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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of intimate partner violence &#40;IPV&#41; in youth dating is very high&#44; even higher than in adulthood&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">1&#44;2</span></a> Although psychological IPV is its most frequent expression&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#44;4</span></a> other forms of more direct and recognizable IPV&#44; like physical or sexual IPV&#44; are also common among youth&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2&#44;4</span></a> Furthermore&#44; as some violent behaviors are often not properly perceived by victims&#44; these figures may be higher&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">5&#44;6</span></a> According to data from the Spanish Government&#44; one out of every three women does not identify controlling behavior as abusive&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> Many young people even justify acts of violence as play or a joke&#44; or they mistakenly interpret them according to romantic sexist ideals&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;9</span></a> presenting high IPV-tolerance&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10&#44;11</span></a> Tolerance of violent behavior and gender role attitudes have been associated with the difficulty of recognizing abuse&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Health professionals &#8212;mainly doctors&#44; nurses&#44; and psychologists&#8212; play a central role in identifying and addressing IPV&#46; Victims of abuse consider health professionals as necessary support persons&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> Therefore&#44; the comprehensive approach to IPV from the healthcare system has little chance of success if practitioners are not suitably trained to recognize violence and are sufficiently sensitive to its relevance&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a> Given that training in IPV is known to increase its recognition and improve attitudes and skills for its treatment&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">16&#44;17</span></a> beginning this training during university studies seems reasonable&#46; However&#44; the development of IPV-related skills and content are poorly covered in health sciences curricula&#44; both internationally<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> and in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To date&#44; no prior study has compared IPV-tolerance and gender role attitudes of future health professionals&#46; Furthermore&#44; we found no studies addressing differences in IPV-tolerance and gender role attitudes among students of consecutive academic courses&#46; Therefore&#44; the objectives were to explore the differences in IPV-tolerance and sexist attitudes among medicine&#44; nursing&#44; and psychology students from three Spanish universities&#44; and to study the evolution of these indicators&#44; comparing students of consecutive academic courses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cross-sectional study among male and female students of the degrees of medicine&#44; nursing&#44; and psychology from three Spanish universities &#40;Universities of Oviedo&#44; Extremadura and Seville&#41;&#44; selected according to the availability of a member of the research team&#46; Inclusion criteria were &#8805;18 years and having been in a dating relationship for at least one month&#46; In order to compare the degrees&#44; students in fifth and sixth course of the medicine degree were excluded&#46; We surveyed 1&#44;430 students who met selection criteria&#44; 905 from the University of Oviedo&#44; 411 from the University of Extremadura&#44; and 114 from the University of Seville&#46; Medicine students represented 38&#46;8&#37; of the sample &#40;n &#61; 555&#41;&#44; nursing students 37&#46;0&#37; &#40;n &#61; 529&#41;&#44; and psychology students 24&#46;2&#37; &#40;n &#61; 346&#41;&#46; Considering all the students registered in the selected health science degrees&#44; response rates were 54&#46;3&#37; in medicine&#44; 50&#46;2&#37; in nursing&#44; and 23&#46;6&#37; in psychology&#46; Overall response rate was 40&#46;3&#37;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All participants gave passive informed consent &#40;questionnaire instructions indicated implicit consent by completion and return of the form&#41;&#46; The study received approval of the universities and of the Committee of Research Ethics of Asturias &#40;Spain&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection and study variables</span><p id="par0030" class="elsevierStylePara elsevierViewall">Students&#8217; information was obtained through a questionnaire administered in the classrooms between December 2016 and March 2017&#46; Previously&#44; we explained the aims of the study and the anonymous and voluntary nature of participation&#46; Students who had a history of more than one dating relationship were asked to respond with reference to the most problematic relationship&#46;&#160;The questionnaire measured IPV-tolerance and sexist attitudes using two scales&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the one hand&#44; the <span class="elsevierStyleItalic">Perceived Disturbance Scale</span>&#160;included in the&#160;<span class="elsevierStyleItalic">Dating Violence Questionnaire</span>&#160;&#40;DVQ-R&#41;&#44; which assesses the level of annoyance about 20 violent behaviors on a five-point scale &#40;not at all &#61; 0&#44; not much &#61; 1&#44; somewhat &#61; 2&#44; quite a bit &#61; 3&#44;&#160;and&#160;very much &#61; 4&#41; &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Table I of the online Appendix</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a>&#160;These behaviors are grouped into five forms of IPV&#58; detachment&#44; humiliation&#44; coercion&#44; physical abuse&#44; and sexual abuse&#46; Subsequently&#44; given that perceived annoyance about violent behaviors can be considered the opposite of their tolerance&#44; the scale was inverted&#46; Thereby&#44; higher scores indicated higher IPV-tolerance&#46; Then&#44; options &#8220;not at all&#8221;&#44; &#8220;not much&#8221; or &#8220;somewhat&#8221;&#160;were globally considered&#160;as &#8220;IPV-tolerant&#8221;&#46;&#160;Following a zero-tolerance policy&#44; which is widely used when referring to several forms of violence or sexism&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">6&#44;22</span></a>&#160;students were deemed to be considered IPV-tolerant if they were tolerant of at least one of the behaviors&#46;&#160;Although to date&#44; the validation of DVQ-R has only been published with reference to the&#160;<span class="elsevierStyleItalic">Victimization&#160;Scale</span> &#8212;with good internal consistency &#40;Cronbach&#39;s alpha&#58; 0&#46;85&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a>&#8212; the satisfactory validity of the&#160;<span class="elsevierStyleItalic">Perceived Disturbance&#160;Scale</span> could be expected&#44; as both scales use the same items&#46; Moreover&#44; this scale was considered appropriate by consensus of the same panel of experts&#46; Lastly&#44; the&#160;<span class="elsevierStyleItalic">Perceived Disturbance&#160;Scale</span> has been successfully used in previous research&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand&#44; we used the <span class="elsevierStyleItalic">Gender Role Attitudes Scale</span> &#40;GRAS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a> This 20-item scale describes different egalitarian or sexist expressions that people use about the role that men and women play in society according three functions&#58; social&#44; occupational&#44; and family&#46; Each item is rated on a five-point Likert scale ranging from 0 &#40;strongly disagree&#41; to 