|Year : 2019 | Volume
| Issue : 1 | Page : 8-13
Shutting our eyes to an open secret: Knowledge, attitude, and behavior of dentists regarding domestic violence in India
Zoha Abdullah, Joseph John
Department of Public Health Dentistry, Asan Memorial Dental College and Hospital, Chengalpattu, Tamil Nadu, India
|Date of Submission||24-Mar-2018|
|Date of Acceptance||14-Jan-2019|
|Date of Web Publication||15-Mar-2019|
Dr. Zoha Abdullah
Department of Public Health Dentistry, Asan Memorial Dental College and Hospital, Asan Nagar, Keerapakkam, Oragadam Main Road, Chengalpattu, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: The majority of victims of domestic violence sustain maxillofacial injuries. Dental professionals can play a vital role in preventing violence against women, helping identify abuse early, providing victims with the necessary treatment, and referring women to appropriate care. Aim: The aim of this study was to assess the level of knowledge, attitude, and behavior regarding domestic violence among dental health practitioners in India. Materials and Methods: The authors surveyed a random sample of 106 dental health practitioners using a pretested, structured, and validated questionnaire to evaluate their knowledge, attitude, and behavior regarding domestic violence. Survey items were developed based on the domestic violence and health-care literatures. Collected data were subjected to statistical analysis using Chi-square test, and P < 0.05 was considered statistically significant. Results: Sixty-four percent of the responding dentists believed that it is not their responsibility to screen patients for abuse; 7.5% never screened for abuse, even when signs of abuse were present; and 34.9% did not have enough time in their practice to raise the issue of domestic violence. The majority of respondents believed that domestic abuse should be a private matter and asking about abuse is an invasion of privacy. Female respondents' attitude toward domestic violence was more positive when compared to the males. Conclusion: The level of knowledge regarding domestic violence among the respondents was insufficient. The findings of this study strongly recommend that this issue be included in the undergraduate dental education curriculum to improve the health care and assistance provided to the victims of abuse.
Keywords: Attitude of health personnel, attitudes, dentistry, dentists, domestic violence, knowledge, perceptions of domestic violence, screening
|How to cite this article:|
Abdullah Z, John J. Shutting our eyes to an open secret: Knowledge, attitude, and behavior of dentists regarding domestic violence in India. J Indian Assoc Public Health Dent 2019;17:8-13
|How to cite this URL:|
Abdullah Z, John J. Shutting our eyes to an open secret: Knowledge, attitude, and behavior of dentists regarding domestic violence in India. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Dec 15];17:8-13. Available from: http://www.jiaphd.org/text.asp?2019/17/1/8/254334
| Introduction|| |
Domestic violence, also known as intimate partner violence, is defined as a pattern of control involving physical, sexual, and/or psychological assaults against current or former intimate partners. Domestic violence is one of the most prevalent yet relatively hidden and ignored forms of violence against women in India. There are legislations in India against domestic violence since 2005, popularly known as the Protection of Women from Domestic violence Act. Despite this, estimates of the prevalence of domestic violence within India vary widely (from 18% to 70%, with differences in study methodology). The incidence of domestic violence in India is at epidemic proportions, where every third woman aged between 15 and 49 years report having been physically or sexually violated.
According to the National Crime Records Bureau and the National Family Health Surveys in India, <1% of the incidents of sexual violence and 2% of the incidents of physical violence by husbands were reported to the police. The overall health consequences (physical, mental, and sexual health) of domestic violence are severe. Worldwide, the percentage of women who suffer serious injuries as a result of physical domestic violence tends to range from 19% to 55%.
Considering the low rate of reporting to the authorities, the negative health consequences of domestic violence, and the exposure of health-care workers to victims, the involvement of the health-care system presents an important opportunity for screening and referral of victims of domestic violence.
The question that may arise is “what has dentistry got to do with domestic violence?” The dental profession can play a vital role in preventing violence against women, helping identify abuse early, providing victims with the necessary treatment, and referring women to appropriate care. Most victims of domestic violence sustain maxillofacial injuries. One study reported that 94% of victims of domestic violence have head, neck, and facial injuries, and a second study found that 88% of assaulted women have some facial injury, including lacerations, bruising, and fractures. Regrettably, few oral health-care professionals are well informed and educated about the relationship between head-and-neck injuries and domestic violence.
A 1998 survey done in the USA showed that 9.2% of women who sought care for physical assault by an intimate partner referred a dentist. In a 1994 survey of health-care professionals in Oregon, only 6% of dentists commonly suspected physical abuse among their patients, compared with 23% of physicians and 53% of social workers.
