Principles of “Humanistic Environment” in Dental Education: Design, Validation, and Standardization of a Questionnaire

Six completely related researches were found in the literature (Pubmed, Google Scholar). A questionnaire consisting of 67 questions was collected for evaluation. The questionnaire was submitted to 9 members of a panel of experts for a survey. Using statistical methods, Content Validity Index (CVI) and Content Validity Ratio (CVR) were determined and its reliability was evaluated. According to the relevant formula and Lawshe table questions with a score higher than 0.79 and 0.78 were included in the questionnaire, respectively. The questionnaire was also administered to 8 students for determining the Face Validity. Cronbach's Alpha was calculated 0.808, using SPSS (v.#22) software. The Reliability Analysis was determined based upon 15 students’ opinions.


Background
The word humanism stems from the Latin root of "humanitas" meaning compassion for others. (1) In this regard, the Humanistic Environment Index has been introduced to health sciences with two dimensions: Mutual Trust and Mutual Respect. (2) Mutual Trust is a level of deep belief between patient and physician founding one of the main requirements of the Humanistic Environment. Increased trust provides the basis for increased effectiveness of treatment. A study by Keating et al. (3) noted that patients who trust their physicians would show more successful treatment outcomes. In other words, patients cared and treated under humanistic attitude of a health care provider will present an effective therapeutic result. (4)(5)(6)(7) The other important component that plays a viable role in creating the Humanistic Environment is Mutual Respect. The importance of Respect is the connection between physician and patient that can certainly serve as a means of establishing a civilized relationship for alleviating patient's complaint. (8) In 1948, World Health Organization recognized "the inherent dignity" in its Universal Declaration of Human Rights. (9) The organization emphasizes that the rights of patients should be protected requiring educating policy makers and healthcare providers regarding the kind of treatment and respect they are owed, despite variations in local legislation. Plus, Islam as a divine religion pays a great deal of attention to the issue of dignity in its doctrines, especially when it comes to delivering quality of health services for patients. (10) In fact, decrees of Islam in the topic of patients' right goes beyond the regularly recommended international guidelines. It further dedicates especial Worldly Reward as well as Hereafter Bonus to the visitors of a patient. (11) According to the above principles, two aspects of trust and respect should be incorporated in the body of training program of students who are designated to provide health services. In a health educational system, students receive clinical skills training as they acquire theoretical knowledge. To achieve these two goals, it is necessary to focus on the different aspects of humanistic principles for provision of higher quality of health care service. Undoubtedly the establishment of the Humanistic Environment in educational settings initially launches with mutual respect between faculty members and students.
In recent years, many studies have investigated and evaluated the educational environment of academic dental settings. A research has shown that stress is one of the factors affecting the quality of education, acquisition of practical skills, satisfaction, and student success. (12) Today, based on the standards released by the Commission on Dental Accreditation (CODA), commitment to Humanistic Environment is one of the accreditation criteria for educational centers in the United States. (13) There is much emphasis on the need to integrate the humanistic environment principles with dentistry education. There are some references to the theoretical and idealistic de nitions -the review, explanation, and practical interpretation of humanistic environment-in dental schools. Yet, studies have shown that above attributes are not fully implemented to effectively promote oral health services. (14) Evidence has shown that an urgent need calls for revision of these guidelines which can directly motivate the students to advance the quality of delivering health care services, consequently. The quality of services boosts all regular educational trainings and fruits the better treatment outcome. (15) A comprehensive study by Quick et al. (8) was conducted to examine the requirements for creating a Humanistic Environment in dental education settings. According to their study, dental education systems should strive to develop a professional communication for enhancing academic environments. Identi cation of these indicators and their implementation methods in the dental education setting requires discussion, planning, and cooperation at the national level which tailored for each cultural context.
Stern (16) believes that professional performance has four essential components. These include humanism, responsibility, altruism, and excellence; so the content of a holistic curriculum should include all of these components. In health science programs, there is a deep and more important look at the interaction of the above components.
According to Haden et al., (17) dental education environment, in addition to being a scienti c learning environment, which fruits in delivering health care services, is a space for learning professional interaction with public. Consequently, this environment should foster more inclusive performance (of students, residents, etc.) alongside scienti c learning. In such environments, reinforcing the Humanistic attitude will provide a signi cant impact on ourishing the performance of students based on ethics, respect, patience, understanding, and professional relationships. Therefore, it is unlikely that if a student has completed his/her education under stressful condition, discrimination, and humiliation, contrary to the condition under principles of humanitarian standards shows an appropriate attitude, qualitative practice, or constructive communication with patients. (18) Obviously in such conditions, the result of treatments provided to patients will not be favorable.
At the end, there have been some studies on the role of respect and trust in dentistry educational environments. These studies are based on questionnaires designed for different geographical areas. They are performed in speci c communities considering customs, cultures, and religious beliefs of a particular region. This research was intended to design, standardize, and propose a questionnaire based on the above criteria for the Iranian society with regard to its cultural and religious school of thoughts. The results of this study will provide for a tool policy makers and a guide for researchers for extensive and further investigations in this eld, as well.