4 &#40;strongly agree&#41; &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Table II of the online Appendix</a>&#41;&#46; Given that sexism can be considered the opposite of gender equality&#44; the scores of items referring to egalitarian expressions were reversed to transform them into sexist attitudes&#46; Subsequently&#44; the options &#8220;partially disagree&#8221;&#44; &#8220;agree&#8221; and &#8220;strongly agree&#8221; were considered as sexist attitudes&#44; and the options &#8220;strongly disagree&#8221; and &#8220;disagree&#8221; were considered as egalitarian attitudes&#46; From the perspective of the zero-tolerance policy&#44; students were deemed to have a global sexist attitude when they agreed with at least one sexist attitude considered in of the GRAS&#46; The internal consistency of the GRAS was excellent &#40;Cronbach&#39;s alpha&#58; 0&#46;99&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The questionnaire also included potential confounders&#46; Sociodemographic and basic academic data were collected &#40;sex&#44; age&#44; degree&#44; and course&#41;&#46; We also studied the perception of abuse&#44; fear&#44; and&#47;or entrapment through three dichotomous &#40;yes&#47;no&#41; self-reported variables&#46; Through these variables we classified students in three levels of perception of abuse&#58; a first group that perceived themselves as abused &#40;i&#46;e&#46;&#44; &#8220;perceived abuse&#8221;&#41;&#59; a second group that did not feel abused by their partners but reported being afraid of their partner or having felt trapped during their relationship &#40;i&#46;e&#46;&#44; &#8220;unperceived abuse&#8221;&#41;&#59; and a third group made up of youths who claimed not having been abused or feeling afraid or entrapped &#40;i&#46;e&#46;&#44; &#8220;non-abused&#8221;&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of the 1430 students surveyed&#44; we excluded 108 with lacking data in some questionnaire items&#44; leaving a final sample of 1322 individuals &#40;534 from medicine&#44; 497 from nursing&#44; and 291 from psychology&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Sex- and age-differences according to degrees were respectively studied by means of the non-parametric chi-square independence test and the independent t-test&#44; using medicine degree as reference&#46; Differences in abuse perception according sex within each degree were analyzed using the non-parametric chi-square independence test&#46; Then&#44; using the zero-tolerance criteria to operationalize IPV-tolerance and sexism&#44; logistic regressions separately by sex were used to compare the estimated crude proportion of IPV-tolerant students and sexist attitudes according to the degree&#46; Moreover&#44; we obtained adjusted proportions derived from predicted probabilities using logit models separately by sex&#44; adding the degree as indicator and the age and perception of abuse &#40;perceived abuse&#44; unperceived abuse&#44; non-abused&#41; as potential confounders&#46; These results are shown for each IPV-tolerance forms and sexism functions&#46; Analogously&#44; crude and adjusted proportions for total IPV-tolerance and total sexism according to the academic course &#40;included in the regression model as categorical variable&#41; were calculated separately by sex and degree&#46; Subsequently&#44; to estimate the evolution of IPV-tolerance and sexist attitudes throughout academic formation&#44; we obtained the p-trend by running analogous regression models but with academic course modelled as a continuous variable &#40;from 1 &#61; first course to 4 &#61; fourth course&#41;&#46; Lastly&#44; in order to determine the robustness of our findings&#44; we repeated main analyses using linear regression models and introducing IPV-tolerance and sexism as quantitative variables&#44; both of them ranging from 0 to 80 points &#40;maximum IPV-tolerance&#47;sexism&#41;&#46; All analyses were conducted and presented separately for each sex&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Data analysis was performed using STATA v&#46;13&#46; Only values of p &#60;0&#46;05 were considered statistically significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Of the total sample&#44; 1060 were women &#40;80&#46;2&#37;&#41; and 262 were men &#40;19&#46;8&#37;&#41;&#46; The percentage of women was higher in the psychology &#40;87&#46;3&#37;&#59; p &#60;0&#46;001&#41; and nursing degrees &#40;86&#46;9&#37;&#59; p &#60;0&#46;001&#41; than in medicine &#40;70&#46;0&#37;&#41;&#46; Mean age &#40;&#177; standard deviation&#41; was 21&#46;3 in nursing &#40;&#177; 4&#46;7 years&#41;&#44; 20&#46;6 in medicine &#40;&#177; 2&#46;9 years&#41;&#44; and 19&#46;5 in psychology &#40;&#177; 1&#46;7 years&#41;&#46; Compared to medicine students&#44; mean age was significantly higher in nursing students &#40;p &#61; 0&#46;001&#41; and lower in psychology students &#40;p &#60;0&#46;001&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding students&#8217; perception of abuse&#44; 8&#46;4&#37; men and 8&#46;0&#37; women perceived themselves as abused&#44; whereas 25&#46;6&#37; of men and 25&#46;1&#37; of women were in a situation of unperceived abuse&#46; Unperceived abuse was more frequent in the psychology degree&#44; followed by nursing and medicine &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A higher percentage of psychology students were tolerant towards all forms of IPV than were students of medicine and nursing&#46; This was consistent across sexes&#44; despite the lack of statistical power in the men&#39;s stratum&#44; except for humiliation &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Findings regarding sexist attitudes were similar &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the proportion of IPV-tolerant students and students with sexist attitudes according to sex&#44; academic course&#44; and degree&#46; Compared to students of the first courses&#44; only female medical students of higher courses showed less total IPV-tolerance&#46; Likewise&#44; the percentage of sexist attitudes was significantly lower among male medical students of higher courses&#46; Similar results were obtained when repeating the analyses modeling IPV-tolerance and sexism as quantitative variables &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Table III of the online Appendix</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#sec0080">Table IV of the online Appendix</a> shows the proportion of students with IPV-tolerance and sexist attitudes according to sex and academic course&#44; in the whole sample&#46; Male students of higher courses had less tolerance toward sexual violence and fewer occupational sexist attitudes&#46; In the case of female students&#44; tolerance to all forms of IPV &#40;except for humiliation&#41; and occupational sexist attitudes were significantly lower among students of higher courses&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">According to the results of this study&#44; the prevalence of IPV-tolerance and sexism was significantly higher in psychology students than in medicine or nursing students&#46; When analyzing students&#8217; differences between consecutive academic courses&#44; IPV-tolerance was lower in female medical students of higher courses&#44; and sexist attitudes were lower in male medical students of higher courses&#44; suggesting that some aspects of future doctors&#8217; training may address violence more than in other degrees&#46; These sex differences deserve further consideration&#46; In any case&#44; it should be considered that the overall high prevalence of IPV-tolerance and sexism observed among students of health sciences could be due to the very sensitive zero-tolerance criterion employed &#40;cut-off point&#58; presence of tolerance towards a single IPV behavior and presence of a single sexist attitude&#41;&#44; which may