J Dent Educ. 72(11): 1277-1289 2008
© 2008 American Dental Education Association
Milieu in Dental School and Practice |
Instruction in Dental Curricula to Identify and Assist Domestic Violence Victims
Joan C. Gibson-Howell, R.D.H., Ed.D.;
Marcia A. Gladwin, R.D.H., Ed.D.;
Marilyn J. Hicks, R.D.H., M.S.;
Jessie F.E. Tudor, B.S., M.S.;
Robert G. Rashid, D.D.S., M.S.
Key words: domestic violence, domestic violence education, dental curriculum
Submitted for publication 03/07/08;
accepted 08/20/08
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Abstract
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Since most domestic violence injuries occur in the head and neck areas, it is critical that dental professionals be prepared to identify, interview, and assist potential victims. The purposes of these surveys in 1996 and 2007 were to investigate U.S. and Canadian dental school curricula regarding the inclusion of domestic violence topics, determine the topics emphasized, determine beliefs of course directors about domestic violence issues, and report progress of dental curricula in preparing dental professionals regarding domestic violence over the eleven-year period. Surveys were sent to associate deans for academic affairs of dental schools in the United States and Canada in 1996 (N=64) and the United States in 2007 (N=56). Each academic dean was asked to forward the survey to the faculty member who taught this topic. Topics most frequently included and emphasized in dental school curricula were the responsibility of the health care professional (HCP) regarding domestic violence, how to identify physical and behavioral indicators, and how to refer the abused victim. The topics least frequently included and emphasized in the curricula regarded education of the abused and the impact of domestic violence on society. There were four strong beliefs reported by dental course directors: a trusting, professional rapport is essential for disclosure; the dentist or a dental team member may be the first HCP to recognize signs of abuse; the dentist has a professional responsibility to refer for assistance; and domestic violence education should be included in dental curricula. Over the eleven years, the surveys demonstrate that course directors have become more aware of the need to inform dental students about domestic violence and that more schools have increased the amount of information about domestic violence in dental courses. However, due to the complexity and sensitivity of this topic, course instructors in dental schools may consider other teaching methods to enhance learning. The authors identified the need for further course development and make recommendations to use experiential learning to enhance dental students’ interpersonal and interviewing skills. These strategies may increase dentists’ comfort and confidence when treating and assisting possible victims of domestic violence.
It is estimated that 1.5 million women incur serious injury by rape and/or physical assault by an intimate partner annually in the United States; it is also estimated that two to four million women are abused every twelve seconds by their partners. Domestic violence accounts for over 50 percent of all female homicides; and it is known that women of all ages, races, religions, incomes, and education levels experience domestic violence.1
Domestic violence may also be called intimate partner violence or violence against women. Domestic violence is defined by Chez as "a pattern of regularly occurring abuse and violence or the threat of violence in an intimate (though not necessary cohabitated) relationship."2 Family violence, a broader term, is defined as "child physical and sexual abuse and neglect, intimate partner violence, and elder abuse and neglect."3 This article will use the terms "domestic violence" and "intimate partner violence" interchangeably and will specifically discuss females as victims.
Health care professionals are mandated to report two types of family violence to law enforcement agencies: child abuse/neglect and elder abuse/ neglect.4 As a result, these topics are commonly included in the educational curricula of health care providers, including dentists5 and dental hygienists.6,7 However, because reporting of domestic violence is not required by most states, these topics are less likely to be included in dental and dental hygiene curricula.5–7 In fact, several professional associations have argued against mandatory reporting because it may be misconstrued as reducing the power of an already vulnerable person, it may not improve the situation for the victim, and it breaches confidentiality.4 To date, the evidence is not sufficient to warrant mandatory reporting of domestic violence by state law.4
Even though health care professionals are not mandated to report domestic violence, medical educators emphasize that including these topics in medical curricula may increase the numbers of suspected victims identified and referred for help.8–13 However, dental curricula often do not include domestic violence topics.5 Because of this, dentists may observe injuries, but either do not consider domestic violence as the cause or are afraid to address the issue with the possible victim.1 However, since head and neck injuries account for 65–75 percent6 of physical trauma that occurs during domestic violence incidents,1 dental personnel are in a favorable position to identify signs of domestic violence during their extraoral and intraoral examinations. In addition, the unique knowledge and skills of the dental professional are often necessary to treat the orofacial and dental structures of domestic violence victims.