Methods
In this study, a questionnaire was designed to evaluate respect and trust in dental schools using relevant resources and articles. The Validity and Reliability tests were then assessed and the questionnaire was standardized. It was designed based on the following steps:

* First
Step: collecting and drafting questionnaire items At this stage, a comprehensive search was performed for collecting related articles published in either Farsi or English literature. After reviewing the questionnaires, the question items were categorized into three groups. These included: relevant and useful questions, duplicate questions (shared in multiple questionnaires), and unrelated questions. Thus, the unrelated and duplicate questions were excluded and the rest were retained. Also, some other relevant questions were designed and added, based upon the cultural and social principles of the Iranian society. Finally, a set of 67 questions was compiled for experts' evaluation, after inclusion of relevant queries. This was the basis for evaluation, editing, and categorization.

* Second
Step: examining the content validity of the questionnaire An introductory text was developed before questions' list to orient all experts to the different aspects of the theme of study. Then, 7 experts in the eld of community oral health, one expert in the eld of health education, and one person in the eld of behavioral sciences and sociology were asked to contribute their knowledge to the study. To assess Content Validity Ratio (CVR), they were requested to rate the necessity of each question according to their scienti c skills and regarding to the following three criteria: a. Essential, b. Useful but not Essential, or c. Unnecessary.
Using Lawshe table (19) and the following formula, the questions that received the CVR score of equal or higher than 0.78 were retained and the rest were removed.
[Please see the supplementary les section to view the formula.] In this formula, N e is the number of experts who have identi ed a question as Necessary, and N is the total number of experts.
Furthermore, professionals were asked to determine the association between each question with the subject of study. This was the Content Validity Index (CVI) for measuring the appropriateness of each question. The ranking for the index was: a. Not Related, b. Slightly Relevant, c. Relevant, or d. Completely Relevant. Later, the number of experts who chose either relevant or completely relevant options for each question was divided by the total number of experts and expressed as a percentage. The questions that gained the CVI score of equal or higher than 0.79 were saved and the rest were omitted.
The nal list contained 39 questions were tted in 7 humanistic environment elds. It should be added that the experts were inquired to suggest useful questions from their point of view if it was not addressed in the questionnaire. Yet, no additional topic/theme was proposed.

* Third Step: Face Validity
At this stage, the questionnaire was distributed among 17 members of the target group for valuation of the Face Validity. The criteria were the level of Transparency and Relevance of each question to the subject of the study. Besides the 9 members of panel of experts, 8 participating students who were at the At this stage, the questionnaire was distributed among a new group of 15 members of contributing students, who were at the same stage of education, for assessment of its reliability. Then, the data were recorded in SPSS software (v. #22) for scoring the Kappa Coe cient statistical analysis of the questionnaire.

Results
The initial questionnaire contained a set of 67 questions in the eld of humanistic environment, gathered from the literature. According to the expert's opinion, 28 questions were either unquali ed or irrelevant to the present community with the speci c cultural structure. The rest, the 39 selected questions were basically classi ed in 7 distinguished elds. (Table 1 To analyze Reliability Index of the questionnaire, the Kappa Coe cient index was used employing the test-retest method with the SPSS (v. #22) software. The lowest and highest score for questions were 0.336 and 1.000, respectively. (Table 2: a & b) Furthermore, the calculation for average score was 0.6707.

