Predoctoral Dental Education

Dental Students’ Attitudes About Treating

Populations That Are Low-Income Rural,
Non-White, and with Special Needs: A Survey
of Four Classes at a U.S. Dental School
Carly T. McKenzie, Stephen C. Mitchell
Abstract: The aim of this study was to explore dental students’ attitudes about treating populations that are low-income rural,
non-white, and with special needs. All 259 students in all four years at one U.S. dental school were invited in January 2018 to
participate in a survey with questions about treating these three populations in the following areas: personal value, perceived
preparedness, comfort, future intent to treat, and professional responsibility. A total of 227 students completed the survey, for an
overall 87.6% response rate. By class, participants were as follows: D1 n=63, 100% response rate; D2 n=60, 98.4% response rate;
D3 n=67, 98.5% response rate; and D4 n=37, 53.6% response rate. The results showed that dental school class did not predict
willingness to treat the specified populations. Regarding populations that are rural and non-white, personal value and professional
responsibility significantly correlated with intent to treat. Women perceived stronger professional responsibility regarding treat-
ment of populations that are low-income rural (M=1.97, SD=1.09; p=0.004) and non-white (M=1.95, SD=1.07; p=0.013) than
did men (M=2.44, SD=1.23; M=2.34, SD=1.22, respectively). More advanced students reported greater preparedness regarding
populations that are rural and non-white, but not patients with special needs. Preparedness correlated with intent to treat for pa-
tients with special needs only. Women were less comfortable than men in treating patients with special needs (χ²=6.10, p=0.014).
Hometown residence had a limited effect for patients with special needs only. Rural residence did not predict students’ attitudes
about serving rural patients. Overall, the students reported positive intentions to serve populations that are low income, but
showed less confidence and willingness in treating patients with special needs, especially among women. These results suggest
that the students’ comfort in serving patients with low income was more static and less malleable than preparedness. As prepared-
ness and personal value were positively correlated, students may have found worthwhile what they felt prepared to do.
Carly T. McKenzie, PhD, is Assistant Professor, Department of Clinical and Community Sciences, Behavioral and Population
Sciences Division, School of Dentistry, The University of Alabama at Birmingham; and Stephen C. Mitchell, DMD, is Associate
Professor, Department of Pediatric Dentistry and Director of Sparks Dental Clinic for the Developmentally Disabled, School of
Dentistry, The University of Alabama at Birmingham. Direct correspondence to Dr. Carly T. McKenzie, Department of Clinical
and Community Sciences, School of Dentistry, University of Alabama at Birmingham, 1919 7th Ave. S., Birmingham, AL 35294-0007;
205-996-2208; cmckenzi@uab.edu.
Keywords: dental education, attitude of health personnel, access to care, underserved patients, vulnerable populations, social
responsibility, attitudes, minority health
Submitted for publication 8/28/18; accepted 11/14/18; first published online 3/25/19
doi: 10.21815/JDE.019.074

P
opulations with low income face a multitude of
challenges in achieving optimal oral health as
socioeconomic factors affect both general and
oral health, which are closely related.1,2 Individuals’
oral health and socioeconomic status (SES) have been
found to be positively correlated.3,4 Relationships
between income and health are of special concern
in Alabama, as it is a relatively poor state and ranks
near the bottom (46th) in per capita income.5 Dispari-
ties in oral health status based on income are evident.
Low-income Alabamians report having poor or fair
overall oral health at more than three times the rate
of their high-income counterparts.6 This low level
of oral health translates into numerous oral health-
related functional and psychosocial difficulties for
these residents.
Despite greater incidence of oral health prob-
lems, about 75% of Alabamians with low incomes
have avoided dental care due to cost.6 However, con-
cerns about cost do not fully explain income-based
oral health disparities. Oral health outcomes indicate
that public insurance may not equate to oral health
care access. For example, even though Alabama
Medicaid-eligible children (unlike adults) receive

