Comparative cross-sectional study assessing specialized and general dentist readiness and barriers in performing routine domestic violence screening
The World Health Organization defines domestic violence as intimidating coercive behaviour by current or former spouses/partners that causes physical, sexual, and psychological harm. It is a serious yet preventable public health issue that affects millions of people worldwide . It has been estimated that 1 in every 3 women are subject to different forms of intimate partner violence and that only 34% of intimate partner violence victims seek medical attention . A recent study reported that 2 in every 10 men and 3 in every 10 women are victims of domestic violence, and less than 20% of those victims seek medical attention . Dental clinics have been identified as indispensable settings to identify patients who are victims of domestic violence . This is because the head, neck and oral structures are the most common locations of physical injury caused by domestic violence perpetrators . Studies suggested that dental schools around the world are increasingly recognizing the role of dental health care providers in identifying signs of domestic violence in head and neck injuries. Therefore, most of dental schools around the world offer formal focused training in identifying domestic violence in dental setting. This included as topic in core courses of patient care and management, dental public health, dental ethics, oral pathology, and interprofessional collaboration. In the past ten years, domestic violence received more attention in dental school in the middle east region. Yet, the emphasis and depth in domestic violence focused training vary in middle eastern dental schools depending on the country, local health care policies, and educational institution . However, several studies have suggested that dental health care professionals might miss or not screen for potential head and neck injuries during the treatment of domestic violence patients . Routine domestic violence screening in dental clinics can be considered the least common and most difficult practice among dental care providers due to several potential barriers . The barriers to performing routine domestic violence screening are related to health care providers’ lack of knowledge, lack of supportive resources, discomfort, fear of privacy intrusion, lack of adequate chair time to perform domestic violence screening, and a perceived gender preference that patients are more likely to discuss domestic violence events with female providers . On the other hand, other studies have shown that general dentists have a major role in supporting domestic violence victims by showing empathy, acknowledging victims’ worth, and providing help . The dental literature lacks a comparative evaluation between specialized and general dentists’ readiness and potential barriers to performing routine domestic violence screening in dental settings . Therefore, the current study was conducted to improve the comprehension of factors that influence both specialized and general dentists’ readiness to address domestic violence by screening all patients in dental settings. The rationale of the current study was that both specialized and general dentists can be the first line of defence against domestic violence. Understanding both readiness and barriers for routine domestic violence screening for all dental patients might improve the recognition of dentistry as an effective profession in identifying domestic violence victims. The objective of the current study was to compare the readiness and barriers to performing routine domestic violence screening for all dental patients between specialized and general dentists. 

