Vous êtes sur la page 1sur 10

Dental Students and Intimate Partner Violence: Measuring Knowledge and Experience to Institute Curricular Change

Pamela D. Connor, Ph.D.; Simonne S. Nouer, M.D., Ph.D.; SeèTrail N. Mackey, M.C.J., M.P.A.; Megan S. Banet, M.A.; Nathan G. Tipton, M.A.

Abstract: Our study documents the shortage of intimate partner violence (IPV) content exposure within one dental school cur- riculum, with an eye toward utilizing this information to revise an existing comprehensive family violence curriculum that will be fully integrated into required university coursework to improve competence and help overcome knowledge gaps. IPV is defined by the Centers for Disease Control and Prevention as physical and sexual violence, threats of physical and sexual violence, or psychological/emotional abuse including coercive tactics that adults or adolescents use against current or former intimate part- ners. We report on the results of a four-part (background, IPV knowledge, opinions, and personal experience), sixty-seven-item validated survey instrument used to measure knowledge, attitudes, beliefs, and self-reported behaviors among dental students pre- paring to become health care professionals working in the field. Survey responses from the nearly 80 percent of fourth-year dental students who completed the survey were examined within the context of students’ actual IPV knowledge, as well as opinions and attitudes that could directly or indirectly influence patients. Our findings indicate that a sizeable number of students received no IPV training prior to or during dental school, leading to perceptions that they lack knowledge about IPV and are not well prepared to address IPV with patients. A notable percentage of students (20 percent) also reported personal experience with IPV.

Dr. Connor is Professor, Department of Preventive Medicine, University of Tennessee Health Science Center; Dr. Nouer is As- sistant Professor, Department of Preventive Medicine, University of Tennessee Health Science Center; Ms. Mackey is Research Manager, Department of Preventive Medicine, University of Tennessee Health Science Center; Ms. Banet is Study Coordinator, Department of Preventive Medicine, University of Tennessee Health Science Center; and Mr. Tipton is Coordinator, Department

of Preventive Medicine, University of Tennessee Health Science Center. Direct correspondence and requests for reprints to Dr. Pamela D. Connor, Department of Preventive Medicine, University of Tennessee Health Science Center, 600 Jefferson Avenue,

3 rd Floor, Memphis, TN 38105; 901-448-3300 phone; 901-448-3770 fax; dconnor@uthsc.edu.

Keywords: knowledge, attitudes, practice, intimate partner violence, IPV, domestic violence, dental students, dental curriculum, dental education

Submitted for publication 9/2/10; accepted 1/19/11

I ntimate partner violence (IPV) is a persistent, prevalent public health care issue that has mul- tiple catastrophic effects on individuals, families,

and the larger community. 1,2 The Centers for Dis- ease Control and Prevention (CDC) defines IPV as physical and sexual violence, threats of physical and sexual violence, or psychological/emotional abuse including coercive tactics that adults or adolescents use against current or former intimate partners. 3 While research has shown that some men suffer from abuse—primarily by their male partners—the majority of partner violence occurs between men and their female partners. According to findings from the National Violence Against Women Survey, it is estimated that approximately 1.3 million women and 835,000 men are physically assaulted by an intimate partner annually in the United States. 4 Dental professionals, including dentists, den- tal hygienists, and dental assistants, are uniquely qualified to address the problem of IPV as it occurs

in their patients’ lives, given that routine dental examinations involve close inspection of patients’ heads and necks—areas where signs of physical battering and abuse are readily visible. 5-11 Typical injuries associated with IPV that may be detected by a dental professional include intraoral bruises from slaps or hits; soft and hard palate bruises and abrasions; fractured teeth, nose, mandible, and/or maxilla; abscessed teeth; torn frenum; hair loss from pulling or other trauma and lacerations to the head; and attempted strangulation marks on the neck. 9,10 However, research has also shown that, even when head and neck injuries are evident, dentists may be less likely than other health care providers to screen for IPV, 5,12 offer minimal intervention when working with IPV victims as patients, 12,13 or address IPV with their patients. 5 According to numerous studies, lack of training has been cited by dental professionals as a primary reason for shortcomings in screening, intervention,

