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Dentistry responding to domestic violence and abuse:
a dental, practice-based intervention and a feasibility
study for a cluster randomised trial
Paul Coulthard,*1 Gene Feder,2 Maggie A. Evans,2 Medina Johnson,3 Tanya Walsh,4 Peter G. Robinson,5 Christopher J.
Armitage,6 Estela Barbosa,7 Martin Tickle4 and Omolade Femi-Ajao4
Introduction
Domestic violence and abuse (DVA) takes place
between individuals in intimate relationships
and between adult family members and may
manifest as physical violence, sexual abuse,
financial abuse, psychological abuse and/
or controlling behaviour.1 It is a violation
of human rights with short- and long-term
consequences for physical and mental health.
The COVID-19 pandemic has highlighted
DVA and the increased risk brought about by
household isolation.2
When DVA involves physical assault, the
face is a very common target, with studies
suggesting that between 65–95% of assaults
involve trauma to the face, mouth and
teeth.3,4,5,6 Consequently, the dentist, dental
care professional, oral surgeon and the oral
and maxillofacial surgeon all have a critical
role to play in identifying DVA.7,8
There are approximately 15.4 million
incidents of DVA annually in Britain.1 Aside
from the physical and psychological harm,
the total annual monetary cost of DVA in
England for the government, the individual
Describes the process of developing an
intervention us ed in general medic al practices
experiencing domestic violence and abuse to
advocacy ser vices for use in general dental
practices.
An adapted intervention was generally acceptable
high level of engagement.
dental pr actices in the UK as there are in general
medical practices and so it was not possible
was not possible.
Key points
Abstract
Objectives
general medical practices to aid recognition and support referral into specialist support of adults presenting with
injuries and other presenting factors that might have resulted from domestic violence and abuse. Also, to explore
Design Feasibility study for a cluster randomised trial of a practice-based intervention.
Setting Greater Manchester general dental practices.
Results
in terms of training the clinical team and establishing a direct referral pathway to a designated advocate
educator. General dental practices were keen to adopt the inter vention, discuss with patients when presented
in dentistry for diagnoses, procedures and outcomes is not developed in the UK.
Conclusion
was general acceptability, we did not have enough empirical data to plan a definitive cluster randomised trial
1Queen Mar y Universit y of London, London , E1 2AD, UK;
2Univers ity of Bristol, B ristol, BS8 2PS, U K; 3Chief Execu tive,
IRISi, BS 8 2PS, UK; 4Univers ity of Manchest er, Manches ter,
M13 9WL, UK; 5Un iversity of Bri stol Dental Hosp ital, Bristol,
BS1 2LY, UK; 6Manchester U niversity NHS F oundation Trust,
National I nstitute for He alth and Care Resea rch Greater
Manches ter Patient Safet y Translational Rese arch Centre,
Univers ity of Manchest er, M13 9WL, UK; 7Univer sity
College L ondon, London, EC1V 0H B, UK.
*Correspondence to: Paul Coulthard
Email address: p.coulthard@qmul.ac.uk
Refereed Paper.
Submit ted 2 December 2021
Revised 15 June 2022
Accepted 24 J une 2022
https://doi.org/10.1038/s41415-022-5271-x
BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 | 949
OPEN | VERIFIABLE CPD PAPER
(human and emotional suffering), the NHS,
employers and the criminal justice system is
around £23 billion. An estimated 2.0 million
UK adults aged 16–59years experienced
domestic abuse in the year ending March
2018, equating to a prevalence rate of
approximately 6 in 100 adults. Women were
around twice as likely to experience domestic
abuse as men (7.9% compared to 4.2%).9
Policy frameworks and National Institute
for Health and Care Excellence quality
standards around DVA often refer to ‘all
healthcare professionals’ being involved
in identifying, supporting and referring
to specialist advocacy services.10 However,
dentistry is not oen explicitly mentioned and
implementation in dental services has been
low. ere is very limited specic dentistry
DVA training and referral pathways.