have increased false positives&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The fact that both male and female students of the psychology degree were more IPV-tolerant than the other health science students included in our study&#44; even after adjusting for age and perception of abuse&#44; deserves a profound reflection&#46; Interestingly&#44; in a recent study requested four groups of people to rate a series of simulated cases of self-inflicted violence&#44; and psychology students committed errors similar to those of the group of volunteers&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> In another study&#44; the acceptance by police officers and psychology students of some sexist stereotypes that emerge in cases of rape were compared&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> The results revealed that the students were more tolerant than the police officers toward myths like &#8220;she asked for it&#8221; and &#8220;he did not mean to&#8221;&#46; Perhaps during psychology studies&#44; the excess of theoretical and practical exposure to information and examples of dysfunctional behaviors and situations desensitizes students&#44; increasing their tolerance&#46; This is similar to medical and nursing students&#8217; progressive loss of empathy towards physical disease during their studies&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a> This explanation has also been supported in another observation derived from our results&#58; the differences between the degrees in total tolerance in the first course are very small when compared with the differences that emerge in the fourth year&#46; This suggests that advancing in psychology studies may contribute to the students&#8217; acceptance of IPV&#59; or at least&#44; studying psychology may not foster IPV-rejection&#44; unlike the other degrees&#46; Another possible explanation for this finding is that psychology students were also notably more sexist than the other health science students&#46; It seems clear that the less gender equity there is&#44; the more IPV-tolerance and perpetration will exist&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">27&#44;28</span></a> This same consideration may explain sex differences in IPV-tolerance&#44; as male students were both more sexist and more IPV-tolerant than female students&#46; Accordingly&#44; sexist attitudes could be a first step in the pathway toward IPV-tolerance&#46; In any case&#44; beyond the possible explanations for these findings and considering the fatal implications of graduate psychologists with some IPV-tolerance or sexist attitudes&#44; the design of suitable curricular tools to fight against IPV-tolerance and sexism are urgently needed&#46; Previously&#44; future research should confirm our findings and explore in greater depth the reasons we have hypothesized&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Differences in gender-role attitudes between psychology&#44; medicine&#44; and nursing students can also be analyzed similarly&#46; In this case&#44; the differences are very marked in the first course&#44; indicating that psychology&#44; medicine&#44; and nursing students probably have different conceptions of gender equity already before starting their studies&#46; In general&#44; sexist attitudes were particularly manifest in the occupational sphere&#46; This agrees with results of other authors who have warned that sexist occupational attitudes can be the most firmly rooted in society&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">23&#44;29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Notwithstanding the cross-sectional nature of the study design&#44; which urges caution in the interpretations&#44; our results concerning the overall evolution of IPV-tolerance and sexism according to the academic course revealed interesting sex differences&#46; On the one hand&#44; there was a significant trend towards less IPV-tolerance in women over academic courses&#44; but not in men&#46; On the other hand&#44; there was a significant decrease of sexism in men&#44; but not in women&#46; These findings suggest that changes in sexist attitudes come first&#44; and only then does the teachable moment to produce changes in IPV-tolerance emerge&#46; Given that women began university studies with more egalitarian attitudes than men&#44; the progression throughout academic courses could produce improvements in IPV-tolerance&#46; If this hypothesis is true&#44; men would fail to find their teachable moment to reduce IPV-tolerance until postgraduate training or during clinical practice&#44; which is probably too late&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The analysis of the evolution of the prevalence of IPV-tolerance and sexist attitudes in each degree suggests that only medicine students underwent a consistent and positive change throughout their studies&#44; male students in sexist attitudes and female students in IPV-tolerance&#46; It is difficult to offer a tentative hypothesis to explain this phenomenon because&#44; in all three degrees&#44; IPV is addressed at some point&#44; and professors seem to be sufficiently committed to this formation&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20&#44;30</span></a> In addition&#44; the psychology degree has the most curricular content about violence&#44; but if we were seeking a student sensitized toward suffering&#44; we would probably choose a nursing student&#46; So&#44; how is the medicine degree different&#63; Perhaps medicine students are urged very early on to become participants in the unavoidable responsibility they will acquire to identify and treat cases of IPV&#44; and this makes them more sensitive to the problem&#46; There are numerous studies and experiences suggesting that any training in IPV is satisfactory for medicine students&#44; especially if it is transversal and addresses real cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">31&#44;32</span></a> Therefore&#44; perhaps a greater effort should be made in nursing and psychology degrees&#44; seeking higher student commitment towards IPV&#44; emphasizing that they will be partly responsible for dealing with IPV and banishing some stereotypical ideas that contribute to IPV-tolerance and sexism&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; The main one involves the cross-sectional nature of the data&#44; which prevents us from analyzing with a high degree of validity the association between a certain academic course and changes in IPV-tolerance and sexist attitudes&#46; Thereby&#44; in order to appropriately test this hypothesis&#44; we recommend conducting longitudinal research with a large cohort of students&#46; A second limitation was our convenience sample&#44; which does not allow the generalization of results&#46; However&#44; the aim was not to study the prevalence of IPV-tolerance and sexism&#44; but their association across some health science degrees and over academic courses&#46; In addition&#44; although groups of students were quite comparable according to degree&#44; some strata had few participants&#44; and there was also a high disparity in the number of students from each university&#46; Another limitation regarding the sample was having obtained a response rate below 50&#37;&#44; mainly due to a percentage of students who do not attend classes regularly&#46; Moreover&#44; students who attend regularly may differ from the others in academic variables&#46; A third limitation was that our study did not include a sample of students from the social work degree&#44; although social workers are acknowledged as essential health professionals to deal with IPV and as the best trained to provide an appropriate response&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">17&#44;34</span></a> A fourth limitation was that the DVQ-R did not account for some current important forms of