Comparison of knowledge level and attitude towards obstructive sleep apnoea amongst dental and medical undergraduate students of Universiti Sains Malaysia

2.1 Study design, ethics and sample size

A comparative cross-sectional study of clinical undergraduate students from years 3, 4 and 5 of medical and dental schools of USM Health Campus was carried out. Participants were selected by non-probability stratified sampling. Ethical approval to conduct this study was obtained from the Human Research Ethics committee of USM (JEPeM Code: USM/JEPeM/17120724), along with the deans of the respective schools. Each group (consisting of year 3, 4 and 5 students from the dental and medical schools of USM) had a total of 50 students. A total of 216 participants (36 from each year; 108 from medical and 108 from dental school) were recruited without any exclusion criteria calculated using PS software.

2.2 Data collection procedure

Data collection commenced following all ethical clearances and the participants were given an outlined explanation of the study following approval of their respective department staff-in-charge. Data was collected using an English questionnaire during a face-to-face interview with the researcher and their assistant after a consent form was filled out by the participant. Total study period was October 2017 to October 2018.

Based on a study by Ojeda [14] it was reported that 60%of the respondents have knowledge regarding sleep apnoea. Power and Sample size Calculations (PS) software was used to calculate sample size based on comparing proportion. To detect the difference of 20%of the respondents with 80%of power and alpha 0.05, a sample size of 108 was calculated for each group. So therefore 108 clinical medical students and 108 clinical dental students were recruited for the study. Researcher was able to reach the sample size. No missing data was found during data collection.

2.3 Research tool

The questionnaire consisted of three parts; the first part comprises socio-demographic questions, the second part comprises 16 questions assessing knowledge of OSA, and the third part comprises four questions assessing subjects’ attitude towards OSA. The OSAKA questionnaire is a self-administered questionnaire, which was developed by Schotland and Jeffe [15]. Knowledge questions consist of 16 true or false statements about OSA with ‘I Don’t Know’ as a third option, which was scored as an incorrect response. The right answer was scored 1; the wrong answer and ‘I Don’t Know’ were scored as 0 [15]. Attitude questions consist of 4 questions assessed using a 5-point Likert scale based on five statements on the importance of OSA (Likert scale: 1 = unimportant, 2 = of little importance, 3 =moderately important, 4 = important, 5 = very important) and their confidence in identifying and managing OSA patients (Likert scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 =strongly agree) [15].

2.4 Statistical analysis

Data collected in this study were analysed in IBM SPSS version 24.0. The significance level was set at 0.05. Descriptive analysis was carried out to obtain the frequency and percentage for categorical variables (gender, degree) and the mean and standard deviation or median and interquartile range for continuous variables (age, year of study). Descriptive analysis was carried out to assess the knowledge and attitude of OSA amongst dental and medical undergraduate students of USM. The Mann–Whitney U test was carried out to compare the knowledge and attitude of OSA amongst dental and medical undergraduate students of USM.

3.1 Sociodemographic background

Table 1 shows the sociodemographic characteristics of the participants. The mean age of the participants was 23.14 years (SD = 1.105), ranging from 21 years to 28 years. The majority of the respondents (67.6%) were female.

Amongst the 216 students, 108 students were from the dental school, and 108 students were from the medical school. In Table 2, the correct responses of the undergraduate students to individual questions in the OSA knowledge questionnaire are shown. Approximately 44.4%of dental and 43.5%of medical students answered correctly, stating that women with OSA may have fatigue alone. When asked whether uvulopalatopharyngoplasty is curative for most patients with OSA, 33.3%and 36.1%of dental and medical students provided the correct answer, respectively.

Only 18.5%and 38.5%of dental and medical students, respectively, provided correct answers to questions about the prevalence of OSA amongst adults. Less than half (42.6%) of the students felt that OSA is associated to hypertension. More than half (65.3%) of the students answered correctly that overnight sleep is the gold standard diagnosis for OSA. Approximately 25.0%of the students answered correctly that laser-assisted uvuloplasty is an appropriate treatment for severe OSA. When questioned about the loss of upper airway muscle tone’s contribution to OSA, 65.7%of the students answered correctly. More than half (63.0%) of the students felt that the most common cause of OSA in children is the presence of large tonsils. Approximately 61.1%of the students answered appropriately to the question about the relationship on craniofacial and oropharyngeal examination as an assessment means for patients with OSA. Less than half (44.9%) of the students felt that alcohol at bedtime does not show any treatment effect on OSA. Approximately 46.3%of the students answered correctly to the question about the association of automobile crashes with untreated OSA. For the question about the association of collar size of 43 cm or greater in men and its link to OSA, 22.2%of students answered correctly. Among them less than half (34.7%) of the students answered correctly when asked whether “OSA is more common in women than in men”. Approximately 18.5%of the students considered that less than five apnoeas or hypopneas per hour is normal in adults. Slightly below half (46.3%) of the students answered correctly that cardiac arrhythmias may be associated with untreated OSA. When whether continuous positive airway pressure can cause nasal congestion, 31.4%and 35.2%of dental and medical students answered correctly, respectively. Approximately 16.6%and 20.3%of dental and medical students answered correctly when asked about the first-line therapy for OSA.

The overall mean value on the attitude of students towards OSA was 3.7, indicating that medical and dental students considered OSA as a very important clinical disorder and the importance of identifying patients with OSA, based on the five choices provided in the questionnaire.

When assessing the attitude of students towards OSA, the mean value of considering OSA as a clinical disorder was 3.66. Based on the answers provided, the majority of the students considered OSA as a very important clinical disorder. The mean value on attitude towards the identification of patients with OSA amongst dental and medical undergraduate students was 3.78, indicating that students consider it very important to identify patients with OSA. This finding is also based on the five options provided in the questionnaire.

