Training instances related to health psychology and counseling in the curricula of Chilean dentistry undergraduate programs.

: Introduction: Recent evidence shows the positive impact of oral health promotion interventions based on psychological models. However, no data exist regarding the training of these skills in Chilean dentistry undergraduate programs. Objective: To identify training instances related to health psychology and counseling in the curricula of Chilean dentistry undergraduate programs. Methodology: Cross-sectional study, the unit of analysis was the curricula of dentistry programs offered by Chilean universities in 2016. Results: Dentistry curricula of 20 Chilean universities were analyzed. On average, each university has 1.95±2.16 courses (semester) related to psychology and/or counseling. Private universities have 1±0.63 courses, while traditional, 3.11±2.80. In 4 (20%) universities it was not possible to identify courses related to this topic, while two universities (both traditional) had 7 and 8 courses in this area, respectively. Conclusion: There are few instances of psychology/counseling training in dentistry programs in Chile. Considering the implementation of a policy focused intensely on health care and the positive impact of the application of psychological models to dental practice it is necessary to give more importance to these skills in Chilean undergraduate dental training.


INTRODUCTION.
Curriculum and learning have been the two areas of greatest interest in dental education worldwide 1 . Curriculum seems to be the major concern, particularly in developed countries, when it comes to improve the teaching and training of dental surgeons to make it more efficient in order to meet the needs of the population 2,3 . In this regard, an aspect that has been emphasized in dental education is training in research 4 . It has also been studied in Chile 5 . Once we have realized that the future of dentistry lies on evidence-based practice, evidence must come precisely from research.
In recent decades a number of theoretical advances with practical implications have been developed in psycholo-gy to strengthen or restore the health of people 6 . Several of these theories have proven effective in the field of oral health promotion 7 . Some of the most important theories in this regard are the salutogenic model 8 , social cognitive theory 9 , the theory of reasoned action 10 and the health belief model 11 , among others. In general, the application of these theories can promote health through the empowerment of people, helping them to develop the necessary skills to maintain or restore their health. These skills are included in the concept of health literacy, which in dentistry corresponds to oral health literacy 12 .
Nowadays, there is plenty of evidence of the crucial role literacy plays in oral health and in the state of oral health of people themselves and those who are under their care 12 . For this reason, a call has been made in order to improve the teaching of these psychological models to dental students 7 . Recent evidence has shown that dental students trained in motivational interviewing, based on some of the theories mentioned above, have had a positive impact on the health of their patients 13 .
Despite the above, there is little information about relevant areas in the curriculum of Chilean dental education 5 . Furthermore, there is no data with respect to training in psychology or health counseling techniques. As evidence shows 7-13 , they could have a positive impact on the oral health of patients in the long term.
The objective of this research is to identify training instances related to health psychology and counseling in the curricula of Chilean dentistry undergraduate programs.

MATERIALS AND METHODS.
This is a descriptive exploratory study based on the methodology proposed by Moreno to describe training in research in dental programs in Chile 5 . The unit of analysis was the curricula of dental programs offered by Chilean universities in 2016.
Curricula were found on institutional websites (universities) and downloaded on February 29 th , 2016. The following variables were included in the analysis: name and type of university (traditional or private), number of psychology/counseling courses or subjects and the semester in which the course/subject is taught.
As the contents of psychology and health counseling courses can only be assessed in the syllabus of each subject, which is not freely accessible, the name of the subjects or courses was used as an indicator of their content. Subjects/ courses including words such as the following were included in this study: psychology, psychosocial, promotion and prevention, plus their variants or similar keywords.
Data were tabulated in a spreadsheet MS Excel 2013 (Microsoft Corp., Redmond, USA). A descriptive analysis was performed using a distribution table for each semester.