or broaching the subject of IPV (other reasons given included, but were not limited to, lack of cultural competence or insufficient access to resources). 14-18 This perceived lack of training persists in spite of policies and resolutions passed by the American Den- tal Education Association (ADEA) and the American Dental Association (ADA) that have encouraged (and continue to encourage) dental educators to include topics related to child abuse/neglect and domes- tic/intimate partner violence as part of curricular preparation for students who are becoming dental professionals. 4,19,20 Since 1990 most dental and dental hygiene cur- ricula have included information on child abuse and neglect, due in large part to state statutes mandating that dentists and other health professionals report suspected child abuse cases; however, curricular content related to other types of domestic violence— particularly IPV—is present in less than half of dental school curricula. 4,13,21 As a result, providers may ob- serve injuries but either do not diagnose IPV as the cause or—as is often the case—do not feel confident in their ability to screen and manage IPV victims. 1,4 The purpose of this study was to document the shortage of IPV content exposure within one dental school curriculum, then to utilize this information to revise an existing comprehensive family violence curriculum that will be fully integrated into required university coursework to improve competence and help overcome knowledge gaps. We report on the results of an IPV self-assessment tool 22 originally designed as a comprehensive and reliable method of ascertaining physician preparedness to manage IPV patients. In its final form, this tool (the Physi- cian Readiness to Manage Intimate Partner Violence Survey, or PREMIS) measured the extent of educa- tion, knowledge, and attitudes about IPV among physicians by way of a fifteen-minute survey. The PREMIS demonstrated good internal consistency and reliability for ten final developed scales that were closely correlated with theoretical constructs and predictive of self-reported behaviors. The PREMIS was modified and validated by this study’s authors 23 in order to assess these measures among health professions students (medical, dental, nursing, and social work). Results from our survey also document the prevalence of students’ lifetime personal IPV experience, which allowed us to explore the conflicting role this exposure has in both identify- ing IPV in patients and intervening in a manner both appropriate and safe for student and patient.

August 2011 Journal of Dental Education

We report here on responses from dental students who participated in this study. Our find- ings constitute the first phase of an overarching and comprehensive curriculum revision effort for the representative health care professions at our institu- tion. As part of this effort, we will use our data to ascertain students’ curricular needs; revise an exist- ing IPV prevention and intervention curriculum and deploy it in accordance with these identified needs; incorporate this curriculum—either wholly or in part—into future course catalogs as an established part of students’ required coursework; and longitu- dinally track student IPV knowledge gain.

Review of the Literature

Research by Love et al., 6 Chiodo et al., 18 and Littel 24 has established that education on IPV needs to be “standardized and incorporated into dental school and continuing education curricula,” thereby mak- ing intervention with victims a normal and standard part of dental professionals’ responsible practice. 5 Indeed, IPV education has been intended to help dental students not only be aware of IPV prevalence, but also that they are being informed about physical and behavioral indicators of IPV, thus making them an invaluable part of the victims identification team in the health care arena. 4 However, changes with regard to improved or increased IPV content in the overall dental curriculum have progressed slowly, in spite of ambitious comprehensive curriculum reviews conducted by the majority of U.S. and Canadian dental schools. 25 For example, a study of dental hygiene students surveyed by Gutmann and Solomon 16 found that although most dental and dental hygiene curricula include the specific topics of child abuse and neglect, other manifestations of domestic violence (e.g., elder abuse, teen dating abuse, or IPV) are addressed far less frequently. Their findings revealed that while child abuse was taught in seven-tenths of programs, elder abuse was taught in just over half, and IPV was taught in less than half of dental hygiene programs. Stewart et al., 21 moreover, reported in 2002 that, of forty-two U.S. and Canadian dental schools with predoctoral programs, 100 percent included child abuse in their curricula, while 87 percent included elder abuse. The authors, however, did not survey these institutions regarding IPV education. As well, Gironda et al. 26 surveyed 291 predoctoral dental students in 2006–08 to gather a comprehensive sam-

1011

pling of student perceptions of and education about elder abuse. Gironda et al.’s study aims are similar to those of our study although their focus was on elder abuse rather than IPV. Those authors concluded that most students did not feel adequately trained to report a case of elder abuse, suggesting that dental students need education on psychosocial aspects of older adulthood as well as training in detecting and reporting elder abuse. Gibson-Howell et al. 5 investigated U.S. and Canadian dental school curricula in 1996 and again in 2007 to assess if and how specific domestic violence topics were being included in the curriculum. While these authors concluded that inclusion of domestic violence curricular topics—which included health care professional responsibility, physical and be- havioral indicators, referral and reporting protocols, and prevalence—had increased over the eleven years of their two surveys, they also noted that survey re- spondents believed less strongly in 2007 than in 1996 that domestic violence is an increasing health care issue and that, correspondingly, domestic violence prevalence and societal impact were not perceived as widespread. Even more disturbing are findings from a study conducted by Nelms et al. 27 that oral health care workers continue to be less likely than any other health care provider to address domestic violence within their role as health care professionals, due in large part to barriers including lack of education and limited time or resources. Research has consistently found that dental students and professionals who receive any educa- tion about IPV are more likely to screen for IPV and provide appropriate intervention. 11,15,28-30 In fact, two IPV/family violence initiatives have been replicated and deployed in numerous health care settings. RA- DAR, a provider-focused initiative that promotes assessment and prevention of IPV, involves a five- step approach: Routinely ask about current and past violence; Ask direct questions; Document findings; Assess safety; and Review options and referrals. 31 Research has not indicated, however, if RADAR is taught as part of college or university medical school curricula. Another promising IPV/family violence ini- tiative is the PANDA (Prevent Abuse and Neglect through Dental Awareness) program. According to Mouden, 32 PANDA began as a model program in Missouri in 1992 to help close the gap in dental knowledge about stopping child abuse and neglect. However, while PANDA’s overarching focus on child abuse is certainly important both in terms of reinforc-