June 2019  ■  Journal of Dental Education 669

 dental benefits, their oral health still lags behind that
of their more affluent peers. Schools with at least 75%
of students from low-SES households, as compared
to schools with less than 25% low-SES students,
have substantially more decay experience (50.7%
vs. 24.2%), untreated decay (23.5% vs. 10.3%), and
urgent need (7.3% vs. 0.6%) among their pupils.7
Non-whites in Alabama are often at the lower
end of the SES spectrum in disproportionate num-
bers. Both black and Hispanic populations have
greater percentages of people living in poverty than
whites.8 Workforce characteristics may influence
big-picture oral health outcomes. Diversity in the
health care workforce is associated with greater ac-
cess to care and better patient outcomes as well as
language barrier reduction.9,10 Prior studies called for
more dentists to practice in predominantly non-white
communities, and the lack thereof was found to be a
potential contributor to lower rates of preventive care
among non-white populations.11,12 Indeed, statistics
indicate that non-white Alabamians generally have
poorer oral health outcomes and lower preventive
care rates than their white counterparts.7,13
Populations that are low income in rural Ala-
bama experience challenges accessing dental care
at least in part due to a poorly distributed dental
workforce. Approximately 98% of the 67 counties
in Alabama have been classified as dental health
professional shortage areas (HPSAs).14 The state has
30% fewer dentists than the national rate and ranks
48th in the nation in dentist to population ratio.15
Even for the populations given dental coverage via
Medicaid, dental provider access is uneven. For
example, the four largest Alabama counties house
69% of the state’s pediatric dentists, and only 19 of
67 Alabama counties have a pediatric dentist at all.
Despite 41% of state residents living in rural areas,16
rural Alabama counties have only one dentist per
4,400 people, significantly worse than the national
average of 1:1,700.15 The majority of current dentists
in rural Alabama are over 60 years of age, and those
providers who accept Medicaid often limit the num-
ber of publicly insured patients served.17,18
Dental patients in Alabama who have spe-
cial needs such as intellectual and developmental
disabilities face additional hurdles. At present, only
one interdisciplinary facility in the state offers dental
services for these patients. According to the Centers
for Disease Control and Prevention (CDC)’s 2009-10
National Survey of Children with Special Healthcare
Needs, almost 18% of the Alabama pediatric popula-
tion has special medical needs, but the majority of
670
general practitioners are not willing and able to serve
this population.19 Given that this population incurs,
on average, almost double the amount of out-of-
pocket medical expenses of other populations, the
additional resources required to travel for dental care
are likely an additional barrier.20
Alabama depends on adequately trained general
dentists to serve these vulnerable populations, including
Medicaid-eligible children. Statistics regarding service
of Medicaid-eligible children, a proxy for low-income
status, show that Alabama needs more practitioners
willing and able to meet the oral health needs of these
populations. In 2018, Alabama averaged 571,697 eli-
gible children, but only 506 Alabama dental providers
treated more than 50 Medicaid patients.21 As dental
educators, we are responsible for ensuring that future
providers are well equipped to meet the dental needs
of all populations, including those who are low-income
rural, non-white, and with special health needs. Thus,
in conjunction with the U.S. Health Resources and
Services Administration (HRSA), the University of
Alabama at Birmingham School of Dentistry (UAB
Dentistry) implemented a multifaceted training pro-
gram designed to provide predoctoral dental students
with knowledge and experiences specific to three
low-income pediatric populations: rural, Medicaid-
eligible non-white, and those with special needs.
Data specific to Alabama’s workforce and oral health
outcomes support the focus on these populations.
The aim of this study was to explore dental
students’ attitudes about treating populations that are
low-income rural, non-white, and with special needs.
We sought to identify the self-reported attitudes of
UAB Dentistry dental students toward meeting the
oral health needs of these populations as we begin
this training program. We focused on three primary
questions: How would year in dental school correlate
with students’ attitudes about treating populations
that are underserved? What relationships would
emerge between demographic variables and self-
reported attitudes regarding each population? And
how positive and prepared would students report
feeling about treating such populations? There is
some evidence that the educational experience it-
self affects practitioner attitudes.22-24 Therefore, in
addition to addressing these questions, we wanted
to collect baseline data prior to implementation of
the multifaceted training program. Given concerns
about workforce characteristics and future capabil-
ity of the profession to meet the needs of vulnerable
patients, key demographic variables such as gender
and economic status may be relevant as well.
Journal of Dental Education  ■  Volume 83, Number 6

