Substance Abuse

ISSN: 0889-7077 (Print) 1547-0164 (Online) Journal homepage: https://www.tandfonline.com/loi/wsub20

Improving medical students’ attitude toward

patients with substance use problems through
addiction medicine education

Astri Parawita Ayu, Margot van der Ven, Eva Suryani, Natalia Puspadewi,
Satya Joewana, Elisabeth Rukmini, Cor de Jong & Arnt Schellekens

To cite this article: Astri Parawita Ayu, Margot van der Ven, Eva Suryani, Natalia Puspadewi,
Satya Joewana, Elisabeth Rukmini, Cor de Jong & Arnt Schellekens (2020): Improving medical
students’ attitude toward patients with substance use problems through addiction medicine
education, Substance Abuse, DOI: 10.1080/08897077.2020.1732512

To link to this article: https://doi.org/10.1080/08897077.2020.1732512

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SUBSTANCE ABUSE
https://doi.org/10.1080/08897077.2020.1732512

ORIGINAL RESEARCH

Improving medical students’ attitude toward patients with substance use

problems through addiction medicine education
Astri Parawita Ayu, MD, PhDa,b , Margot van der Ven, MScb, Eva Suryani, MDa, Natalia Puspadewi, MD,
MMedEda, Satya Joewana, MDa, Elisabeth Rukmini, PhDa, Cor de Jong, MD, PhDb , and
Arnt Schellekens, MD, PhDb,c
a
School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia; bNijmegen Institute for Scientist-
Practitioners in Addiction, Nijmegen, the Netherlands; cDepartment of Psychiatry, Radboud University Medical Centre, Nijmegen, the
Netherlands

ABSTRACT KEYWORDS
Background: Patients with addiction often encounter negative attitudes from health care professio- Attitude; perception;
nals, including medical doctors. Addiction medicine training might improve medical students’ atti- addiction medicine
tudes toward patients with addiction problems and change the way they think about addiction. education; medical students
We evaluated the effect of comprehensive addiction medicine training on students’ attitudes and
illness perceptions and explored which perceptions are most relevant for attitude development.
Methods: In a quasi-experimental non-randomized study, fourth-year students (n ¼ 296) partici-
pated in either addiction medicine training (intervention) or one of three other blocks (control).
We used the Medical Condition Regards Scale to measure attitudes and the Illness Perception
Questionnaire Addiction version for perceptions. We analyzed the effect of the intervention using
repeated measures MANOVA. The contribution of illness perception to attitude was explored in
the intervention group using linear regression analysis. Results: Addiction medicine training
improved students’ attitudes toward patients with addiction, compared to the control group. After
the training, students expressed a less demoralized perception, a stronger perception of a coher-
ent understanding of addiction, addiction as a cyclical condition, and attributed addiction more to
psychological factors, compared to the control group. In the intervention group, attitude and
emotional representation before training and illness coherence after the training were associated
with attitude after the training. Conclusions: Addiction medicine training is effective in improving
medical students’ attitudes toward patients with addiction and changing their illness perceptions
of addiction. The development of an understanding of addiction might be particularly relevant for
attitude improvement. These findings underscore the relevance of addiction medicine training as
part of medical curricula and argue for including aspects related to attitude development in
the curriculum.

Introduction cardiovascular problems with cocaine consumption, and pul-

Addiction is a chronic relapsing condition, involving bio-
logical, psychological and social aspects.1 It is manifested in
compulsive behaviors, such as using a substance or gam-
bling. The worldwide prevalence of illicit substance addic-
tion is estimated at around 0.6% (0.4–0.9%).2 About 1% of
the global all-cause Disability-Adjusted Life Years (DALYs)
are due to illicit substance addiction.3 The most common
substance use disorders however, are alcohol and tobacco
use disorder. Alcohol and tobacco use account for 132.6 mil-
lion and 148.6 million DALYs worldwide, respectively.4,5
Addiction is often accompanied by physical and psychi-
atric complications. For example, hepatitis C and HIV infec-
tions are associated with injecting substance use,
monary disorders with marijuana smoking.3,6–8 All psychi-
atric disorders occur more commonly among patients with
substance use disorders, particularly anxiety disorders,
depressive disorders and attention deficit hyperactivity dis-
order (ADHD).9 Thus, addiction is a significant public
health problem, and all physicians will encounter patients
with addiction-related health problems in clinical practice.
Despite the importance to appropriately address addic-
tion-related problems, physicians often express negative atti-
tudes toward patients with addiction.10–12 Many of them
evaluate treating patients with addiction as unpleasant, unre-
warding, and beyond their remit.10,13 Studies among health
professionals (physicians, psychiatrists, psychologists, nurses,

