|Year : 2018 | Volume
| Issue : 1 | Page : 23-31
|Relationship between attitude toward persons with dementia and knowledge of dementia in Taiwanese dental hygiene students: A cross-sectional study
Sumio Akifusa1, Hsiu-Yueh Liu2, Mao-Suan Huang3, Madoka Funahara1, Maya Izumi1, Kazuaki Harada1, Yasuo Shono1
1 School of Oral Health Sciences, Faculty of Dentistry, Kyushu Dental University, Kitakyushu, Fukuoka, Japan
2 Department of Oral Hygiene, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Research Center for Biomedical Devices, School of Oral Hygiene, Taipei Medical University, Taipei, Taiwan
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|Date of Submission||24-Oct-2019|
|Date of Decision||12-May-2020|
|Date of Acceptance||25-Jun-2020|
|Date of Web Publication||19-Feb-2021|
| Abstract|| |
Purpose: In an aging society, fostering an appropriate attitude toward persons with dementia and knowledge of dementia is important for dental hygiene students. This study aimed to investigate the factors related to the attitude and the knowledge.
Subjects and Methods: Between May and June 2019, 227 students of two universities in Taiwan were surveyed. We developed the Taiwanese versions of the dementia attitude, knowledge, and ageism scales from Japanese versions. Data related to an association with persons with dementia and older adults were also collected.
Results: Data from 186 students were used in the analysis. Scores of the attitude and ageism scales were significantly correlated; however, scores of the knowledge assessment scale were not correlated with those of the other two scales. Interest in dementia was associated with positive attitude, and association of persons with dementia with higher knowledge. Desire to work with patients with dementia was associated with positive attitude and lower ageism, but not knowledge. Binomial logistic regression analysis revealed ageism was correlated with attitude (1 odds ratio: 1.12, confidence interval 1.07–1.18, P < 0.001.
Conclusions: The attitude toward persons with dementia was associated with ageism, but not knowledge in Taiwan dental hygiene students. As the study year increased, the attitude was more negative.
Keywords: Ageism, attitude, dementia, dental hygiene students, knowledge
|How to cite this article:|
Akifusa S, Liu HY, Huang MS, Funahara M, Izumi M, Harada K, Shono Y. Relationship between attitude toward persons with dementia and knowledge of dementia in Taiwanese dental hygiene students: A cross-sectional study. J Educ Ethics Dent 2018;8:23-31
|How to cite this URL:|
Akifusa S, Liu HY, Huang MS, Funahara M, Izumi M, Harada K, Shono Y. Relationship between attitude toward persons with dementia and knowledge of dementia in Taiwanese dental hygiene students: A cross-sectional study. J Educ Ethics Dent [serial online] 2018 [cited 2021 Apr 18];8:23-31. Available from: https://www.jeed.in/text.asp?2018/8/1/23/309667
| Introduction|| |
The Taiwanese population is rapidly aging at a rate of 12.1%. According to Taiwan Alzheimer's Disease Association, the number of persons with dementia is 227 thousands and those with mild cognitive impairment is 524 thousands, indicating that the promotion of policy measures against dementia is a pressing issue. A recent comprehensive review revealed that older adults with dementia suffered from the high levels of dental plaque accumulation, root caries, gingival bleeding, periodontitis, stomatitis, mucosal lesions, and reduced salivary flow. Residents in the aged care facilities frequently have poor dental and oral hygiene due to neglect by the facility staff, unless oral hygienists intervene oral care. In the hospitals, older adults with dementia tend to be provided substandard care. A study of the National Health Insurance database of Taiwan revealed that the odds of dental care utilization by older adults with dementia was 0.55 (confidential interval [CI] = 0.52–0.59), suggesting that the persons with dementia received less dental care. As the population of older adults is increasing, the demand for oral care in older adults with dementia will increase both in the dental clinics and during dental home visits. To provide appropriate oral care for persons with dementia, it is crucial for dental professionals to possess adequate basic knowledge of dementia and a positive attitude toward persons with dementia. However, as far as we know, there was no information on the attitude toward and the knowledge of Taiwanese dental hygiene students, which constitute the future workforce of oral care for older adults.