A high percentage of domestic violence injuries occur in the head-and-neck area, presenting the oral health-care professionals with a unique opportunity to play a role in conducting routine assessments for domestic violence. While it is not the job of the health-care practitioners to give advice to someone experiencing domestic violence on what direct action they should take, it is their job to provide information on how to contact the appropriate local services.
Despite the global recognition of domestic violence as a public health issue and protocols being put in place to assist the victims of abuse, there is a lack of education and sensitization of health professionals regarding screening and referral of the patients who are victims of domestic violence in India.
By far, no studies have been conducted to assess the levels of knowledge, attitude, and practices regarding domestic violence among dental health practitioners in India. Therefore, the aim of this study was to assess the levels of knowledge, attitude, and practices regarding domestic violence among dental health practitioners in India.
| Materials and Methods|| |
The Institutional Review Board (Reference no. IHEC/SDMDS13PHD2) of the university approved the study. We obtained written informed consent from all participants, and the anonymity of the participants was maintained. The study was conducted in full accordance with the Declaration of Helsinki. Data collection was scheduled in the month of October 2013.
We recruited a convenient sample of 106 dental health practitioners from Chennai, and the self-administered questionnaire was given to them.
The questionnaire was designed to test the knowledge, attitude, and behavior regarding domestic violence and was adapted from questionnaires used previously by the authors and previously published.,, The questionnaire was pretested on a sample of 11 dentists to test the validity and reliability of the questionnaire. The responses of these participants were excluded from the main study.
Responses were coded and entered into an SPSS database. Data were entered in Microsoft Excel spreadsheet and analyzed using SPSS software (version 21, IBM Corporation, Texas, USA). Descriptive statistics were conducted. Bivariate analysis (Chi-square test) was used to assess the association between independent variables with each of the main outcomes of interest.
| Results|| |
We conducted the survey with 106 participants, of which 62 (58.5%) were male and 44 (41.5%) were female. The majority of the respondents had not received any education on domestic violence in dental school or in continuing education (58.5%). Seventy-six percentage of the participants reported that they would like more training in this area [Table 1].
The response to the question “how much do you know about how to give the patients the message that no one deserves to be abused?” was associated with gender. The majority of female practitioners had little or lot of knowledge regarding the question (70.4% and 11.4%, respectively) when compared to the male practitioners. This association was statistically significant (P < 0.03). The responses to the questions “how much do you know about your role in recognizing and helping domestic violence victims and how to help patients when they do not disclose being abused” were associated with prior education on domestic violence (P < 0.01) [Table 2].
|Table 2: Knowledge regarding domestic violence among dental health professionals: Aggregate responses and associations between responses and independent variables|
Click here to view
When asked if they felt comfortable asking patients about domestic abuse, even a majority of the female respondents (81.8%) said “no.” However, the majority of the correct responses to the attitude-related questions were given by females. Therefore, a statistically significant association was found between gender and the attitude-related questions using Chi-square test (P > 0.05). When asked if improving detection of domestic abuse is a valid use of health resources, 100% of female dental health professionals stated “yes.” The respondents with prior education on domestic violence felt that the victims should not leave their partners. The response to the question “my profession should be more involved in identifying domestic abuse cases” was also significantly associated with prior education on domestic violence [Table 3].
|Table 3: Attitudes regarding domestic violence among dental health professionals: Aggregate responses and associations between responses and independent variables|
Click here to view
The majority of the respondents never screened new patients for abuse. Forty-five respondents did not screen for abuse even when multiple injuries were present. A majority of the respondents who always screened victims with multiple injuries were females and those who had any prior education on domestic violence (P < 0.05 and P < 0.04, respectively). Similarly, a majority of the females and those with domestic violence education did not feel that asking the patients about their abuse was an invasion of their privacy (P < 0.01 and P < 0.03, respectively) [Table 4].
|Table 4: Screening behaviors regarding domestic violence among dental health professionals: Aggregate responses and associations between responses and independent variables|
Click here to view
| Discussion|| |
Today, women rights and empowerment issues are being discussed extensively, but the ground reality in developing countries like India has not changed radically. At the government level, development of a national strategy and policy for the health-care professionals on how to deal with domestic violence victims is fundamental and vital. In addition, there has to be an increase in the awareness among dentists, that in addition to physicians, dentists have an opportunity, a legal and an ethical duty, and obligation to identify and make the appropriate referrals for patients who are victims of domestic violence.
