Encyclopedia
Please note this is a comparison between Version 1 by Bettina Pfleiderer and Version 2 by Lindsay Dong.
Domestic violence (DV) is an important public health topic with a high prevalence in society. Dentists are also frontline responders to DV, as they not only treat victims of DV with dental injuries, but they can also screen for the presence of DV because they see patients for regular check-ups. Although dentists, as members of the health care sector, are important frontline responders to DV, they are neither trained adequately nor do most feel competent enough to ask victims about DV or support them as needed, as DV is often not taught at dentistry schools at all. DV education should be mandatory at dentistry schools and in further training for dentists with a focus on communication with victims, how DV can be identified and how to support victims well.
- domestic violence
- intimate partner violence
- dentistry
- domestic violence education
1. Introduction
Since the outbreak of COVID-19, domestic violence (DV) came increasingly into the limelight [1], as many people were forced to stay mostly at home and live socially distanced due to quarantine measures [1]. Recent data have indicated that DV against woman is on the rise [2], in particular the numbers of calls to shelters and helplines have increased during the COVID-19 pandemic [3]; for example, case numbers rose by 18% in Spain and by 30% in France in early 2020 [4]. It soon became clear that the detection and support of victims as well as the first line response to DV need to be improved.
What starts with humiliation and manipulation might end in hurting and injuring the abused person. Different forms of DV, such as sexual, physical, emotional and economic violence, can occur [5]. A distinction is made between short-, medium- and long-term consequences: short- time consequences are physical injuries, which in the worst case could lead to death. The medium- and long-term effects of DV on health can result in a range of psychological and psychosomatic symptoms [6]. Moreover, it is important to keep in mind that about 28–50% (depending on the country) of murders of women are committed by their intimate partners [7].
DV is gendered and women are affected the most; about 80% of all reported DV incidents have women as victims [8]. According to the World Health Organization report “Violence against woman prevalence estimates, 2018” [5], 26–28% of all women between the age of 20–44 years do experience or have experienced domestic violence once in their lifetime; 10–16% of all women between age of 20–44 years do experience or have experienced sexual violence from a current or past partner in the past 12 months [2][5].
DV is gendered and women are affected the most; about 80% of all reported DV incidents have women as victims [8]. According to the World Health Organization report “Violence against woman prevalence estimates, 2018” [5], 26–28% of all women between the age of 20–44 years do experience or have experienced domestic violence once in their lifetime; 10–16% of all women between age of 20–44 years do experience or have experienced sexual violence from a current or past partner in the past 12 months [2,5].
Even though most cases of dental trauma seen in young age (childhood till the age of 19) is often due to accidents [9][10], dentists should still consider the presence of DV as one possible cause for this kind of trauma.
Even though most cases of dental trauma seen in young age (childhood till the age of 19) is often due to accidents [9,10], dentists should still consider the presence of DV as one possible cause for this kind of trauma.
Dentists seeing patients on a regular basis have the opportunity to detect potential victims of DV, as victims can present with injuries in the region of head, neck and face. Ochs et al. [11] reported that nearly 95% of all victims of physical violence have these kinds of injuries. Another research of Brazilian origin confirmed this: a total of 37.6% of their victim sample had traumas of the head, neck and face. Teeth were affected in 2% of all victims [12]. Although most DV victims do not seem to have dental-related injuries, dentists can nevertheless be considered frontline responders, since it is likely that some patients they see at their dental practice are victims of DV and may depict signs of injuries in the head and facial region.
