Disability and Health Journal 12 (2019) 65e71

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Disability and Health Journal

journal homepage: www.disabilityandhealthjnl.com

Original Article

‘Understanding Disability’: Evaluating a contact-based approach to

enhancing attitudes and disability literacy of medical students
Julie Lynch, M.Sc. a, *, Jason Last, M.B., B.Ch., B.A.O., M.Sc. b,
Philip Dodd, M.B., M.Sc., M.R.C.Psych., M.A., M.D. c, Daniela Stancila, M.D., M.R.C.P.U.K. d,
Christine Linehan, M.A., Ph.D. e
a
School of Psychology, University College Dublin, Belfield, Ireland
b
School of Medicine, University College Dublin, Belfield, Ireland
c
Consultant Psychiatrist/Director of Psychiatry at St. Michael's House, Dublin 9, Ireland
d
National Rehabilitation Hospital, Dublin, Ireland
e
Director of UCD Centre for Disability Studies, University College Dublin, Ireland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Health disparities and disparities in the provision of healthcare to people with disabilities
Received 22 January 2018 remains a topic of concern. Research demonstrates that attitudes of healthcare providers contribute to
Received in revised form this disparity. The approach to disability education and training in medical school warrants evaluation.
15 July 2018
Objectives: This study sought to investigate the efficacy of an educational intervention in cultivating
Accepted 19 July 2018
positive attitudes towards disability in medical students, and determine the specific impact of an
interaction-based hospital visit to patients undergoing neurological rehabilitation.
Keywords:
Methods: Web-based questionnaires were distributed to medical students undertaking a 12-week ‘Un-
Attitudes
Disability
derstanding Disability’ module. Measures of anxiety, attitude, competency and empathy were obtained
Medical students from 65 students at the beginning (T1), middle (T2) and end (T3) of the module. At T2, approximately
Education half of the students had completed a hospital visit and half had not.
Intergroup contact Results: Scores changed significantly across all constructs between the beginning and end of the module
suggesting a positive overall module effect. Findings confirmed a significant difference in anxiety and
empathy levels between the group of students who had completed the visit to the rehabilitation hospital
by the middle survey wave and those who had not, indicating a specific placement effect.
Conclusions: Our findings suggest that interpersonal contact with individuals with disabilities has a
distinct impact on the affective variables of anxiety and empathy. Previous research suggests that this
contributes towards improved attitudes to disability. Overall, we provide strong evidence for the in-
clusion of contact-based educational interventions in medical school to enhance students' attitudes to
disability.
© 2018 Elsevier Inc. All rights reserved.

Determining disparity in the provision of healthcare to various
populations is a complex task. Within the context of disability, this
process is complicated further by having to distinguish between
health differences that are avoidable, and those that are unavoid-
able and possibly related to the underlying health condition that
initiated the disability. Researchers have defined health disparities
for this population as differences in health status that cannot be
solely attributed to the presence of disability, and/or the provision
of disparate healthcare that is solely attributed to the presence of
disability.1,2 Contemporary research evidencing the disparities
experienced by people with disabilities suggests that inadequate
health coverage, limited access to care and poor quality care
contribute to unfavourable health outcomes for this population.3,4
An inquiry into the premature deaths of people with intellectual
disabilities in the UK, for example, suggests that 37% of deaths in
this population were avoidable and due to poor quality healthcare,
compared to just 13% in the general population.5 Research indicates
that attitudes of healthcare providers can impact the quality of care

* Corresponding author. School of Psychology, University College Dublin, Belfield, Dublin 4, Ireland.
E-mail addresses: julie.lynch@ucdconnect.ie (J. Lynch), Jason.last@ucd.ie (J. Last), Philip.dodd@smh.ie (P. Dodd), Daniela_stancila@yahoo.com (D. Stancila), Christine.
linehan@ucd.ie (C. Linehan).

https://doi.org/10.1016/j.dhjo.2018.07.007
1936-6574/© 2018 Elsevier Inc. All rights reserved.
