Asking, validating, documenting, referring: AVDR. We developed an approach that can simplify the dentist’s role in addressing DV. This four-stage process, known as asking, validating, documenting and referring (AVDR), involves the following:

– asking patients about abuse;

– providing validating messages that acknowledge that battering is wrong while confirming the patient’s worth;

– documenting signs, symptoms and disclosures in the patient’s dental record in writing and with photographs;

– referring victims to DV specialists and resources in the community.

Dentists can use AVDR intervention even when abuse is suspected but not disclosed, and patients have reported that intervention has been helpful in that circumstance.^14,15 The objective of the AVDR approach is to help patients without imposing unreasonable expectations that dentists solve the problem of family violence.

In a study in which women who had experienced DV described their experiences with their health care providers, most of the women interviewed believed that their health care providers were "uninterested, uncaring, or uncomfortable" about the abuse.¹⁶ One woman reported that the most helpful health care provider was a nurse practitioner who demonstrated empathy. We sought to investigate whether empathy is, indeed, related to dentists’ attitudes, awareness and practices pertaining to DV or to the efficacy of our AVDR tutorial. Hojat and colleagues¹⁷ developed the Jefferson Scale of Physician Empathy to measure empathy of medical students and physicians in relation to patient care. The researchers used factor analysis to identify three components of empathy:

– perspective taking (the core ingredient in empathy);

– compassionate care (emotions involved in care);

– "the ability to stand in the patient’s shoes" (thinking like the patient).¹⁸

Sherman and Cramer¹⁹ validated the Jefferson scale in a sample of dental students. We decided to use the Jefferson scale to explore the importance of dentists’ empathy in a context of addressing DV in patients and modified it appropriately. We also sought to replicate the above-described factor analysis in our sample of dentists.

The specific aims of this study were

– to provide a brief multimedia tutorial to educate dentists to recognize and respond to DV;

– to determine the effectiveness of the tutorial in improving the knowledge, attitudes and behavior scores of dentists in an intervention group relative to a control condition;

– to examine the relationship of empathy scores with knowledge, attitude and behavior scores regarding DV.

	SUBJECTS, METHODS AND MATERIALS

TOP ABSTRACT DV AND DENTISTRY SUBJECTS, METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The institutional review board of the University of California San Francisco approved the study, for which we obtained informed consent from all participants.

Subject selection and recruitment. For inclusion in the study, dentists had to practice in the United States and be engaged in at least 20 hours of outpatient care per week. In September and October of 2003, we recruited a convenience sample of dentists from attendees at the 2003 annual session of the American Dental Association held in San Francisco, participants in continuing dental education courses of the University of the Pacific, San Francisco, and attendees at meetings of the San Francisco Dental Society. At the ADA’s annual session, we recruited participants at a booth and table clinic. We raffled off a liquid crystal display television to attract more participants. We also recruited residents in the dental clinics at University of California San Francisco.

The AVDR tutorial. We created an interactive multimedia computer-based tutorial tailored to dental professionals to present the AVDR approach. The tutorial begins with information on how dentists can identify signs of abuse. The program then presents different ways in which the dentist can ask a patient who shows signs of abuse about DV and provide validating messages, whether or not the patient discloses abuse. The tutorial also educates dentists on how to document DV in the dental record and to refer patients to local DV assistance resources when appropriate. Two skilled actors appear in the tutorial: one is a real dentist, and the second portrays a dental patient who presents with indicators of abuse (laceration on the gingivae and a loose tooth). Participants are asked to make a selection among different questions a dentist could ask the patient by choosing questions and statements to deliver. These inputs elicit a variety of reactions from the patient. The dentist follows with advice and guidance about the simulated dentist-patient interaction. The tutorial proceeds through the four stages of the AVDR lesson and takes approximately 15 minutes to complete.

Study design. In a two-group controlled trial, we examined the impact of the tutorial on practicing dentists. After providing informed consent, all participants completed our modified version of the Jefferson Scale of Physician Empathy.¹⁹ The control group took a pretest and the posttest and then completed the tutorial. The experimental group took the pretest, completed the tutorial and then took the posttest. These components of the trial were delivered on laptop computers, which randomly assigned the participants to control and experimental groups, resulting in randomization with laptops as strata. Participants completed the tutorial—including the pretest, posttest and Jefferson scale—during the same encounter in which they were recruited and then received a small reimbursement.