CONTACT Astri Parawita Ayu, MD, PhD astri.parawita@atmajaya.ac.id School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia,
Jl. Pluit Raya No. 2 Jakarta 14440, Indonesia.
Supplemental data for this article can be accessed on the publisher’s website.
ß 2020 Taylor & Francis Group, LLC
2 A. P. AYU ET AL.
social workers) and medical students have shown a more
negative attitude toward patients with substance use
problems and addiction than that toward patients with, for
instance, diabetes, pneumonia, dementia, panic disorders,
and depression.10,14 Several authors suggest that this nega-
tive attitude affects the quality of care for these patients.12,15
Indeed, patients with addiction report that they often experi-
ence discrimination, includes receiving inadequate treatment
when accessing healthcare.16,17
The attitude of health professionals is among others asso-
ciated with their perception of a certain condition.18 For
example, medical doctors are more reluctant in treating
patients with addiction, when they believe that patients can
control their substance use themselves. Importantly, physi-
cians express widely different perceptions of addiction.
Some doctors perceive addiction as a disease, while others
believe that addiction is a choice or way of coping with
life,13 a moral weakness,19 or a social problem.20 Such per-
ceptions are thought to influence the quality of care for
patients with an addiction.15,21
Attitude and perception are, therefore, two distinct con-
cepts that have some overlapping aspects. The former
focuses on the feelings of medical doctors and their behavior
toward working with patients with a particular medical con-
dition, whereas the latter depicts their ideas and cognitions
about the illness in question. Both concepts are considered
to influence doctors’ clinical behaviors toward the patients
and can be altered by education.
A large body of studies has shown that addiction medi-
cine training in undergraduate medical education can
improve knowledge, skills, and attitudes concerning addic-
tion among medical students.22–24 Such studies involved
various types of addiction medicine training, ranging from
several hours of a workshop25 to a 3-week structured mod-
ule on addiction medicine.26 These studies generally show
improvement of medical students’ attitudes after addiction
medicine training,22,23 including alcohol,27 nicotine,24 and
substance use in pregnancy.23,24
A major drawback of these studies is that they commonly
lack rigorous designs, for example, including a control
group, pre-post measurements, and well-validated assess-
ment tools.22,23 Furthermore, no studies explored the effects
of addiction medicine training on illness perceptions of
addiction in relation to attitude development. Only one
study assessed the effect of a structured, comprehensive
addiction medicine curriculum of several weeks on under-
graduate medical students’ attitudes toward addiction.26
However, this study lacked a control group and did not
apply well-validated assessment tools.
Here, we investigate the effect of comprehensive 5-week
elective addiction medicine training on undergraduate med-
ical students’ attitudes toward patients with addiction and
their illness perceptions of addiction, compared to a control
group. Specifically, we tested the hypotheses that students in
the addiction medicine block (1) developed more positive
attitudes toward patients with addiction, and (2) changed
their perceptions of addiction, compared to those in the
other blocks. Furthermore, we explored the role of
perceptions of addiction in medical students’ attitude devel-
opment after addiction medicine training.
Methods
Study design
This is a quasi-experimental non-randomized study with pre
and post measurements. Addiction medicine training was
the intervention and three other elective pieces of training
(health care entrepreneurship, palliative care, medical educa-
tion) were the control condition.
Participants
A total of 296 fourth-year medical students of Atma Jaya
Catholic University of Indonesia participated in this study.
Some participants were recruited in 2014 (n ¼ 108), from
three elective blocks: addiction medicine (n ¼ 40), health-
care entrepreneurship (n ¼ 35) and palliative care (n ¼ 33).
Others were recruited in 2016 (n ¼ 188), from four elective
blocks: addiction medicine (n ¼ 46), healthcare entrepre-
neurship (n ¼ 47), palliative care (n ¼ 48), and medical edu-
cation (n ¼ 47). Students were not randomly allocated to
the block since they could enroll in the block of their pref-
erence. However, some students might not have been
placed in their block of preference due to limited space
availability.
Intervention
In Indonesia, medical education is divided into two levels:
preclinical and clinical. The Atma Jaya Catholic University
of Indonesia provided the above mentioned elective blocks
for fourth-year medical students at the pre-clinical level.
Each elective block runs for 5 weeks. Students at the pre-
clinical level, including in these electives, do not engage in
any clinical work.
The Addiction medicine block covered addiction topics
ranging from theoretical aspects (e.g., epidemiology, neuro-
biology, etc.) to more clinical aspects, such as assessment
and treatment, and comorbidities (see Supplemental
Material 1). The topics were provided as lectures, group dis-
cussions, problem-based learning, and case-based learning.
Students also learned to interview patients with addiction in
recovery, as a clinical skills training. The block offered field
trips to national addiction treatment centers. Students spent
approximately 40 h per week to do activities in the block,
including self-study.
Instruments
The Medical Condition Regard Scale
The Medical Condition Regard Scale (MCRS) intends to
measure attitude toward addicted patients. This is a one-
dimensional scale, which measures the degree of regard
toward patients with the medical condition under study.
The MCRS was developed among medical students using