66 J. Lynch et al. / Disability and Health Journal 12 (2019) 65e71
provided6 and can affect individuals' adaptation to their disability,
self-image and rehabilitation outcomes,7e9 highlighting the need
for more targeted educational programmes in medical school to
ensure optimum health outcomes for this vulnerable population.
With over one billion people worldwide (between 12 and 20% of
the population, depending on which statistics are interpreted)
currently estimated to be living with a disability10,11 and medical
advances steadily extending longevity for people with disabilities,
the application of research in this area is considered to be of utmost
relevance.
The importance of researching the attitudes of healthcare
providers was initially identified by Mary Paris, who reported the
direct impact of attitude on the opinions, decisions and behav-
iours of hospital staff.12 Medical students' attitudes to disability
may be shaped during their training, with far-reaching implica-
tions in their future practice of medicine. As tomorrow's doctors,
it is imperative that their training is evaluated and refined to
cultivate compassionate and empathic practitioners that are
capable of providing high quality care to people with disabilities.
Medical schools tend, by definition, to embody a medical model of
disability, whereas disability theorists argue that this perspective
reduces disability to individual deficit and fails to address the
social factors and prejudice that contributes to the overall
disability experience.13,14 An inappropriate focus on a patient's
disability rather than the presenting condition also compromises
the provision of quality healthcare.15,16 The School of Medicine at
[name removed for peer review] has challenged this approach to
disability education by implementing a 12-week compulsory
‘Understanding Disability’ module into their medical training,
comprising of taught elements and direct experience with pa-
tients with disabilities (further detailed in methodology). This
study seeks to evaluate this contact-based approach to educating
medical students on disability.
Theoretical framework
The assumptions of the intergroup contact hypothesis17 align with
the theoretical framework of this research. Originally developed
and tested from field research in the context of prejudice between
interracial groups, the intergroup contact hypothesis stipulates that
contact with individuals from a different social group or ‘outgroup’
may result in improved attitudes and reduced prejudice towards
the group in question. The three most commonly tested mediators
of this relationship have been identified as knowledge, anxiety and
empathy.18 In accordance with the declaration “Ignorance promotes
prejudice”,19 evidence in this field indicates that building compe-
tencies through increased knowledge about the outgroup (in this
case patients with disabilities) will reveal similarities between pa-
tients with disabilities and medical students to such extent that
attitudes will be improved. Similarly, intergroup contact may help
students to adopt the perspective of outgroup members, empathise
with their concerns, thereby contributing to improved intergroup
attitudes. Finally, anxiety towards the outgroup may stem from fear
of embarrassment, incompetence, threatened identity or rejec-
tion.18 Intergroup contact can reduce such threat and anxiety, thus
reducing prejudice and improving attitudes.20 Indeed, contact-
based educational programmes (which, as the name suggests,
combine contact with educational material) have been purported to
hold much promise as evidence-based strategies to reduce
discrimination and stigmatisation against certain outgroups.21 It is
expected that the hospital visit component of the module will have
a particularly strong impact on anxiety and empathy given these
constructs represent more affective, person-oriented constructs
than knowledge-based competencies.
Objectives
In essence, this research aimed to evaluate the efficacy of a
contact-based intervention grounded in intergroup contact theory
that facilitates enhanced attitudes towards people with disabilities,
taking into consideration the specific impact, if any, of the visit to
the rehabilitation hospital.
Method
Design
A quasi-experimental longitudinal design was selected for the
purpose of this study. Students were asked to complete an online
survey at the beginning (T1), middle (T2) and end (T3) of their
‘Understanding Disability’ module. A two-way mixed ANOVA
facilitated the investigation of a time effect (impact of overall
module across the three time periods), a group effect (impact of
hospital visit/associated follow-up at T2 when half the students had
completed the hospital placement and half had not) and an inter-
action effect (impact of hospital placement grouping on responses
at different times). Standardised measures of anxiety,22 attitude,23
competency24 and empathy25 were employed to measure individ-
ual change across the three time periods.