When evaluating attitude towards patients with OSA, the mean value of confidence in identifying patients at risk for OSA was 3.0. Based on the answer provided, the students neither agree nor disagree on their confidence to identify patients. When assessing about the attitude on managing the patients with OSA, the mean value of their confidence for managing patients was 2.75. Based on the answers provided, the students neither agree nor disagree on their confidence level in managing patients with OSA.

When assessing the students’ attitude towards OSA based on individual questions, 0.5%of students considered OSA as an unimportant clinical disorder, whilst 2.8%of students considered it to be somewhat important. Approximately 42.6%of the students felt that OSA is an important clinical disorder, 38.9%students felt that OSA is very important, and 15.3%students stated that OSA is an extremely important clinical disorder. When inquired on the significance of identifying patients with OSA, 0.5%of the students answered that identifying patients with OSA is not important, and 3.7%of the students felt that it is somewhat important. However, 34.3%students said that it is important, and 40.7%of the students responded that identifying patients with OSA is important. Approximately 20.8%of the students said that identifying OSA in patients is important.

When the attitude of students towards patients with OSA was assessed, 6.5%strongly disagreed and answered that they are not confident in identifying patients with OSA, whilst 22.7%disagreed and said that they cannot identify patients with OSA. Approximately 40.7%of the students neither agreed nor disagreed on their ability to identify patients with OSA. Approximately 25.0%of students agreed that they can identify OSA confidently during the examination of the patient, whereas 5.1%of the students were very much confident and strongly agreed that they can identify patients with OSA.

Approximately 10.6%students were not confident enough and strongly disagreed to managing patients with OSA. Approximately 25.0%of the students disagreed and answered that they cannot manage patients with OSA. Only 15.3%of the students agreed that they can manage patients with OSA, and 2.8%of students strongly agreed that they have full confidence and competence to treat patients with OSA. Tables 3 4 show the attitude and knowledge profile of undergraduate students who participated in the study.

At 95%of significance level, significant difference has been observed in knowledge level regarding OSA (Question no 1 to Question no 18) where p < 0.05. Based on the comparison of the knowledge amongst dental and medical undergraduate students, the medical undergraduate students had greater knowledge regarding OSA.

When the attitude of dental and medical students towards OSA was assessed at a significance level of 95%where p < 0.05, the mean rank values were 99.8 and 117.2 amongst dental and medical students, respectively. When the attitude of dental and medical students towards patients with OSA was assessed at a significance level of 95%no significant difference was found where p > 0.05 and the mean rank values were 104.1 and 112.8 amongst dental and medical students, respectively. When comparing the attitude towards confidence in treating patients significant difference was seen where p < 0.05 and mean rank value was 90.3 and 126.6 for dental and medical undergraduate students. Towards OSA, medical students had an advantage over dental students based on their confidence level in identifying and treating patients with sleep disorder, such as OSA.

This finding shows that medical undergraduate students have greater knowledge and attitude towards OSA than their dental undergraduate counterparts.Table 5A and B shows a comparison of the knowledge and attitude profile of undergraduate students who participated in the study.

5.1 Sociodemographic background, knowledge, and attitude profile

Sociodemographic background exerts a remarkable effect on the knowledge and attitude of individuals on OSA [17]. Furthermore, their covert nature warrants increased awareness amongst healthcare professionals. Although < 50%dental students were aware of OSA, > 80%of students related snoring to OSA and is in agreement with previous studies [18, 19]. Similar to previous research [20], the findings suggest that dental students were academically less informed about CPAP opposed to medical students.They considered laser guided surgical intervention as a good treatment of choice for severe OSA.

In our study, less than one third of the medical and dental students agreed that CPAP therapy may cause nasal congestion. These findings are almost similar to a study carried out in Ecuador among medical graduates. But when asked that CPAP is the first line therapy for OSA or not very few of them answered correctly. These findings are contradictory to a study performed in Ecuador among newly becoming medical graduates [13].

All findings point toward the already established stigma that dental students are less informed about OSA than medical students [13]. Of the students who were informed, majority could identify the disorder as requiring clinical attention. This was concurrent with findings from Indiana dentists who considered OSA as life threatening [21].

Globally, while differences in opinion exist whether the students feel competent to administer treatment to OSA patients [13] or not [16]. Our study agreed with the latter of the two with majority of the students doubting their abilities to successfully identify cases of OSA.

5.2 Comparison of knowledge and attitude profile of dental and medical undergraduate students

Similar to other parts of the world [12], our study also found dental undergraduates were less knowledgeable about OSA than their medical counterparts. Furthermore, dental students were less concerned with patients’ sleeping disorders and were less likely to rule out possible OSA cases. Dental professionals in response suggested that medical professionals also fail to give out referrals to dental practices arguing that the practitioners are not aware of oral devices used by dentists in the treatment of OSA, As a result more detrimental consequences like neurological disorders might happened in some cases of OSA [21].

Insufficient information in dental curriculum regarding sleeping disorders may persists and lack of qualified teaching staffs are also observed which. These situation contributes to the low levels of knowledge, awareness and confidence possessed by dental undergraduates [20, 23]. Thus, our study findings indicate for a need to introduce a clear, revised sleep medicine curriculum relevant for both medical and dental school [24]. The lack of epidemiological knowledge and management skills within medical and dental students is suggested to also be a cause of inadequate exposure to such cases of sleep medicine within their undergraduate clinical curriculum thus more clinical exposure is also needed [24, 25].

The study was limited by the inevitable risk of bias within the answers obtained as well as the small sample size. Furthermore, a single centre should not represent the whole Malaysian population, and therefore future studies are recommended for larger populations ranging across different parts of Malaysia.