diverse medical conditions, including heartburn, pneumo-
coccal pneumonia, depression, and intravenous drug use.14
It consists of 11 items on a six-point Likert scale (1: strongly
disagree to 6: strongly agree). Therefore, the total score
ranges from 11 to 66. Higher scores reflect more positive
attitudes toward a specific condition, but there is no cutoff
value for high versus low scores.14
The MCRS has good psychometric properties (coefficient
a ¼ 0.87, test–retest reliability ¼ .84).14 The MCRS was also
able to detect improvement of students’ attitudes toward
depression, before and after a psychiatric clinical rotation
(mean score: 48.3 and 52.1, respectively, p < .001). In add-
ition, the MCRS has been used successfully to evaluate atti-
tude development among medical27–29 and other health
professional students30–34 in previous studies.
The Illness Perception Questionnaire Addiction version
Perceptions of addiction were measured with the Illness
Perception Questionnaire Addiction version (IPQ-A). This
questionnaire is an adaptation of the revised version of
the Illness Perception Questionnaire (IPQ-R), which is
mostly used to evaluate patients’ perceptions about their
illness.35 The IPQ-R was developed based on the illness
representative, a concept to understand an illness based
on cognitive (identity, timeline, consequences, control/cure,
and cause) and emotional components.35,36 The IPQ-A
focuses on what health professionals think about the con-
dition addiction and consists of two domains: perception
(37 items) and attribution (15 items). A five-point Likert
scale (strongly disagree to strongly agree) is used for
each item.
The psychometric study of the IPQ-A revealed that it has
eight subscales for the perception domain and four subscales
for the attribution domain, which reflect similar factor struc-
tures with those of the IPQ-R.37 Moreover, the reliability of
most of its scales was good (emotional representation: 0.88
and illness coherence: 0.86) and acceptable (consequences:
0.77, smoking-alcohol: 0.78, demoralization: 0.81, and psy-
chological attribution: 0.82). Only five of them had poor
(treatment control: 0.53 and timeline cyclical: 0.63) and
questionable (timeline chronic: 0.67, patient control: 0.67,
and risk factors: 0.71) reliability.37 In addition, the IPQ-A
was able to differentiate illness perception of students from
different countries (Indonesia and the Netherlands) and
from various majors (medicine, psychology, and educa-
tional science).37
The perception subscales are: demoralization, a high score
reflects a demoralized perception of addiction; timeline
chronic, a high score reflects a perception of a chronic time-
line of addiction; consequences, a high score reflects a per-
ception of severe consequences of addiction on daily life and
social function; personal control, a high score reflects a per-
ception that the patient can control addiction; treatment
control, a high score reflects a perception that a treatment
will be helpful in managing addiction; illness coherence, a
high score reflects a perception of having a coherent under-
standing of addiction; timeline cyclical, a high score reflects
a perception of a cyclical timeline of addiction; and
SUBSTANCE ABUSE 3
emotional representations, a high score reflects a perception
of the emotional consequence of addiction.
The attribution scale reflects health professionals’ ideas
about causes of addiction, which consists of four subscales:
psychological attribution, risk factors, smoking/alcohol, and
overwork. The psychological attribution section consists of
items such as stress or worry and thinking negatively about
life. The risk factors attribution section includes items such
as a germ or virus, diet or eating habits, and accident or
injury as potential causes for addiction. High scores on a
subscale reflect a stronger belief that a factor causes addic-
tion. Since illness perception is a valence neutral concept,
representing personal beliefs about an illness36,38 the score
of the IPQ-A, being either high or low, does not indicate a
good or bad perception.
Procedure
Questionnaires were distributed in the classroom on the first
day of each elective block for the baseline measurement and
on the last day for follow-up. All participants were asked to
fill in questionnaires anonymously. Students were informed
about the study, and they provided written informed con-
sent beforehand. The ethics committee of the School of
Medicine of the Atma Jaya Catholic University of Indonesia
granted ethical clearance for this study (Format J, 7
October 2013).
Analysis
We analyzed all data using IBM SPSS software, version
24.0.39 First, we used multivariate analysis of variance
(MANOVA) to explore differences in baseline attitudes and
perceptions of addiction between the three blocks. The base-
line scores were dependent variables and the four blocks
(addiction medicine, healthcare entrepreneurship, palliative
care, and medical education) were the independ-
ent variables.
Second, we analyzed the effect of the intervention (addic-
tion medicine block) on attitudes and perceptions of addic-
tion using repeated measures MANOVA. This analysis uses
a within-subject approach, meaning that individual changes
were also tracked, by comparing pre-post measures within
subjects. The dependent variables were the attitude and per-
ception of subscale scores. The within-subjects variable was
the time (two levels: baseline and follow-up) and the
between-subjects variable was the block (addiction medicine,
versus healthcare entrepreneurship, palliative care, and med-
ical education). We used Helmert contrast analysis, in order
to analyze the difference between the intervention and the