Instruments administered. DV assessment instrument. The pretest and posttest each consisted of 24 questions; participants completed them on laptop computers. The questions covered the range of the AVDR intervention, as well as knowledge and attitudes about DV (Table, pages 600–1). All participants received the questions in the same order. The posttest repeated the 24 questions, in a different order and with some differences in wording.

We assessed the effect of the tutorial on the change in mean scores from pretest to posttest for all 24 test questions simultaneously, using resampling-based step-down bootstrap multiple testing (1 million resamples).²⁰ We tested interactions between the intervention and other factors, including specialty (general practitioner versus specialist), sex, race (white versus nonwhite), graduation year (before 1999 versus 1999 or later), DV training (0 hours versus > 0 hours) and total empathy score (< 117 [the median score] versus 117 or greater).

We conducted a principal components analysis with orthogonal rotation on the dentists’ empathy scale scores. We also conducted t tests to look for significant differences in total empathy scores between men and women and between the intervention and control groups, as well as correlations to look for relationships between empathy scores and baseline, posttest and change scores on the DV assessment instrument.

	RESULTS

TOP ABSTRACT DV AND DENTISTRY SUBJECTS, METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We recruited 177 participants. We excluded three participants because of computer problems. Of the resulting 174 participants, 88 were in the control group, and 86 were in the experimental group; 60 percent were men; 2 percent were American Indian or Alaskan Native, 48 percent were non-Hispanic white, 6 percent were Hispanic, 40 percent were Asian/Pacific Islander, and 4 percent were of other or unknown racial descent.

We found no statistically significant differences between the intervention and control groups in demographic, educational or dental practice characteristics. Nor did we find any statistically significant differences between the demographic groups on scores for any of the 24 baseline questions.

Effects of the AVDR DV tutorial. The table shows the baseline scores and mean change scores (and standard deviations [SDs]) for the experimental and control groups on each of the 24 questions asked in the DV assessment instrument.

For all 12 questions about intentions to practice AVDR and perceived knowledge of how to help patients affected by DV, the dentists who received the tutorial improved their scores, on average, significantly more than did the dentists in the control group (all P < .005). The tutorial had less effect on questions pertaining to beliefs or attitudes; members of the experimental group raised their scores significantly more than did those of the control group on four of 12 such questions (all P < .01).

Overall, the tutorial significantly improved scores on 16 of the 24 assessment items (P = .01 when we adjusted for multiple comparisons). We found no significant differences when testing for intervention effects by category of practice (specialty/general), sex, race, year of graduation, previous DV training or empathy.

Empathy scores. We failed to replicate the above-mentioned factorization of the empathy scale. We found no separate interpretable factors. Accordingly, we used the total empathy score in further analyses pertaining to empathy.

For the entire sample, the mean total empathy score was 115.5 (SD = 11.87); the range was 77 to 140 (possible range = 20–140). There was no difference between the intervention (mean = 115.18, SD = 12.29) and control (mean = 115.83, SD = 11.49) groups in mean baseline empathy score. Women’s scores were higher than men’s scores, but they were not statistically different (respective means: 117.28, SD = 11.02; 114.33, SD = 12.32).

Total empathy scores correlated significantly with total baseline (and posttest) scores on the DV assessment instrument (baseline Pearson product moment correlation r = 0.34, P < .0001; posttest r = 0.40, P < .0001). Empathy did not correlate with change scores (posttest minus pretest) for the complete assessment instrument (r = 0.13, P = .092). Looking at subscales of the assessment instrument, we found that empathy correlated with the baseline and posttest scores, but not with change scores for the intended behavior (AVDR practices) subscale (baseline r = 0.19, P < .01; posttest r = 0.26, P < .001) and for the subscale pertaining to beliefs/attitudes about helping patients who are DV victims (baseline r = 0.41, P < .001; posttest r = 0.49, P < .0001). Empathy scores did not correlate with perceived knowledge questions at baseline or perceived knowledge change scores (though they did correlate with perceived knowledge at posttest; r = 0.19, P < .01).