IPV&#44; like cyber-abuse&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a> Another limitation involved the small number of sociodemographic or academic variables and variables related to students&#8217; history of personal and family violence&#44; as they could have conditioned the results&#46; Although the associations we found are maintained when adjusting for the available variables&#44; perhaps other uncontrolled variables are responsible for part of the association&#44; particularly the students&#8217; social and educational environment&#44; which may be different in the three degrees&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; the level of IPV-tolerance and sexism among the students of medicine&#44; nursing&#44; and psychology was high&#44; especially in male students&#46; Compared to medicine and nursing degrees&#44; the frequency of students&#8217; tolerance towards IPV and sexist attitudes was significantly higher in the psychology degree&#46; Only medicine students underwent a hypothetical positive trend throughout their studies&#44; female students in IPV-tolerance and male students in sexist attitudes&#46; Designing university curricula that seek the development of egalitarian gender-role attitudes is urgently needed&#44; with special focus on male students&#44; as a first step in the pathway toward decreasing IPV-tolerance&#46; Longitudinal studies are needed that follow up a group of young people from the beginning to the end of their university studies&#44; as well as qualitative studies that examine the quantity and quality of training about violence offered by the universities and received by the students&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Editor in charge</span><p id="par0135" class="elsevierStylePara elsevierViewall">Miguel &#193;ngel Negr&#237;n Hern&#225;ndez&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Transparency declaration</span><p id="par0140" class="elsevierStylePara elsevierViewall">The corresponding author on behalf of the other authors guarantee the accuracy&#44; transparency and honesty of the data and information contained in the study&#44; that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Authorship contributions</span><p id="par0145" class="elsevierStylePara elsevierViewall">F&#46;J&#46; Rodr&#237;guez-D&#237;az and A&#46; Lana designed the study&#46; V&#46; Garc&#237;a-D&#237;az and A&#46; Fern&#225;ndez-Feito collected the data&#46; A&#46; Fern&#225;ndez-Feito and C&#46; Bringas-Molleda performed the statistical analyses&#46; V&#46; Garc&#237;a-D&#237;az and A&#46; Lana drafted the first version of the manuscript&#46; Lastly&#44; all authors contributed to the critical revision of the paper and approved the &#64257;nal manuscript for publication&#46; All authors have agreed to be accountable for all aspects of the study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">The study was supported by grants from the Ministerio de Sanidad&#44; Servicios Sociales e Igualdad of Spain &#40;Project SUBINMU012&#47;009&#41; and from the Universidad de Oviedo&#47;Consejer&#237;a de Educaci&#243;n&#44; Cultura y Deporte del Principado de Asturias &#40;Project UO-15- INVES-32&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To explore university health science students&#8217; intimate partner violence tolerance and sexist attitudes and to examine their trend throughout the academic years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study of students of both sexes of the degrees of medicine&#44; nursing&#44; and psychology from three selected Spanish universities &#40;n &#61; 1&#44;322&#41;&#46; Data were collected anonymously using two validated scales&#58; the Dating Violence Questionnaire &#40;DVQ-R&#41; and the Gender Role Attitudes Scale &#40;GRAS&#41;&#46; Logistic regressions were used to compare tolerance toward violence and sexist attitudes across the degrees&#46; The evolution of these variables throughout different academic courses was assessed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Of the sample&#44; 62&#46;8&#37; were tolerant towards intimate partner violence&#46; The percentage of tolerant students was significantly higher in Psychology &#40;75&#46;9&#37;&#41; than in Nursing &#40;57&#46;7&#37;&#41; and Medicine Degrees &#40;60&#46;3&#37;&#41;&#46; A higher percentage of sexist students was also found in psychology students &#40;80&#46;8&#37;&#41; than in nursing &#40;62&#46;2&#37;&#41; and medicine students &#40;62&#46;7&#37;&#41;&#46; Compared to the first-year students&#44; female medicine students of the last courses were less tolerant to intimate partner violence &#40;p-trend &#60;0&#46;001&#41;&#44; and male medicine students had less sexist attitudes &#40;p-trend &#61; 0&#46;002&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Tolerance of intimate partner violence and sexist attitudes were very high&#44; especially among psychology students&#46; These indicators were significantly better among medicine students of higher courses&#44; suggesting a positive effect of medical training&#46; Intimate partner violence in the university education of the future health professionals should be addressed&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Explorar la tolerancia de la violencia en la pareja y las actitudes sexistas en estudiantes universitarios&#47;as de ciencias de la salud&#44; y estudiar su tendencia a lo largo de los cursos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en estudiantes de ambos sexos de medicina&#44; enfermer&#237;a y psicolog&#237;a de tres universidades espa&#241;olas &#40;n &#61; 1322&#41;&#46; Se utilizaron dos escalas validadas y an&#243;nimas&#58; <span class="elsevierStyleItalic">Cuestionario de Violencia entre Novios-Revisado</span> &#40;DVQ-R&#41; y <span class="elsevierStyleItalic">Escala de Actitudes de Rol de G&#233;nero</span> &#40;EARG&#41;&#46; Mediante regresiones log&#237;sticas se compararon la tolerancia al abuso y las actitudes sexistas entre titulaciones&#44; y se estudi&#243; su evoluci&#243;n a lo largo de la formaci&#243;n acad&#233;mica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El 62&#44;8&#37; se mostraron tolerantes ante la violencia en la pareja&#46; El porcentaje de estudiantes tolerantes fue significativamente m&#225;s elevado en psicolog&#237;a &#40;75&#44;9&#37;&#41; que en enfermer&#237;a &#40;57&#44;7&#37;&#41; y medicina &#40;60&#44;3&#37;&#41;&#46; Tambi&#233;n se encontr&#243; un mayor porcentaje de estudiantes sexistas en psicolog&#237;a &#40;80&#44;8&#37;&#41; que en enfermer&#237;a &#40;62&#44;2&#37;&#41; y medicina &#40;62&#44;7&#37;&#41;&#46; En comparaci&#243;n con estudiantes de nuevo acceso&#44; las estudiantes de medicina de los &#250;ltimos cursos fueron menos tolerantes a la violencia &#40;p &#60;0&#44;001&#41; y los estudiantes de medicina varones tuvieron menos actitudes sexistas &#40;p &#61; 0&#44;002&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La tolerancia de la violencia en la pareja y las actitudes sexistas fueron muy elevadas&#44; especialmente en psicolog&#237;a&#46; Estos indicadores fueron significativamente mejores en estudiantes de medicina de los cursos superiores&#44; lo que sugiere un efecto positivo de la formaci&#243;n m&#233;dica&#46; Se deber&#237;a mejorar el abordaje de la violencia en la pareja en la formaci&#243;n universitaria de los&#47;las futuros&#47;as profesionales sanitarios&#47;as&#46;</p></span>"
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Original article
Tolerance of intimate partner violence and sexist attitudes among health sciences students from three Spanish universities
Tolerancia de la violencia en la pareja y las actitudes sexistas entre estudiantes universitarios/as de ciencias de la salud de tres universidades españolas
Vanesa García-Díaza, Ana Fernández-Feitoa,
Autor para correspondencia
fernandezfana@uniovi.es

Corresponding author.