control group.
Finally, we performed explorative linear regression analy-
ses to evaluate the predictors of the attitude after training
(follow-up) in the intervention group. The attitude follow-
up was the dependent variable (outcome). The correlations
between the follow-up attitude and all perception subscales
(baseline and follow-up) were explored. Perception subscales
that significantly correlated with the attitude at follow-up
4 A. P. AYU ET AL.
Table 1. Characteristics of participants.
Addiction medicine Healthcare entrepreneurship
(n ¼ 86)
Female, n (%) 58 (67.4)
Age, mean ± SD 20.56 ± 0.63
were included as predictors in the linear regression analysis
using the stepwise method.
Results
In 2014, in total 140 questionnaires were handed in the pre-
measurement and 153 in the post-measurement (70% and
75% response rate, respectively). Among these, 108 complete
questionnaires from both pre and post measurements were
analyzed. In 2016, 188 questionnaires were handed in (100%
response rate), both in pre and post-measurement. All ques-
tionnaires were filled in completely, and thereby they were
included in the analysis. There were no significant differen-
ces in gender and age between participants of the interven-
tion and control group. Table 1 describes the demographic
characteristics of the participants.
Baseline
At baseline, there were no differences in attitude, while only
the perception of Illness Coherence was significantly differ-
ent between addiction medicine and all other blocks
together (p ¼ .04). The Illness Coherence score of addiction
medicine block was slightly lower than that of the healthcare
entrepreneurship, the palliative block, and the medical edu-
cation block. This finding indicated that students who
enrolled in addiction medicine block perceived themselves
as having a less coherent understanding of addiction, com-
pared to their counterparts, driven by a difference with the
medical education block.
The effect of addiction medicine block on the attitude
toward addiction
There was no main effect of time on attitude, but there was
a main effect of block (F(3, 292) ¼ 3.993, p ¼ .008). This
result indicates a more positive attitude in the addiction
medicine block, compared to others. There was a significant
interaction between time and block for attitude (F(3,
292) ¼ 11.13, p < .001), indicating different attitude develop-
ment between blocks. In the intervention group, attitude
scores increased during the block (baseline: mean ¼ 44.74,
SD ¼ 6.87; follow-up: mean ¼ 47.16, SD ¼ 7.05), which was
not the case in the control condition. In two control blocks
(healthcare entrepreneurship and palliative care) the attitude
decreased significantly (baseline: mean ¼ 44.34, SD ¼ 6.00;
follow-up: mean ¼ 41.92, SD ¼ 6.55 and baseline: mean-
¼ 44.94, SD ¼ 5.77; follow up: mean ¼ 42.59, SD ¼ 5.35,
respectively). There was no change in the Medical Education
block (baseline: mean ¼ 44.89, SD ¼ 6.88; follow-up: mean-
¼ 44.94, SD ¼ 7.83).
Palliative care Medical education
(n ¼ 82) (n ¼ 81) (n ¼ 47 )
52 (63.4) 57 (70.4) 29 (61.7)
20.54 ± 0.65 20.68 ± 0.74 20.64 ± 0.61
Additionally, we did separate post hoc analyses concern-
ing the attitude changes within each intervention and con-
trol group. We found a significant effect of time in both
groups [F(1, 85) ¼ 11.232, p ¼ .001 and F(1, 209) ¼ 18.67,
p < .001), respectively]. These results suggest an improved
attitude of students in the intervention group and a decline
in the control group.
The effect of addiction medicine block on illness
perceptions of addiction
A main effect of time on perceptions of addiction was
observed, indicating that perceptions changed over time.
These perceptions were Emotional Representation (F(1,
292) ¼ 5.06, p ¼ .03), Demoralization (F(1, 292) ¼ 6.11,
p ¼ .01), Illness Coherence (F(1, 292) ¼ 14.49, p < .001),
Timeline Chronic (F(1, 292) ¼ 5.97, p ¼ .02), and Timeline
Cyclical (F(1, 292) ¼ 8.97, p < .01). There was also a main
effect of block on Demoralization (F(3, 292) ¼ 7.19,
p < .001), Illness Coherence (F(3, 292) ¼ 6.84, p < .001),
Consequences (F(3, 292) ¼ 2.78, p ¼ .04), and Timeline
Chronic (F(3, 292) ¼ 3.84, p ¼ .01).
There was an interaction between time and block for sev-
eral subscales (see Table 2). Further analysis with Helmert
Contrast showed that the change of Demoralization
(p < .001), Illness Coherence (p < .001), Timeline Cyclical
(p ¼ .01), Psychological (p ¼ .02) subscales in Addiction
Medicine block were significantly different to the
other blocks.
Table 2 describes the differences in perception and atti-
tude between the intervention and control groups. Detail
information about each block can be found in the
Supplemental Material 2.
Relationship between illness perceptions and attitude
Within the intervention group, several perception subscales
correlated with the attitude scale. Multicollinearity between
the predictors (the attitude scale before the training, the per-
ception subscales before and after the training) was not a
problem because the VIF scores were below 10 and toler-
ance was above 0.2.40 Pearson’s correlation analysis showed
only weak to moderate correlations (r < 0.5) between predic-
tors, except for Consequences baseline and Demoralization
baseline (r ¼ 0.51, p < .001).
The stepwise regression model revealed three predictors
of post-training attitude: baseline attitude, baseline percep-
tion of emotional representation and post-training illness
coherence. The attitude at baseline accounted for 28.9%,
while emotional representation at baseline and illness coher-
ence at follow up accounted for 13.5 and 3.4% of the vari-
ance in post-training attitude, respectively. The total
 SUBSTANCE ABUSE 5