There is little published research exploring the scope of domestic violence topics included in dental curricula. Therefore, the purposes of these surveys in 1996 and 2007 were to investigate U.S. and Canadian dental school curricula regarding the inclusion of domestic violence topics, determine the ranking emphasis of topics taught, ascertain the beliefs of course directors about domestic violence issues, and report any change in dental curricula with respect to domestic violence over an eleven-year period.
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Review of the Literature
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Domestic violence has been called an "unspoken scar on our society" and the number one women’s health care crisis in the United States.12 It is reported that domestic violence represents a major public health threat in the United States and has been identified as one of the leading indicators for Healthy People 2010 that must be addressed.14 Domestic violence costs the country approximately $50 billion annually because it is the most common cause of nonfatal injuries in the United States.15
According to medical professionals, 1.5 million women nationwide seek medical care annually due to injuries caused by domestic violence.4 Morbidity statistics report that 24 to 35 percent of women treated in hospital emergency rooms exhibit signs and injuries related to physical battering and that 10 to 50 percent of women’s suicide attempts are related to battering.16 Often the domestic violence victim is not identified in the emergency room, physician’s office, or community health clinic. Knowing the subtle signs of domestic violence, whether physical, mental, or emotional, is the key to correctly identifying, assessing, and assisting the victim.2
A study by Love et al.1 surveyed private practice dentists regarding their attitudes and behaviors about domestic violence. The respondents reported minimal intervention when working with domestic violence victims as patients. Eighty-seven percent of dentists in this study said they did not screen for domestic violence even when head and neck injuries were evident. Reasons they gave for not reporting included lack of training, too embarrassed to initiate a conversation, did not have a list of local referral agencies, did not have time, believed the patient would not follow up, the spouse or a child was present with the patient during the dental appointment, and concern about offending patients. In another study,15 investigators from the Minnesota Domestic Abuse Program interviewed 218 women and identified 144 different injuries. The most commonly documented injuries were to the head and neck area (40 percent) followed by musculoskeletal (28 percent) injuries. Other injuries identified at a lesser percent were sprains, fracture/dislocation, and foot injuries.
In 1996, the House of Delegates of the American Association of Dental Schools (AADS), now the American Dental Education Association (ADEA), approved a policy statement—still in effect—encouraging dental educators to include the following topics regarding child abuse/neglect and domestic violence in educational preparation of dental professionals: familiarity with signs and symptoms, instruction in recognizing signs, and monitoring state and federal regulations.17 In addition, the American Dental Association (ADA) enacted a policy in 1996 encouraging the inclusion of intimate partner violence information in dental school curricula.18
Research into the inclusion of domestic violence topics in dental and dental hygiene curricula has been minimal. In a study of dental hygiene curricula, 70.5 percent of responding program directors reported that child abuse/neglect was included in their curricula, and 54.9 percent responded that elder abuse/neglect was included; however, intimate partner violence was included less, at 46.8 percent.6 As for dental schools, a study published in 1990 reported that 96 percent of dental school curricula included the recognition and reporting of child abuse.5 In 2002, another study reported that 100 percent of dental schools included child abuse in their curricula, but only 87 percent included elder abuse.19 More recently, a study was done utilizing a videotaped tutorial with dental students and a mock domestic violence victim. The results demonstrated some improved knowledge and attitudes among the students regarding the topic.20
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Methods
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For our study, we developed a two-part survey (Figure 1
). Part one consisted of eleven domestic violence topics, and part two consisted of five belief statements regarding domestic violence issues. The topics and belief statements were derived from women’s health and domestic violence publications.21–26 A definition of domestic violence, as put forth by Chez,2 was included on the survey. We obtained assistance in refining the survey from a domestic violence expert/administrator in the community and three dental educators. Minor revisions were made prior to submission to the Institutional Review Board (IRB). The West Virginia University IRB approved the 1996 survey. The Ohio State University IRB approved the 2007 survey. The questionnaire was not tested for validity or reliability.
A mailing list for dental schools was obtained from the ADEA academic institution membership list for the two years. A cover letter explaining the purpose of the survey was mailed to the associate dean of academic affairs or the equivalent of that position in each dental school. The recipient was asked to forward the survey to the faculty member who taught domestic violence topics in the curriculum. The letter also informed the recipients that completing the survey was voluntary and there was no incentive to participate.