Disability module
The twelve-week module consisted of weekly lectures from allied
health professionals (e.g. physiotherapists, psychologists, occupa-
tional therapists and physicians), academics (senior lecturers) and
advocates with disabilities; applied anatomy laboratory sessions (of
relevance to disability); a one-day visit to a national rehabilitation
hospital; and finally a series of case presentations. More specifically,
the hospital visit involved students breaking into small groups of
four or five and attending an introductory lecture that included an
overview of the World Health Organization's International Classifi-
cation of Function, Disability and Health2 and history taking in a
rehabilitation setting. This introductory lecture was delivered by a
clinical tutor [DS] - a registrar in rehabilitation medicine - whose role
was to prepare the students for their interaction with the patients
and generally oversee the provision of this interaction-based edu-
cation to doctors in training. Following this, the students had the
opportunity to take history from patients admitted into one of the
neurological rehabilitation programmes (brain injury programme,
spinal cord system of care programme, or prosthetic, orthotic and
limb absence rehabilitation programme) and engage in a tutorial
during which eight patient histories from the hospital visit were
contemplated and discussed. Weekly lectures covered a broad scope
of topics relevant to intellectual, developmental, physical and sen-
sory disabilities, including but not limited to key concepts in
disability and equality legislation, community support mechanisms
for people with physical or intellectual impairments, and enhanced
anatomy and physiology knowledge to understand the pathways
interrupted within an individual with a disability rather than the
mechanism of disease or trauma. This module ran concurrently to
the rest of the medical school curriculum.
Sample
Participants were medical students enrolled in the ‘Under-
standing Disability’ module in the School of Medicine, [university
name removed for review]. The class comprised 320 undergradu-
ate, graduate entry and international medical students who were
either in their second year of a graduate 4-year programme or third
year of an undergraduate 6-year programme. Of the 320 students
 J. Lynch et al. / Disability and Health Journal 12 (2019) 65e71 67

enrolled in this module, 65 completed the survey at all three data
collection points, a response rate of 20.3%. Analyses on all four
variables revealed no baseline differences between undergraduate,
graduate entry and international medical students, therefore the
combined dataset of all student types was analysed. The mean age
of this sample of 65 students was 23.89 years, with a gender
breakdown of 52.3% male34 and 47.7% female.31 This gender
breakdown was representative of the overall class. For the purpose
of analysis, participants were placed into two groups; the group
who had completed the hospital visit by Time 2 (Group A) and the
group who had not completed the hospital visit by Time 2 (Group
B). Group A had 38 students (19 male, 19 female). Group B had 27
students, 15 male (56%) and 12 female (44%). A one-way analysis of
variance confirmed no significant difference on any baseline vari-
able between male and female students.
Materials
Demographics
Gender and age of participants were gathered at the beginning
of data collection, prior to administering the first survey.
Anxiety
This 12-item scale is a modified version of the intergroup anx-
iety scale developed by Stephan and Stephan.22 Participants are
asked how they would feel when interacting with individuals who
have a disability. The response format employs a 10-point scale
ranging from ‘Not at all’ to ‘Extremely’ on the following items:
uncertain, worried, awkward, anxious, threatened, nervous,
comfortable, trusting, friendly, confident, safe and at ease (the
latter six are reverse scored). A lower score on this scale indicates
lower levels of anxiety. The scale demonstrates good internal
consistency in this study (a ¼ 0.871).
Attitude
Symons and colleagues23 developed a 30-item questionnaire to
measure medical students' attitudes towards people with disabil-
ities. ‘Medical Student Attitudes Toward Persons with Disabilities’
comprises six factual/demographic items and 24 opinion questions
and demonstrates good internal consistency in the current study
(a ¼ 0.768). It utilises a 4-point Likert scale ranging from 1 (Strongly
Disagree) to 4 (Strongly Agree), with a higher score indicating a
more positive attitude.
Competency
‘Disability Competency’24 is a ten question self-report survey
that measures competency regarding physical and psychiatric
disability issues on a national and global scale. The response format
employs a 100-point analogue rating scale; 0 corresponds with ‘no
confidence’ and 100 corresponds with ‘highest confidence’. Stu-
dents were asked to place a slider along each line indicating their
confidence level for each competency question, thus higher scores
indicated high levels of self-reported competency. The scale dem-
onstrates good internal consistency in this population (a ¼ 0.901).