Table 2. The effect of addiction medicine training on the attitude and perceptions.
Intervention (addiction medicine) Control
(n ¼ 86) (n ¼ 210)
Baseline Follow-up Baseline Follow-up
mean (SD) mean (SD) mean (SD) mean (SD) F(3, 292) pa
Attitude 44.74 (6.87) 47.16 (7.05) 44.70 (6.10) 42.85 (6.51) 11.131 .000b
(MCRS, score: 11–66)
Perception (IPQ-A, score: 1–5)
Emotional representations 3.83 (0.67) 3.96 (0.61) 3.79 (0.68) 3.90 (0.63) 5.277 .001
Demoralization 1.99 (0.49) 1.87 (0.46) 2.13 (0.51) 2.24 (0.59) 10.231 .000c
Illness coherence 3.04 (0.53) 3.81 (0.51) 3.16 (0.59) 3.14 (0.61) 36.456 .000c
Consequences 4.21 (0.49) 4.32 (0.40) 4.22 (0.52) 4.18 (0.51) 3.899 .009
Timeline chronic 3.29 (0.59) 3.57 (0.68) 3.34 (0.62) 3.40 (0.68) 4.662 .003
Patient control 3.93 (0.50) 4.02 (0.51) 3.94 (0.54) 3.89 (0.53) 1.173 .320
Timeline cyclical 3.27 (0.52) 3.29 (0.56) 3.35 (0.53) 3.48 (0.56) 1.838 .140b
Treatment control 3.48 (0.56) 3.55 (0.58) 3.58 (0.60) 3.61 (0.65) 1.496 .216
Attribution (IPQ-A, score: 1–5)
Risk factors 2.75 (0.56) 2.75 (0.68) 2.86 (0.69) 2.83 (0.65) 4.505 .004
Smoking-alcohol 4.11 (0.59) 4.23 (0.61) 4.09 (0.59) 4.06 (0.58) 1.037 .376
Psychological attributions 4.31 (0.52) 4.42 (0.44) 4.26 (0.48) 4.22 (0.48) 6.790 .000b
Overwork 3.67 (0.93) 4.04 (0.68) 3.80 (0.87) 3.71 (0.87) 4.819 .003
a
Effect of the interaction between time and block.
b
Significant difference between addiction block and other blocks (Helmert contrast) (p < .05).
c
Significant difference between addiction block and other blocks (Helmert contrast) (p < .01).
The total attitude score of the Medical Condition Regards Scale. The score of perception scales of Illness Perception Questionnaire Addiction Version. The
score of attribution scales of Illness Perception Questionnaire Addiction Version.