Methods
The University of Alabama at Birmingham
Institutional Review Board approved this study
(#300000980). We used an author-designed online
survey to examine UAB Dentistry predoctoral den-
tal students’ attitudes about treating patients from
three populations that are at-risk: low-income rural,
low-income non-white, and individuals with special
needs. All 259 students in all four years in 2017-18
were invited to participate.
Students in three of the dental classes received
the survey link via the learning management system
used for coursework. One class received the survey
link via email. Some classes were allocated in-class
time to complete the survey if desired, which ap-
peared to boost response rates. Timing and our op-
portunity to access each cohort determined survey
distribution methods. All students completed the
survey in January 2018 (T1). Students will receive
the survey at two future points (T2, T3) after
engaging in educational interventions. The T1
baseline measure reported in this article enabled a
concurrent comparison of attitudes based on year
in dental school.
The survey assessed students’ attitudes about
treating three populations that are vulnerable as
targeted by the HRSA-supported training program:
low-income rural, low-income minority, and those
with special needs. The term “minority” is used in-
terchangeably here with “non-white” as Alabama’s
population is predominantly white (65.6%) with the
largest minorities being black or African American
(26.8%) and Hispanic or Latino (4.3%).25 The term
“special needs” is widely used at our institution,
including in didactic course and rotation names,
to reference patients with intellectual and develop-
mental disabilities. For each population of interest,
questions covered the following areas from the
perspective of a treating dentist: personal value,
preparedness, comfort, future intent to treat, and
professional responsibility.
To measure personal value and perceived
preparedness, the survey used semantic differential
scales, an established method of assessing attitudes.
Semantic differential scales use pairs of word “an-
chors” that prompt respondents to indicate degree of
agreement with a concept along a continuum.26 These
scales have been widely used in attitude research,
including measurement of stereotypes,27 and have
been found to be easily understood by respondents.28
June 2019  ■  Journal of Dental Education
An additional five-point rating scale assessed level
of comfort in treating the specific population as used
in a prior study assessing similar attitudes among
dental students.29
In addition to attitudes about value, prepared-
ness, and comfort, two questions assessed perceived
personal and professional responsibility. To assess
personal responsibility, participants selected one
choice from six options regarding their own intent to
treat patients from specified populations. A question
with Likert-scale response options from 1=strongly
agree to 7=strongly disagree asked about perceived
responsibility of the dental profession as a whole
to serve each population of interest. All questions
assessing attitudes and responsibility were repeated
for each of the three populations of interest. Lastly,
respondents reported their type of hometown resi-
dence (rural/suburban/urban), gender, and highest
level of parental education.
For reliability analyses, we used Cronbach’s
alpha to assess internal validity for the personal value
and preparedness constructs. For the first research
question concerning the relationship between year
in dental school and attitudes about treating popula-
tions that are underserved, we compared cohort data.
Dental school class served as the categorical predictor
variable. For each of the three populations, outcome
variables were the following: personal value, per-
ceived preparedness, comfort, personal responsibil-
ity, and professional responsibility. For personal
value, preparedness, and professional responsibility,
a one-way ANOVA was used to determine significant
differences among the four classes. The Bonferroni
procedure informed post hoc comparisons. Use of
the chi-square test statistic (χ²) detected differences
among classes regarding comfort and personal re-
sponsibility.
Statistical analyses were used to separate each
population for investigation of the second research
question. Demographic variables (gender, parental
education, hometown residence) served as predictors.
The ANOVA procedure tested categorical predictors’
relationships with the numeric variables of personal
value, preparedness, and professional responsibility.
The chi-square test statistic (χ²) was used to investi-
gate relationships between demographic predictors
and both comfort and personal responsibility. De-
scriptive statistics and a correlation matrix further
informed the third research question, which focused
on how positive and prepared students felt in treating
vulnerable populations.
671

Results
A total of 227 students completed the survey,
for an overall 87.6% response rate. Some students
skipped items, so the number of respondents to
individual items varied. By class, participants were
as follows: D1 n=63, 100% response rate; D2 n=60,
98.4% response rate; D3 n=67, 98.5% response
rate; and D4 n=37, 53.6% response rate. Women
were 46.7% (n=101) of overall respondents. The
survey did not record respondents’ racial or ethnic
identification. Internal reliability (Cronbach’s alpha)
values indicated very strong consistency for the pre-
paredness construct and acceptable consistency for
the personal value construct for all three populations
(Table 1). These results allowed averaging the three
items in both constructs for each population.
To address how year in dental school cor-
related with the students’ attitudes about treating
the three populations, a series of one-way ANOVA
investigations compared the outcomes of personal
value, preparedness, and professional responsibility
for the D1, D2, D3, and D4 classes for each patient
population (Table 2). We found significant differ-
ences among classes on the preparedness variable
regarding populations that are low-income rural
and that are minority, with more advanced students
reporting greater perceived preparedness. Interest-
ingly, students did not report feeling significantly
more prepared to treat patients with special needs
in the upper level classes. The only significant find-
ing regarding patients with special needs related to
personal value, with the D3 class having less positive
responses than the D1 and D2 classes.

Table 1. Responses of participating students in all four classes regarding attitudes about treating three populations with
low income, by number of respondents to each prompt
Special
Prompt Category Response Options Rural Minority Needs

For me personally, I think Personal Worthwhile, Not worth it n=221, n=221, n=215,
being the treating dentist for value Unenjoyable, Enjoyable‡ α=0.668 α=0.777 α=0.699
[specified] patients would be† Important, Unimportant
When I think about personally Perceived Unprepared, Prepared‡ n=221, n=215, n=213,
providing dental treatment to preparedness Competent, Incompetent α=0.917 α=0.915 α=0.918
[specified] patients, I feel† Confident, Insecure
How comfortable are you Comfort No problem, OK, Some concern, n=223, n=219, n=215,
treating [specified] patients? Rather not, Will not N/A N/A N/A
Will you treat [specified] Intent to Yes: I will design my practice to specifically 12 13 11
patients after graduation from treat meet the needs of this population. (5.4%) (5.9%) (5.1%)
dental school? Yes: If someone from this population 141 154 92
has need of my services, they will be (62.9%) (70.3%) (42.6%)
scheduled just like any other patient.
Yes: Specific times/days or a specific 42 34 64
location will be available for this population. (18.8%) (15.5%) (29.6%)
Yes total 195 201 167
(87%) (92%) (77%)
No: My practice will not be able to 4 6 28
adequately meet the needs of this (1.8%) (2.7%) (13.0%)
population.
No: My practice will not be located near 24 12 6
patients from this population. (10.7%) (5.5%) (2.8%)
No: I am not comfortable treating patients 1 0 15
from this population. (0.5%) (6.9%)
No total 29 (13%) 18 (8%) 49 (23%)
Yes plus no total 224 219 216