ing the dental profession’s role as mandated report- ers and promulgating knowledge that could lead to possible intervention and prevention, it nevertheless minimizes the education dental professionals might receive on the myriad potential challenges associated with IPV. 33 Furthermore, although Mouden notes that predoctoral and postdoctoral education in the clinical and legal aspects of child abuse and neglect remains insufficient to close this awareness gap, the audi- ence to which PANDA is overwhelmingly directed is established dental professionals rather than dental students. 32 Thus, in spite of these promising dental aware- ness programs, there remains a dearth of compre- hensive IPV curricular content in dental schools. For example, a six-month phone survey of students in health professional studies at 212 Canadian institu- tions of higher learning conducted by Wathen et al. 34 found that fewer than half (46 percent) of predoctoral dental programs and no postdoctoral dental programs offered course content on IPV. Danley et al. 11 have attempted to fill this curricular void through the AVDR approach. AVDR—which involves Asking patients about abuse; providing Validating mes- sages acknowledging that battering is wrong while confirming the patients’ worth; Documenting signs, symptoms, and disclosures of abuse; and Referring victims to domestic violence specialists in the com- munity—was successfully tested in brief tutorial form on dental students in 2002. Students in this study showed significant improvements in attitudes and beliefs about domestic violence screening and intervention. Danley et al. caution, however, that re- search is still needed to determine whether education leads to actual changes in screening, intervention, and other behaviors. As well, these authors did not measure actual student behavior, nor did they collect data related to students’ personal IPV experience.

Methods of This Study

For our study, we initiated the Intimate Partner Violence Survey for Future Healthcare Providers project to measure student knowledge of and at- titudes about IPV, as well as the extent, content, and sufficiency of IPV training received by students prior to and during their graduate studies. Between 2007 and 2008, a total of 318 students in four populations (dentistry, medicine, nursing, and social work gradu- ate programs) at our institution were recruited by their deans to participate in this study. Both the deans

and the departmental/college faculties approved of the survey and the study prior to inviting student participation, which was voluntary. Deans arranged for the study organizers to meet directly with students as they attended various student functions, during which time the survey was administered. Institutional Review Board approval was granted for this survey. In addition to measurements of student knowledge and attitudes, the survey included an IPV experience variable to determine how students’ personal biogra- phies influenced their vocational choice, as well as to postulate the extent to which this experience affected how students screened, assessed, and intervened with victims of IPV. Given the need for consistency in dental school IPV education and training, this study concentrates specifically on responses generated from and reported by this population. Of the original 318 students, seventy-seven were from the field of dentistry, out of which sixty-one completed the survey, yielding a 79.2 percent response rate. This response rate, while good, was the lowest of the four disciplines surveyed, with nursing students having the highest response rate (100 percent), followed by medical students (93.6 percent) and students in social work (87.5 percent). All dental students surveyed were in their final year of study and had completed their clinical rounds. Our study utilized a modified version of the Physician Readiness to Manage Intimate Partner Vio- lence Survey (PREMIS) 22 that we adapted for student populations. 23 Our adaptation measured knowledge, attitudes, beliefs, and self-reported behaviors through a four-part (background, IPV knowledge, opinions, and personal experience), sixty-seven-item survey. The survey was modified so that the language focused on students in the health care arena rather than the practicing physicians for whom the origi- nal survey was designed. The PREMIS respondent profile was also adapted to reflect the disciplines represented by the students in our study population. Two questions related to personal and family IPV experience were added: 1) Have you ever experi- enced physical violence, sexual abuse, intimidation, economic deprivation, or threats of violence in an intimate partner relationship? and 2) Have you ever witnessed physical violence, sexual abuse, or psy- chological abuse directed toward a family member? These questions were used to document personal student experience with IPV rather than being used as part of a long-range assessment and were de- signed to be dichotomous “yes/no” for purposes of gathering evidence on personal experience. Lifetime