Table 3. Linear model of predictors of the attitude after addiction medi- control group. Finally, we found that students’ attitudes
cine training. before training and illness perceptions, namely emotional
Ba SE bb pc representation (baseline) and illness coherence (follow up),
Step 1 were associated with attitude after training.
Constant 22.49 4.27 <.001
Attitude baseline (MCRS) 0.55 0.09 0.54 <.001 The attitude improvement observed in the intervention
Step 2 group and the declining attitude in the control group sug-
Constant 13.38 4.38 <.01
Attitude baseline (MCRS) 0.40 0.09 0.39 <.001
gests that addiction medicine education contributed to stu-
Emotional representation baseline (IPQ-A) 4.18 0.95 0.40 <.001 dents’ attitude development. These findings are in line with
Step 3 previous studies showing attitude improvement after an
Constant 6.63 5.21 .21
Attitude baseline (MCRS) 0.35 0.09 0.34 <.001 hour of online module,41 a 15-h course in Screening Brief
Emotional representation baseline (IPQ-A) 3.82 0.94 0.36 <.001 Intervention and Referral to Treatment (SBIRT),42 a 1-week
Illness coherence follow up (IPQ-A) 2.72 1.20 0.20 .03 summer school for medical students,43 a 1-week rotation in
Baseline: the measurement prior to addiction medicine training. Follow up: addiction treatment care during psychiatry rotations,27 and a
the measurement after addiction medicine training.
The best model to explain the attitude after the training consisted of 3-week addiction medicine learning module.26 However,
a
three predictors. these studies lack pre and post measurements,43 a compre-
Unstandardized coefficient: correlation coefficient between predictor and out- hensive addiction medicine curriculum,27 or a control condi-
come variable. bStandardized coefficient: correlation coefficient in standard
deviation unit. cSignificance of correlation between predictor and out- tion.26,41,42 Considering such limitations, our study used a
come variable. quasi-experimental design to evaluate a comprehensive
5-week education on addiction medicine by comparing pre-
and post-measurement results between intervention and
control group. By doing this, we improved the method and
variance explained by all three predictors was 45.8%.
confirmed the results of previous studies. In fact, our find-
Table 3 describes the results of the linear regression model.
ings closely align with findings from Christison, et al., where
the attitude score of students after an addiction rotation
Discussion went up from 44 to 47, which is in the same range as in our
study.27 Therefore, it can be speculated that different types
In this study, we evaluated the effect of addiction medicine of addiction medicine education can be beneficial for stu-
training (intervention) on medical students’ attitudes toward dents’ attitude development.
patients with addiction and their illness perceptions of The observed improvement in attitude toward addiction
addiction. We observed that after the intervention, students’ after training is highly relevant, considering the negative
attitudes improved significantly, compared to that of those attitudes and stigma that addicted patients often receive
in the control condition. In addition, participants in the from medical doctors.10,12 Our findings underscore the
intervention group also developed stronger beliefs that they importance of appropriate addiction medicine training dur-
have a coherent understanding of addiction, attributed ing medical school. Given the enormous addiction-related
addiction more to psychological factors, and developed less health burden, all doctors should receive adequate training,
demoralized views toward addiction, as compared to the because the development of more positive attitudes among
6 A. P. AYU ET AL.
medical students might contribute to better care for these
patients.10,22,44
Our findings further suggest that addiction medicine
training may influence perceptions of addiction among med-
ical students, which has never been studied before.
Specifically, medical students in the intervention group
expressed a less demoralized view toward addiction, devel-
oped stronger beliefs that they have a coherent understand-
ing of addiction, and attributed addiction to psychological
factors, as compared to the control group. This suggests that
addiction medicine training might be an effective way of
developing perceptions of addiction in medical students.
The Demoralization subscale refers to demoralization
among the respondents. It is associated with feelings of
helplessness and hopelessness about the condition, meaning
that nothing can be done, either by the patient or treatment,
that can improve the patient’s condition.37 The 5-week
addiction medicine block seems to stimulate students’ sense
of hope toward the patients’ condition. More coherent
understanding seems to fit with gaining knowledge and
skills related to addiction medicine and the development of
a professional frame of mind. Though illness perceptions
cannot be considered right or wrong; positive or negative,45
it is tempting to speculate that particularly low demoraliza-
tion and perceived better understanding could contribute to