Statistical package for the social sciences (SPSS)
IBM SPSS 22.0 [IBM Corp: Armonk, NY] was used for all data
analysis.
Procedure
Ethical approval was sought and obtained from [university
name removed for blind review]'s Taught Graduate Research Ethics
Committee (TG-REC). Students were invited to participate in this
study at the beginning of the module (T1) via targeted email
facilitated by administration of [university name removed for blind
review]'s School of Medicine. This email contained a link to the
survey hosted by Qualtrics which led directly to an information
sheet, followed by an online consent form and the four different
instruments outlined above. Similar emails were issued at T2 and
T3. Qualtrics was programmed to present these instruments to
participants in random order. Students developed their own per-
sonal identification codes to facilitate the pairing of responses at
the three different survey waves while maintaining anonymity. The
survey was left open for a period of 4e5 days at each wave of data
collection and students were sent a reminder email after 72 h to
increase response rate. Data collection at T1 occurred during first
week of term (no student had yet completed the hospital visit).
Data collection at T2 was specifically coordinated so that approxi-
mately half of the students had completed their visit to the National
Rehabilitation Hospital (Group A) and half had not (Group B). Data
collection at T3 commenced in week 12 after all taught elements
were completed.
Results
A two-way mixed ANOVA with independent variables of group
(Group A and Group B) and time (T1, T2 and T3) was conducted on
the four dependent variables of anxiety, attitude, competency and
empathy to determine the efficacy of the overall module and to
explore the specific impact of the hospital visit. As per the theo-
retical background of the study, it is hypothesised that a change in
anxiety, competency and empathy scores ultimately contribute to
improved attitudes to disability. The data met all the necessary
assumptions of a mixed design ANOVA and in the case of violated
sphericity, degrees of freedom were corrected using Greenhouse-
Geisser estimates (ε). To examine our comparisons of interest
while maintaining our Type 1 error rate, a Bonferroni correction
was applied for post hoc tests when interpreting main effects and
the p value was reduced to 0.0125. The breakdown of means and
standard deviations of each variable across time and group are
provided in Table 1.
Table 1
Descriptive statistics.
Group A (n ¼ 38) T1 T2 T3
Mean SD Mean SD Mean SD

Anxiety 53.95 14.71 46.63 13.73 43.58 15.10

Empathy Attitude 67.68 6.41 70.92 6.63 72.21 7.43
Hojat25 developed the Jefferson Scale of Physician Empathy Competency 27.77 13.39 53.15 18.69 68.43 18.51
Medical Student Version (JSPE-MS) to measure empathy among Empathy 112.92 8.63 115.29 9.13 116.71 10.22
students of health professions. Participants are asked to indicate
Group B (n ¼ 27) T1 T2 T3
the extent of their agreement or disagreement with 20 different
statements, ranging from 1 (Strongly Disagree) to 7 (Strongly Mean SD Mean SD Mean SD
Agree). A higher number on the scale indicates higher agreement, Anxiety 52.22 14.75 53.74 13.64 44.85 14.44
which indicates higher levels of empathy (although it is noted that Attitude 67.67 6.53 68.67 6.81 72.33 8.34
the JSPE-MS is not disability-specific). Internal consistency for this Competency 25.98 17.35 48.93 19.50 61.11 18.63
Empathy 109.96 10.72 109.37 10.78 116.30 13.62
scale in the current study is suitable (a ¼ 0.755).
68 J. Lynch et al. / Disability and Health Journal 12 (2019) 65e71
Anxiety
A significant interaction was observed between group and time
for anxiety, F(1.809,113.938) ¼ 4.804, p < .0125, partial h2 ¼ 0.071,
ε ¼ 0.904. A test of simple effects was conducted in light of the
significant interaction.26
Group A (visited the National Rehabilitation Hospital between Wave
1 and Wave 2)
Group A demonstrated a significant decrease in anxiety scores
from Time 1 (M ¼ 53.95) to Time 2 (M ¼ 46.63) during which they
completed their hospital visit, mean difference of 7.32, 95% CI (3.05,
11.58), p < .01. This decrease in anxiety plateaued somewhat be-
tween Time 2 (M ¼ 46.63) and Time 3 (M ¼ 43.58) with the mean
difference of 3.05 not reaching significance, 95% CI (1.09, 7.20),
p > .05. The difference in anxiety scores between Time 1 and Time 3
for Group A presented as statistically significant, with a mean dif-
ference of 10.39, 95% CI (5.08, 15.66), p < .01.