The aim of this study was to evaluate the relationship between the attitude toward persons with dementia and knowledge of dementia in Taiwanese dental hygiene students. In addition, the factors potentially affecting attitude, including the prevalence of ageism, an association with older adults or persons with dementia in daily life, and desire to work with dementia patients were examined.
| Subjects and Methods|| |
This study was conducted with the approval of the Medical Ethics Committee of Kyushu Dental University (No. 15-9). Informed consent was considered to have been provided by the participants when they agreed to respond to the questionnaires.
Surveys for this cross-sectional study were conducted between May and June 2019. We recruited 227 students from two universities, located at Taipei and Kaohsiung in Taiwan, with dental hygiene schools conducting a 4-year degree program. The data of participants with any missing responses to the questionnaire (41 persons) were excluded from the data analysis. Finally, 186 students were included in the study. The number of students from the first to 4th years was 47, 48, 41, and 50, respectively.
Questionnaire translation process
We followed the internationally accepted guidelines.,, First, a bilingual translation (by translator whose native language was Taiwanese and second language was Japanese) of the Dementia Attitude Scale, Dementia Knowledge Assessment Scale, and Fraboni Scale of Ageism into the Taiwanese language (forward translation) was carried out. The Taiwanese translation was checked by two native Taiwanese language experts. Second, the Taiwanese translation was sent to two additional bicultural experts (whose native language was Taiwanese and second language was Japanese), who translated it into Japanese (back-translation). This back-translated version was subsequently compared to the original Japanese version to ensure that the translations were accurate. We repeated the forward translation and back-translation procedures until the discrepancies between the original and back-translated versions were resolved.
The questionnaires involved the following topics: a daily life association with individuals with dementia, professional interest in dementia, currently living with an older adult, and living with a person with dementia. The answers for these questions were divided into Yes or No at the time of analysis. Desire to work with patients with dementia was also evaluated with the questionnaires. The desire was assessed using a 5-point Likert scale, and classified as follows: “strong desire to work,” “passable desire to work,” “neutral,” “weak desire to work,” and “no desire to work.” In this analysis, “desire to work” and “passable desire to work” were designated as Yes; and “neutral,” “not much desire to work,” and “no desire to work” were designated as No.
The attitude of the students toward persons with dementia, their knowledge of dementia, and prevalence of ageism in the students were assessed using the Taiwanese versions of the scales described in the questionnaire translation process section. Attitude toward dementia was assessed using a 4-point Likert scale, with a maximum obtainable score of 72. A higher score indicated a more positive attitude. All questions assessing dementia knowledge were to be responded to with “yes,” “no,” or “I do not know.” The response “I do not know” was classified as an incorrect answer, because it indicated that the students did not have accurate knowledge of the topic in question. The maximum obtainable score was 15. A higher score indicated greater knowledge of dementia. The prevalence of ageism was assessed using the Taiwanese version of the Fraboni Scale of Ageism developed in this study. The scale contains three domains: Discrimination, avoidance, and antilocution. The items of the scale were assessed using a five-point Likert scale, with a maximum obtainable score of 95. A higher score on the scale indicated a lower intensity of ageism. The ageism scale consists of three subdomains, antilocution, avoidance, and discrimination. The term Antilocution, is a neologism in psychology, meaning the most elementary form of prejudice.
Questionnaires for the scales for dementia attitude, knowledge, and ageism translated to Taiwanese are shown in the Appendix [Table A1], [Table A2], and [Table A3] respectively.
First outcomes were the attitude, the knowledge, and the ageism of students. Second outcomes were the factors correlating with the attitude. In the statistical analysis, factors considered potential confounders were student year, sex, and ageism. The factors considered potential effect modifiers were relationship to persons with dementia, interest in dementia, desire to work with patients with dementia, and living with older adults.
When effect size = 0.15 (medium size for multiple regression analysis), α error = 0.05, power = 0.8, and number of predictors = 7, total sample size was calculated as 103 using the G*Power 3 software (Heinrich Heine University of Dusseldorf, Dusseldorf, Germany).