A lack of training, the presence of a patient’s
partner or children, concern about offending
patients, funding restrictions, limited use of
IT and dentists’ own embarrassment about
raising the topic of abuse are important
barriers to identifying, referring and
supporting victims of DVA within dental
services.11 There may also be misconceptions
and lack of awareness about the role of
dentists and dental care professionals in
supporting patients experiencing DVA.12
Furthermore, there is a dearth of research
on the effectiveness of domestic violence
interventions within dentistry.13
An evidence-based programme of practice
training and a referral pathway to DVA advocacy
has been developed with general medical
practices (GMPs) and is commissioned in over
40 areas nationally.14,15,16 e Identication and
Referral to Improve Safety (IRIS)care pathway
has been widely used within GMPs to identify
and support patients experiencing DVA and has
been shown to improve identication and referral
of victims and survivors to appropriate specialist
support agencies.16,17,18,19 It has also been shown to
be cost-eective.20 However, this care pathway has
never been used within general dental practices
(GDPs). IRIS cannot be directly translated
to GDPs due to some signicant dierences
between the dental and medical practice settings.
In this paper, we report the feasibility of using a
similar practice-based intervention (IRIS) for use
to supportGDPs.
e IRIS intervention comprises:
• Practice-based DVA training sessions for
clinical and administrativesta
• Installation of soware to prompt enquiring
and recording of DVA information
• A referral pathway to a named DVA advocate,
who also delivers training and supports
victims to contact appropriate DVA services.
Across England, 28.9 million patients are
seen by an NHS dentist, costing about £4
billion annually.21 A high proportion of NHS
practices are ‘mixed’, with some care provided
independently of the NHS payment system
and there are also dental practices that are
entirely private. Some of these patients have
been reported to present with injuries resulting
from domestic violence within general
dental practices.16 Work of Coulthard and
Warburton (2007) on the role of the dental
team in responding to DVA highlighted the
unique characteristics of the dental practice
in oering victims the space and privacy to
disclose abuse without interference from the
perpetrator.22 Dental personnel are in a unique
position to recognise, document and refer such
victims and survivors of domestic violence for
appropriate assistance.
We wanted to determine whether an IRIS-
type care pathway in dentistry was feasible. e
research had two aims:
• Assess the feasibility of adapting the IRIS
intervention to aid recognition and support
the referral of adults presenting in a primary
care dental setting with injuries that might
have resulted fromDVA
• Explore the feasibility of a cluster randomised
trial design to evaluate the adapted IRIS
intervention in dental practices.
e objectives relating to aim one were:
• Adapt a GMP DVA training and support
intervention for the GDPcontext
• Assess the level of engagement of practice-
based staff with regards to training
andsupport
• Examine the acceptability of IRIS
intervention within primary care dental
practices with a nested qualitativestudy.
e objectives relating to aim two were:
• Measure recruitment rates and examine
reasons for attrition/non-participation
• Establish the suitability of the primary
and secondary outcome measures and test
the feasibility of data collection for a trial
in primary care dental practices. Primary
outcome=number of referrals to DVA advocate
for nine months aer training of intervention
practices. Secondary outcome = DVA
disclosure rate for nine months aer training
of intervention practices
• Document the types of dental injuries
resulting fromDVA
• Articulate health economics costs that can
be measured directly and ensure robust
collection of these costs to inform the cost-
eectiveness analysis in a denitivetrial
• Estimate sample size for an adequately
powered denitivetrial.
Methods
Design and sampling strategy
is cluster randomised feasibility study selected
GDPs as the unit of randomisation, identied
through the Greater Manchester Dental
Professional Network. ese practices reected
a range of geographic sites/socioeconomic
indicators and a mix of NHS and private practice.
e study took place over 24months, with an
additional three-month non-cost extension.
e intervention involved implementing the
dierent components of the IRIS care pathway
by training sta in GDPs and providing a link
to a designated advocate educator from the
collaborating agency, Manchester Women’s
Aid’s IRISteam.