Group B (visited the National Rehabilitation Hospital between Wave
2 and Wave 3)
The decrease in anxiety scores from the beginning to the end of
the module for Group B did not reach significance with the adjusted
Bonferroni, with a mean difference between Time 1 and Time 3 of
7.37, 95% CI (1.10, 13.64), p ¼ .016. In contrast to Group A, Group B
demonstrated no significant difference in anxiety scores between
Time 1 (M ¼ 52.22) and Time 2 (M ¼ 53.74), but instead demon-
strated a significant decrease in anxiety scores between Time 2
(M ¼ 53.74) and Time 3 (M ¼ 44.85), the time period during which
they completed their hospital visit, mean difference of 8.89, 95% CI
(3.97, 13.81), p < .01. These interactions are visually presented in
Fig. 1.
As evidenced from Fig. 1, the test of simple effects confirmed a
significant difference between Group A and Group B at T2,
F(1.809,113.938) ¼ 10.881, p < .01, and revealed no significant dif-
ference between Group A and Group B at either Time 1 or Time 3.
Attitude
No significant interaction occurred between group and time for
attitude, F(1.824,114.938) ¼ 1.794, p ¼ .170, partial h2 ¼ 0.028,
ε ¼ 0.912. Analysis of the main effects revealed a significant main
effect of time, F(1.824,114.938) ¼ 21.351, p < .001, partial h2 ¼ 0.253.
Further analysis of pairwise comparisons revealed a significant
improvement in attitude scores between the beginning (T1) and
the middle (T2) of the module, and between the middle (T2) and
the end (T3) of the module. Naturally, a significant difference in
attitude scores was also observed between the beginning (T1) and
the end (T3) of the module, with a mean difference of 4.60, 95% CI
Fig. 1. Difference in anxiety scores across time and group.
Fig. 2. Difference in attitude scores across time and group.
(2.65, 6.55), p < .001. There was no significant main effect of group,
F(1,63) ¼ 0.209, p ¼ .65, partial h2 ¼ 0.003. A visual representation
of the change in attitude scores over time is presented in Fig. 2.
Competency
No significant interaction was reported between time and group
for competency, F(1.642, 103.447) ¼ 0.823, p ¼ .421, partial
h2 ¼ 0.013, ε ¼ 0.821. Analysis of main effects revealed a significant
main effect of time F(1.642, 103.447) ¼ 157.476, p < .001, partial
h2 ¼ 0.714. Closer inspection of pairwise comparisons indicated
significant differences between students' competency scores across
all three time periods. The steady increase in competency scores
from Time 1 to Time 2 to Time 3 is presented visually in Fig. 3.
The mean competency score from the beginning of the module
to the end of the module reports a substantial difference of 37.90,
95% CI (31.64, 44.16), p < .001. No significant main effect of group
was reported, F(1,63) ¼ 1.461, p ¼ .231, partial h2 ¼ 0.023.
Empathy
A significant interaction was observed between group and time
for empathy, F(2,126) ¼ 3.668, p ¼ .03, partial h2 ¼ 0.055. A test of
simple effects was conducted to further explore the nature of this
result. Group A (who had completed their hospital visit by the
middle survey wave) reported no significant difference in empathy
across any of the three waves of the survey (T1 M ¼ 112.92, T2
M ¼ 115.29, T3 M ¼ 116.71). The trend of the data however, depicts
an increase in levels of empathy after the group's hospital place-
ment. Group B (who had not completed their hospital visit by the
middle survey wave) reported a significant increase in empathy
scores from T1 (M ¼ 109.96) to T3 (M ¼ 116.3), 95% CI (2.24, 10.43),
p < .01, as well as a significant increase in empathy scores from T2 to
Fig. 3. Difference in competency scores across time and group.
