Development and preliminary validation of an ageism scale for dental students

Transcription

1 ARTICLE ABSTRACT Purpose/aim: This work presents the preliminary validation of a novel scale assessing ageism attitudes among dental students. Method and materials: A 27-question scale was created based on existing ageism scales. The new ageism scale was applied to 144 dental students. Content validity was achieved by experts consensus. Questions whose deletion increased the overall α, loading < 0.40, loading on more than one factors, or those unexpectedly grouped in another factor were thoroughly examined. Principal Component Analysis assessed internal structure of the measure. Results: The final ageism scale included four items in a single factor that explained 58.5% of the overall variance with substantially higher reliability than other factors. The Cronbach s α for this single four-items factor was Conclusions: This preliminary analysis of a novel ageism scale for dental professionals pointed to four items achieving high reliability, providing guidance for a future definitive validation study with a larger sample. KEY WORDS: ageism, older adult, aged, geriatric dentistry, dental education Development and preliminary validation of an ageism scale for dental students Ryan Rucker, DDS Candidate ; 1 Patrick B. Barlow, PhD ; 2 Jennifer Hartshorn, DDS ; 3 Laura Kaufman, DMD ; 4 Becky Smith, DDS ; 5 Anastassia Kossioni, DDS, MSc, PhD ; 6 Leonardo Marchini, DDS, MSD, PhD 7 * 1 Student, The University of Iowa College of Dentistry and Dental Clinics, Iowa ; 2 Assistant Professor, Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa ; 3 Clinical Assistant Professor, Department of Preventive and Community Dentistry, The University of Iowa College of Dentistry and Dental Clinics, Iowa ; 4 Clinical Assistant Professor, Department of General Dentistry, Boston University Henry M. Goldman School of Dental Medicine, Massachusetts ; 5 Clinical Associate Professor, Department of Restorative Clinical Sciences, University of Missouri-Kansas City School of Dentistry, Missouri ; 6 Associate Professor, Division of Gerodontology, Department of Prosthodontics, Dental School, National and Kapodistrian University of Athens, Athens, Greece ; 7 Assistant Professor, Department of Preventive and Community Dentistry, The University of Iowa College of Dentistry and Dental Clinics, Iowa. *Corresponding author leonardo-marchini@uiowa.edu Spec Care Dentist 38(1): 31-35, 2018 Introduction The world population is aging, and for the first time in human history the majority of the population can expect to reach at least 60 years of age. This has been recognized as one of humanity s major achievements. 1 However, a growing older adult population requires profound changes in the existing health care systems, as diseases burden disproportionally affect the aged cohorts. Many older adults have multiple comorbidities, with appropriate medical care compromised by many factors, including ageism. 2 The term age-ism was introduced by Butler 3 in 1961 and refers to age discrimination, or the prejudice by one group toward another age group. Ageism is prevalent and may negatively impact older populations. 4 The negative consequences include older job applicants receiving less positive ratings than young ones, stereotyping in the media, the absence or nonemphasis of geriatrics in medical and dental schools, and inappropriate medical and dental care for conditions dismissed as being part of the aging process. 5 The importance of understanding ageism in an ever-aging society led to the development and application of several tools to help researchers assess ageism among different populations and in different cultures. These tools include the Kogan scale, 6 10 the Palmore quiz, 11,12 the Fraboni scale, the UCLA-GAS scale by Reuben et al., the Maxwell and Sullivan scale, 24 and, more recently, the North and Fiske scale. 25 Those scales are either generic 8,9,11,13,25 or were initially developed to investigate the attitudes of primary care residents 17 or family practice residents 24 toward the elderly patients. There is evidence that ageism is pervasive among dental students as well. 26,27 Therefore, recent studies have suggested that geriatric dentistry courses should emphasize developing positive attitudes and empathy toward the elderly, instead 2018 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: /scd Spec Care Dentist 38(1)