, Carolina Bringas-Molledab, Francisco Javier Rodríguez-Díazc, Alberto Lanaa
a Department of Medicine, Faculty of Medicine and Health Sciences, University of Oviedo/ISPA, Oviedo, Spain
b Department of Psychology and Anthropology, Faculty of Teacher Formation, University of Extremadura, Cáceres, Spain
c Department of Psychology, Faculty of Psychology, University of Oviedo, Oviedo, Spain
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            "entidad" => "Department of Medicine&#44; Faculty of Medicine and Health Sciences&#44; University of Oviedo&#47;ISPA&#44; Oviedo&#44; Spain"
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            "entidad" => "Department of Psychology and Anthropology&#44; Faculty of Teacher Formation&#44; University of Extremadura&#44; C&#225;ceres&#44; Spain"
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            "entidad" => "Department of Psychology&#44; Faculty of Psychology&#44; University of Oviedo&#44; Oviedo&#44; Spain"
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        "titulo" => "Tolerancia de la violencia en la pareja y las actitudes sexistas entre estudiantes universitarios&#47;as de ciencias de la salud de tres universidades espa&#241;olas"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Perception of abuse &#40;&#37;&#41; according to the degree and sex&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of intimate partner violence &#40;IPV&#41; in youth dating is very high&#44; even higher than in adulthood&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">1&#44;2</span></a> Although psychological IPV is its most frequent expression&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#44;4</span></a> other forms of more direct and recognizable IPV&#44; like physical or sexual IPV&#44; are also common among youth&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2&#44;4</span></a> Furthermore&#44; as some violent behaviors are often not properly perceived by victims&#44; these figures may be higher&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">5&#44;6</span></a> According to data from the Spanish Government&#44; one out of every three women does not identify controlling behavior as abusive&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> Many young people even justify acts of violence as play or a joke&#44; or they mistakenly interpret them according to romantic sexist ideals&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;9</span></a> presenting high IPV-tolerance&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10&#44;11</span></a> Tolerance of violent behavior and gender role attitudes have been associated with the difficulty of recognizing abuse&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Health professionals &#8212;mainly doctors&#44; nurses&#44; and psychologists&#8212; play a central role in identifying and addressing IPV&#46; Victims of abuse consider health professionals as necessary support persons&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> Therefore&#44; the comprehensive approach to IPV from the healthcare system has little chance of success if practitioners are not suitably trained to recognize violence and are sufficiently sensitive to its relevance&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a> Given that training in IPV is known to increase its recognition and improve attitudes and skills for its treatment&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">16&#44;17</span></a> beginning this training during university studies seems reasonable&#46; However&#44; the development of IPV-related skills and content are poorly covered in health sciences curricula&#44; both internationally<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> and in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To date&#44; no prior study has compared IPV-tolerance and gender role attitudes of future health professionals&#46; Furthermore&#44; we found no studies addressing differences in IPV-tolerance and gender role attitudes among students of consecutive academic courses&#46; Therefore&#44; the objectives were to explore the differences in IPV-tolerance and sexist attitudes among medicine&#44; nursing&#44; and psychology students from three Spanish universities&#44; and to study the evolution of these indicators&#44; comparing students of consecutive academic courses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cross-sectional study among male and female students of the degrees of medicine&#44; nursing&#44; and psychology from three Spanish universities &#40;Universities of Oviedo&#44; Extremadura and Seville&#41;&#44; selected according to the availability of a member of the research team&#46; Inclusion criteria were &#8805;18 years and having been in a dating relationship for at least one month&#46; In order to compare the degrees&#44; students in fifth and sixth course of the medicine degree were excluded&#46; We surveyed 1&#44;430 students who met selection criteria&#44; 905 from the University of Oviedo&#44; 411 from the University of Extremadura&#44; and 114 from the University of Seville&#46; Medicine students represented 38&#46;8&#37; of the sample &#40;n &#61; 555&#41;&#44; nursing students 37&#46;0&#37; &#40;n &#61; 529&#41;&#44; and psychology students 24&#46;2&#37; &#40;n &#61; 346&#41;&#46; Considering all the students registered in the selected health science degrees&#44; response rates were 54&#46;3&#37; in medicine&#44; 50&#46;2&#37; in nursing&#44; and 23&#46;6&#37; in psychology&#46; Overall response rate was 40&#46;3&#37;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All participants gave passive informed consent &#40;questionnaire instructions indicated implicit consent by completion and return of the form&#41;&#46; The study received approval of the universities and of the Committee of Research Ethics of Asturias &#40;Spain&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection and study variables</span><p id="par0030" class="elsevierStylePara elsevierViewall">Students&#8217; information was obtained through a questionnaire administered in the classrooms between December 2016 and March 2017&#46; Previously&#44; we explained the aims of the study and the anonymous and voluntary nature of participation&#46; Students who had a history of more than one dating relationship were asked to respond with reference to the most problematic relationship&#46;&#160;The questionnaire measured IPV-tolerance and sexist attitudes using two scales&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the one hand&#44; the <span class="elsevierStyleItalic">Perceived Disturbance Scale</span>&#160;included in the&#160;<span class="elsevierStyleItalic">Dating Violence Questionnaire</span>&#160;&#40;DVQ-R&#41;&#44; which assesses the level of annoyance about 20 violent behaviors on a five-point scale &#40;not at all &#61; 0&#44; not much &#61; 1&#44; somewhat &#61; 2&#44; quite a bit &#61; 3&#44;&#160;and&#160;very much &#61; 4&#41; &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Table I of the online Appendix</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a>&#160;These behaviors are grouped into five forms of IPV&#58; detachment&#44; humiliation&#44; coercion&#44; physical abuse&#44; and sexual abuse&#46; Subsequently&#44; given that perceived annoyance about violent behaviors can be considered the opposite of their tolerance&#44; the scale was inverted&#46; Thereby&#44; higher scores indicated higher IPV-tolerance&#46; Then&#44; options &#8220;not at all&#8221;&#44; &#8220;not much&#8221; or &#8220;somewhat&#8221;&#160;were globally considered&#160;as &#8220;IPV-tolerant&#8221;&#46;&#160;Following a zero-tolerance policy&#44; which is widely used when referring to several forms of violence or sexism&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">6&#44;22</span></a>&#160;students were deemed to be considered IPV-tolerant if they were tolerant of at least one of the behaviors&#46;&#160;Although to date&#44; the validation of DVQ-R has only been published with reference to the&#160;<span class="elsevierStyleItalic">Victimization&#160;Scale</span> &#8212;with good internal consistency &#40;Cronbach&#39;s alpha&#58; 0&#46;85&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a>&#8212; the satisfactory validity of the&#160;<span class="elsevierStyleItalic">Perceived Disturbance&#160;Scale</span> could be expected&#44; as both scales use the same items&#46; Moreover&#44; this