 J. Lynch et al. / Disability and Health Journal 12 (2019) 65e71
T3 (mean difference of 6.93, 95% CI (3.03, 10.82), p < .001), the time
period during which they completed their hospital placement.
Fig. 4 below presents the interaction between time and hospital
placement grouping.
A test of simple effects confirmed a significant difference be-
tween Group A and Group B at Time 2 when Group A had
completed their hospital placement and Group B had not,
F(1,126) ¼ 16.936, p < .01.
Overall, the findings depict a general trend in improved scores
across all constructs from the beginning to the end of the module.
The difference in scores between Group A and Group B at Time 2 is
particularly distinct for the variables of anxiety and empathy. While
the difference in empathy scores over time did not reach statistical
significance for Group A (those who had attended the hospital by
Time 2), more favourable scores (i.e. decreased anxiety, increased
empathy) at Time 2 were nonetheless evident for this group in
comparison to their counterparts (Group B). In combination, the
findings reveal a positive trend across all constructs over the
duration of the module. As mentioned previously, there were no
significant baseline differences between male students and female
students on any of the four variables. It is notable that there were
also no significant differences in anxiety, attitude, competency and
empathy between males and females after the module, as indicated
by a one-way analysis of variance.
Discussion
The objective of this study was to evaluate the efficacy of a
contact-based educational intervention for medical students that
combined taught elements of disability education with direct
experience/interaction with patients with disabilities. Ultimately it
was hypothesised that this contact-based approach would cultivate
positive attitudes towards this patient group - a fundamental step
towards reducing the healthcare disparities experienced by people
with disabilities today. Our findings reflect this, and a change in
mean scores from T1 to T3, i.e. the beginning to the end of the
module, is demonstrated across all four constructs of anxiety,
attitude, competency and empathy.
This study aimed to identify the impact, if any, of the hospital
placement component of the module to isolate the importance of
the medical students' personal interaction with the patient group.
The interactions observed between time and group at T2 suggest a
specific placement effect on the constructs of anxiety and empathy.
These results lend partial support to the theoretical framework of
intergroup contact (i.e. contact with individuals from the outgroup
improves attitudes towards the outgroup) as the researchers
identify anxiety and empathy as the principle mediators of the
attitude-contact relationship.18 Pettigrew and Tropp highlight a
possible causal sequence whereby anxiety must first be reduced
Fig. 4. Difference in empathy scores across time and group.
69
before other mediators have the potential to impact on attitude.18
The significant difference in anxiety and empathy levels between
Group A and Group B at Time 2 (when Group A had completed the
hospital visit and Group B had not) is evidence of the strength of
affective factors (as opposed to cognitive factors) with respect to
improving attitudes by means of intergroup contact. This is
something earlier research has addressed.27,28 It is likely that a
cognitively-oriented mediator such as competency (which reflects
more upon their skills as a physician and the scope of their
knowledge) would not be impacted by a contact-based experience.
It is also possible that the measures employed in this study were
simply not robust enough to accurately detect all mediation effects.
Nonetheless, the decreased anxiety and increased empathy evident
from the students' scores after their contact with patients with
disabilities in the rehabilitation hospital speaks to the crucial
importance of this interpersonal contact in truly understanding the
patient's experience and meaning of disability.
These results have far-reaching implications, most obviously for
patients with disabilities who will benefit from improved quality of
care, but also for the academic medical community, as the findings
confirm the importance of including appropriate disability educa-
tion in undergraduate and graduate programmes. Educators - both
nationally and internationally - have yet to reach a consensus about
what medical practitioners should know about people with dis-
abilities, but most will agree it extends beyond technical compe-
tence29 and an emphasis on constructs such as attitude, anxiety and
empathy is crucial. Disability affects more than one billion people in
the world today,10 thus every physician regardless of his or her
eventual speciality should expect to encounter people with dis-
abilities in clinical practice. Developing the clinical competence and
comfort levels of medical students when treating patients with
disabilities by way of such a contact-based educational intervention
has the potential to contribute to broader efforts to decrease the
health disparities for this clinical population. With regard to the
feasibility of a medical school implementing such a contact-based
approach to disability education, it is relevant to note that reha-
bilitation hospitals are but one possible avenue for engaging con-
tact between medical students and people with disabilities;
outpatient and community settings have the capacity to offer the
same crucial interpersonal interaction.
