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Dentists’ perceptions and attitudes towards emergency care for women in situations of violence: A scope review

Silvilene Giovane Martins Pereira, Andrea Maria Duarte Vargas, Aline Araujo Sampaio, Carlos José de Paula Silva, Bárbara da Silva Mourthé Matoso, Efigênia Ferreira e Ferreira

Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte MG Brasil. smartins2010@yahoo, com.br – http://orcid.org/0000-0002-06665-211X
Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte MG Brasil. vargasnt@task.com – http://orcid.org/0000-0002-4371-9862
Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte MG Brasil. alinea.sampaio@hotmail.com – http://orcid.org/0000-0002-8704-5994
Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte MG Brasil. case.odo@gmail.com – http://orcid.org/0000-0001-8897-9345.
Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte MG Brasil. barbarammatoso@gmail.com – https://orcid.org/0000-0001-9273-376X
Universidade Federal de Minas Gerais. Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte MG Brasil. efigenia@gmail.com – http://orcid.org/0000-0002-0665-211X
.
CORRESPONDING AUTHOR
Silvilene Giovane Martins Pereira
Av. Antônio Carlos, 6627, Pampulha. Belo Horizonte CEP: 31.270-901
smartins2010@yahoo
(31) 98587-1416

ABSTRACT
The purpose of this study was to evaluate, through a scope review, studies that address the perceptions and attitudes of dentists regarding the care of women in situations of violence. Using the descriptors women violence, dentist attendance or dentist care, 473 articles were identified, of which 13 were included at the end of the selection process. Although the need for training was predominant, it was not sufficient. There is a weakness in understanding violence as a health problem, in understanding the role of the professional in solving this problem, and the factors that can contribute to its growth or its control. The results revealed that the dentist had greater difficulty than other professionals in coping with the issue and required extensive training. The recognition of these cases of abuse by the dentist requires the incorporation of educational measures that cause cultural changes, deconstruction of gender norms and the denaturalization of this social phenomenon.

KEYWORDS: violence against women, dentist, scope review

INTRODUCTION
The Declaration on the Elimination of Violence against Women,1 proclaimed by the United Nations General Assembly, in article 1, defines violence against women as any act of violence based on gender that results in, or may result in, physical, sexual or psychological harm or suffering for women, including the threats of such acts, coercion or arbitrary deprivation of liberty, occurring either in public or private life.
It is a phenomenon that has taken on alarming proportions in the world and is considered an international public health problem and a violation of the human rights. A study led by WHO2 reviewed data from 80 countries and found that approximately 30% of women experience physical and/or sexual violence by an intimate partner at least once in their lives. In Brazil, according to the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação, SINAN), of the total number of reports of violence in 2017, 71.8% were made by women.3 Gender is one of the most significant social determinants of health outcomes; however, the global health community is largely blind to it.4
There is a consensus in the literature that women in situations of violence are present in the health system; however, in most cases, violence itself will not be detected by health professionals in their practices.5 In this sense, both the professional and the health system and the educational institutions that train them are essential in responding to violence against women.6,7
In emergency or emergency care hospitals, oral and maxillofacial surgeons are part of the medical team that cares for patients with trauma in the cranial, face and neck region; thus, these professions are confronted daily with women who have experienced violence.8
Maxillofacial trauma can lead to facial disfigurement; these injuries are traumatic in the biological, social and emotional dimensions and occur most often in women,9,10 especially in cases of interpersonal violence. Not infrequently, these professionals lack the knowledge and skills to receive, comprehend and listen to what these women are telling them.11-13
The literature shows that among health professionals, the dental surgeon has a good chance of identifying cases of women in situations of violence, since the dental examination involves the evaluation of the oral cavity and adjacent structures, and maxillofacial trauma is one of the main injuries observed in cases of abuse. However, these professionals have difficulty identifying and dealing with cases of violence.9-18
Women in situations of violence impose an immense burden on the system and health professionals. In the prolonged context observed, with the COVID-19 pandemic, the obstacles may have been even greater. On the one hand, there is an increase in violence caused by the change in lifestyle due to the pandemic, and on the other hand, there is less access to health care services aggravated by the growing demand, which increases the challenges of assisting these women.19-21
Considering the role of health care in the recognition and care of women in these situations, it is of fundamental importance to conduct studies that allow the expansion of knowledge about this phenomenon, especially with regard to the performance of the dental surgeon.
In this context, the objective of this scope review was to map what has been produced in the literature on the care provided by the dental surgeon (DC) in emergency health services when assisting women in situations of violence.