Note: In each prompt, “[specified]” indicates one of the three populations of interest, as reported in the three right columns. Response
data for top three prompts are number of respondents (n) and Cronbach’s alpha assessing internal validity. Response data for fourth
prompt are n (% of total). On first two prompts, Response Options are pairs of words with which respondents indicated agreement along
a continuum between the two words.
†Semantic Differential Scales, 6-pt.
‡Reverse coded

672 Journal of Dental Education  ■  Volume 83, Number 6

Table 2. Comparison of four dental classes’ personal value, perceived preparedness, and professional responsibility scores
D1 D2 D3 D4 ANOVA
Population/Construct N Mean SD N Mean SD N Mean SD N Mean SD F p-value

Low-income rural
Personal value 62 2.29 0.94 59 1.98 0.89 65 2.30 0.96 35 1.90 0.89 2.59 0.054
Preparedness 62 3.33 1.36 59 2.79 1.12 64 2.22 0.82 35 1.99 1.20 15.95 <0.001*a
Professional responsibility 62 2.13 1.12 60 2.12 0.99 64 2.33 1.38 36 2.11 1.09 0.48 0.694
Low-income minority
Personal value 62 2.14 0.88 59 1.97 0.87 65 2.23 1.02 35 1.84 0.89 1.69 0.171
Preparedness 60 3.14 1.37 58 2.70 1.03 62 2.17 0.90 35 1.93 0.90 12.57 <0.001*b
Professional responsibility 61 2.08 1.01 59 2.12 1.10 64 2.27 1.14 35 1.94 1.14 0.63 0.594
Low-income special needs
Personal value 60 2.08 0.96 57 2.06 0.85 64 2.54 1.03 34 2.35 0.91 3.49 0.017*c
Preparedness 59 3.81 1.33 56 3.91 1.20 64 3.75 1.48 34 3.59 1.17 0.43 0.735
Professional responsibility 61 1.98 1.12 56 2.11 1.16 64 2.33 1.30 34 2.03 1.14 0.99 0.398
Note: For “Personal value” and “Preparedness,” response options ranged from 1=positive view to 7=negative view. For “Professional
responsibility,” response options ranged from 1=strongly agree to 7=strongly disagree. Students skipped some items.
*Significant at p<0.05
Bonferroni results: D1 vs. D2, D3, D4; D2 vs. D3, D4; bBonferroni results: D1 vs. D3, D4; D2 vs. D3, D4; cBonferroni results:
a

D1 vs. D3; D2 vs. D3

For the categorical outcomes of comfort treat-
ing and personal responsibility, use of the chi-square
test statistic (χ²) detected differences among classes
(Table 3). Combining answers to the comfort ques-
tion provided sufficient cell sample sizes when sepa-
rated by class. Student responses of “no problem” or
“OK” in response to “How comfortable are you treating
low-income rural/minority/special needs patients?”
were combined to form the “Yes” (i.e., comfortable)
answer category. Responses of “some concern,”
“rather not,” or “will not” were combined to form the
“No” (i.e., not comfortable) category. Responses to
the personal responsibility question (“Will you treat
this population after graduation?”) were combined
to create a dichotomous yes/no variable for chi-
square analysis. (See Table 1 for detailed summary
of responses to the personal responsibility question.)
Chi-square analyses did not detect any general trends
of willingness to treat the populations of interest
based on progression through the dental curriculum.
The next series of analyses focused on relation-
ships between demographic variables and attitudes

Table 3. Dental school class comparison for comfort treating and personal responsibility responses for two populations
with low income
Comfortable Treating Test Personal Responsibility Test
Population/Class N Yes % Yes N No % No χ² p-value Verdict N Yes % Yes N No % No χ² p-value Verdict

Rural total 176 78.9% 47 21.1% 195 87.1% 29 12.9%

Minority
D1 46 76.7% 14 23.3% 2.44 0.485 Not sig. 58 95.1% 3 4.9% 9.82 0.02* Sig.
D2 49 81.7% 11 18.3% 57 96.6% 2 3.4%
D3 54 84.4% 10 15.6% 53 82.8% 11 17.2%
D4 31 88.6% 4 11.4% 33 94.3% 2 5.7%
Total 180 82.2% 39 17.8% 201 91.8% 18 8.2%
Special needs
D1 28 46.7% 32 53.3% 5.49 0.139 Not sig. 50 82.0% 11 18.0% 5.36 0.147 Not sig.
D2 17 29.8% 40 70.2% 46 80.7% 11 19.3%
D3 21 32.8% 43 67.2% 43 67.2% 21 32.8%
D4 9 26.5% 25 73.5% 28 82.4% 6 17.6%
Total 75 34.9% 140 65.1% 167 77.3% 49 22.7%
Note: Students skipped some items. For rural patients, the differences among classes were not significant for comfortable treating
(p=0.342) or personal responsibility (p=0.263).