August 2011 Journal of Dental Education

experience was considered “yes” if students answered affirmatively to any of these questions. Responses to these questions could then be examined within the context of students’ actual IPV knowledge as well as opinions and attitudes that could directly or indirectly influence patients. The adapted instrument demonstrated high reliability within some IPV constructs, and six of the eight opinion scales described in the original PREMIS were identified (Legal Requirements, Preparation, Self-Efficacy, Alcohol/Drugs, Victim Autonomy, and Victim Understanding). 22 Three scales from the original PREMIS (Legal Requirements, Preparation, and Self-Efficacy) presented a Cronbach’s α≥ .70, demonstrating acceptable reliability, and a new scale (IPV Screening) was also identified that showed good reliability (α=.74; see Table 1). Data on IPV training for dental students prior to and during dental school were individually tabulated for each category, and the results presented individu- ally in order to facilitate comparison with regard to total hours of training received. Responses to ques- tions about personal experience with some kind of physical violence, sexual abuse, intimidation, or threats of violence in an intimate partner relationship and/or witnessed physical violence, sexual abuse, or psychological abuse directed toward a family member were combined to create a lifetime IPV experience variable, with positive (“yes”) answers to either or both questions indicating students’ ex- posure to IPV sometime during their lifetime. Three summary scales were also created rather than being derived from factor analysis. These were Perceived Preparation (twelve items asking respondents how well prepared they were to work with IPV victims); Perceived Knowledge (sixteen items asking how much respondents felt they knew about IPV); and Actual Knowledge (which used seven multiple- choice questions and eleven true/false questions with a total possible score of 38). For preparedness and perceived knowledge, the average was estimated by respondent; then, the overall average was calculated for the sample. For actual knowledge, the sum of correct scores for each respondent was calculated; then, the sum of correct responses for the sample was averaged. Internal consistency for both the Per- ceived Preparation and Perceived Knowledge scales was high, with a Cronbach’s alpha equal to 0.97. 22 There were no appropriate tests to evaluate internal consistency on the Actual Knowledge scale. Independent t-tests compared the summary scales of students with IPV training prior to dental

1013

Table 1. Survey of health care students regarding intimate partner violence (IPV): opinion scales

Scales

Alpha

Total Items

Sample Item

1. Legal requirements

0.914

3

I am aware of legal requirements in this state regarding reporting of suspected cases of elder abuse.

2. Preparation

0.886

4

I don’t have the necessary skills to discuss abuse with an IPV victim who is from a different cultural/ethnic background

3. IPV screening

0.740

2

I would ask all new patients about abuse in their relationships.

4. Self-efficacy

0.797

7

I can recognize victims of IPV by the way they behave.

Scales with low reliability

5. Alcohol/drugs

0.478

2

Alcohol abuse is a leading cause of IPV.

6. Victim autonomy

0.363

3

If a patient refuses to discuss the abuse, staff can only treat the patient’s injuries.

7. Victim understanding

0.460

4

I understand why IPV victims do not always comply with staff recommendations.

school to those without training; students with IPV training during dental school were compared to those without training; and students reporting personal experience with IPV were compared to those with no personal IPV experience. Pairwise deletion was used to exclude students with missing data. Significance was reached with an alpha less than .05. Sample sizes in analyses varied due to missing data. Scale scores were stratified only by gender, and there were no demographic differences between male and female dental students. Furthermore, given limitations due to our small sample size and age group, it is unlikely that categorizing by age group would add any significant information to the analysis (see Table 2).

Results

The majority of these dental students (62.3 percent) were male, with a mean age of twenty-seven years. Nearly three-fourths (70.0 percent) reported receiving no IPV training prior to dental school, and a quarter (25.0 percent) who were trained prior to dental school received between one and five hours of training. “Some” IPV training was defined as one or more hours of received training. During dental school, these students documented much higher rates of IPV training, with 57.0 percent receiving between one and five hours of training, while 5.0 percent had between six and fifteen hours of train- ing and 2.0 percent received more than fifteen hours of training. Over one-third (36.0 percent) of these students reported having no IPV training in dental school. A fifth (20.0 percent) acknowledged having

some experience with IPV in their lifetime, whether through personal victimization or witnessing abuse or violence directed at a family member (see Table 3). The dental students in this study reported that they received IPV training in their general graduate coursework, as well as through their specialized focus areas of oral and maxillofacial surgery, pediatrics, and prosthodontics. While these students received different “doses” of IPV training depending on their chosen academic concentration, our study grouped them together as a single “graduate” group in order to measure the extent of their core IPV knowledge.