	DISCUSSION

TOP ABSTRACT DV AND DENTISTRY SUBJECTS, METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
This study tested the efficacy of an educational and behavioral change intervention designed to help dentists overcome their reluctance to identify and treat victims of DV and to effect positive changes in dentists’ knowledge, attitudes and behaviors with respect to caring for patients who experience DV. The ultimate goal is to help prevent further DV and associated oral trauma in patients seeking dental care. To reach this goal, a better understanding of educating dentists in this area is necessary.

Results suggest that the intervention effectively improved dentists’ intentions to practice ADVR intervention; it also improved dentists’ perceived knowledge both of DV and of how to help its victims. For example, after taking the tutorial, dentists reported that they would be more likely to inquire about a patient’s safety after recognizing injuries to the head or neck. This one change in practice could increase greatly the number of victims who are not only identified, but also helped, at dental visits. The first step, asking about abuse, often is the hardest for any health care provider.²¹ Dentists in our study reported that after the tutorial they felt empowered to get through this first step and open the door for their patients. In our previous research, patients reported that it often was a health care provider who first made them think about their abusive situations, a realization that eventually helped them change those situations.²²

The tutorial was less effective in changing dentists’ beliefs and attitudes regarding DV. However, even though dentists may not believe that they can help those who experience abuse, they are willing to try. A 15-minute computer-based intervention may not change dentists’ core beliefs and attitudes, but it may lead them to adopt a pragmatic approach to addressing DV.

The tutorial was tested with dental students,¹² and we found the same general pattern of results as in that research. For both dental students and dentists, the tutorial significantly improved knowledge and intended behaviors regarding DV. With beliefs and attitudes, however, dentists improved their scores on four of the 12 questions, whereas dental students showed no change. The tutorial appeared equally effective across demographic variables (age, sex and race) and practice variables (specialty, years of practice).

We expected that dentists with greater empathy would be more receptive to the issue of DV. Our results indicate that may be partly true: dentists who scored higher in empathy had higher baseline and posttest scores on measures of intended DV-related practices and beliefs and attitudes about the issue. However, empathy scores were unrelated to scores on perceived knowledge of DV or the effects of the ADVR tutorial. This last result is consistent with the idea that empathy is a stable trait, not easily influenced by the intervention. And the effectiveness of the tutorial (in increasing knowledge about DV and intentions to address it in clinical practice) is not dependent on the dentist’s level of empathy.

Limitations. There are several limitations to this study. We recruited a convenience sample of dentists willing to take the tutorial for a small reimbursement, which introduces a potential bias. The posttest immediately followed the tutorial, so we did not assess long-term effects of the tutorial. We did not follow up with participants to see if the tutorial has helped them in their clinical practices. Yet our findings suggest that by improving intended behaviors and knowledge regarding DV, the multimedia tutorial can be an effective medium for preparing dentists to triage for DV.

We acknowledge the barriers to screening for DV in oral health care settings. Despite these, Love and colleagues¹¹ found that as little as one hour of education about DV increased the likelihood that dentists would screen patients for abuse. While the literature lacks models of intervention for dentists thus far, the AVDR tutorial provides one approach for dentists, demonstrating concrete intervention behaviors that can be applied within the scope of their practice.

Advances in technology have made the dissemination of multimedia educational programs highly efficient, and computer-assisted instruction has been shown to be an effective method of dental education in addition to the traditional classroom setting.²³ For example, a two-hour, case-based educational program for physicians delivered over the Internet improved physicians’ confidence in and beliefs about treating patients who had experienced DV as effectively as a more intensive, classroom-based approach.²⁴ We have made the AVDR tutorial widely available to practicing dentists and instructors at dental schools. We believe that it is a great step forward in dental education about DV to offer this tutorial on the Internet or on digital video disc (DVD) to dentists and other oral health care professionals, and to integrate it into dental schools nationwide. (Editor’s note: A note at the end of the article provides further information on this DVD.)

	CONCLUSIONS

TOP ABSTRACT DV AND DENTISTRY SUBJECTS, METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The AVDR tutorial is a quick and effective way to increase knowledge and awareness of DV among oral health care practitioners. It offers simple strategies for assessment and intervention with dental patients who may be experiencing abuse.