2. Dentists’ Competence and Knowledge on Domestic Violence
Despite the high prevalence of DV, the numbers of victims detected in dental practices are comparatively low [13][14][15], which can be explained in part by the low frequency of regular screenings for DV and the lack of training on DV [8][13][14][15]. The majority of dentists are aware that they will most likely see DV victims in their dental practise; however, they do not feel sufficiently competent in helping victims due to a lack of knowledge [13]. Moreover, they do not feel comfortable enough asking their patients about DV. The reasons provided for not asking were that the victims were either accompanied by family and/or that the dentists were afraid of offending the victim; in addition, a lack of information about what to do after the victim disclosed that they were suffering from violence presented another obstacle to asking [8][13][14][15]. This, too, can be attributed to a lack of training, as many dentists are not informed about their reporting duty [15]. Even in cases where DV was suspected, a record in the patients’ file was made, but victims did not receive any information about shelters and/or contact points for DV victims [8][13][15][16]. DV victims clearly want to have more support [16]. The importance of DV as a public health problem has not been questioned [17][18][19] and the statement that dentists have an important role in detecting victims has reached strong agreement [19]. The belief that victims do not appreciate the support they are given and that victims will stay with their perpetrator even if they are supported by others did not change even after a training programme [19]. However, even if beliefs regarding DV did not change significantly [19], most who participated in the trainings felt more competent in understanding the topic and talking to the victim after they had received some form of training [17]. In all studies on DV training, the impact was found to be positive, as knowledge and confidence in dealing with cases where DV is suspected increased significantly among the participants of trainings [17][18][20][21][19]. Therefore, it is problematic that very few dental schools have courses on DV in their curricula [22]. The reasons given for this were a lack of time for this topic in the curriculum and a lack of knowledge regarding the topic of DV [22], which shows that DV needs more attention in the dental health sector. In those dental schools where DV was taught, most teaching formats included some form of an online teaching session (
Dentists seeing patients on a regular basis have the opportunity to detect potential victims of DV, as victims can present with injuries in the region of head, neck and face. Ochs et al. [11] reported that nearly 95% of all victims of physical violence have these kinds of injuries. Another study of Brazilian origin confirmed this: a total of 37.6% of their victim sample had traumas of the head, neck and face. Teeth were affected in 2% of all victims [12]. Although most DV victims do not seem to have dental-related injuries, dentists can nevertheless be considered frontline responders, since it is likely that some patients they see at their dental practice are victims of DV and may depict signs of injuries in the head and facial region.
2. Dentists’ Competence and Knowledge on Domestic Violence
Despite the high prevalence of DV, the numbers of victims detected in dental practices are comparatively low [21,22,24], which can be explained in part by the low frequency of regular screenings for DV and the lack of training on DV [8,21,22,24].
The majority of dentists are aware that they will most likely see DV victims in their dental practise; however, they do not feel sufficiently competent in helping victims due to a lack of knowledge [21]. Moreover, they do not feel comfortable enough asking their patients about DV. The reasons provided for not asking were that the victims were either accompanied by family and/or that the dentists were afraid of offending the victim; in addition, a lack of information about what to do after the victim disclosed that they were suffering from violence presented another obstacle to asking [8,21,22,24]. This, too, can be attributed to a lack of training, as many dentists are not informed about their reporting duty [24]. Even in cases where DV was suspected, a record in the patients’ file was made, but victims did not receive any information about shelters and/or contact points for DV victims [8,21,24,25]. DV victims clearly want to have more support [25].
The importance of DV as a public health problem has not been questioned [16,17,29] and the statement that dentists have an important role in detecting victims has reached strong agreement [29]. The belief that victims do not appreciate the support they are given and that victims will stay with their perpetrator even if they are supported by others did not change even after a training programme [29]. However, even if beliefs regarding DV did not change significantly [29], most who participated in the trainings felt more competent in understanding the topic and talking to the victim after they had received some form of training [16].
In all studies on DV training, the impact was found to be positive, as knowledge and confidence in dealing with cases where DV is suspected increased significantly among the participants of trainings [16,17,20,28,29]. Therefore, it is problematic that very few dental schools have courses on DV in their curricula [23]. The reasons given for this were a lack of time for this topic in the curriculum and a lack of knowledge regarding the topic of DV [23], which shows that DV needs more attention in the dental health sector.
In those dental schools where DV was taught, most teaching formats included some form of an online teaching session (
Table 1). Only Raja et al. [17] reported that they used role-playing with actors and videos of real victims to enhance the impact of the tutorial, which was also very well received by the attending dental students. Role-playing may encourage more participants to engage with the topic and improve their knowledge.
Regarding the gap in knowledge and the lack of mandatory DV training, there is no major difference between dentists and medical doctors. Studies have shown that there is also a lack of training for medical doctors and a lack of knowledge on how to deal with victims [23]. In addition, many physicians do not know how to interact with special victim groups or have often overlooked males [24] and/or children [25] as victims and do not know how to support them well. It has been shown that medical doctors, similar to dentists, are often too afraid to ask patients about DV [26]. A lack of time and not feeling competent to identify and support victims seems to be the major hurdles for medical doctors in taking further steps after DV has been disclosed [26]. DV is not a mandatory topic among Europe′s medical profession groups [26], which needs to be changed.
Looking at the studies available (
). Only Raja et al. [16] reported that they used role-playing with actors and videos of real victims to enhance the impact of the tutorial, which was also very well received by the attending dental students. Role-playing may encourage more participants to engage with the topic and improve their knowledge.