*Significant at p<0.05

June 2019  ■  Journal of Dental Education 673

 regarding each specified population. A few results
significantly differed based on gender, with women
reporting stronger perceived responsibility of the
dental profession as a whole than did men to treat
populations that are low-income rural and non-white
(Table 4). Another significant finding related to gen-
der is that women reported feeling less prepared and
comfortable regarding treating patients with special
needs. We combined two hometown categories to
create an inner city-urban designation in addition to
suburban and rural. Hometown residence predicted
statistically significant results for personal value
and preparedness related only to serving patients
with special needs. Students identifying an inner
city-urban hometown residence had higher positive
personal value and preparedness scores than did the
suburban group. We combined parental education
responses to form three categories: some college or
less, college degree, and advanced degree. Parental
education did not significantly relate to any variables.
The third research question concerned how
positive and prepared students reported feeling
regarding treatment of the specified populations. A
correlation matrix supplemented the prior analyses in
answering this question. Regarding personal value,
students’ views towards all three populations were
strongly correlated, but the relationship between
minority and rural personal value was the stron-
gest (r=0.767; p<0.001) (Table 5). Results among
the preparedness variables replicated this pattern.

Table 4. Significant results of demographics analyses

Population Predictor Variable Outcome Variable Test Statistic p-value

Low-income rural Gender Professional responsibility F=8.58 0.004*

Women N=114 M=1.97, SD=1.09
Men N=101 M=2.44, SD=1.23
Low-income minority Gender Professional responsibility F=6.25 0.013*
Women N=115 M=1.95, SD=1.07
Men N=101 M=2.34, SD=1.22
Low-income special needs Gender Preparedness F=6.96 0.009*
Women N=112 M=4.01, SD=1.25
Men N=100 M=3.54, SD=1.33
Gender Comfortable treating χ²=6.10 0.014*
Women N=113 27.4% Yes, 72.6% No
Men N=101 43.6% Yes, 56.4% No
Hometown Personal value F=5.03 0.007*a
Inner city-urban (N=55) M=2.02, SD=1.00
Suburban (N=121) M=2.44, SD=1.00
Rural (N=38) M=2.02, SD=0.63
Hometown Preparedness F=5.45 0.005*a
Inner city-urban (N=54) M=3.28, SD=1.33
Suburban (N=121) M=3.97, SD=1.24
Rural (N=38) M=3.89, SD=1.39
Note: Response options on “Preparedness” and “Personal value” ranged from 1=positive view to 7=negative view.
Response options on “Professional responsibility” ranged from 1=strongly agree to 7=strongly disagree. Students
skipped some items.
*Significant at p<0.05
a
Bonferroni results: urban vs. suburban

Table 5. Correlation matrix for personal value of and preparedness to serve specified populations with low income
Rural Minority Special Needs Rural Minority Special Needs
Correlation Personal Value Personal Value Personal Value Preparedness Preparedness Preparedness

Rural personal value 1.00 0.767* 0.557* 0.299* 0.282* 0.249*

Minority personal value 1.00 0.587* 0.302* 0.341* 0.218*
Special needs personal value 1.00 0.082 0.106 0.387*
Rural preparedness 1.00 0.878* 0.467*
Minority preparedness 1.00 0.446*
Special needs preparedness 1.00
*Significant at p≤0.001