Study design, setting, and participants This current cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist, and ethical approval was obtained from the Research Ethics Committee of the Faculty of Dentistry at King Abdulaziz University in Jeddah, Saudi Arabia. In 2021, the total number of practising dentists in the western province was 8808, and the sample size calculation estimated the current study sample of 369 subjects with a 95% confidence interval and 5% margin of error .The inclusion criteria to participate in this study were as follows: specialized and general dentists of either sex, an active licences to practice dentistry, and actively working and engaging in patient care for at least five days per week. The exclusion criteria were dentists with limited licences or limited privileges, dental interns, and dentists working in administrative positions with less than five days per week of active practice and patient care engagement. The current study was carried out from January 2022 to June 2023. A validated and structured questionnaire was used to evaluate study subjects’ readiness and barriers to performing routine domestic violence screening . The western Province in Saudi Arabia has 3 major metropolitan cities: Jeddah, Makkah, and Taif. A list of all dental hospitals distributed throughout the western province was obtained, and probability sampling using a disproportionate stratified random sampling technique based on dentists’ professional level was used to recruit an equal number of general and specialized dentists for the study population. Study participation was voluntary, and those who refused to participate were replaced by another participant with the same characteristics by the same probability sampling protocol. Ten calibrated data collectors approached all dentists who agreed to participate in this study with five portable devices (iPads) locked with a password to complete the study questionnaire. Questionnaire design The questionnaire used in this study was in English and was adopted and modified from previous studies . The questionnaire’s cover page included a full description of the study’s objective, confidentiality assurance, anonymity assertion, informed consent, and contact information of the study investigator to respond to any study-related inquiries. The questionnaire consisted of 31 closed-ended questions in 7 main domains, and it required 10–15 min to complete. The first domain consisted of 9 items assessing study subjects’ demographics and their readiness to perform routine domestic violence screening in a dental setting. The items used to assess dental practitioners’ readiness to perform domestic violence screening were scored using a 10-point scale ranging from 1, which represented the lowest readiness, to 10, which represented the highest readiness . The second to the seventh domains used in this study were adopted from the shortened version of the Domestic Violence Healthcare Providers Survey (DVHPS), which is a universal and widely used survey to identify health care providers’ readiness and potential barriers to performing domestic violence screening in health care settings. Responses for all items in the second domain to the seventh domain were recorded on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = strongly agree). The second, third, fourth, and fifth domains included 7 items evaluating dentists’ self-efficacy, 4 items assessing the fear of offending patients, 5 items examining judgements of victim personalities, and 3 items evaluating professional role resistance to perform domestic violence screening, respectively. The sixth and seventh domains included 2 items each to explore dentists’ assessments of victim disobedience and psychiatric support . The calculation method utilized in previous studies was adapted to calculate the mean of each domain of the DVHPS for each study participant. The mean of each domain in the DVHPS was computed by creating a summative variable of all items within the domain and dividing by the total number of items in the domain . Study variables Descriptive characteristics, including dentist’s sex, dental profession level, training in identifying domestic violence victims during dental education, and routine domestic violence screening, were categorical variables. Additionally, age, years of dental experience, working hours/week, number of patients treated per day, and dentists’ readiness to perform domestic violence screening were included as descriptive continuous variables. Summative variables of the DVHPS domains, which included the self-efficacy, fear of offending patients, victim personality/trait, professional role resistance, victim disobedience, and psychiatric support domains, were used as domestic violence screening barrier predictors in independent two-sample t test models. Differences between dental profession levels was the outcome of interest. Statistical analysis Descriptive univariate analyses, such as frequencies, percentages, means, and standard deviations, were used to report the study population’s demographic characteristics. The means of specialized and general dentists’ readiness to perform routine domestic violence screening were calculated. Additionally, the means of different DVHPS domains were estimated. Bivariate analyses including two-sample t tests and chi-square tests were executed to assess differences between specialized and general dentists in demographic attributes and DVHPS domains. All statistical analyses were performed using SAS statistical software version 9.3 (SAS Institute, Cary, NC, USA) with the level of significance set at P < 0.05. 

This current cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist, and ethical approval was obtained from the Research Ethics Committee of the Faculty of Dentistry at King Abdulaziz University in Jeddah, Saudi Arabia. In 2021, the total number of practising dentists in the western province was 8808, and the sample size calculation estimated the current study sample of 369 subjects with a 95% confidence interval and 5% margin of error .The inclusion criteria to participate in this study were as follows: specialized and general dentists of either sex, an active licences to practice dentistry, and actively working and engaging in patient care for at least five days per week. The exclusion criteria were dentists with limited licences or limited privileges, dental interns, and dentists working in administrative positions with less than five days per week of active practice and patient care engagement. The current study was carried out from January 2022 to June 2023. A validated and structured questionnaire was used to evaluate study subjects’ readiness and barriers to performing routine domestic violence screening . The western Province in Saudi Arabia has 3 major metropolitan cities: Jeddah, Makkah, and Taif. A list of all dental hospitals distributed throughout the western province was obtained, and probability sampling using a disproportionate stratified random sampling technique based on dentists’ professional level was used to recruit an equal number of general and specialized dentists for the study population. Study participation was voluntary, and those who refused to participate were replaced by another participant with the same characteristics by the same probability sampling protocol. Ten calibrated data collectors approached all dentists who agreed to participate in this study with five portable devices (iPads) locked with a password to complete the study questionnaire. 