Knowledge, Attitudes, and Perceptions

These dental students generally did not per- ceive themselves as either well prepared to address IPV with patients or knowledgeable about IPV. For instance, when they responded about whether they intended to address IPV with their patients, over three-fourths (78.3 percent) said they would be unlikely to ask all new patients about abuse in their relationships, and the remaining fifth (21.7 percent) indicated they were uncertain. In addition, a low percentage of these students (16.7 percent) said they would feel comfortable discussing IPV with patients. Nearly a third (31.6 percent) reported that they were aware of state reporting requirements regarding IPV. Perceived effectiveness of previous IPV train- ing was measured through the Perceived Preparation scale. Participants’ scores and responses ranged from 1 (not prepared) to 7 (quite well prepared). The dental students reported a Perceived Preparation score of

3.6 (SD=1.0), lower than the overall mean across disciplines of 3.8 (SD=1.5). Students were also sur- veyed on a Perceived Knowledge scale, on which scores ranged from 1 (nothing) to 7 (very much). The dental students reported an average Perceived Knowledge score of 3.5 (SD=0.8), lower than the overall mean score across disciplines of 3.8 (SD=1.4). On the third measure (Actual Knowledge), the dental students reported a mean Actual Knowledge score of 22.2 (SD=5.1), lower than the overall mean Actual Knowledge score of 24.2 (SD=5.4).

Effects of Training

The dental students with IPV training prior to dental school had significantly higher rates (M=24.61; SD=3.91) of Actual Knowledge than those who had had no IPV training prior to dental school (M=21.00; SD=5.38), t(61)=2.57, p=.013. The dental students who had received IPV training during dental school also had significantly higher Actual Knowledge rates (M=23.32; SD=4.83) than those dental students who had received no IPV training during dental school (M=20.00; SD=5.31), t(61)=2.50, p=.015. Differences between the dental students reporting IPV training both prior to and during dental school and those who reported no IPV training prior to or during dental school were higher but not significant in terms of Perceived Preparation and Perceived Knowledge (see Table 4). We were also able to verify knowledge gaps by identifying questions with the lowest percentage of correct answers among the thirty-eight questions used to assess Actual Knowledge. Eleven questions were identified in which less than 50 percent of the dental students gave a correct answer, out of which three questions (“Victims of IPV are able to make appropriate choices about how to handle their situ- ation”; “Even if a child is not in immediate danger, health care providers in all states are mandated to report an instance of a child witnessing IPV to Child Protective Services”; and “What is the strongest single risk factor for becoming a victim of intimate partner violence?”) had correct answer rates of less than 25 percent (see Table 5). It should be noted with regard to differences in summary scale rates that, at our institution, IPV is recommended but not mandated for inclusion in all programs. As a result, each college and depart- ment implements IPV instruction in different ways and with substantial variation in method, content, and success.

August 2011 Journal of Dental Education

Table 2. Dental student scores in this study stratified by gender, by mean and standard deviation

 

Male

Female

Perceived preparation

Mean (SD)

3.6 (1.0)

3.6 (0.9)

Perceived knowledge

Mean (SD)

3.5 (1.0)

3.5 (0.8)

Actual knowledge Mean sum of scores (SD)

22.0 (5.4)

22.2 (5.1)

Table 3. Dental students in study: demographics and background characteristics

Number (Percentage)

Course

Dentistry

61 (21.3%)

Age (Mean/SD)

27.4 (2.74)

Range

25 to 40

Gender

Male

38 (62.3%)

Female

23 (37.7%)

Hours of IPV training in dental school None

22 (36.0%)

1–5 hours

35 (57.0%)

6–15 hours

3 (5.0%)

More than 15 hours

1 (2.0%)

Hours of IPV training prior to dental school None

43 (70.0%)

1–5 hours

15 (25.0%)

6–15 hours

3 (5.0%)

More than 15 hours

0 (0)

Personal IPV experience a Self

6 (10.0%)

Family

8 (13.3%)

Any personal experience

12 (20.0%)

Note: All values are total and percentages, unless otherwise stated. SD=standard deviation

a Missing data=1

Effect of Personal Experience with IPV

A tenth (10 percent, N=6) of all dental students surveyed (N=61; missing data N=1) reported being the victim of some form of IPV, including physi- cal violence, sexual abuse, intimidation, economic deprivation, or threats of violence in an intimate