2 of only increasing their geriatric-related knowledge, as intrinsic biases toward oral health-related behavior in elderly people have been recorded, including whether older people can maintain good oral hygiene, whether teeth are a priority for them, or if they can keep dental appointments. 30 To date, there is not any ageism scale specific for dentists, as the majority of the existing tools have been created to be used by physicians. Therefore, the purpose of this study was to develop and provide preliminary validation for a novel ageism scale for dental professionals. This information may help increase knowledge of potential biases and highlight the need to develop educational strategies within dental education addressing the ageism issues. Methods Dental students ageism scale development, item relevance, and content validity A group of faculty members from the U.S. and Europe with expertise in teaching geriatric dentistry (LK, BS, JH, AK, LM) met and agreed upon the need for developing a novel ageism scale for dental professionals. The experts prepared a new scale after an extensive literature review of previous questionnaires, 9,11,17,24,25 finding particularly relevant some items from the scales by Maxwell and Sullivan 24 and Reuben et al., 17 and new items were created to address dental-related situations. After several rounds of review and rewriting, a 27-item scale (Table 1 ) was approved by the panel with regard to relevance and content validity. A psychometry specialist (PB) oversaw and advised the experts group. A six-point Likert scale, with no neutral option (strongly disagree = 1, disagree = 2, slightly disagree = 3, slightly agree = 4, agree = 5, strongly agree = 6), was used for answering each item. Participants The scale was distributed to 144 thirdand fourth-year dental students. The students received a gift card as an Table 1. Twenty-seven questions elaborated for the preliminary version of the dental students ageism scale. 1. Research funding should be mainly allocated to the treatment of pediatric issues instead of geriatric ones 2. Taking a medical history from elderly patients is frequently time-consuming 3. Taking a medical history from elderly patients is frequently complex 4. I would rather treat elderly patients than younger dental patients 5. I tend to pay more attention toward my elderly patients than my younger patients 6. I tend to have more sympathy toward my elderly patients than my younger patients 7. In general, elderly people contribute a lot to society 8. Elderly patients are better off in nursing homes 9. Elderly patients tend to be more appreciative of the dental care I provide than younger patients 10. Elderly patients often won t accept recommended treatment plans 11. Elderly patients have fixed ideas about what is proper dental treatment 12. My dental treatment planning for elderly patients is consistent with my middle-aged patients 13. Elderly people do not take good care of their teeth 14. Elderly patients do not usually comply with dental advice 15. It is government s responsibility to provide dental care for elderly people 16. The elderly patient does not live long enough to make it worthwhile to invest time and effort in complex dental treatment 17. The elderly patient does not live long enough to make it worthwhile to invest money in expensive dental treatment 18. Dental treatment of elderly patients is too time-consuming 19. It is too costly to provide out of office dental care to homebound elderly patients 20. Cost is a major barrier to many elderly patients seeking dental care 21. Dental treatment is usually successful in elderly patients 22. My exposure to geriatric dentistry has been adequate 23. It is normal for elderly people to have oral problems 24. I would provide more homecare or nursing home dental treatment If I had more training 25. Elderly patients should be treated by a someone with advanced training in geriatric dentistry 26. I feel comfortable treating someone with a long medication list 27. I tend to favor extractions over extensive restorative procedures when planning treatment for an elderly patient incentive to participate, regardless of their completion of the survey. The survey was answered anonymously, and contained demographic questions including age, gender, race/ethnicity (as an open-ended question), students class year (D3 or D4), and whether they currently live or have ever lived with elderly people. Consent to participate was indicated by agreement to fill in the questionnaires. The study was approved by the University of Iowa Institutional Review Board (IRB ID # ). Statistical analysis Participant demographic characteristics were summarized using descriptive statistics such as means and standard deviations as well as frequency distributions and percentages. Item responses were also evaluated using these measures to examine the presence of normality and outlying values. A Principal Components Analysis (PCA) was used to explore the underlying factor structure of the data. Prior to interpretation, The Kaiser Meyer Olkin (KMO) test was used as a 32 Spec Care Dentist 38(1) 2018 Ageism scale for dental students