The questionnaire used in this study was in English and was adopted and modified from previous studies . The questionnaire’s cover page included a full description of the study’s objective, confidentiality assurance, anonymity assertion, informed consent, and contact information of the study investigator to respond to any study-related inquiries. The questionnaire consisted of 31 closed-ended questions in 7 main domains, and it required 10–15 min to complete. The first domain consisted of 9 items assessing study subjects’ demographics and their readiness to perform routine domestic violence screening in a dental setting. The items used to assess dental practitioners’ readiness to perform domestic violence screening were scored using a 10-point scale ranging from 1, which represented the lowest readiness, to 10, which represented the highest readiness . The second to the seventh domains used in this study were adopted from the shortened version of the Domestic Violence Healthcare Providers Survey (DVHPS), which is a universal and widely used survey to identify health care providers’ readiness and potential barriers to performing domestic violence screening in health care settings. Responses for all items in the second domain to the seventh domain were recorded on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = strongly agree). The second, third, fourth, and fifth domains included 7 items evaluating dentists’ self-efficacy, 4 items assessing the fear of offending patients, 5 items examining judgements of victim personalities, and 3 items evaluating professional role resistance to perform domestic violence screening, respectively. The sixth and seventh domains included 2 items each to explore dentists’ assessments of victim disobedience and psychiatric support . The calculation method utilized in previous studies was adapted to calculate the mean of each domain of the DVHPS for each study participant. The mean of each domain in the DVHPS was computed by creating a summative variable of all items within the domain and dividing by the total number of items in the domain . 

Descriptive characteristics, including dentist’s sex, dental profession level, training in identifying domestic violence victims during dental education, and routine domestic violence screening, were categorical variables. Additionally, age, years of dental experience, working hours/week, number of patients treated per day, and dentists’ readiness to perform domestic violence screening were included as descriptive continuous variables. Summative variables of the DVHPS domains, which included the self-efficacy, fear of offending patients, victim personality/trait, professional role resistance, victim disobedience, and psychiatric support domains, were used as domestic violence screening barrier predictors in independent two-sample t test models. Differences between dental profession levels was the outcome of interest. 

Descriptive univariate analyses, such as frequencies, percentages, means, and standard deviations, were used to report the study population’s demographic characteristics. The means of specialized and general dentists’ readiness to perform routine domestic violence screening were calculated. Additionally, the means of different DVHPS domains were estimated. Bivariate analyses including two-sample t tests and chi-square tests were executed to assess differences between specialized and general dentists in demographic attributes and DVHPS domains. All statistical analyses were performed using SAS statistical software version 9.3 (SAS Institute, Cary, NC, USA) with the level of significance set at P < 0.05. 

Out of 491 dentists were approached, a total of 400 dentists agreed to participate in this study with a response rate of 81.46%.; 50% of the participants were general dentists, and the other 50% were specialized dentists. The sex distribution was 53% and 47% for male and female dentists, respectively. Almost 44% of the study participants received training in identifying domestic violence during their dental training. More than half of the study participants (58%) routinely screened their patients for domestic violence at their dental clinics (Table ). The mean age of the study participants was 46.31 ± 8.79 years, with an average dental work experience of 12.6 ± 4.88 years. The study population showed an average of 30.10 ± 4.21 working hours/week and treated 7.90 ± 3.64 patients per day on average. The mean readiness score of all study participants in performing domestic violence screening for all patients was 6.11 ± 2.52 (Table ). The estimated summative mean response of the study participants for each domain of the DVHPS is presented in Table . Based on previous studies, an estimated mean domain score of ≥ 4 signifies a high level of the assessed characteristic of the domain. On the other hand, a mean score < 4 denotes a low level of that domain’s characteristic . Based on these criteria, the results suggested low self-efficacy, fear of offending patients, judgement of victim personalities/traits, professional role resistance, victim disobedience, and psychiatric support. Bivariate analyses including chi-square and independent two-sample t tests were performed to evaluate domestic violence screening readiness and identify potential barriers between specialized dentists and general dentists. The chi-square test indicated no significant difference in sex and training in identifying domestic violence during dental training between general and specialized dentists. However, routine domestic violence screening was more frequently performed by general dentists compared to specialized dentists and was statistically significant at a p value less than 0.001 (Table ). Table shows the results of the independent two-sample t test to estimate the difference between general and specialized dentists. The two dental profession levels were comparable, as there was no statistically significant difference in age, years of dental experience, working hours per week, or number of treated patients per day. However, general dentists showed significantly higher readiness to perform domestic violence screening for all patients compared to specialized dentists, with a p value less than 0.0001. Additionally, general dentists showed significantly higher self-efficacy and lower professional role resistance to perform domestic violence screening for all patients compared to specialized dentists. Both findings were statistically significant at p values less than 0.0001. General dentists presented slightly higher scores for the fear of offending patients, victim personality/trait judgement, victim disobedience, and psychiatric support domains than specialized dentists, yet these findings were not significantly different. 