METHODS
The scoping review methodology was chosen for this study because it is an approach that aims to map the scientific production that supports an area of knowledge. This mapping should include relevant studies in a field of interest and the purpose of recognizing the evidence produced.22,23
This type of review is appropriate to identify knowledge gaps, to clarify key concepts on a given topic or even, in some cases, to synthesize evidence in a more effective and rigorous manner. It has characteristics similar to a systematic review, such as systematization, transparency and reproducibility, and concomitantly recognizes the nature and extent of the scientific evidence associated with the researched topic.22,23
During the investigation, the protocol of the Joanna Brigs Institute for Scope Reviews (JBI)22 was used, and the studies were selected based on the flowchart recommended by this protocol.
The research question was constructed using the Population, Concept and Context (PCC) strategy, as suggested by the JBI23 protocol:
P - population (dental surgeons)
C - concept (attitude of the dental surgeon when assisting women in situations of violence)
C - context (care of maxillofacial trauma in emergency hospitals for women in situations of violence)
Based on the PCC, the following research question was researched: "What has been produced in the scientific literature about the attitudes of the dental surgeon in clinical emergency care to women in situations of violence?"
The bibliographic search strategy was constructed by combining the descriptors, based on the elements of the research question (PCC): women violence AND dentist attendance OR dentist care AND dentist attitude, using Boolean operators “AND” and “OR”.
The electronic search was performed in four databases, and the strategy was the same in each: PubMed, Medline Ovid, Web of Science and SCOPUS. The studies were identified in November 2019 and exported using EndNoteX7. Duplicates were excluded with the use of software and manual identification.
No restrictions were established on the design, date of publication or language of the studies, and articles were identified from 1962 onwards.
The first selection considered titles and abstracts. The articles were selected by two reviewers [blinded], and there was good agreement between them (Cohen\'s Kappa = 0.775). Then, the full articles were analysed (blinded) by three researchers. For the inclusion of the selected texts, the researchers opted for a consensus. The flowchart of the selection process, from the initial search to the inclusion of the selected studies, is shown in Figure 1.
The inclusion criteria that determined the selection of studies were informed by the question and objective of the study. The reviewers discussed each of the criteria agreed upon at the team meetings. The following inclusion criteria were defined:
1. articles with available abstracts
2. sample/population that at least included the dentist
3. the topic should be care for women in situations of violence, without defining the type of violence
4. emphasis on the care and behaviour of the dental surgeon
To summarize the findings, the following categories were defined: (1) author, country, year of publication; (2) objective; (3) methodological aspects; and (4) results. The included studies were published from 2000 to 2018.
RESULTS
In this scope review, 13 articles were included. Eight were cross-sectional studies, two were qualitative studies, two were literature reviews and one was a document analysis. With regard to the country of origin of the studies, the publications were produced in seven countries, with the highest concentration of publications in the United States (seven). Seven articles had dentists or dentistry students as their sole population. The others evaluated health professionals, and all included the dental surgeon. Regarding language, all studies were published in English. Table 1 shows the summary of the selected articles.
Table 1