In 1996, surveys were mailed to fifty-three U.S. and eleven Canadian dental schools. The return envelopes were coded for the purpose of a second mailing. A second mailing was completed to increase the response rate. In 2007, fifty-five surveys were mailed to only U.S. dental schools. There was no second mailing.
The respondents were asked to check off "Yes" or "No" as to whether each topic was included in their curricula. For each "Yes" response, the respondents ranked course topics by emphasis, with 1 indicating the greatest emphasis. The respondents were then asked to indicate their agreement with five belief statements using a Likert scale, ranging from strongly agree (1) to strongly disagree (5).
The data were analyzed using the JMP Version 7 (SAS Inc., Cary, NC). The data are reported as raw numbers, percent responses, and median rankings. The results of each survey are reported separately, then analyzed and compared in Tables 1 and 2. A two-tailed Fisher’s exact test was performed on each topic in part one to identify if a significant difference existed between the responses for each year. P-values <0.05 were determined to be significant. Because of low response rates for some categories in part two, we collapsed the strongly agree and agree categories and the strongly disagree and disagree categories and reported them together. All results, including the undecided responses, are reported in Table 2. Throughout this article, topic frequency and belief statements are reported by percentage of those who answered the question. Topics ranked by emphasis are expressed as a median due to the wide distribution of responses. Not all respondents answered all topics and belief statements.
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Results of the 1996 Survey
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Of the sixty-four surveys mailed, there were thirty-six responses from the first mailing and nineteen responses from the second mailing for a total response of fifty-five or 85.9 percent. Not all participants responded to all topics and statements.
The most frequently reported content in the dental school curriculum was topic 10, responsibility of the health care professional. The other topics are listed in descending order by the frequency in which they were selected: topic 5, physical and behavioral indicators; topic 7, referral protocol; topic 9, reporting protocol; topic 2, prevalence; topic 8, documentation protocol; topic 4, characteristics of the abused and abuse; topic 1, interviewing protocol; topic 3, psychosocial and socioeconomic etiological factors; topic 11, impact on society; and topic 6, education of the abused about alternative living options. Table 1
lists the topics in the order they appeared in the survey and shows the response rate for each. Figure 2 compares "Yes" responses by topic for the two surveys.
Respondents were also asked to rank the list of topics in order by most to least emphasized in their curricula. The topics most emphasized were topic 1, interviewing protocol; topic 5, physical and behavioral indicators of domestic violence; and topic 10, the responsibility of the health care professional. The other topics listed in descending order of emphasis were as follows: topic 2, prevalence; topic 7, referral protocol; topic 8, documentation protocol; topic 9, reporting protocol; topic 3, psychosocial and socioeconomic etiological factors; topic 11, impact of domestic violence on society; topic 4, characteristics of the abused and the abuser; and topic 6, education of the abused regarding alternative living options. Table 1 lists the topics in the order they appeared in the survey and shows the ranking of topic importance for each. Figure 3 compares median rankings of the domestic violence topics emphasized in dental curricula.
In part two of the survey, the respondents were asked to select the number on the Likert scale that corresponded to their agreement with each belief statement. The statements in descending order according to the strength of their belief were as follows: belief 15, a trusting patient/operator rapport is important for disclosure of incidents; belief 14, a dentist or dental team member may be the first health care professional to recognize and offer support; belief 13, dentists have a professional responsibility to make a referral for assistance; and belief 16, some aspects of domestic violence should be included in the dental curriculum. The belief statement that generated the greatest amount of disagreement and indecisiveness was topic 12, domestic violence is increasing as a health care issue. Table 2 lists the belief statements in the order they appeared on the survey, along with the response rates for each category of agreement.
Figure 4 compares the respondents’ beliefs regarding domestic violence issues listed in the 1996 survey.
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Results of the 2007 Survey
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Of the fifty-five surveys mailed in 2007, there were twenty-five responses, resulting in a 45.4 percent response rate. There was no second mailing. Not all participants responded to all topics and statements.
Topic 10, responsibility of the health care professional, was the topic identified as most often included in the curriculum. The other topics identified in descending order are as follows: topic 5, physical and behavioral indicators of domestic violence; topic 7, referral protocol; topic 9, reporting protocol; topic 2, prevalence; topic 8, documentation protocol; topic 3, psychosocial and socioeconomic etiological factors of domestic violence; topic 4, characteristics of the abused and abuser; topic 1, interviewing protocol; topic 11, impact of domestic violence on society; and topic 6, education of the abused regarding alternative living options. Table 1 lists the topics in the order they appeared in the survey, along with the response rate for each. Figure 2 compares the "Yes" responses by topic for the two surveys.