Domestic violence is a major public health concern with a relatively high prevalence rate worldwide, regardless of cultural, religious, or ethnic background . The prevalence of domestic violence and domestic violence-related injuries has increased in recent years, especially during the COVID-19 pandemic, because of induced stressors and preexisting vulnerabilities . Dentists and the dental workforce can be fundamental frontline screeners and assist domestic violence victims because they not only treat domestic violence-related head and neck injuries but also have more amiable relationships with their patients and biannual dental checkup visits . Therefore, the dental environment can be utilized as a safe discreet setting for the detection and prevention of domestic violence and its related head and neck injuries . Routine domestic violence screening in dental settings combined with proper management and referral of victims is a pivotal preventive response to reduce the occurrence and dental comorbidity of domestic violence . This current study suggested that more than half of the study population (58%) performed routine domestic violence screening for their patients in their dental practice. Moreover, the results of this study indicated an acceptable readiness to implement routine domestic violence screening for all dental patients among the dentists included in the study population. This finding is in accordance with other studies reported in the dental literature . However, this study suggested contrasting results between general and specialized dentists in routine domestic violence screening and readiness to perform domestic violence screening. General dentists were 27.6% more likely to perform routine domestic violence screening than specialized dentists. Moreover, general dentists showed an average readiness to implement domestic violence screening score equal to 7.03 ± 2.82 compared to an average readiness score of 5.61 ± 1.63 among specialized dentists. This study is the first study in the dental literature to compare routine screening and readiness to perform domestic violence screening between general and specialized dentists. The results of this study showed that the general dentist population was largely comparable to the specialized dentist population across most of the study variables. The lower inclination of specialized dentists to perform routine domestic violence screening and readiness to perform domestic violence screening for their patients compared to that of general dentists could be attributed to two considerable barriers. First, the self-efficacy of specialized dentists was significantly lower than that of general dentists. Second, professional role resistance was significantly higher among specialized dentists than among general dentists. These two vital barriers might be the main determinants for the lower tendency of specialized dentists to perform routine domestic violence screening and lower readiness to implement domestic violence screening. These findings agree with those of other studies reported in the literature. Dentists are more likely to be disinclined to screen their patients for domestic violence due to an array of barriers . Some of these barriers are lack of chair time to screen for domestic violence, lack of education to perform efficient domestic violence screening in dental settings, a considerably large number of patients needing to be treated per single work day in the dental clinic, fear of offending patients, and fear of violating patients’ privacy . Barriers to domestic violence screening can be largely attributed to a lack of education and continuous training for dentists in the field of domestic violence. Studies have suggested that continuous education in domestic violence for dental health care providers can diminish potential barriers and enhance the readiness and effectiveness in performing domestic violence screening . To enhance dentists’ involvement in screening for domestic violence, it is essential for both dental practices and dental schools to focus on raising awareness, providing training, and developing appropriate policies. By equipping dental professionals with the necessary knowledge, skills, and resources to identify and address domestic violence, dental practices can become a vital component of the broader community support system for victims. Integrating domestic violence screening into dental care is not merely an opportunity but a professional responsibility that can profoundly impact the health and safety of vulnerable populations . A limitation of the current study is that it was cross-sectional and, therefore, a causal association could not be established. This study may be prone to self-reported bias, as the participants may have deviated from the true value of the same measurement. Future research should evaluate potential subdomain barriers in the DVHPS that affect specialized dentists’ readiness to perform domestic violence screening for all patients using factor analysis. Factor analysis might offer a composite of subdomain variables that might contribute to specialized dentists’ low readiness to implement domestic violence screening for dental patients. Moreover, further research should be conducted to evaluate the continuous education of dentists in the field of domestic violence and its effectiveness in facilitating the execution of domestic violence screening in dental settings and in a broader multidisciplinary team. 

This study noted an acceptable readiness to perform domestic violence screening among dentists. However, an evident difference between general and specialized dentists in performing routine domestic violence screening and readiness to implement this screening was noted. According to the DVHPS assessment tool, the greatest barriers in performing domestic violence screening among specialized dentists were self-efficacy and professional role resistance. Education and reinforcement of the need for and importance of domestic violence screening in dental settings should be emphasized by higher authorities to legitimize practising dentists to implement domestic violence screening, identify victims, provide treatment accordingly, and appropriately refer patients to supportive services. 