scale was considered appropriate by consensus of the same panel of experts&#46; Lastly&#44; the&#160;<span class="elsevierStyleItalic">Perceived Disturbance&#160;Scale</span> has been successfully used in previous research&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand&#44; we used the <span class="elsevierStyleItalic">Gender Role Attitudes Scale</span> &#40;GRAS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a> This 20-item scale describes different egalitarian or sexist expressions that people use about the role that men and women play in society according three functions&#58; social&#44; occupational&#44; and family&#46; Each item is rated on a five-point Likert scale ranging from 0 &#40;strongly disagree&#41; to 4 &#40;strongly agree&#41; &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Table II of the online Appendix</a>&#41;&#46; Given that sexism can be considered the opposite of gender equality&#44; the scores of items referring to egalitarian expressions were reversed to transform them into sexist attitudes&#46; Subsequently&#44; the options &#8220;partially disagree&#8221;&#44; &#8220;agree&#8221; and &#8220;strongly agree&#8221; were considered as sexist attitudes&#44; and the options &#8220;strongly disagree&#8221; and &#8220;disagree&#8221; were considered as egalitarian attitudes&#46; From the perspective of the zero-tolerance policy&#44; students were deemed to have a global sexist attitude when they agreed with at least one sexist attitude considered in of the GRAS&#46; The internal consistency of the GRAS was excellent &#40;Cronbach&#39;s alpha&#58; 0&#46;99&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The questionnaire also included potential confounders&#46; Sociodemographic and basic academic data were collected &#40;sex&#44; age&#44; degree&#44; and course&#41;&#46; We also studied the perception of abuse&#44; fear&#44; and&#47;or entrapment through three dichotomous &#40;yes&#47;no&#41; self-reported variables&#46; Through these variables we classified students in three levels of perception of abuse&#58; a first group that perceived themselves as abused &#40;i&#46;e&#46;&#44; &#8220;perceived abuse&#8221;&#41;&#59; a second group that did not feel abused by their partners but reported being afraid of their partner or having felt trapped during their relationship &#40;i&#46;e&#46;&#44; &#8220;unperceived abuse&#8221;&#41;&#59; and a third group made up of youths who claimed not having been abused or feeling afraid or entrapped &#40;i&#46;e&#46;&#44; &#8220;non-abused&#8221;&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of the 1430 students surveyed&#44; we excluded 108 with lacking data in some questionnaire items&#44; leaving a final sample of 1322 individuals &#40;534 from medicine&#44; 497 from nursing&#44; and 291 from psychology&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Sex- and age-differences according to degrees were respectively studied by means of the non-parametric chi-square independence test and the independent t-test&#44; using medicine degree as reference&#46; Differences in abuse perception according sex within each degree were analyzed using the non-parametric chi-square independence test&#46; Then&#44; using the zero-tolerance criteria to operationalize IPV-tolerance and sexism&#44; logistic regressions separately by sex were used to compare the estimated crude proportion of IPV-tolerant students and sexist attitudes according to the degree&#46; Moreover&#44; we obtained adjusted proportions derived from predicted probabilities using logit models separately by sex&#44; adding the degree as indicator and the age and perception of abuse &#40;perceived abuse&#44; unperceived abuse&#44; non-abused&#41; as potential confounders&#46; These results are shown for each IPV-tolerance forms and sexism functions&#46; Analogously&#44; crude and adjusted proportions for total IPV-tolerance and total sexism according to the academic course &#40;included in the regression model as categorical variable&#41; were calculated separately by sex and degree&#46; Subsequently&#44; to estimate the evolution of IPV-tolerance and sexist attitudes throughout academic formation&#44; we obtained the p-trend by running analogous regression models but with academic course modelled as a continuous variable &#40;from 1 &#61; first course to 4 &#61; fourth course&#41;&#46; Lastly&#44; in order to determine the robustness of our findings&#44; we repeated main analyses using linear regression models and introducing IPV-tolerance and sexism as quantitative variables&#44; both of them ranging from 0 to 80 points &#40;maximum IPV-tolerance&#47;sexism&#41;&#46; All analyses were conducted and presented separately for each sex&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Data analysis was performed using STATA v&#46;13&#46; Only values of p &#60;0&#46;05 were considered statistically significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Of the total sample&#44; 1060 were women &#40;80&#46;2&#37;&#41; and 262 were men &#40;19&#46;8&#37;&#41;&#46; The percentage of women was higher in the psychology &#40;87&#46;3&#37;&#59; p &#60;0&#46;001&#41; and nursing degrees &#40;86&#46;9&#37;&#59; p &#60;0&#46;001&#41; than in medicine &#40;70&#46;0&#37;&#41;&#46; Mean age &#40;&#177; standard deviation&#41; was 21&#46;3 in nursing &#40;&#177; 4&#46;7 years&#41;&#44; 20&#46;6 in medicine &#40;&#177; 2&#46;9 years&#41;&#44; and 19&#46;5 in psychology &#40;&#177; 1&#46;7 years&#41;&#46; Compared to medicine students&#44; mean age was significantly higher in nursing students &#40;p &#61; 0&#46;001&#41; and lower in psychology students &#40;p &#60;0&#46;001&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding students&#8217; perception of abuse&#44; 8&#46;4&#37; men and 8&#46;0&#37; women perceived themselves as abused&#44; whereas 25&#46;6&#37; of men and 25&#46;1&#37; of women were in a situation of unperceived abuse&#46; Unperceived abuse was more frequent in the psychology degree&#44; followed by nursing and medicine &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A higher percentage of psychology students were tolerant towards all forms of IPV than were students of medicine and nursing&#46; This was consistent across sexes&#44; despite the lack of statistical power in the men&#39;s stratum&#44; except for humiliation &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Findings regarding sexist attitudes were similar &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the proportion of IPV-tolerant students and students with sexist attitudes according to sex&#44; academic course&#44; and degree&#46; Compared to students of the first courses&#44; only female medical students of higher courses showed less total IPV-tolerance&#46; Likewise&#44; the percentage of sexist attitudes was significantly lower among male medical students of higher courses&#46; Similar results were obtained when repeating the analyses modeling IPV-tolerance and sexism as quantitative variables &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Table III of the online Appendix</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#sec0080">Table IV of the online Appendix</a> shows the proportion of students with IPV-tolerance and sexist attitudes according to sex and academic course&#44; in the whole sample&#46; Male students of higher courses had less tolerance toward sexual violence and fewer occupational sexist attitudes&#46; In the case of female students&#44; tolerance to all forms of IPV &#40;except for humiliation&#41; and occupational sexist attitudes were significantly lower among students of higher courses&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">According to the results of this study&#44; the prevalence of IPV-tolerance and sexism was significantly higher in psychology students than in medicine or nursing students&#46; When analyzing students&#8217; differences between consecutive academic courses&#44; IPV-tolerance was lower in female medical students of higher courses&#44; and sexist attitudes were lower in male medical students of higher courses&#44; suggesting that some aspects of future doctors&#8217; training may address violence more than in other degrees&#46; These sex differences deserve further consideration&#46; In any case&#44; it should be considered that the overall high prevalence of IPV-tolerance and sexism observed among students of health sciences could be due to the very sensitive