The respondents were also asked to rank the identified topics by most to least emphasized in their curricula. The topics in order from most to least emphasized were as follows: topic 9, reporting protocol; topic 10, responsibility of the health care professional; topic 5, physical and behavioral indicators; topic 4, characteristics of the abused and abuser; topic 7, referral protocol; topic 8, documentation protocol; topic 1, interviewing protocol; topic 2, prevalence; topic 11, impact of domestic violence on society; topic 3, psychosocial and socioeconomic etiological factors of domestic violence; and topic 6, education of the abused about living options. Table 1 lists the topics in the order they appeared in the survey along with the rankings of topic importance for each. Figure 3 compares the ranking of emphasis of domestic violence topics in dental curricula.
In part two of the survey, respondents were asked to select the number on the Likert scale that corresponded to their agreement with each belief statement. The statements in descending order according to the strength of their belief were as follows: belief 15, a trusting patient/operator rapport is important to encourage disclosure of incidents; belief 16, dental educators should include some aspects of domestic violence in the dental curriculum; belief 13, dentists have a professional responsibility to make a referral for assistance; belief 14, dentists or dental team members may be the first health care professional to recognize and offer support to the domestic violence victim; and belief 12, domestic violence is increasing as a health care issue. Table 2 lists the belief statements in the order they appeared on the survey, along with the response rates for each category of agreement. Figure 5 shows a comparison of the respondents’ beliefs regarding domestic violence issues.
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Discussion
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When we compared the results of these surveys, it was evident that inclusion of all domestic violence topics in the dental curriculum had increased over the eleven years. Of the eight topics that had increased at a statistically significant level, the following three are of particular interest: responsibility of the health care professional, physical and behavioral indicators, and prevalence. These findings demonstrate that dental educators are increasingly aware of domestic violence prevalence, that dental students are being informed about the physical and behavioral indicators of domestic violence, and that dental students are part of the identification team of victims in the health care arena.
The critical issue is whether dental students translate their knowledge into daily practice so that potential victims can be identified and assisted. To do this, dental professionals must be comfortable that they can ask the right questions, can converse in a caring manner, and are prepared to refer the person for assistance. When dental professionals are trained and feel confident to follow through with this process, more victims may be identified earlier and more lives may be saved from years of victimization.
We were disappointed that the impact of domestic violence on society was the least included topic in the dental curriculum in both surveys. Previous studies have confirmed that domestic violence cuts across all sectors of life and that the majority of people do not consider its overall impact on society. Family, friends, and employers of the abused and abuser are directly affected. Business and health care costs are also directly and indirectly affected. When health care costs increase, all members of society, as taxpayers, are affected. We believe that this lack of awareness needs to be explored in order to decrease the prevalence of domestic violence in this country.
The beliefs of course directors may influence the scope and depth of coverage of domestic violence topics in dental curricula. Recognizing that, we were also disappointed that the survey respondents believed less strongly in 2007 than in 1996 that domestic violence is an increasing health care issue. This decrease may be related to the age of the course directors or cultural changes over the last eleven years. Another possibility could be that there were different respondents in the most recent survey. Other possible reasons may include thoughts that the issue does not affect them, they are facing a lack of curriculum time, they feel it is not important to address social issues in the curriculum, or they don’t feel they have enough expertise to do so.
Although there were no statistical differences between the two surveys regarding the belief statements, three beliefs increased in strength from 1996 to 2007: including some aspects of domestic violence in the dental curriculum, dentists have a professional responsibility to refer, and trusting patient/operator rapport is important to disclosure. This increase is encouraging in light of very little published literature regarding dentistry and domestic violence.
Another observation of interest is that respondents felt strongly supportive of two belief statements: a trusting patient/operator rapport is important, and appropriate communication with the patient encourages disclosure. Yet when health care professionals are faced with an issue of this complexity, trust on the part of the potential victim does not mean that the dental professional will feel comfortable asking questions. Therefore, student activities, whether real or simulated, may improve the clinician’s confidence when interviewing suspected victims of domestic violence.