more positive attitudes toward addiction.
Though some perceptions assessed with the IPQ-A may
not align with current scientific knowledge (e.g., addiction
cannot be cured), these perceptions might still be present,
also among health professionals. Especially for a stigmatized
condition as addiction, such nonscientific perceptions might
be highly relevant for attitude. For example, a clinician who
holds demoralized perception of addiction, and the percep-
tion that treatment cannot control addiction is less likely to
motivate a patient with addiction for treatment, despite a
large body of evidence for treatment effectiveness.44
The attitude before training emerged as an important fac-
tor for the development of attitude among addiction medi-
cine block students after the training. In other words, the
more positive attitude at baseline, the more positive the atti-
tude becomes at follow-up. It is important to point out here
that we analyzed the predictors of attitude after training
only within the intervention group. Therefore, the fact that
all groups had similar baseline attitudes is therefore not rele-
vant in the context of this finding.
One previous study showed that attitude only improved
among general practitioners who had a positive attitude
before an addiction medicine training and deteriorated
among those who already had a negative attitude.46 Though
it might not be feasible to tailor addiction medicine training
to specific individual training needs or individual attitudes,
it might be relevant to keep this in mind when developing
addiction medicine curricula or when teaching addiction
medicine to medical students.
Of all perceptions, emotional representation (baseline)
and illness coherence (follow up) were associated with atti-
tude after the training. In other words, students who per-
ceived addiction to be emotionally stressful developed a
more positive attitude during training, as did those who
developed a better understanding. The instruments used in
this study intend to measure what health professionals think
about the condition addiction (perception) and their actual
attitude toward patients with those conditions (attitude). It
has been suggested that how people perceive addiction (per-
ception) is associated with their attitude toward patients in
clinical practice (attitudes).18 As such, this study aimed at
gaining a better understanding of the relationship between
illness perception and attitude in the context of education
that provides knowledge about addiction for medical stu-
dents. Although these are quite abstract concepts, which are
not easy to delineate sharply, this study found two percep-
tions to mainly influence the attitude development of stu-
dents who received addiction training. Though we cannot
infer any causal conclusions, our observations support the
idea that the perception that a condition is emotionally
stressful and a better understanding of the condition might
contribute to more positive attitudes. It has been suggested
that interaction with patients with addiction may be particu-
larly relevant to improve understanding of addiction, which
subsequently improves the attitude.26,47
The regression model accounted for nearly 46% of the
variance in attitude after the training. This means that other
factors are also important for attitude toward patients with
addiction. For example, we did not assess knowledge, skills,
personal experience with substance use, stigma, the teachers’
values concerning addiction, and the influence of drug pol-
icy.26,48–50 Indonesia has a strict policy concerning substance
use and applies the death penalty for drug traffickers.51 Such
a strong punitive policy might influence how society, includ-
ing the medical community, perceives drug use.52 Moreover,
although the majority of people living in Indonesia are
Muslim, this study was conducted in a catholic university,
with a track record in teaching and research in addiction
topic. We did not evaluate the university’s value or policy
concerning substance use. These might be relevant factors to
take into account in future studies. Furthermore, teachers’
attitudes toward conditions are referred to as the “hidden
curriculum” that can influence attitude development among
medical students.53
The results of our study should be interpreted in light of
its strengths and weaknesses. First, attitude toward addiction
was assessed by self-report. One study compared the effect
of a 6-month addiction medicine training in general
practitioners on self-reported attitude and self-reported
behavior.54 While there was a significant improvement in
self-reported attitude, this was not the case for the self-
reported behavior. Therefore, it remains to be seen whether
the observed improvement in self-reported attitude actually
reflects improved behavior in real-life. It is also not known
what numeric difference should be considered clinically
meaningful, and whether attitude differences indexed by this
instrument translate into actual differences in clinical behav-
ior.14 Qualitative methods such as semi-structured interviews
might be able to capture more aspects of illness perceptions
and attitude than self-report questionnaires.