Development phase
We worked with a range of stakeholder’s
and a patient and public involvement (PPI)
group, including victims and survivors of
D VA , Manchester Women’s Aid, Trafford
Domestic Abuse Service and Mankind, as
well as dentists, dental care professionals
and practice administrative staff over six
months. This development group of ten
individuals adapted the training delivered
during the feasibility study. is group size
provided reasonable representation of the
stakeholders. e research team prepared dra
intervention models and the group met over
three workshops to nalise the IRIS-dentistry
intervention. Using the Behaviour Change
Wheel,23 the methodology adopted for the
development phase corresponded with the
updated Medical Research Council framework
for complex interventions.
Example slides from the training presentation
are shown in Figures1 and2.
Recruitment, training, data collection
and follow-up
We recruited six GDPs between June and July
2018, based on evidence from Eldridge et al.,24
against using information from feasibility studies
alone to estimate sample sizes for full cluster
randomised controlledtrials.
950 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 |
We aimed to train all practice sta (dentists,
dental nurses, practice manager, hygienist,
safeguarding lead) in the intervention practices,
taking into consideration peer inuence and
group reinforcement.
Three practices were randomly allocated
to the intervention arm and three to the usual
practice (no intervention) arm, using block
randomisation. Practice principals were provided
with a participation information sheet and
consent was obtained. e practice-level training
was delivered in the GDP by the advocate
educator from Manchester Women’s Aid’s IRIS
team, together with a dentist; the study principal
investigator (PC). is dual approach is a key
component of the IRIS intervention. Clinical
training session one was a two-hour training
session delivered over two one-hour sessions,
and clinical training session two was one-hour
training delivered six weeks aer the second hour
clinical session one training. e sessions were
arranged at lunchtimes and lunch was provided.
Over the course of the study period,
additional training was delivered to
reinforce the intervention and enhance sta
capacity. In addition, during the non-cost
extension period (September to October
2019), additional training was delivered to
newly employed staff in the intervention
practices. e comparator, usual practice (no
intervention) GDPs were asked to follow their
usual practice for safeguarding high-risk and
vulnerable adult patients.
We aimed to collect the following data: date
disclosure of DVA; age; sex; type of injury
resulting from DVA; and whether a referral was
made. All six practices were given anonymised
paper-copy forms to capture data. These
forms were necessary as there were no unied
IT systems within the practices to facilitate
electronic data capture. e data forms were
then collected weekly from the manager at each
practice by the project coordinator (OF-A).
Nested qualitative study
During follow-up, qualitative interviews
explored the adherence to and acceptability
of the IRIS intervention and study design.
Individual interviews were conducted with
dentists from the three intervention practices
that attended the clinical session one and
clinical session two training. Three focus
group discussions also took place with dental
care professionals and reception and practice
management sta at the intervention practices.
Intervention development for dental
practice context
The IRIS intervention for general medical
practices consists of:
• Practice-based DVA training sessions for
clinical and administrativesta
• Installation of soware to prompt enquiring
and recording of DVA information
• A referral pathway to a named DVA
advocate, who also delivers training and
supports victims to contact appropriate
DVA services.
e training package for GDP was developed
by the PPI group, advocate educators,
dentists, dental care professionals (hygienists,
therapists and nurses), receptionists and
practice managers over three stakeholder
workshops. e standard IRIS PowerPoint
presentation was modified to include
‘domestic violence and abuse – a dental issue?’,
with a section providing facts and gures and
illustrated clinical cases of dental injury. A
video was produced in the dental setting
illustrating ‘how to’ and ‘how not to’ facilitate
disclosure of DVA and how to respond and
manage a referral. Stakeholder workshops
also discussed the relevant differences of
GDPs toGMPs.