674 Journal of Dental Education  ■  Volume 83, Number 6

Examination of correlations among the personal
value and preparedness variables indicated consistent
positive relationships. Interestingly, the strongest of
these was between special needs personal value and
special needs preparedness, although the former did
not show significant correlations with either of the
other preparedness variables.
Finally, a series of one-way ANOVAs evaluated
the effect of perceived personal value, preparedness,
and professional responsibility regarding intent to
treat. For both the populations that are low-income
rural and minority, personal value and professional
responsibility significantly predicted whether a
student answered yes or no for intent to treat after
graduation (Table 6). Preparedness had no bearing
on these results for minority and rural populations,
but did predict intent to treat patients with special
needs along with the other two significant predictors.
Students who reported intending to treat patients with
special needs reported feeling significantly more
prepared than did students who did not intend to treat
members of this population.
Discussion
Taken together, these results indicate that the
vast majority of these dental students had a positive
intention to treat patients in the three specified at-
risk populations, especially low-income rural and
non-white patients. Approximately three-fourths of
the students reported intending to treat patients with
special needs. Intent to serve at-risk patients did not
appear to change much as the students progressed
through dental school. Some prior research indicated
a negative effect of dental education and practice on
provider attitudes about service to at-risk popula-
tions.22,30 In Habibian et al.’s study, students reported
feeling personal responsibility and impact-potential
for treating populations with low income, although
their self-reported capability declined over time.22
Our study’s findings did not indicate such a trend
based on advanced class status, but coincided with
a general feeling of personal responsibility among
these students towards at-risk populations.
Our findings did indicate that the D3 class had
slightly greater resistance than the other classes to
treating at-risk populations. This finding may be a
characteristic of this particular cohort, or it may be
an artifact of the third year generally—a notoriously
difficult period in predoctoral dental education. How-
ever, small cell sample sizes affected interpretation
and precluded broad generalization of this finding.
Nevertheless, the consistently positive correlations
between preparedness and personal value hint that
students may find worthwhile what they feel prepared
to do. Similarly, Rohra et al. found that students’
participation in high-quality, community-anchored
educational activities positively affected their at-
titudes about treating vulnerable populations. 31
This finding may have more to do with increased
confidence than population exposure, especially
for patients with special health needs, for whom
additional training is particularly warranted. As a
result, some students may diminish the importance
of serving those patients whom they feel unprepared

Table 6. Relationship between intent to treat and personal value, preparedness, and professional responsibility
Intent to Treat: Yes Intent to Treat: No ANOVA
Population/Construct N Mean SD N Mean SD F p-value

Low-income rural
Personal value 193 2.02 0.82 27 3.04 1.21 32.09 <0.001*
Preparedness 193 2.63 1.22 27 2.82 1.03 0.58 0.446
Professional responsibility 194 2.04 1.08 28 3.18 1.22 26.33 <0.001*
Low-income minority
Personal value 200 1.97 0.86 18 3.15 1.04 29.93 <0.001*
Preparedness 197 2.52 1.19 17 2.84 0.99 1.18 0.279
Professional responsibility 201 2.00 1.04 18 3.56 1.42 35.00 <0.001*
Low-income special needs
Personal value 166 2.03 0.80 48 3.04 1.07 49.72 <0.001*
Preparedness 165 3.55 1.32 48 4.58 0.95 25.30 <0.001*
Professional responsibility 167 1.92 1.01 48 2.85 1.46 25.99 <0.001*
Note: For “Personal value” and “Preparedness,” response options ranged from 1=positive view to 7=negative view. For “Professional
responsibility,” response options ranged from 1=strongly agree to 7=strongly disagree. Students skipped some items.
*Significant at p≤0.001