zero-tolerance criterion employed &#40;cut-off point&#58; presence of tolerance towards a single IPV behavior and presence of a single sexist attitude&#41;&#44; which may have increased false positives&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The fact that both male and female students of the psychology degree were more IPV-tolerant than the other health science students included in our study&#44; even after adjusting for age and perception of abuse&#44; deserves a profound reflection&#46; Interestingly&#44; in a recent study requested four groups of people to rate a series of simulated cases of self-inflicted violence&#44; and psychology students committed errors similar to those of the group of volunteers&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> In another study&#44; the acceptance by police officers and psychology students of some sexist stereotypes that emerge in cases of rape were compared&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> The results revealed that the students were more tolerant than the police officers toward myths like &#8220;she asked for it&#8221; and &#8220;he did not mean to&#8221;&#46; Perhaps during psychology studies&#44; the excess of theoretical and practical exposure to information and examples of dysfunctional behaviors and situations desensitizes students&#44; increasing their tolerance&#46; This is similar to medical and nursing students&#8217; progressive loss of empathy towards physical disease during their studies&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a> This explanation has also been supported in another observation derived from our results&#58; the differences between the degrees in total tolerance in the first course are very small when compared with the differences that emerge in the fourth year&#46; This suggests that advancing in psychology studies may contribute to the students&#8217; acceptance of IPV&#59; or at least&#44; studying psychology may not foster IPV-rejection&#44; unlike the other degrees&#46; Another possible explanation for this finding is that psychology students were also notably more sexist than the other health science students&#46; It seems clear that the less gender equity there is&#44; the more IPV-tolerance and perpetration will exist&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">27&#44;28</span></a> This same consideration may explain sex differences in IPV-tolerance&#44; as male students were both more sexist and more IPV-tolerant than female students&#46; Accordingly&#44; sexist attitudes could be a first step in the pathway toward IPV-tolerance&#46; In any case&#44; beyond the possible explanations for these findings and considering the fatal implications of graduate psychologists with some IPV-tolerance or sexist attitudes&#44; the design of suitable curricular tools to fight against IPV-tolerance and sexism are urgently needed&#46; Previously&#44; future research should confirm our findings and explore in greater depth the reasons we have hypothesized&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Differences in gender-role attitudes between psychology&#44; medicine&#44; and nursing students can also be analyzed similarly&#46; In this case&#44; the differences are very marked in the first course&#44; indicating that psychology&#44; medicine&#44; and nursing students probably have different conceptions of gender equity already before starting their studies&#46; In general&#44; sexist attitudes were particularly manifest in the occupational sphere&#46; This agrees with results of other authors who have warned that sexist occupational attitudes can be the most firmly rooted in society&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">23&#44;29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Notwithstanding the cross-sectional nature of the study design&#44; which urges caution in the interpretations&#44; our results concerning the overall evolution of IPV-tolerance and sexism according to the academic course revealed interesting sex differences&#46; On the one hand&#44; there was a significant trend towards less IPV-tolerance in women over academic courses&#44; but not in men&#46; On the other hand&#44; there was a significant decrease of sexism in men&#44; but not in women&#46; These findings suggest that changes in sexist attitudes come first&#44; and only then does the teachable moment to produce changes in IPV-tolerance emerge&#46; Given that women began university studies with more egalitarian attitudes than men&#44; the progression throughout academic courses could produce improvements in IPV-tolerance&#46; If this hypothesis is true&#44; men would fail to find their teachable moment to reduce IPV-tolerance until postgraduate training or during clinical practice&#44; which is probably too late&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The analysis of the evolution of the prevalence of IPV-tolerance and sexist attitudes in each degree suggests that only medicine students underwent a consistent and positive change throughout their studies&#44; male students in sexist attitudes and female students in IPV-tolerance&#46; It is difficult to offer a tentative hypothesis to explain this phenomenon because&#44; in all three degrees&#44; IPV is addressed at some point&#44; and professors seem to be sufficiently committed to this formation&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20&#44;30</span></a> In addition&#44; the psychology degree has the most curricular content about violence&#44; but if we were seeking a student sensitized toward suffering&#44; we would probably choose a nursing student&#46; So&#44; how is the medicine degree different&#63; Perhaps medicine students are urged very early on to become participants in the unavoidable responsibility they will acquire to identify and treat cases of IPV&#44; and this makes them more sensitive to the problem&#46; There are numerous studies and experiences suggesting that any training in IPV is satisfactory for medicine students&#44; especially if it is transversal and addresses real cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">31&#44;32</span></a> Therefore&#44; perhaps a greater effort should be made in nursing and psychology degrees&#44; seeking higher student commitment towards IPV&#44; emphasizing that they will be partly responsible for dealing with IPV and banishing some stereotypical ideas that contribute to IPV-tolerance and sexism&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; The main one involves the cross-sectional nature of the data&#44; which prevents us from analyzing with a high degree of validity the association between a certain academic course and changes in IPV-tolerance and sexist attitudes&#46; Thereby&#44; in order to appropriately test this hypothesis&#44; we recommend conducting longitudinal research with a large cohort of students&#46; A second limitation was our convenience sample&#44; which does not allow the generalization of results&#46; However&#44; the aim was not to study the prevalence of IPV-tolerance and sexism&#44; but their association across some health science degrees and over academic courses&#46; In addition&#44; although groups of students were quite comparable according to degree&#44; some strata had few participants&#44; and there was also a high disparity in the number of students from each university&#46; Another limitation regarding the sample was having obtained a response rate below 50&#37;&#44; mainly due to a percentage of students who do not attend classes regularly&#46; Moreover&#44; students who attend regularly may differ from the others in academic variables&#46; A third limitation was that our study did not include a sample of students from the social work degree&#44; although social workers are acknowledged as essential health professionals to deal with IPV and as the best trained to provide an appropriate response&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">17&#44;34</span></a> A fourth limitation was that the DVQ-R did not account for some current important forms of IPV&#44; like cyber-abuse&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a> Another limitation involved the small number of sociodemographic or academic variables and variables related to students&#8217; history of personal and family violence&#44; as they could have conditioned the results&#46; Although the associations we found are maintained when adjusting for the available