Second, the post-measurement of the training effect dir-
ectly followed the training. One previous study reported per-
sisting positive effects of addiction medicine training,
provided in the second year, on medical students’ attitude
up to their graduation four years later.55 More studies with
long-term follow-up are needed to evaluate the sustainability
of the observed effects of addiction medicine training
over time.
Third, we carried out this study at the only medical school
in Indonesia with specific comprehensive, 5-week addiction
medicine training. This limits the generalizability of the
results. Nevertheless, since this study is the first on this topic
from South East Asia, it offers new insight concerning addic-
tion medicine education, particularly for this region.
Additionally, future studies might also explore perceptions
and attitudes toward addiction in other professionals.
Fourth, the students chose their preferred block, although
some students were transferred to the addiction medicine
block because of the limited availability at their preferred
block. It seems that the attitude prior to training did not influ-
ence students’ decision to choose a certain block since we did
not find a significant difference in attitude between the inter-
vention and control group at baseline. Nevertheless, it is also
important to consider that students’ preference of block might
be motivated by other aspects of attitude that cannot be
addressed by the MCRS. In addition, other factors, such as
culture or the activities proposed by the block might also
encourage students to enroll in a certain block. Despite the
fact that we did not find any significant differences in attitude
at baseline, any selection bias cannot be fully ruled out.
Conclusions
In conclusion, our findings strengthen the evidence of the
effectiveness of addiction medicine training in improving
medical students’ attitudes toward patients with addiction.
Moreover, we also showed that illness perception can be
influenced by education, which may influence attitude devel-
opment. These findings show that perception and attitude
are relevant in the context of addiction medicine training.
Though we did not provide evidence that attention for atti-
tude and perception as part of the curriculum are the effect-
ive ingredients of the curriculum, we suggest that addiction
medicine training for medical students should not solely
focus on knowledge and skills development, but should also
incorporate aspects of attitude and personal views on addic-
tion. Providing such comprehensive addiction medicine
training at undergraduate medical school, including reflec-
tion and attitude development, might contribute to a better
quality of medical care for patients with addiction in
the future.
Author contributions
Astri Parawita Ayu contributed in research conception and
design, analysis of data, interpretation of the result, and
writing and revision of the manuscript.
SUBSTANCE ABUSE 7
Margot Van Der Ven contributed in the collection of data,
interpretation of the result, and writing the manuscript.
Eva Suryani contributed in the collection of data and
revision of the manuscript.
Natalia Puspadewi contributed in the interpretation of
the results and revision of the manuscript.
Satya Joewana contributed in research conception and
design, interpretation of the results and revision of
the manuscript.
Elisabeth Rukmini contributed in research conception
and design, interpretation of the result, and revision of
the manuscript.
Cor De Jong contributed in research conception and
design, interpretation of the result, and revision of
the manuscript.
Arnt Schellekens contributed in research conception and
design, analysis of data, interpretation of the result, and
writing and revision of the manuscript.
Funding
Author Astri Parawita Ayu received a grant to perform this research
from the Directorate General of Resources for Research, Technology
and Higher Education, Ministry of Research, Technology, and Higher
Education of the Republic of Indonesia [94.19/E4.4/2014]. The funder
has no role in study design, in data collection, analysis, and interpret-
ation, in the writing of the report, and in the decision to submit the
article for publication.
ORCID
Astri Parawita Ayu http://orcid.org/0000-0003-0979-1593
Cor de Jong http://orcid.org/0000-0003-1824-7303
Arnt Schellekens http://orcid.org/0000-0002-7715-5209
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