June 2019  ■  Journal of Dental Education 675

 to treat. If so, the feeling of increased preparedness
that accompanies progression through dental school
may moderate decreasing idealism. Future research
will need to investigate this potential relationship
with other cohorts.
Not surprisingly, year in school did predict
perceived preparedness to treat patients who are low-
income rural and minority, with each class from D1
to D4 reporting greater preparedness. These patients
are part of the population treated in the school’s clin-
ics, and students provide patient care at external sites
with high percentages of rural and non-white patients.
Unfortunately, this trend did not emerge for patients
with special needs, as it appears that dental educa-
tion did not significantly help the students feel more
prepared to serve those patients. Although students do
not typically treat patients with special needs in the
school’s clinics, they do complete external rotations
in a location that exclusively serves individuals with
intellectual and/or developmental disabilities. Given
that these patients often require more complex dental
care and/or special considerations during treatment
planning, on the face it seems counter-intuitive that
educational progression would not positively influ-
ence perceived preparedness. However, advancement
in training often fosters better understanding of one’s
own capabilities and limitations. Further research
should explore the mechanism behind this finding to
determine how best to increase perceived prepared-
ness to treat these patients.
Year in school also did not predict these stu-
dents’ level of comfort in treating at-risk patients,
indicating that comfort was more static and less mal-
leable than preparedness. In other words, the students
reported feeling better prepared to serve rural and
minority patients with low income, but not neces-
sarily more comfortable. Interestingly, the D3 class
also reported less personal value serving patients with
special needs than did students in the first two years.
Prior studies have found varying effects of
gender in treatment of populations that are under-
served.22,30,32 In our study, women reported greater
perceived professional responsibility for popula-
tions that are rural and minority, which is consistent
with other research.22,30 However, this gender-based
correlation was not found for patients with special
needs. Women reported feeling less prepared and less
comfortable than men in treating this population. This
finding is consistent with the possibility that students
may downplay responsibility for populations they
lack confidence in treating.
676
Hometown residence predicted students’ per-
sonal value and preparedness scores regarding treat-
ing patients with special needs, with inner city-urban
students reporting more personal value and greater
preparedness to serve these patients than did their
suburban peers. This limited effect of hometown
residence is interesting and may result from greater
experience in a more diverse community. However,
our findings were consistent with other research
that found that rural/urban residential status was
not a consistent predictor of attitudes about serving
vulnerable populations,22,32 including rural patients.
A consistent trend did emerge in that the
responses showed strong overlap between per-
sonal value and perceived preparedness regarding
populations that are rural and minority low-income.
Although these populations have some distinct char-
acteristics, students’ responses on the two strongly
correlated with one another. In addition, within each
population, responses showed the strongest agree-
ment between personal value and preparedness. If
students reported feeling prepared, they were more
likely to report greater personal value as well. This
correlation was most evident for patients with special
needs. Correlations do not inform causality, but it
may be that, by increasing perceived preparedness,
students will see increased personal value in serving
these populations as well.
As expected, the students who reported greater
personal value regarding serving these populations also
answered affirmatively for intent to treat. Analysis of
professional responsibility’s relationship with intent
to treat mirrored this correlation as well. Prepared-
ness made a difference in intent to treat patients with
special needs only but was not significantly related
to intent to treat either rural or minority patients.
This study had several limitations. First, the D4
response rate was lower than that of the other classes.
This difference was likely a result of how the survey
was distributed. The D4 students received the survey
link embedded as an optional assignment in an online
course and did not have in-class time allocated to
complete the survey. An additional factor may be sur-
vey fatigue among second-term D4 students, a time
in the curriculum when students are inundated with
surveys. Other limitations of this study also relate
to the sample. All students attended the same dental
school, limiting the generalizability of the results.
Although different cohorts mitigated this limitation
somewhat, characteristics of this particular envi-
ronment such as curriculum, student body, faculty,
patient populations, and external rotation experiences
Journal of Dental Education  ■  Volume 83, Number 6
may have affected responses. Additionally, those stu-
dents who are most resistant to serving the specified
patient populations may have opted out of the survey
at higher rates. If present, this bias may be mitigated
by the repeated measures design. However, respondents
may not have answered questions honestly due to
perceived social pressure regarding desired responses,
leading to potential desirability bias. Even though the
surveys were anonymous, accurate self-assessment of
bias and perceived responsibility regarding vulnerable
populations is difficult. Another limitation is that this
study cannot inform conclusions about change over
time, as we collected only cross-sectional, baseline
data. Finally, intended behavior differs from executed
behavior. Follow-up research should explore the cor-
relation between students’ treatment intentions and
future patients treated.
Conclusion
The dental students in this study largely re-