variables&#44; perhaps other uncontrolled variables are responsible for part of the association&#44; particularly the students&#8217; social and educational environment&#44; which may be different in the three degrees&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; the level of IPV-tolerance and sexism among the students of medicine&#44; nursing&#44; and psychology was high&#44; especially in male students&#46; Compared to medicine and nursing degrees&#44; the frequency of students&#8217; tolerance towards IPV and sexist attitudes was significantly higher in the psychology degree&#46; Only medicine students underwent a hypothetical positive trend throughout their studies&#44; female students in IPV-tolerance and male students in sexist attitudes&#46; Designing university curricula that seek the development of egalitarian gender-role attitudes is urgently needed&#44; with special focus on male students&#44; as a first step in the pathway toward decreasing IPV-tolerance&#46; Longitudinal studies are needed that follow up a group of young people from the beginning to the end of their university studies&#44; as well as qualitative studies that examine the quantity and quality of training about violence offered by the universities and received by the students&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Editor in charge</span><p id="par0135" class="elsevierStylePara elsevierViewall">Miguel &#193;ngel Negr&#237;n Hern&#225;ndez&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Transparency declaration</span><p id="par0140" class="elsevierStylePara elsevierViewall">The corresponding author on behalf of the other authors guarantee the accuracy&#44; transparency and honesty of the data and information contained in the study&#44; that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Authorship contributions</span><p id="par0145" class="elsevierStylePara elsevierViewall">F&#46;J&#46; Rodr&#237;guez-D&#237;az and A&#46; Lana designed the study&#46; V&#46; Garc&#237;a-D&#237;az and A&#46; Fern&#225;ndez-Feito collected the data&#46; A&#46; Fern&#225;ndez-Feito and C&#46; Bringas-Molleda performed the statistical analyses&#46; V&#46; Garc&#237;a-D&#237;az and A&#46; Lana drafted the first version of the manuscript&#46; Lastly&#44; all authors contributed to the critical revision of the paper and approved the &#64257;nal manuscript for publication&#46; All authors have agreed to be accountable for all aspects of the study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">The study was supported by grants from the Ministerio de Sanidad&#44; Servicios Sociales e Igualdad of Spain &#40;Project SUBINMU012&#47;009&#41; and from the Universidad de Oviedo&#47;Consejer&#237;a de Educaci&#243;n&#44; Cultura y Deporte del Principado de Asturias &#40;Project UO-15- INVES-32&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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            0 => "Violencia de pareja"
            1 => "Sexismo"
            2 => "Actitudes"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To explore university health science students&#8217; intimate partner violence tolerance and sexist attitudes and to examine their trend throughout the academic years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study of students of both sexes of the degrees of medicine&#44; nursing&#44; and psychology from three selected Spanish universities &#40;n &#61; 1&#44;322&#41;&#46; Data were collected anonymously using two validated scales&#58; the Dating Violence Questionnaire &#40;DVQ-R&#41; and the Gender Role Attitudes Scale &#40;GRAS&#41;&#46; Logistic regressions were used to compare tolerance toward violence and sexist attitudes across the degrees&#46; The evolution of these variables throughout different academic courses was assessed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Of the sample&#44; 62&#46;8&#37; were tolerant towards intimate partner violence&#46; The percentage of tolerant students was significantly higher in Psychology &#40;75&#46;9&#37;&#41; than in Nursing &#40;57&#46;7&#37;&#41; and Medicine Degrees &#40;60&#46;3&#37;&#41;&#46; A higher percentage of sexist students was also found in psychology students &#40;80&#46;8&#37;&#41; than in nursing &#40;62&#46;2&#37;&#41; and medicine students &#40;62&#46;7&#37;&#41;&#46; Compared to the first-year students&#44; female medicine students of the last courses were less tolerant to intimate partner violence &#40;p-trend &#60;0&#46;001&#41;&#44; and male medicine students had less sexist attitudes &#40;p-trend &#61; 0&#46;002&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Tolerance of intimate partner violence and sexist attitudes were very high&#44; especially among psychology students&#46; These indicators were significantly better among medicine students of higher courses&#44; suggesting a positive effect of medical training&#46; Intimate partner violence in the university education of the future health professionals should be addressed&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Explorar la tolerancia de la violencia en la pareja y las actitudes sexistas en estudiantes universitarios&#47;as de ciencias de la salud&#44; y estudiar su tendencia a lo largo de los cursos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en estudiantes de ambos sexos de medicina&#44; enfermer&#237;a y psicolog&#237;a de tres universidades espa&#241;olas &#40;n &#61; 1322&#41;&#46; Se utilizaron dos escalas validadas y an&#243;nimas&#58; <span class="elsevierStyleItalic">Cuestionario de Violencia entre Novios-Revisado</span> &#40;DVQ-R&#41; y <span class="elsevierStyleItalic">Escala de Actitudes de Rol de G&#233;nero</span> &#40;EARG&#41;&#46; Mediante regresiones log&#237;sticas se compararon la tolerancia al abuso y las actitudes sexistas entre titulaciones&#44; y se estudi&#243; su evoluci&#243;n a lo largo de la formaci&#243;n acad&#233;mica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El 62&#44;8&#37; se mostraron tolerantes ante la violencia en la pareja&#46; El porcentaje de estudiantes tolerantes fue significativamente m&#225;s elevado en psicolog&#237;a &#40;75&#44;9&#37;&#41; que en enfermer&#237;a &#40;57&#44;7&#37;&#41; y medicina &#40;60&#44;3&#37;&#41;&#46; Tambi&#233;n se encontr&#243; un mayor porcentaje de estudiantes sexistas en psicolog&#237;a &#40;80&#44;8&#37;&#41; que en enfermer&#237;a &#40;62&#44;2&#37;&#41; y medicina &#40;62&#44;7&#37;&#41;&#46; En comparaci&#243;n con estudiantes de nuevo acceso&#44; las estudiantes de medicina de los &#250;ltimos cursos fueron menos tolerantes a la violencia &#40;p &#60;0&#44;001&#41; y los estudiantes de medicina varones tuvieron menos actitudes sexistas &#40;p &#61; 0&#44;002&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La tolerancia de la violencia en la pareja y las actitudes sexistas fueron muy elevadas&#44; especialmente en psicolog&#237;a&#46; Estos indicadores fueron significativamente mejores en estudiantes de medicina de los cursos superiores&#44; lo que sugiere un efecto positivo de la formaci&#243;n m&#233;dica&#46; Se deber&#237;a mejorar el abordaje de la violencia en la pareja en la formaci&#243;n universitaria de los&#47;las futuros&#47;as profesionales sanitarios&#47;as&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3rd course&#40;n &#61; 74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">4th course&#40;n &#61; 52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-trend<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1st course &#40;n &#61; 350&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2nd course &#40;n &#61; 241&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3rd course &#40;n &#61; 274&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">4th course &#40;n &#61; 195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-trend<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="11" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">IPV-tolerant&#44; total</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Medicine&#44; n</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">78&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#37; crude&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">92&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#37; adjusted<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#37; adjusted<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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