Discussion
Although the health sciences education is mainly focused on clinical competencies, the Humanistic Environment should not be neglected. (13,15,(20)(21)(22)(23)(24)(25) Unfortunately, this issue has neither been integrated in the academic curriculum nor been fully addressed in the literature. Some researchers have studied only on the Trust issue in non-educational settings. (26) No study has investigated the subject of Respect in academic atmospheres.
It is obvious that there cannot be a standard questionnaire applicable to all societies. As mentioned in the previous sections, in order to evaluate the Humanistic Environment in different societies, it is necessary to harmonize the content of the questionnaire with the culture, social conditions, and beliefs of any society. This research has attempted to provide a suitable tool for evaluating the educational environment of the dental schools of Iran, or for other countries with similar values.
The questionnaires used in the present research were stemmed from two groups of domestic and international publications. These are explained as below:

A) Examination of international questionnaires
In the process of designing the questionnaire, a comprehensive search of the available international sources and references (Google Scholar and PubMed) was carried out. One of the most comprehensive and related articles was conducted by Quick et al. (18) Many other studies were focused on the non-educational communities. (26) Also, some questions were designed by extracting from the American Dental Association Principles of Ethics and Code of Professional Conduct protocol. (27) Similar approach was used for designing questions from the American Medical Association Code of Ethics recommendations. (28) After examining the content of all questionnaires, the initial selection of the questions was based upon the appropriateness and relatedness of their scope to this study. Obviously, some of the unrelated and incompatible questions with the culture of the present community were eliminated in the rst place. For example, given that American society has a very diverse racial composition; questions related to this issue were incompatible with our country's social system.

B) Examination of domestic questionnaires
Related studies to this research have also been carried out domestically. Obviously, the questions raised in these questionnaires were a rmed by most experts, later on. Fortunately, there were some studies performed in the different domestic educational elds. (29) In fact, there is a bylaw released by Ministry of Health for educators of all health related institutes and for all health care professionals to exercise, after graduation. (30) The interesting point in the questionnaires was related to some common concerns in the domestic as well as international student populations. These viewpoints re ect the similar problems in all student communities regardless of their geographic location, culture, beliefs, or even social behavior. The unkind way that teachers interact with students is a clear example that can be mentioned. Another pattern is discrimination in the clinical assignments and in evaluation of their performance. Among the questions that were generally rejected by scholars and experts were the consumption of alcoholic beverages and increased coffee drinks. The questions regarding taking prescribed and non-prescribed medications were repeated in different forms in the questionnaire by Quick et al (2).
In the standardization process, the questions in the Law and Regulations section received the lowest score. This indicates that despite numerous educational regulations, some issues have not yet been e ciently addressed in the legislation. The only question that received most concern by experts, in this section, was exclusively related to cheating while studying.
On the other hand, questions about patients' participation in treatment and clinical services scored the highest in the Professional Ethics section. No questions in this eld were disagreed by the panel of experts. Therefore, it seems that one of the most important humanistic behaviors is to justify patients with a proposed treatment plan to obtain their satisfaction.
In this study, Face Validity was evaluated with the help of 17 individuals from the target population. Fortunately, there was no misconception in any question and the content was approved by the experts. There was fully consensus on all related items.

Conclusions
First, this study strongly emphasizes that principle of Humanistic Environment should be integrated in all clinically-based health educational elds. Second, it also remarks that execution of this concept establishes the more kindly interaction between students and faculty members. Third, linking professionalism to humanism assures the quality of treatment and satisfaction of health care recipients, as well. Forth, this investigation con rms that Humanistic Environment approach in a health care setting requires tailoring an appropriate standard tted to social values of an individual community. The questionnaire contained an explanatory sheet prior to table of the questions. It clearly explained that the data will be collected anonymously and the participation was NOT obligatory. However, the plan of study was also verbally explanation of the procedures and objectives of the study for volunteer participants.

Declarations
2. Consent to publish: Not Applicable (The data is gathered anonymously) 3. Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. Formula.docx