ported a high degree of responsibility for and future
intent to treat populations that are at-risk after gradu-
ation. Progression through dental education did not
have a significant effect on students’ self-reported
preparedness to treat patients with special needs. As
these findings suggest that students may have found
worthwhile what they felt prepared to do, educational
interventions designed to familiarize students with
care of special needs patients in particular would be
worthwhile.
Acknowledgments
This project was supported from funding
provided by the U.S. Health Resources and Services
Administration Predoctoral Pediatric Training in
General Dentistry and Dental Hygiene (HRSA-17-068).
REFERENCES
1. Frieden TR. A framework for public health action: the health
impact pyramid. Am J Public Health 2010;100(4):590-5.
2. Sheiham A. Oral health, general health, and quality of life.
Bull World Health Org 2005;83(9):644-5.
3. Sgan-Cohen HD, Mann J. Health, oral health, and poverty.
J Am Dent Assoc 2007;138(11):1437-42.
4. Petersen PE, Kwan S. The 7 th WHO global confer-
ence on health promotion: towards integration of oral
health (Nairobi, Kenya, 2009). Community Dent Health
2010;27(Suppl 1):129-36.
5. U.S. Department of Commerce, Bureau of Economic
Analysis. GDP & personal income regional data. 2018.
At: www.bea.gov/iTable/index_regional.cfm. Accessed
10 Oct. 2018.
June 2019  ■  Journal of Dental Education
6. Health Policy Institute, American Dental Association. Oral
health and well-being in Alabama. 2018. At: www.ada.
org/~/media/ADA/Science%20and%20Research/HPI/
OralHealthWell-Being-StateFacts/Alabama-Oral-Health-
Well-Being.pdf. Accessed 10 Oct. 2018.
7. Alabama Department of Public Health. The oral health
of Alabama’s kindergarten and third grade children com-
pared to the general U.S. population and Healthy People
2020 targets. 2013. At: www.astdd.org/docs/al-3rd-grade-
bss-2011-2013.pdf. Accessed 10 Jan. 2018.
8. Center for American Progress. Alabama, 2016. TalkPoverty.
org. At: talkpoverty.org/state-year-report/alabama-2016-
report/. Accessed 10 Jan. 2018.
9. Institute of Medicine and National Research Council.
Improving access to oral health care for vulnerable
and underserved populations. 2011. At: www.hrsa.gov/
sites/default/files/publichealth/clinical/oralhealth/
improvingaccess.pdf. Accessed 10 Jan. 2018.
10. Patrick DL, Lee RSY, Nucci M, et al. Reducing oral health
disparities: a focus on social and cultural determinants.
BMC Oral Health 2006;6(Suppl 1):S4.
11. Dasanayake AP, Li Y, Chhun N, et al. Challenges faced by
minority children in obtaining dental care. J Health Care
Poor Underserved 2007;18(4):779-89.
12. Drury TF, Garcia I, Adesanya M. Socioeconomic dispari-
ties in adult oral health in the United States. Ann New
York Acad Sci 1999;896:322-4.
13. Dasanayake AP, Li Y, Wadhawan S, et al. Disparities in
dental service utilization among Alabama Medicaid chil-
dren. Community Dent Oral Epidemiol 2002;30:369-76.
14. Phillips N. Dental health professional shortage areas:
October 2017. Alabama Office of Primary Care &
Rural Health. 2017. At: www.alabamapublichealth.
gov/ruralhealth/Dental%20HPSA%20Map%20-
%20October%202017.pdf. Accessed 10 Jan. 2018.
15. StateMaster. Health statistics: total dentists (per capita) by
state. At: www.statemaster.com/graph/hea_tot_den_percap-
health-total-dentists-per-capita. Accessed 10 Jan. 2018.
16. U.S. Department of Commerce, Economics and Statistics
Administration. Alabama: 2010 census of population and
housing. 2012. At: www.census.gov/prod/cen2010/cph-2-
2.pdf. Accessed 10 Jan. 2018.
17. Health Policy Institute, American Dental Association.
Practicing Alabama dentists. Chicago: American Dental
Association, 2017. 
18. University of Alabama at Birmingham School of Dentistry.
Alabama dental practice resource service. At: uabcsch.maps.
arcgis.com/apps/MapJournal/index.html?appid=579cd34
7475247598ef40bbc4cc5de4e. Accessed 1 March 2018.
19. Data Resource Center for Child and Adolescent Health,
Child and Adolescent Health Measurement Initiative.
2009-10 national survey of children with special health-
care needs. At: childhealthdata.org/browse/survey/
results?q=1792&r=2. Accessed 30 Apr. 2018.
20. Newacheck PW, Kim SE. A national profile of health
care utilization and expenditures for children with
special health care needs. Arch Pediatr Adolesc Med
2005;159(1):10-7.
21. Alabama Medicaid Agency. Dental statistics FY 2010-17.
At: www.medicaid.alabama.gov/documents/4.0_
Programs/4.2_Medical_Services/4.2.2_Dental/4.2.2_
Dental_Stats_Report_5-3-17.pdf. Accessed 10 Oct. 2018.
677
 22. Habibian M, Seirawan H, Mulligan R. Dental students’
attitudes toward underserved populations across four years
of dental school. J Dent Educ 2011;75(8):1020-9.
23. Major N, McQuistan MR, Qian F. Changes in dental stu-
dents’ attitudes about treating underserved populations:
a longitudinal study. J Dent Educ 2016;80(5):517-25.
24. Brown BR, Inglehart MR. Orthodontists’ and orthodontic
residents’ education in treating underserved patients:
effects on professional attitudes and behavior. J Dent Educ
2009;73(5):550-62.
25. U.S. Department of Commerce. QuickFacts Alabama. At:
www.census.gov/quickfacts/al. Accessed 12 Oct. 2018.
26. Osgood CE, Tannenbaum PH, Suci GJ. The measurement
of meaning. Urbana: University of Illinois Press, 1957.
27. Prothro ET, Keehn JD. Stereotypes and semantic space.
J Soc Psychol 1957;45:197-209.
28. Heise DR. The semantic differential and attitude research.
In: Summers GF, ed. Attitude measurement. Chicago:
Rand McNally, 1970:235-53.
678
29. Kuthy RA, McQuistan MR, Riniker KJ, et al. Students’
comfort level in treating vulnerable populations and future
willingness to treat: results prior to extramural participa-
tion. J Dent Educ 2005;69(12):1307-14.
30. Behar-Horenstein LS, Feng X. Dental student, resident,
and faculty attitudes toward treating Medicaid patients.
J Dent Educ 2017;81(11):1291-300.
31. Rohra AK, Piskorowski WA, Inglehart MR. Community-
based dental education and dentists’ attitudes and behavior
concerning patients from underserved populations. J Dent
Educ 2014;78(1):119-30.
32. Holtzman JS, Seirawan H. Impact of community-
based oral health experiences on dental students’ at-
titudes towards caring for the underserved. J Dent Educ
2009;73(3):303-10.
Journal of Dental Education  ■  Volume 83, Number 6