DISCUSSION
The included studies discussed the perception and attitudes of health professionals caring for women in situations of violence. Among the 13 included, three addressed only issues of care, and the other ten discussed education and training. They encompassed the need to identify the skills and competencies of professionals but did not go far beyond technical-biological knowledge.
The idea of education, clinical experience, training and qualifications is reinforced as a solution to the identification problem, the first challenge to be faced.11,15,24 The professionals themselves requested more training, especially dentists.25 More efficient learning methods were tested25 or the validity of protocols was discussed as a solution to the observed failures.5
Only one of the studies was conducted in Brazil,26 with 111 dental surgeons, and it presents results similar to those already mentioned. The results indicate a lack of knowledge of the existing legislation, the process of identification and notification, and even the existence of forms for the process as a cause of inoperability in the face of violence. While they affirm the need for intervention, they believe they are not responsible for these activities,11 even though through clinical practice, they have the opportunity to identify and recognize violence.
In one of the evaluated studies, a systematic review,7 the authors question the fragility of their results, which we also consider in the present study. Some presented unclear methods, undefined sample compositions, and insufficient analyses.
However, the aspects mentioned in the present study, even as hypotheses, should be considered. In other studies,11,12,17 with goals that removed them from the present study, these problems are pointed out. In contrast, in one of the studies,14 20% of the participants (n = 309) reported their own experience with interpersonal violence, and in another,24 the violence was considered justifiable.
The scope review allowed us to reflect on the construction of the DCs’ perception of violence against women, that it does not occur in isolation and that it should be incorporated into all aspects of the human and academic experience of this professional. Good results in the care of these women can lead to better recognition and coping with the phenomenon.
Training is necessary and urgent. This finding validates the first worldwide document of the World Health Organization26 on the subject, recommending that gender issues be included in the curriculum of health professionals to ensure comprehensive health care. However, other aspects could, if understood, facilitate recognition of violence and confronting the problem.
The first point to be considered, which was not mentioned in any of the studies, refers to gender norms. Global data indicate associations between gender norms and health.4,27,28 Gender norms are the spoken and unspoken rules of societies about the acceptable behaviours of girls and boys, women and men: how they should act, appear and even think or feel. How this social environment determines and/or influences the subjects may contribute to health inequities throughout life.
Women in situations of violence usually experience gender-based violence, and patriarchal and sexist norms favour gender-based violence, which is constructed from the inequality between men and women in interpersonal relationships, naturalized and reproduced for generations.28,29
Women often face institutional violence by health professionals, who reproduce the existing discrimination in health services. Likewise, inadequate information and nonwelcoming attitudes full of moral judgement are frequently reported in domestic violence investigations.4,30
In this context, this review demonstrated that the training of human resources and the professional practices of DCs are still limited and that this limitation begins at the undergraduate level; since the topic of violence against women is rarely introduced in curricular matrices, it continues and is reflected negatively in professional practice.7,11-13,30 It is important to note that this limitation may also result from personal attitudes that lead to the nonrecognition of violence and reflect the dental health professionals’ gender norms, cultural aspects, stigmas and values4,6,30-34 This result is confirmed by a study conducted with a random sample of 321 dentists from the national list of the American Dental Association (ADA), which found that the majority of respondents (71%) did not receive any type of education related to violence against women in their undergraduate programs, (77%) received training in continuing education courses, and 61% reported that they would like to have more training in this area.8
In addition to the ethical duty arising from professional training, every DC has the legal duty to act according to the specific normative guidelines in reporting violence.11,24 Worldwide, commitments are made to confront violence against women, established in international conventions, declarations and treaties.
In Brazil, in the legal field, the Maria da Penha Law (Law No. 11.340/2006)33 is considered by the United Nations (UN) the third-best law in the world in the fight against domestic violence; it represents an important advance because it conceptualizes this violence as based on gender, in addition to articulating elements of repression and addresses the accountability of perpetrators.33
Previously, Law no. 10,778 of November 24, 2003, established the “compulsory notification, in the national territory, of the case of violence against women treated in public or private health services”.34 Law no. 11,340/2006, the result of a feminist movement motivated by a tragic act of violence by the intimate partner of Maria da Penha, has been revised and improved.
