could have been influenced by the fact that the questionnaires came from a university-setting, however, this could not be evaluated in the current study and may warrant future investigation.
The results from this Swiss survey can be summarized as follows:
• Geriatric dentistry was considered an important aspect of dental education by the undergraduate students.
• Students perceived the current geriatric curriculum on an adequate level.
• Hand-on experience in treating geriatric patients in the undergraduate curriculum was positively opinionated.
• Mobile dental services for elders with limited access to care were considered a good solution.
From the results of this survey it can be concluded, that the attitude of the Swiss undergraduate dental students towards an elderly patient is on an acceptable level, but may still be improved.
Acknowledgements
The authors would like extend their warm thanks to all the dental students from the four universities for participating in this survey. The authors would also like to thank Mrs. Elena van der Heijden, Clinic of general, Special care and Geriatric Dentistry, Center of Dental Medicine, University of Zurich, Switzerland and Mrs. Christl Hösch, Research unit, University Center of Dental Medicine Basel, University of Basel, Switzerland for their valuable support in coordinating this survey in their respective universities.