Regarding the gap in knowledge and the lack of mandatory DV training, there is no major difference between dentists and medical doctors. Studies have shown that there is also a lack of training for medical doctors and a lack of knowledge on how to deal with victims [36]. In addition, many physicians do not know how to interact with special victim groups or have often overlooked males [37] and/or children [38] as victims and do not know how to support them well. It has been shown that medical doctors, similar to dentists, are often too afraid to ask patients about DV [39]. A lack of time and not feeling competent to identify and support victims seems to be the major hurdles for medical doctors in taking further steps after DV has been disclosed [39]. DV is not a mandatory topic among Europe′s medical profession groups [39], which needs to be changed.
Looking at the studies available (
Table 1), it is noticeable that no long-term effects of training interventions have been investigated [17][18][20][22][21][19]. It is generally known that teaching must be repeated several times to make it sustainable [27]. In line with this, the topic of DV should not only be taught in one single tutorial, which only takes few hours, but should be included in several lectures at university dental classes. This would also help to reduce the barriers to addressing victims and strengthen competence to document DV cases properly [17][13][14][15][28].
), it is noticeable that no long-term effects of training interventions have been investigated [16,17,20,23,28,29]. It is generally known that teaching must be repeated several times to make it sustainable [40]. In line with this, the topic of DV should not only be taught in one single tutorial, which only takes few hours, but should be included in several lectures at university dental classes. This would also help to reduce the barriers to addressing victims and strengthen competence to document DV cases properly [16,21,22,24,26].
Table 1. Overview of studies (n = 6) on tutorials for dental students with country of research, research design, number of participants, teaching technique and main outcomes before and after the completion of the tutorials.
Overview of studies (n = 6) on tutorials for dental students with country of study, study design, number of participants, teaching technique and main outcomes before and after the completion of the tutorials.
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Domestic violence as a part of the formal education of dentists is an important factor in the prevention of DV and should be mandatory taught at dentistry schools and in further training for dentists on a regular basis using innovative training concepts, such as role-playing. The impact of these interventions should be investigated in further studies.
| Study | Title | Year of Acceptance | Countries of Study | Study Design | Number of Participants | Teaching Technique | Main Outcomes | Differences Before and After Training |
|---|
| R | Remember to screen routinely | Interview patients regularly if any case of violence occurred | |
| A | Ask | Direct and general questions as mentioned above might be used | |
| D | Document | Taking pictures, documenting details and the victim’s reporting in the patient′s chart | |
| A | Asses the patient′s safety | Asking about weapons, children involved and the patient′s feelings about going home [31] | Asking about weapons, children involved and the patient′s feelings about going home [43] |
| R | Review available options |
- An important focus should be put on communication with victims of DV, as dentists do not feel competent at all in this area. The following aspects should be covered and included in trainings:
- Make sure that the patient/victims are alone and can speak freely. Often victims are accompanied by either children or even partners[29][30]. Ask general questions about the state of a suspected victim′s relationship to start the conversation, e.g.,: “How are you getting along with your partner?“ ”How are things at home?” [30] If you feel the suspected victim wants to talk about their experience, direct questions might be asked, such as: “Have you ever been verbally/physically/emotionally/sexually abused by your partner?” [29][30]Make sure that the patient/victims are alone and can speak freely. Often victims are accompanied by either children or even partners [41,42]. Ask general questions about the state of a suspected victim′s relationship to start the conversation, e.g.,: “How are you getting along with your partner?“ ”How are things at home?” [42] If you feel the suspected victim wants to talk about their experience, direct questions might be asked, such as: “Have you ever been verbally/physically/emotionally/sexually abused by your partner?” [41,42]
- Materials from online training platforms, for example, the IMPRODOVA training platform, on DV with case studies, statistics, presentations and quizzes
- [
- 32] for teaching should be incorporated into trainings. The latter is a living document and will be updated on a regular basis.Materials from online training platforms, for example, the IMPRODOVA training platform, on DV with case studies, statistics, presentations and quizzes [44] for teaching should be incorporated into trainings. The latter is a living document and will be updated on a regular basis.
| If there is a direct risk, the victim should get in touch with a shelter, should receive the phone numbers of support groups and should be offered follow-up appointments to check up on the victims′ well-being. |
- As almost all articles on DV training are from the US or UK, studies on trainings should be conducted in other countries to improve the local detection and local support of DV victims.