In the present study, we found that 41.5% of the professionals had a prior domestic violence education in dental school, and this increased the probability that dentists would screen for abuse. This finding was in agreement with the study done by Love et al. However, a majority of the surveyed dental health practitioners (76.4%) stated that they would like further training or education on domestic violence.
Perception of the majority of the respondents with any prior domestic violence education was that they knew about their role in the recognition of abuse. Nearly half of the study population believed that they had no knowledge of how to help patients who did not disclose their abuse. It is a common misapprehension that victims of abuse will be offended by health practitioners questioning about abuse, and generally there is a reticence to ask about violence. About 71.7% of the respondents in the current study stated that they were concerned about offending the patient, similar findings were reported by other studies.,, Questioning is vital, and unless asked directly, very few women voluntarily divulge information about violence. Surveys show that women are extremely willing to be asked about their experiences by health professionals and have often cited not being asked as a reason for nondisclosure of domestic violence., Guilt, shame, anxiety, fear of more abuse, and restriction of movement may be other reasons why victims may not seek care or fail to reveal their symptoms.
The perceived knowledge of the majority of female respondents (70.4%) was that they knew a little about giving the message that no one deserves to be abused. However, regardless of the gender and prior domestic violence education, the number of respondents who responded with the option of “none” to the knowledge questions was significantly high. The possible reason for this could be the lack of training in screening the abuse victims and lack of knowledge among the health professionals about the referral services provided for the abuse victims in India. Two studies assessed the knowledge of dentists' pre and post a tutorial/seminar and found that the postpresentation knowledge had increased among the participants.,
Most respondents in the current study felt that the abused victims should leave their partners. It is imperative for the health-care professionals to comprehend the reasons and dangers related to women leaving their partners. The majority of the respondents with prior domestic violence education agreed that abused women should not leave their partners. Other studies have emphasized the consequence of asking judgmental questions or suggestions of leaving the abusive partner. After receiving a brief training intervention, studies have shown improvement in this blame victim attitude of professionals., Ninety-five out of the 106 respondents (89.6%) stated that they were not comfortable asking patients about abuse. This finding was in agreement with that of Warburton et al. Only 35.8% of respondents stated that it was their responsibility to screen patients for abuse in comparison to 44.4% reported by Warburton et al. This difference could be attributed to the cultural factors, hesitation asking about abuse, feeling inadequate, lack of practical experience, lack of time, and also the fear of offending the patient as reported by a systematic review.
The commonly held belief is that, when injuries are present, the health-care professional would certainly screen for abuse. Contrary to this belief, only 38.7% of the respondents stated that they always screened for domestic violence even when signs of abuse or injuries to the head-and-neck region were present, similar to the study done by Love et al. Few of the barriers cited in previous literature were lack of training, invading their privacy, offending the patient, and indifferent attitudes toward domestic violence. The respondents of this study also projected similar behaviors.
Domestic violence in India is at epidemic proportions, and according to a study, the prevalence varies in different parts of the country. These findings point to the obvious need for a basic protocol to be put in place for screening victims of domestic violence in all health settings. The findings of this study suggest the need for institutions to include information, training, and protocols on how to recognize domestic violence victims, but also sensitization of the health-care professionals on how to conduct interviews and provide support once the victim discloses the abuse. Continuing educational programs and courses could benefit the dental health practitioners who have completed their education and are already in practice. A majority of the current study respondents felt that improving the detection of domestic abuse is a valid use of health resources, which included 100% of the female dentists. The majority also was of the opinion that recognizing domestic abuse will make a difference to the long-term health of a woman with an experience of domestic abuse.
The need for a protocol/model to be developed cannot be overemphasized, keeping in mind the cultural scenario of India, and dentists to follow it when approaching abused patients in their practice. The patients must be asked about the abuse, signs should be documented, and patients should be referred to support services or centers providing further assistance.
The small and convenient sample size of dentists surveyed is one of the most prominent limitations. Therefore, this sample may not be representative of and thus generalizable to all practitioners in the country. Our sample is, however, representative of the practitioners in the region. These data being self-reported, the study participants may have responded in a socially desirable manner. Nevertheless, our study provides imperative findings for future education that will increase the likelihood that dentists will screen and intervene appropriately with victims of domestic violence.