While the data demonstrate that dental curricula have increased the amount of domestic violence topics over the eleven-year period, it is not known what teaching methods or community resources are utilized. Other variables could not be controlled in this study. It is possible that course director respondents were different individuals in 2007 than in 1996. Details of protocols for interviewing, referring, documenting, and reporting were not identified in this study. The 2007 survey did not include Canadian schools, and a follow-up survey was not mailed, which may explain the difference in response rates for the two surveys.
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Recommendations for Course Development
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Drawing on these survey results, our personal and professional experiences, and educational theory regarding adult learning, we suggest that dental educators continue to enhance the domestic violence content in their curricula by providing specific information about identifying, interviewing, documenting, and referring victims. Although classroom information is valuable, having the experience of applying knowledge in lifelike circumstances makes the issue more real and concrete. Emphasis on communication with the possible victim is paramount in the learning experiences of dental students.
This learning environment may be improved if teaching methods included more student-centered activities rather than the traditional lecture format. To be effective in teaching these topics to adult dental students, experts recommended that educators strive to conduct the learning experience using relevant "real-life" activities; so for students to find this information meaningful and connected, clinical experiences should be provided.27,28 We recommend that dental educators consider the following exercises:
- a guided mock interview in a clinical setting by dental students with a domestic violence victim;
- a community service project to identify agencies and safe housing facilities; and
- a guest speaker from a local agency to acquaint students with available community services.
Although student-centered instruction may not be common in dental school curricula, using this method on this topic would enhance learning. Since the depth and scope of the topic are complex, discussions are beneficial to foster a sense of team-work among health care professionals. These clinical activities would most likely help the student/practitioner to overcome whatever fears he or she may have of addressing domestic violence in the dental practice setting.
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Conclusions
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In the past, attempts of dental health care professionals to provide help to their patients who may be experiencing domestic violence may have been taboo, but it is important to remember that these victims may be silently calling out for help. Acting ethically and responsibly may save a woman’s life. The dental health care professionals’ code of ethics and professional oath include a promise to dedicate ourselves to the public’s health, well-being, safety, and welfare.7 Because head and neck trauma are the most common injuries in domestic violence incidents, dental care providers must be well prepared to act as a guiding resource for suspected victims who seek care for their injuries. Inclusion of these topics in the dental curriculum and establishing a protocol in the dental office may provide the confidence needed for a practitioner to advocate and act on behalf of family violence victims. Including this critical health issue in the dental curriculum promotes its application in the clinical setting and reinforces the institutions’ commitment to improve societal health and welfare.
Recommendations for further studies on this topic include the following: establishing guidelines to develop a dental practice protocol; developing an interview, documentation, and referral protocol template; auditing hospital emergency room charts to assess incidence and prevalence of head and neck injuries; interviewing dental residents assigned to hospital emergency areas to explore personal experiences working with domestic violence victims; and interviewing domestic violence victims in academic dental institutions’ emergency/screening clinics to better identify their needs in this setting.
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Acknowledgments
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The principal author gratefully acknowledges the dental school faculty members and administrators who took the time to complete and submit the surveys. She also expresses appreciation to The Ohio State University College of Dentistry, Dental Hygiene Director, Michele Carr, for support of the follow-up survey and to the West Virginia University School of Dentistry Research Committee for providing the financial support for the 1996 survey. Last, but certainly not least, is my loving and supportive husband, Bob, who is my computer genius. I appreciate you so much.
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Author Information
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Dr. Gibson-Howell is Assistant Professor, Dental Hygiene, The Ohio State University College of Dentistry; Dr. Gladwin is Professor, Dental Hygiene, West Virginia University; Prof. Hicks is Professor Emeritus, Dental Hygiene, The Ohio State University College of Dentistry; Ms. Tudor is a Ph.D. candidate and Administrative Assistant, Section of Primary Care, The Ohio State University College of Dentistry; and Dr. Rashid is Professor, Section of Restorative Dentistry, The Ohio State University College of Dentistry. Direct correspondence and requests for reprints to Dr. Joan C. Gibson-Howell, The Ohio State University College of Dentistry, 305 West 12th Ave., #179, P.O. Box 182357, Columbus, OH 43218; 614-292-1235 phone; 614-292-8013 fax; Gibson-howell.1{at}osu.edu.
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Abstract
Review of the literature