All values are presented as mean ± standard deviation. Student's t-test was used for comparing between the two cohorts. The Chi-square test was used for testing independence. During post-hoc analysis of the Chi-square test, the adjusted residual was calculated to assess the difference between each cell. As post-hoc analysis for Chi-square test, adjusted residual was calculated. Internal consistency was assessed with Cronbach's α coefficients and inter-item correlation. A good-poor (G-P) analysis was used to assess discriminant validity. All participants were divided into tertiles, and the lowest and highest tertiles were compared based on total scores and domain scores, for discriminant validity, using the Mann–Whitney U-test. Binominal regression analysis was used to calculate the odds ratio for correlated variables with the dementia attitude scale. For this analysis, the participants were divided into two groups using the median of the dementia attitude scale scores. The statistical analyses were performed using the SPSS software (version 22; SPSS Japan Inc., Tokyo, Japan). Two-tailed P values were calculated in all analyses. The alpha level for significance was set at 0.05.
| Results|| |
The proportion of male participants in this study was 25.3% [Table 1]. There was no difference between the sex proportions among the various study years. The proportion of students with an experience of an association with individuals with dementia was 50.0%. The results of the calculation of the adjusted residual revealed that this proportion was statistically lower in the 2nd year and higher in the 4th year. The proportion of students with a professional interest in dementia was 75.8%; students currently living with older adults was 29.0%; students with an experience of living with dementia persons was only 9.7%; and students with a desire to work with patients with dementia was 51.6%.
[Table 2] shows the reliability of the Taiwanese versions of the Dementia Attitude Scale and Fraboni Scale of Ageism including subdomains assessed using Cronbach's α and inter-item correlation. The results of these analyses revealed that the two scales indicated good reliability. To assess the validity of the two scales, G-P analysis was performed. In all items of the two scales, the mean scores of the upper tertile group were significantly higher than those of the lower tertile group [P < 0.001, [Table A4]]. Next, the scores of the dementia attitude and ageism scales were compared between the study years [Table 3]. The scores of the attitude scale in the 2nd years were significantly higher than that of 4th year (P < 0.05, analyzed using Dunnett's t-test for post hoc analysis of one way analysis of variance). The same result was also obtained with respect to the avoidance scores. There were no significant differences in other two subdomains and total scores of the ageism scale.
|Table 2: Reliability of Taiwanese version of dementia attitude scale and Fraboni ageism scale|
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|Table 3: Comparison of dementia attitude and ageism scale between study years|
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[Table 4] shows the accuracy rate and I-T correlation coefficient for the Taiwanese version of the Dementia Knowledge Assessment scale. The average score for the knowledge scale was 10.6 ± 32.5. The highest accuracy rate was 93.5% for question 10 “Creating familiar environment is effective in eliminating uneasiness and confusion.” The lowest accuracy rate was 11.3% for question 4 “Because it is caused by the aging of the brain, dementia affects anyone when they get old.” I-T correlation coefficient analysis demonstrated a Pearson's correlation coefficient of 0.180–0.602 for all items, with statistical significance. The total score of the 3rd year students was significantly higher than that of the 2nd year students (P < 0.05, analyzed using the Bonferroni t-test for post hoc analysis of one-way analysis of variance).
|Table 4: Item-total correlation coefficient and correct answer rate of Dementia knowledge scale for dementia Taiwanese version|
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[Table 5] shows the correlation between the dementia attitude, knowledge, and ageism scales. The scores of the attitude scale had a significant correlation with the scores of the ageism scale and its subdomains. However, the scores of the knowledge scale had no correlation with the attitude and ageism scales. The total scores and those of antilocution and avoidance, for female participants were higher than those for male participants, suggesting a lower prevalence of ageism in women [Table 6]. Students with an interest in dementia showed higher scores with the attitude and ageism scales, suggesting that these students had positive attitude toward persons with dementia and lower prevalence of ageism. Students with an experience of an association with individuals with dementia indicated higher knowledge scores, but there were no differences with respect to attitude and ageism. Although there was no statistical significance, students currently living with older adults showed a tendency to have a higher ageism scores, suggesting lower prevalence of ageism. Students with a desire to work with patients with dementia had a positive attitude and lower ageism, but there was no difference with respect to knowledge. [Table 7] shows the results of the binomial regression analysis. The students were divided into two groups using the medium of attitude score. The analysis revealed that the odds ratio of ageism was 1.12 (CI: 1.07–1.18, P < 0.001).