In a survey like this, the sensitive nature of the issue and the questions might lead the respondents to respond in a socially desirable manner. To minimize this bias, we structured a self-administered questionnaire. However, Nederhof found in his review of literature that this method did not eliminate the bias completely. Therefore, in addition to this, we maintained anonymity of the participants by assigning an identification number and not asking names of the respondents to minimize the social desirability bias.
Future studies should be conducted on larger populations to ascertain generalizability. Studies should focus on comparing the knowledge, awareness, and attitudes of dentists regarding domestic violence in India before and after educational interventions or training.
| Conclusion|| |
Based on the findings of this study, it can be concluded that the oral health professionals in India still lack sufficient knowledge regarding the issue of domestic violence and its relevance to dentistry, they also lack the attitude and sensitization required to deal with this sensitive issue, and, lastly, there is a lack of the practices of the dental practitioners regarding the issue of domestic violence. Oral health professionals could play a vital role in screening and referral of these victims provided they are trained and educated on how to ask, conducting interviews, documenting the abuse, and referring the victims to further assistance. Furthermore, there is a need for research on the barriers faced by the dentists and also the perceptions of women suffering from abuse and what they need from the dental health practitioners, especially in the Indian scenario.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaur R, Garg S. Addressing domestic violence against women: An unfinished agenda. Indian J Community Med 2008;33:73-6.
] [Full text]
Babu BV, Kar SK. Domestic violence against women in Eastern India: A population-based study on prevalence and related issues. BMC Public Health 2009;9:129.
Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C; WHO Multi-country Study on Women's Health and Domestic Violence against Women Study Team. Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study. Lancet 2008;371:1165-72.
Le BT, Dierks EJ, Ueeck BA, Homer LD, Potter BF. Maxillofacial injuries associated with domestic violence. J Oral Maxillofac Surg 2001;59:1277-83.
Ochs HA, Neuenschwander MC, Dodson TB. Are head, neck and facial injuries markers of domestic violence? J Am Dent Assoc 1996;127:757-61.
Shepherd JP, Gayford JJ, Leslie IJ, Scully C. Female victims of assault. A study of hospital attenders. J Craniomaxillofac Surg 1988;16:233-7.
Love C, Gerbert B, Caspers N, Bronstone A, Perry D, Bird W. Dentists' attitudes and behaviors regarding domestic violence. The need for an effective response. J Am Dent Assoc 2001;132:85-93.
Tjaden P, Thoennes N. Prevalence, Incidence, and Consequences of Violence against Women: Findings from the National Violence against Women Survey. Research in Brief; 1998. Available from: http://www.eric.ed.gov/?id=ED434980
. [Last accessed on 2017 May 14].
Chiodo GT, Tilden VP, Limandri BJ, Schmidt TA. Addressing family violence among dental patients: Assessment and intervention. J Am Dent Assoc 1994;125:69 75.
United Nations. The Fourth World Conference on Women. Beijing, China, New York: United Nations; 1995.
World Health Organization. Responding to Intimate Partner Violence and Sexual Violence against Women: WHO Clinical and Policy Guidelines. Geneva: World Health Organization; 2013.
Hsieh NK, Herzig K, Gansky SA, Danley D, Gerbert B. Changing dentists' knowledge, attitudes and behavior regarding domestic violence through an interactive multimedia tutorial. J Am Dent Assoc 2006;137:596-603.
Warburton AL, Hanif B, Rowsell C, Coulthard P. Changes in the levels of knowledge and attitudes of dental hospital staff about domestic violence following attendance at an awareness raising seminar. Br Dent J 2006;201:653-9.
Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-7.
Bacchus L, Mezey G, Bewley S. Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health Soc Care Community 2003;11:10-8.
Mezey G, Bacchus L, Haworth A, Bewley S. Midwives' perceptions and experiences of routine enquiry for domestic violence. BJOG 2003;110:744-52.
Landenburger KM. The dynamics of leaving and recovering from an abusive relationship. J Obstet Gynecol Neonatal Nurs 1998;27:700-6.
Kaye DK, Mirembe F, Bantebya G. Perceptions of health care providers in Mulago hospital on prevention and management of domestic violence. Afr Health Sci 2005;5:315-8.
Waalen J, Goodwin MM, Spitz AM, Petersen R, Saltzman LE. Screening for intimate partner violence by health care providers. Barriers and interventions. Am J Prev Med 2000;19:230-7.
Nederhof AJ. Methods of coping with social desirability bias: A review. Eur J Soc Psychol 1985;15:263-80.
[Table 1], [Table 2], [Table 3], [Table 4]