1015

Table 4. Students’ IPV training prior to and during dental school

 

Prior Training

Mean

Std. Deviation

p value

Perceived Preparation

Some

3.96

1.03

t=1.94, p=.057

None

3.43

.927

Perceived Knowledge

Some

3.84

.975

t=1.68, p=.099

None

3.42

.860

Actual Knowledge

Some

24.61

3.91

t=2.57, p=.013

None

21.00

5.38

School Training

Mean

Std. Deviation

p value

Perceived Preparation

Some

3.60

1.03

t=.123, p=.903

None

3.57

.906

Perceived Knowledge

Some

3.57

.965

t=.353, p=.725

None

3.49

.823

Actual Knowledge

Some

23.32

4.83

t=2.50, p=.015

None

20.00

5.31

Table 5. Students’ responses to Actual Knowledge questions: number and percentages of correct answers

Number Percentage

What is the strongest single risk factor for becoming a victim of intimate partner violence?

3

4.9%

Which of the following are warning signs that a patient may have been abused by his/her partner?

Chronic unexplained pain

22

36.1%

Substance abuse

16

26.2%

Have you ever been afraid of your partner?

21

34.4%

Has your partner ever hit or hurt you?

26

42.6%

Alcohol consumption is the greatest single predictor of the likelihood of IPV. a

23

38.3%

Being supportive of a patient’s choice to remain in a violent relationship would condone the abuse. a

23

38.3%

Victims of IPV are able to make appropriate choices about how to handle their situation. a

10

16.7%

Health care providers should not pressure patients to acknowledge that they are living in an abusive relationship. a

25

41.7%

Victims of IPV are at greater risk of injury when they leave the relationship. a

17

28.3%

Even if the child is not in immediate danger, health care providers in all states are mandated to report an instance of a child witnessing IPV to Child Protective Services. b

8

13.3%

a 1 missing information b 2 missing information

partner relationship. A slightly higher percentage (13.3 percent, N=8) said that they had witnessed one or more of these manifestations of physical violence, sexual abuse, or psychological abuse directed toward a family member. When personal or family violence was considered as a whole, therefore, one-fifth (20.0 percent, N=12) of all dental students in the study re- ported experiencing some type of domestic violence including IPV.

Discussion

As results from our study show, although ex- posure to and experience with IPV (whether through family members who were victims of IPV or from having personally experienced IPV) can be useful and applicable as students encounter and interact with victims of IPV as part of their career trajectory, it may not necessarily increase perceived or actual knowledge about IPV. Nevertheless, having had those

life experiences may make an individual feel more capable of addressing IPV with patients. Future research, therefore, should continue to monitor the prevalence of IPV among this and other populations of students in the health professions and explore its ramifications in terms of client care and educational

and training efficacy, its association with other mo- tivational factors that lead to choosing dentistry as

a vocation, and its influence on students’ personal

relationships. Our study also found that a sizeable number (ranging from half to nearly two-thirds) of our dental students who were preparing to enter the profession as practicing dentists are still receiving no education about the highly prevalent health problem of IPV. Although the trend in higher education continues

to support providing students with more and better training in IPV, 4 our findings reflect research which affirms that there remains a pronounced deficit in IPV education across disciplines and particularly in

the field of dentistry. 16 This shortfall, in turn, results

in dental health care professionals entering the work-

place unprepared to care for victims, perpetrators, and witnesses of IPV who are increasingly showing up in large numbers in health care facilities. The results of our study also showed some posi- tive effects. The dental students in our study indicated that their training either prior to or during dental school was effective in increasing their confidence in and perceptions of preparedness to address IPV with patients. This confidence could, in turn, potentially in- crease the likelihood of dentists’ asking patients about violence in their personal relationships. Conversely, the lower IPV knowledge scores reported by these dental students is of some concern and indicates that training provided to dental students is not effective in increasing actual knowledge about IPV.

Our study has several limitations, the small sample size of dental students surveyed being prominent among them. Because our sample was

taken from a single institution, our results may not be representative of and thus generalizable to students in other dental schools. Our sample is, however, representative of our local population. We did not follow up with students to assess the extent to which the IPV knowledge they received in dental school has been deployed in their clinical practices. We also did not gather qualitative personal IPV experience data, which would have been instrumental in facilitating

a more directed, focused, and truly student-centered curriculum revision. We acknowledge these short-

August 2011 Journal of Dental Education

comings and recognize that, as Hsieh et al. 15 have noted, the literature lacks substantive approaches and models of IPV interventions thus far. Nevertheless, our study provides important and necessary underpin- nings for future education that will help increase the likelihood that dentists will screen for, and intervene appropriately with, patients affected by IPV.