In 2019, three of these changes,35 stood out: aggressors must compensate victims for costs related to health services provided by the Unified Health System (Sistema Único de Saúde-SUS); the judicial system made procedures for victims of domestic violence a priority; and reporting by observers, even in cases of suspected violence against women, was made mandatory. Compulsory reporting is the legal competence of health professionals who, because they are unaware of the legislation, do not consider it.
Thus, the recognition of violence against women by the DC is a legal duty that is part of professional ethics and personal recognition. However, it was also demonstrated in this review that the legislation, by itself, is not able to impose on the DC the recognition of violence against women and cause real changes in health practices; these professionals have been shown to accept violence and consider it a social, behavioural or psychological issue, rather than a health problem.12,13,24
Given the above, an important aspect that has not yet been investigated by any of the studies in this review is verified, namely, the relationship between the legal duty imposed by law and the voluntary action of each being individually considered. Similarly, this relationship does not go unnoticed between patients and dentists, who in their daily practices are faced with cases of violence against women. Such relationships put into conflict the legal duty to act and the DC’s spontaneous action in response to an individual. In this context, the following question is asked: how to compel a voluntary action not included in the legislation?
This questioning is important to investigate measures that translate effectiveness to what is provided for in the body of law, since all compliance with a rule is preceded by a free action, decision to meet the rule or not, making legislation and human action compatible. In other words, it is necessary to reconcile legislation that has at its core compulsoriness versus the power of choice and the volition given to the DC to recognize the cases observed in their professional practice. It is understood that the first is achieved by force of law, but the second is still unclear because it is related to personal freedoms, experiences and interests, belonging to the power of choice, personal discernment and the personal baggage of life that each being carries, a product of his or her family, professional, educational and social environment.
Hence, we formulated the question: “How do we reconcile volitional action with compulsory action?” To shed light on this question, we understand that without the voluntary action of admitting cases of violence, the mandatory action of fulfilling the legal duties imposed by the profession is not achieved. However, it is striking to realize that the recognition of violence against women, even before any legal provision and academic training, depends on a more sensitive, refined and detached view of empathy for others, so that the DC perceives the phenomenon of violence suffered by women and observes it physically and subjectively in consultations. Finally, the most complete, humane and sensitive training of the dental professional permeates his or her perception of the world and subjectivity with which he or she sees the neighbour as an intimate connection worthy of empathy.36
Thus, according to the Sociocultural Theory of Vygotsky,36 the different psychological functions that the individual develops are constructed by understanding the perceptions of the world around him or her. In other words, logical thinking, the dialectical recollection of human development, passes through external knowledge and becomes internal. Thus, the understanding of the symbols, events and situations experienced in everyday life and the construction of opinions and logical concepts of the universe through the experiences of each individual are paramount for understanding how the perception of the world is constructed. Notably, Vygotsky mentions that emotions are also included in the functionalism of thought. The way one thinks, attributed to the environment in which one lives, also essentially encompasses the feelings and emotions of each human person.37
From this perspective, it is inferred that the training and professional practice of DCs anchored in the biomedical model prevents a dialogue between the DC and women in situations of violence.35 Furthermore, as identified in the studies included in this review, the gender norms that contribute to health inequities are perpetuated throughout life, powerfully shape the attitudes of individuals, and are evidenced by direct results in training and professional practice and with negative consequences, which are important for health throughout life.4,6,9-13,27-29,36
However, even in an ideal scenario, in which the DCs would be trained and qualified to exercise care for women in situations of violence, with a worldview that would allow them to understand the problem, this would not be enough. This is one of the complex problems that cannot be solved without an interdisciplinary team. Competence, generated from the fragmentation of knowledge, cannot completely solve this problem. It is essential that teams be organized for adequate care, prevention, control and coping, to improve the quality of life of these women.

Final considerations
In the studies analysed, there was homogeneity in the findings, with greater emphasis on the lack of training of these professionals. On the other hand, some researchers identified an absence of commitment/social sensitivity, the lack of knowledge of the expanded clinic, and the clinic’s focus on the subject. Even in the face of a clear need to consider the woman in her social context, this does not occur. The practice of care differs from legal and ethical considerations.
Other aspects, although important, were not considered. The recognition of cases of violence against women by the DC requires the incorporation of educational measures that cause cultural changes. Involving the development of actions aimed at the deconstruction of stereotypes, the transformation of gender norms and the denaturalization of this social phenomenon by the DC professional and society.

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