RESULTS.
The curricula of dental programs of 20 universities were analyzed. On average, each university had 1.95±2.16 subjects/courses (semester) related to psychology and/or health counseling. Private universities had 1±0.63 subjects or courses of this kind, while traditional had 3.11±2.80. In four universities (20%) it was not possible to identify subjects/courses related to the topics, while two universities (both traditional) had seven and eight subjects or courses in this area, respectively.
Most of the subjects and courses identified are related to promotion and prevention (education) in oral health. Only in 7 (35%) curricula it was possible to identify the presence of some subjects with an explicit name in the field of psychology.
The distribution of subjects and courses by type, university and semester classified by colors and sequence are summarized in Table 1.

DISCUSSION.
The results of this exploratory study show that there are on average about 2 subjects or courses related to psychology and/or health counseling in the training of Chilean dental students.
However, these results can be misleading because the methodology used in this study has several limitations. First, subjects/courses were evaluated only by their name, which does not necessarily imply that students are trained in psychological models useful in dentistry in the identified subjects/courses. Moreover, it is possible that some of the unidentified subjects actually included training in psychology/counseling, as it is the case of public health courses or integrating subjects.
Second, it is not clear how many actual learning/teaching hours were included in these subjects. If we use the criterion proposed by Moreno 5 , who estimated a minimum of two teaching hours a week for each subject, it can be estimated that there is a minimum of 60 teaching hours during the 6 years of study. But this can also have a large variation, which can be even larger than estimated if the distribution Training instances related to health psychology and counseling in the curricula of Chilean dentistry undergraduate programs. between theoretical and practical hours is included in the analysis. Third, this study examines the curricular component, in circumstances when most dental programs provide extracurricular instances in which it could be possible for students to practice counseling activities, such as summer jobs. Fourth and finally, the last year of the program consists of an internship, in which in addition to clinical work, an important part of most Chilean dental programs seems Training instances related to health psychology and counseling in the curricula of Chilean dentistry undergraduate programs.
to offer students the opportunity of getting engaged in promotion and prevention activities, instances which lead to the development of skills in psychology and counseling applied to dentistry. Another point out of interest is that approximately 3 out of 4 subjects or courses related to psychology/counseling are placed in the first three years of training. If we consider that most or all of the clinical work is done in the last 3 years, it seems that training in these areas it is not clearly integrated into the clinical period, but rather focused on theoretical aspects. However, it is not possible to say that this matter is not integrated in clinical training, as this could be one of the objectives in specialty and/or integrating clinics, as it is the case in periodontics 13 .
Although the role of the dentist is focused on the most prevalent diseases of the oral cavity, caries and periodontal disease, the type of counseling that dentists can provide is not limited to these pathologies. Another instance of counseling that can be advantageous in the dental box is smoking cessation, not only for its impact on oral cancer, but because of its negative impact on overall health. Unfortunately, numerous recent studies have shown that dentists do not have the necessary skills to provide this type of counseling, which is usually of very poor quality 14,15 . While a direct reference to smoking cessation was not found in the curricula, it is important to note that there are guidelines established by the Chilean Ministry of Health to encourage dentists to provide counseling in this area 16 .
However, smoking cessation is not the only untraditional area where dentists can practice counseling. In recent years there have been some experiences of counseling in diabetes 17 , HIV 18 , childhood obesity 19 and substance abuse 20 . This implies the possibility that the impact of a dentist's job is not limited to the treatment of caries and periodontal disease. But for achieving these goals, dentists need to receive the necessary training to meet the needs of the population in relation to health promotion and prevention.
Future research in this field should evaluate the contents of the subjects or courses identified in this study. Similarly it is necessary to assess the skills of Chilean dental students for performing counseling interventions in health care. Considering the implementation of a policy focused intensely on health care and the positive impact of the application of psychological models to dental practice it is necessary to give more importance to these skills in Chilean undergraduate dental training.
In summary and considering the limitations of this study, there are on average about two instances of training in psychology and/or health counseling mainly in the first three years of the dental programs in Chile.
Training instances related to health psychology and counseling in the curricula of Chilean dentistry undergraduate programs.