Conclusion

We are presently charting future directions for our findings. In addition to producing larger studies that will not only include qualitative personal IPV experience data but also ascertain generalizability of findings to larger student populations, we plan to begin evaluating health care systems in which stu- dents will be working to ascertain what, if any, infra- structure changes are needed to support institutional policy, protocols, public advocacy, and foundational research (e.g., data collection) leading to improved IPV screening, identification, management and qual- ity of care for this vulnerable population. At the institutional level, we also plan to incor- porate student survey responses as part of a revision of the family violence curriculum entitled Healing Homes. Healing Homes was initially developed in 2007 by researchers at our institution in cooperation with local African American church leaders and was pilot tested in a faith-based population based on elevated rates of family violence within this com- munity, as well as requests from clergy who observed the problem of family violence in their congregations but were unsure how to confront the problem. Heal- ing Homes was initially designed to teach religious leaders how to recognize family violence, make ap- propriate referrals for crisis and non-urgent services, and be aware of and provide resources within the community that are helpful, safe, and appropriate to pastoral intervention. The curriculum’s modular format is easily adaptable to multiple audiences including primary care providers and other diverse populations and cultures. Healing Homes utilizes a 5R (Recognizing, Responding, Referring to Resources, and being cognizant of mandated Reporting requirements) approach to assess for and respond to presentations of family violence across populations. These 5Rs comprise the crux of the curriculum, but we intend to focus on, modify, and enhance modules on Rec- ognition and mandatory Reporting requirements in

1017

order to specifically address dental students’ survey responses to attitudinal and knowledge areas such as personal comfort in discussing IPV with patients, intent to address IPV with patients, and mandatory reporting requirements. Educating dental students on these 5Rs is crucial to increasing knowledge of IPV, thereby allowing these students to become attuned, empathetic, and proactively responsive to patients who are IPV victims. Moreover, we envision Healing Homes as a required course that will be fully integrated into the university curriculum, rather than as a supplement to the already existing (albeit limited) IPV content dental students currently receive at our institution. As data from our study have indicated, this type of comprehensive content is not only critical to over- coming systemic knowledge gaps about IPV, but our curriculum will also respond to the persistent calls of previous researchers and academic administrators to provide more and better IPV education for dental students as they become professionals working in the field.

REFERENCES

1. Hendler TJ, Sutherland SE. Domestic violence and its relation to dentistry: a call for change in Canadian dental practice. J Can Dent Assoc 2007;73(7):617–17f.

2. Shanel-Hogan KA, Mouden LD, Muftu GG, Roth JR. Enhancing dental professionals’ response to domestic violence. At: endabuse.org/userfiles/file/HealthCare/ dental.pdf. Accessed: August 10, 2010.

3. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: uniform defini- tions and recommended data elements. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2002. At: www.cdc.gov/

ncipc/pubres/ipv_surveillance/Intimate%20Partner%20

Violence.pdf. Accessed: August 10, 2010.

4. Tjaden P, Thoennes N. Prevalence, incidence, and con- sequences of violence against women: findings from the National Violence Against Women Survey. Washington, DC: U.S. Department of Justice, Office of Justice Pro- grams, National Institute of Justice, 2000. At: www.ncjrs. gov/pdffiles1/nij/183781.pdf. Accessed: November 29,

2010.

5. Gibson-Howell JC, Gladwin MA, Hicks MJ, Tudor JFE, Rashid RG. Instruction in dental curricula to iden- tify and assist domestic violence victims. J Dent Educ

2008;72(11):1277–89.

6. Love C, Gerbert B, Bronstone A, Perry D, Bird W. Den- tists’ attitudes and behaviors regarding domestic violence:

the need for an effective response. J Am Dent Assoc

2001;132:85–93.

7. Halpern LR, Susarla SM, Dodson TB. Injury location and screening questionnaires as markers for intimate partner violence. J Oral Maxillofac Surg 2005;63(9):1255–61.

8. Gwinn C, McClane GE, Shanel-Hogan KA, Strack GB. Domestic violence: no place for a smile. J Calif Dent As- soc 2004;32(5):399–409.

9. Le BT, Dierks EJ, Ueeck BA, Homer LD, Potter BF. Maxil-

lofacial injuries associated with domestic violence. J Oral Maxillofac Surg 2001;59(11):1227–84.

10. Perciaccante VJ, Ochs HA, Dodson TB. Head, neck, and facial injuries as markers of domestic violence in women.

J Oral Maxillofac Surg 1999;57(7):760–3.