| Buchanan et al. [ | ||||||
| 20] | Longitudinal curricular assessment of knowledge and awareness of intimate partner violence among first-year dental students | 2021 | USA | Cross-sectional study | n = 232 | |
| 2 | ||||||
| Brief pre- and post- testing, instructional workshop in class. | Before the workshop, two thirds of the students had received no education on DV at dental school. | DV as a healthcare issue and knowledge about procedures when a DV victim is identified improved. | Pre-testing: 51.3% stated that DV is a dental healthcare issue, with 61% of the female and 41% of the male students agreeing with this. | |||
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| Raja et al. [17] | Teaching dental students to interact with survivors of traumatic events: development of a two-day module | 2015 | USA | Cohort study: clinical study of a whole cohort of dental students | n = 92 | |
| Raja et al. [16] | Teaching dental students to interact with survivors of traumatic events: development of a two-day module | 2015 | USA | Cohort study: clinical study of a whole cohort of dental students | n = 92 | |
| 2 | ||||||
| , | n = 102 | |||||
| 2 | ||||||
| First module: lecture and discussion. | Second module: lecture, handouts, role plays, videos, practises on documenting findings in patient charts. | Competence about the topic of DV increased, knowledge about the importance of reporting and documenting DV improved. | Pre- and post-testing: communication skills and understanding of DV victims improved. Students were still unsure of when to report a potential victim of DV. | |||
| Patel et al. [22] | Domestic violence education for UK and Ireland undergraduate dental students: a five-year perspective | 2014 | UK, Ireland | Cross-sectional study | in 2007: n = 12 | |
| Patel et al. [23] | Domestic violence education for UK and Ireland undergraduate dental students: a five-year perspective | 2014 | UK, Ireland | Cross-sectional study | in 2007: n = 12 | |
| 1 | ||||||
| ; | in 2012 | |||||
| 1 | ||||||
| : | n = 11 | Lecture, video lessons, group work. | Reasons for not teaching DV: | |||
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| No difference in attitudes towards the topic of teaching DV to dental students. | |||||
| McAndrew et al. [21] | Effectiveness of an online tutorial on intimate partner violence for dental students: a pilot study | 2014 | USA | Quasi-experimental study | n = 25 | |
| McAndrew et al. [28] | Effectiveness of an online tutorial on intimate partner violence for dental students: a pilot study | 2014 | USA | Quasi-experimental study | n = 25 | |
| 1 | ||||||
| Online tutorial, pre- and post-testing. | Possible to change knowledge, but changing beliefs is difficult. | Post-testing: actual and perceived knowledge and preparation for dealing with DV victims significantly improved; only two opinions about DV improved significantly. | ||||
| Gibson-Howell et al. [18] | Instruction in dental curricula to identify and assist domestic violence victims | 2008 | ||||
| 17 | ||||||
| USA | Cohort study: two-part survey study design | in 1996 | ||||
| Gibson-Howell et al. [] | Instruction in dental curricula to identify and assist domestic violence victims | 2008 | USA | Cohort study: two-part survey study design | in 1996 | |
| 1 | ||||||
| : | n = 55; | in 2007 | ||||
| 1 | ||||||
| : | n = 25 | Most often taught: the role of dentists, signs in behaviour and injures seen in a possible victim and the reporting and referral protocol. | Least discussed: impact of DV in general. |
Similar results in 1996 compared to 2007, no significant improvements. | ||
| Hsieh et al. [19] | Changing dentists’ knowledge, attitudes and behavior regarding domestic violence through an interactive multimedia tutorial | May 2006 | USA | Randomised two group controlled trial | n = 174 | |
| Hsieh et al. [29] | Changing dentists’ knowledge, attitudes and behavior regarding domestic violence through an interactive multimedia tutorial | May 2006 | USA | Randomised two group controlled trial | n = 174 | |
| 2 | ||||||
| Interactive multimedia tutorial with pre- and post-testing. | Possible to change knowledge, but changing beliefs is difficult. | Post-testing: significant improvement in knowledge, but no change in beliefs and attitudes about victims. |
1
Dental schools;
2
dental students.
3. Recommendations
Table 2. Explanation of the R.A.D.A.R acronym with examples
4. Conclusions
To conclude, although the number of DV victims with dental injuries in dental practices is not high, knowing that one in three women suffer from DV clearly indicates that many victims go undetected. In this sense, the low rate of screening questions for new dental patients, especially when signs of facial injury are present, is of concern and clearly supports our call for formal training on DV.4. Conclusions
To conclude, although the number of DV victims with dental injuries in dental practices is not high, knowing that one in three women suffer from DV clearly indicates that many victims go undetected. In this sense, the low rate of screening questions for new dental patients, especially when signs of facial injury are present, is of concern and clearly supports our call for formal training on DV.