3 measure of sampling adequacy with 0.80 or greater being the ideal benchmark and less than 0.60 being inadequate. 31 Bartlett s Test of Sphericity was also used for establishing the factorability of our sample. 31 Factors with an eigenvalue of 1.0 or greater were extracted and used in concert with observable elbows in the Scree Plot as well as proportion of variance accounted for to determine the number of factors to retain. Items with factor loadings lower than 0.40 and items that loaded on multiple factors (i.e., cross-loaded) were removed until the final, most parsimonious solution was reached. Internal consistency reliability was assessed by using Cronbach s α coefficient and corrected item-total correlations were calculated. Items whose deletion increased the reliability of the measure were considered for removal, and the process was repeated. Discriminant validity was assessed by investigating relationships between the final items individually as well as their summarized total scales score in relation to age, gender, race, history of living with elderly people, and student class (D3 or D4) using independent samples t -tests and Pearson s correlations, as appropriate. All data analyses were conducted using SPSS v.24 (IBM, Inc.), were two-sided, and considered p < 0.05 as statistically significant. Results Of the 144 participants, 51.4% were men and 48.6% were women. Their mean age was ± Seventy-four were attending the 3rd year and 70 were attending the 4th and final year in dental school. Note that 13.9% of the participants had lived or were currently living with older people. One-hundred seventeen (88.6%) participants were white and 15 (10.4%) were nonwhite. The initial PCA results indicated a KMO of 0.66, which was not ideal, but considered adequate based on our guidelines, and the Bartlett s Test of Sphericity indicated that the items were appropriately interdependent to justify using PCA ( p < 0.001). Nine factors with eigenvalues greater than 1.0 were extracted in the initial solution; however, the initial Scree Table 2. Principal Components Analysis (PCA) results for final four ageism items. Component (Cronbach s α ) Factor loading Component one (Cronbach s α = 0.75) Q13 Elderly people do not take good care of their teeth.743 Q14 Elderly patients do not usually comply with dental advice.846 Q18 Dental treatment of elderly patients is too time-consuming.730 Q19 It is too costly to provide out of office dental care to homebound elderly.734 patients Plot suggested approximately 4 5 meaningful factors were present. As poorly loading and cross-loading items were removed, the PCA was run again until only four items remained in the solution: (1) Elderly people do not take good care of their teeth (.743); (2) Elderly patients do not usually comply with dental advice (.846); (3) Dental treatment of elderly patients is too time-consuming (.730); and (4) It is too costly to provide out of office dental care to homebound elderly patients (.734). These four items alone accounted for 58.5% of the overall variance, and showed considerable internal consistency with a Cronbach s α of 0.75, which is an acceptably high value (Table 2 ). While the remaining items were statistically related to one another, their interdependence was not so high as to violate issues of multicollinearity. Moreover, the remaining four items were intuitively connected to one another thematically, which, added to their reliability and high factor loadings, led to the decision to accept the final four-item, single-factor solution. Mean ratings to each of the four items as well as their composite score were compared to assess the ability for the items to discriminate among different groups (i.e., sex, training year, race, and history of living with an older adult). These results are shown in Table 3, which demonstrate that men (M = 2.40 ± 0.74) rated significantly higher than women (M = 2.07 ± 0.87) when answering Dental treatment of elderly patients is too time-consuming ( p = 0.018). Men (M = 3.19 ± 1.14) also rated significantly higher than women (M = 2.72 ± 1.01) in response to It is too costly to provide out of office dental care to homebound elderly patients ( p = 0.010) as well as their composite score ( p = 0.035). The only other statistically significant comparison was a difference between white and nonwhite students in answering, Dental Treatment of Elderly Patients is too time-consuming where white students (M = 2.17 ± 0.78) rated themselves significantly lower compared to nonwhite students (M = 2.67 ± 1.05), p = 0.028, 95% CI = 0.93 to 0.05; however, there were very few nonwhite students from which to draw this conclusion. We found no statistically significant differences between the participants ratings and their age, years of training, or history of living with elderly persons. Discussion This study has the strength to be the first, to our knowledge, to describe an ageism scale specifically tailored to dental professionals, as compared to previous ones that are generic or tailored to other health care providers. Moreover, the scale presented here was developed according to current psychometric criteria in contrast to older scales. 24 The scale proved extremely challenging to analyze. When common Factor Analysis best practices (i.e., three items to a factor, removing cross-loading and poorly loading items, etc.) were applied, the 27-item scale dwindled to a single factor with four items remaining that explained more of the overall variance and had a substantially higher reliability value than other solution/number of factors. Correlation between the four items was checked and items were not identified as confounders, and they remained acceptable. If one can achieve Rucker et al. Spec Care Dentist 38(1)