11. Danley D, Gansky SA, Chow D, Gerbert B. Preparing dental students to recognize and respond to domestic violence: the impact of a brief tutorial. J Am Dent Assoc

2004;135:67–73.

12. Mitchell C. The health impact of intimate partner violence.

J Calif Dent Assoc 2004;32(5):396–8.

13. Tilden VP, Schmidt TA, Limandri BJ, Chiodo GT, Garland MJ, Loveless PA. Factors that influence clinicians’ as- sessment and management of family violence. Am J Pub Health 1994;84(4):628–33.

14. Mehra V. Culturally competent responses for identifying and responding to domestic violence in dental care set- tings. J Calif Dent Assoc 2004;32(5):387–95.

15. Hsieh NK, Herzig K, Gansky SA, Danley D, Gerbert B. Changing dentists’ knowledge, attitudes, and behavior regarding domestic violence through an interactive mul- timedia tutorial. J Am Dent Assoc 2006;137(8):596–603.

16. Gutmann ME, Solomon ES. Family violence content in dental hygiene curricula: a national survey. J Dent Educ

2002;66(9):999–1005.

17. McDowell JD, Kassebaum DK, Fryer GE. Recognizing and reporting domestic violence: survey of dental practi- tioners. Spec Care Dentist 1994;14(2):49–53.

18. Chiodo GT, Tilden VP, Limandri BJ, Schmidt TA. Address- ing family violence among dental patients: assessment and intervention. J Am Dent Assoc 1994;125(1):69–75.

19. American Dental Education Association. ADEA policy statements. J Dent Educ 2008;72(7):822.

20. American Dental Association. ADA current policies ad- opted 1954–2008. At: www.ada.org/sections/about/pdfs/ doc_policies.pdf. Accessed: August 18, 2010.

21. Stewart AV, Bernstein ML, Furnish GM. Survey on the teaching of abuse and neglect in the dental curriculum. J Dent Educ 2002;66(2):323(Abstract 209).

22. Short LM, Alpert E, Harris JM Jr, Surprenant ZJ. PRE- MIS: a comprehensive and reliable tool for measuring physician readiness to manage IPV. Am J Prev Med

2006;30(2):173–80.

23. Connor PD, Nouer SS, Mackey SN, Tipton NG, Lloyd AK. Psychometric properties of an intimate partner vio- lence tool for health care students. J Interpers Violence

2010;26(5):1–24.

24. Littel K. Family violence: an intervention model for dental professionals. OVC Bulletin (Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice Publication No. NCJ 204004), December 2004. At: www. ojp.usdoj.gov/ovc/publications/bulletins/dentalproviders/ ncj204004.pdf. Accessed: August 16, 2010.

25. Haden NK, Hendricson WD, Kassebaum DK, Ranney RR, Weinstein G, Anderson EL, Valachovic RW. Curricu - lum change in dental education, 2003–09. J Dent Educ

2010;74(5):539–57.

26. Gironda MW, Lefever KH, Anderson EA. Dental students’ knowledge about elder abuse and neglect and the reporting responsibilities of dentists. J Dent Educ 2010;74(8):824–9.

27. Nelms AP, Gutmann ME, Solomon ES, DeWald JP, Camp- bell PR. What victims of domestic violence need from the dental profession. J Dent Educ 2009;73(4):490–8.

28. Cohn F, Salmon ME, Stobo JD. Confronting chronic ne- glect: the education and training of health professionals on family violence. Washington, DC: National Academy Press, 2002.

29. Harmer-Beem M. The perceived likelihood of dental hygienists to report abuse before and after a training program. J Dent Hyg 2005;79(1):1–12.

30. Aved BM, Meyers L, Burmas EL. Challenging dentistry to recognize and respond to family violence. J Calif Dent Assoc 2007;35(8):555–63.

August 2011 Journal of Dental Education

31. Virginia Department of Health. Project RADAR. At: www. vahealth.org/Injury/projectradarva/index.htm. Accessed:

August 19, 2010.

32. Mouden LD. The role Tennessee’s dentists must play in preventing child abuse and neglect. J Tenn Dent Assoc

1994;74(2):17–21.

33. Sugg NK, Inui T. Primary care physicians’ response to domestic violence: opening Pandora’s box. JAMA

1992;267(23):3157–60.

34. Wathen CN, Tanaka M, Catallo C, Lebner AC, Friedman MK, Hanson MD, et al. Are clinicians being prepared to care for abused women? A survey of health professional education in Ontario, Canada. BMC Med Educ 2009;9:34.

1019