This study was not without its limitations. Overall, the research
would have benefited from a greater sample size (ideally with data
from the full cohort of medical students) and randomisation of
study participants into hospital placement groups, which was not
plausible in this study due to the pre-defined structure of the
course. Low response rates and poor participant retention is an
essential complication of web-based data collection, and it is
acknowledged that the sample of participants in this study may not
be entirely representative of the medical student population. Due
to insufficient sample size, comprehensive analyses of changes in
attitude over time by demographic variables (i.e. gender) were not
conducted. This presents an opportunity for future work as evi-
dence would suggest that male medical students hold more
negative attitudes towards disability than their female counter-
parts.30e32 This study reported no significant gender differences on
any variable, either pre- or post-intervention. Generalisability of
this finding is limited however, due to the preliminary nature of the
analysis and the small sample size. Although the implementation of
a longitudinal design enabled us to observe the development of
attitude over the course of the module, a 12-month follow-up
would provide robust evidence as to whether attitude change
was sustained. There is every possibility that future clinical place-
ments could expose young impressionable students to attending
physicians, nurses or other healthcare workers who possess unin-
formed and negative attitudes towards patients with disabilities,
70 J. Lynch et al. / Disability and Health Journal 12 (2019) 65e71
thus encouraging them to emulate such attitudes and behaviours.33
Moreover, all measures in this study are at best a proxy of behaviour
so future research would benefit from not only linking scores with
observed physician attitude and behaviour, but from connecting
recorded physician scores with patient clinical outcome. It is
important to note that the medical students in this study were
exposed to patients undergoing neurological rehabilitation who
mainly presented with physical disabilities. In light of this, the
impact of the visit to the national rehabilitation hospital on stu-
dents' scores may not be readily generalised to other patient groups
(i.e. intellectual or developmental disabilities). That being said, the
effects of intergroup contact may have similar effects across
different patient groups and further research to confirm this is
broadly recommended. Finally, the Jefferson Scale of Physician
Empathy25 is not disability-specific, and it is plausible that con-
founding factors (i.e. other modules in the curricula) may have had
an impact on students' empathy scores. Future studies may
consider integrating qualitative analysis into the study design to
further support the assertion that contact with people with dis-
abilities increases empathy. Notwithstanding the above, the study
has distinct strengths. A multi-disciplinary research team allowed
for the adoption of an approach that brought perspectives from
medicine, psychology and disability into consideration. The module
was compulsory for the students, which ruled out the possibility of
targeting a select group of students who had chosen the module
out of interest. Finally, the survey was anonymous, minimising
social desirability bias.34
Conclusion
Our findings provide robust evidence for a contact-based
approach to disability education in medical school. Over the
course of the module, students demonstrated improved attitude,
anxiety, competency and empathy. Direct contact with patients
with disabilities had a specific impact on medical students' levels of
anxiety and empathy. It is widely recommended that this approach
to disability education is implemented across medical schools
nationwide, and that accreditation standards for undergraduate
and postgraduate medical programs require the inclusion of
disability education. While this research provides robust evidence
for a feasible educational intervention that can be adopted to
enhance the preparation of medical students for clinical practice, it
is important to appreciate that physician attitude is just one of
many influencing variables of the healthcare disparities evident for
individuals with disability. Time pressure has been flagged as a
significant barrier to good communication during consultations
insofar as shorter consultations impede the potential to develop a
trusting, respectful relationship with the client. This issue is exac-
erbated when complex medical problems arise and when illnesses
are potentially complicated by a disability.35,36 Reducing healthcare
disparities will require a truly multifaceted approach in addressing
issues at the primary, secondary and tertiary levels,37 including
addressing the long-standing stigma that infiltrates societal atti-
tudes and perceptions about people with disabilities. Nonetheless,
cultivating positive attitudes to disability throughout the medical
training of tomorrow's doctors is certainly a good start.
Source of funding
This study was completed without funding.
Conflicts of interest
The authors report no conflicts of interest.
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