|Table 5: Correlation between Dementia attitude scale, knowledge scale, and Fraboni ageism scale|
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|Table 6: Comparison of attitude scale, knowledge scale and Fraboni ageism scale with awareness factors|
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|Table 7: Binominal logistic regression analysis for dementia attitude scale|
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| Discussion|| |
This is a first report on attitude toward persons with dementia, knowledge of dementia, and prevalence of ageism in dental hygiene students in Taiwan; the present study revealed that the attitude was closely correlated to prevalence of ageism, but not to knowledge. In addition, the attitude was more negative as year of study increased.
The average accuracy score of the dementia knowledge scale was 70.4% in the present study. In our previous study, the average accuracy rate was 70.7% in Japanese students, assessed using the Japanese version of dementia knowledge scale. Previous studies using other knowledge scales reported the average accuracy scores of 62%–68% in Taiwanese nurses.,, These data suggested that Taiwanese dental hygiene students had adequate knowledge of dementia. The question 4 “Because it is caused by the aging of the brain, dementia affects anyone when they get old” showed the lowest accuracy rate (11.3%), as compared to Japanese students (70.5%). Taiwanese students might understand that dementia is an inevitable symptom associated with aging.
The attitude score of the 4th year students was the lowest as compared to students of other study years, and the study year inversely correlated with attitude [Table 3]. Previously, our 4-year prospective study demonstrated that the attitude continued to be worse until the 3rd year, and then changed to a positive attitude at the end of the 3rd year. In a prospective study with nursing students in India, both attitude related to Alzheimer's disease among students in the 4th year were significantly higher than those among students in the 3rd year. As these students will form the future clinical workforce in an aged society, programs for improving the attitude toward persons with dementia will be needed. Acquirement of knowledge on dementia would have a lower effect on improvement of the attitude, because the attitude and the knowledge were not correlated in Taiwanese students. In addition, having a relationship to individuals with dementia in the course of daily life or clinical practice showed a positive effect on acquirement of adequate knowledge on dementia, but not positive attitude. The above evidence indicates the necessity of educational methods different from a conventional approach such as practical training in institutes for persons with dementia. Joining as a facilitator or a story teller in TimeSlips™, creative storytelling program with persons with dementia, improved the attitude of medical students. Participation in intergenerational service learning program called Opening Mind through Arts also improved the students' attitude toward older adults with dementia. Humanistic perspectives developed by these nonclinical art-centered programs are prioritized in future patient care.
This study had several limitations. The first is the timing of implementation of survey. This study was implemented from March to June, during the midterm of every study year. Eventual educational effect on the attitude or the knowledge is not yet established. Second, the design of this study is cross-sectional. Actual effect of increase in the study year was unknown. Third, the number of participants was limited, because currently there are only two universities for dental hygiene in Taiwan.
| Conclusions|| |
In our study, the attitude toward persons with dementia, knowledge of dementia, and the prevalence of ageism in Taiwanese dental hygiene students were assessed using the Taiwanese version questionnaires. This was the first study to report the attitude and knowledge of Taiwanese students toward dementia and ageism. The attitude was closely correlated with the ageism, but not with knowledge. The students of 4th year were lowest score in attitude scale, suggesting necessary educational intervention to improve the attitude of upper grade students. Fostering a positive attitude among dental hygiene students in Taiwan toward persons with dementia is critical to provide appropriate oral care for older adults.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Sumio Akifusa
School of Oral Health Sciences, Faculty of Dentistry, Kyushu Dental University, 2-6-1, Manazuru, Kokurakita-ku, Kitakyushu, Fukuoka, 803 8580
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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