4 Table 3. Mean comparisons for individual scale items and composite score by sex, race, training year, and history of living with elderly person. Sex p Race p Year p History w/elderly p M F White Not white D3 D4 Yes No Q (0.83) 2.83 (0.8) (0.82) 2.6 (0.74) (0.85) 2.8 (0.77) (0.93) 2.83 (0.82) Q (0.87) 2.79 (0.74) (0.81) 2.67 (0.82) (0.78) 2.84 (0.85) (0.95) 2.86 (0.8) Q (0.74) 2.07 (0.87) (0.78) 2.67 (1.05) (0.81) 2.31 (0.83) (0.95) 2.21 (0.79) Q (1.14) 2.72 (1.01) (1.13) 2.93 (1) (1.12) 3.09 (1.08) (1.28) 2.95 (1.09) Total (2.86) (2.54) (2.76) (2.79) (2.74) (2.75) (3.45) 10.7 (2.66) Note: Scores are represented as mean (SD). All comparisons were made using independent samples t -tests. such high reliability and overall variance with only four items in a single factor, then it would seem to be an obvious choice to use the small scale rather than the much longer one that was originally administered. Furthermore, all four remaining in the final questionnaire were directly related to dental care. These four items summarize very important parameters that directly impact dental treatment in the elderly, with widely held beliefs among oral health care team members, including the ability of older people to take care of their teeth, their compliance to dental advice, and issues related to the time, cost, and venue of dental care. Relevant dental students perceptions on the oral health behavior of older people have been previously recorded. 30 Females tended to have a more positive attitude toward older people, in accordance to most previous studies, 4,10,25,32,33 offering an indication of the scale s discriminant validity. However, no significant gender effect was recorded among dental graduates in Belgium 28 and other health care providers in Turkey. 18 The history of living with an older person did not have any statistically significant effect on the students attitudes toward the elderly, similarly to what happened among health care providers in Turkey. 18 On the other hand, having grandparents who were alive and being connected with other old people, beside their grandparents, significantly positively influenced Iranian dental students attitudes toward elderly people, 33 indicating a potential cultural effect that requires further investigation. The student class (years of training) did not influence the students attitudes in this study, in contrast to other studies where senior students presented more positive perceptions. 10 It should be considered that specific training in gerodontology may play a more important role in the students ratings than just their years of training. Students specific training in gerodontology was not assessed in this study. The small sample size, limited to just one dental school, precludes any final conclusions regarding the instrument s discriminant validity. Some of the variables indicated the homogeneity of the group (for age and race as well) or a too small sample size in one group to obtain meaningful comparisons (too few students with a history of living with elderly people). However, the findings of this preliminary validation study are encouraging and warrant further investigation, in a larger and more diverse sample. Other important variables that might help checking for the scale discriminant validity is family income and gerodontology training, which might be included in further investigations. As a preliminary study, it was used in a single dental school with a limited sample size in order to provide preliminary data. Further study is planned for a larger sample size, in collaboration with other dental schools and later on in practicing dentists, as well as in other countries to identify any cultural differences. Conclusion The preliminary analysis of a novel ageism scale, specifically tailored to dental professionals and developed based on current psychometric criteria, pointed to four items directly related to dental care potentially achieving high reliability and provide guidance for a future validation study with a larger, more diverse sample of dental students. Acknowledgements This study was supported by The Richard L. and Nancy M. Christiansen Professorship in International Oral Health Education and Research (University of Iowa, College of Dentistry); and a University of Iowa Dental Research Grant. References 1. WHO. World report on ageing and health. World Health Organization ; Geneva, Switzerland; 2015 : Prince MJ, Wu F, Guo Y, et al. The burden of disease in older people and implications 34 Spec Care Dentist 38(1) 2018 Ageism scale for dental students

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