Fig. 1 Example slide from the training presentation
Fig. 2 Example slide from the training presentation
BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 | 951
e modied IRIS training was delivered
by the advocate educator and a dentist (PC)
in September and November 2018. Clinical
session one was a two-hour training session
delivered over two visits, and clinical session
two was a one-hour training session delivered
six weeks aer the second hour of the clinical
session one delivery.
Willingness of general dental practices to
be randomised
All the six dental practices approached
provided written informed consent to be
randomised to the study to intervention or
usual practice (no intervention).
Feasibility of manually collecting
identication referral data from dental
records via dental team members
Dierent systems were being used to record
patient consultation in the three intervention
practices. Two used paper notes, with the
electronic IT soware used for other functions,
such as patient bookings. Weekly visits were
made to each intervention practice to collect
the anonymised paper-copy data study
collectionforms.
Acceptability of the modied IRIS
intervention
Focus groups and individual qualitative
interviews were conducted after the
completion of all clinical session two training.
e selection criteria for study participants
was informed by whether the dentists had
made a referral, their years of experience
(younger dentist/older dentist) and whether
they worked full-time or part-time, with the
intention of having a diverse group. All study
participants in the qualitative interviews had
attended at least two of the three hours of
training. Focused group discussion sessions
were held with dental nurses and reception
sta across the three dental practices in the
interventionarm.
Feasibility of a denitive cluster
randomised trial design
We looked at the feasibility of undertaking
a fully powered cluster randomised trial to
evaluate the adapted IRIS in GDPs. We planned
to satisfy the following objectives:
• Measure recruitment rates and examine
reasons for attrition/non-participation
• Establish the suitability of the primary and
second outcome measures and test the
feasibility of data collection for a trial in
primary care dental practices
• Document the types of dental injuries
observed as resulting fromDVA
• Articulate health economics costs that can
be measured directly and ensure robust
collection of these costs to inform the cost-
eectiveness analysis in a denitivetrial
• Estimate sample size for an adequately
powered denitivetrial.
Results relating to feasibility of
using an adapted iris intervention
in dental pracitices
Intervention development for GDPs
We approached six GDPs and all consented
to recruitment for this feasibility study, of
which three participated in the modied IRIS
intervention forGDPs.
The staff training is delivered by an
advocate educator and general practitioner
duo in the IRIS model and we replicated this
with an advocate-educator and dentist duo.
We were not, however, able install soware
in the electronic medical system of the three
dental practices.
One practice used Soware of Excellence
(SOE), another Bridge-IT and the other, R4
Soware. SOE permits free-text search. e
other types of soware used do not permit
free-text search. e practice using R4 noted
that it was not possible to enter information
about DVA and that concerns would be
discussed with the practice manager who was
the safeguarding lead for the practice.
Level of engagement of practice sta
In total, 16 dentists and 23 dental care
professionals were trained across three dental
practices. is was all of the members of the
dental teams at these practices. e modied
IRIS training was delivered by the advocate
educator and dentist (PC) as planned, in
September and November 2018. Clinical
session one was a two-hour training session
delivered over two visits, and clinical session
two, was a one-hour training session delivered
six weeks aer the second hour of clinical
session one delivery.
Not all sta attended all training sessions or all
of each one. Some sta (three dentists) attended
only the rst hour of clinical session one and
not the second part, and did not attend clinical
session two. Similarly, some sta (four dentists
and seven dental care professionals) attended
the second part of clinical session one but not
the rst part, and did not attend clinical session
two. Only nine dentists and 16 dental nurses
attended the full clinical session training. Two
reception sta and one practice manager also
attended the three hours of training. Additional
one-hour training was delivered in September
2019 for newly employed staff in the three
intervention practices. In total, seven dentists
and nine dental nurses received the one-hour
training in September2019.
Focus groups and individual qualitative
interviews
In total, there were three focus groups and
nine individual interviews. Underlying
themes were identified from five selected
transcripts by two study investigators (MAE,
OF-A) independently and these were used for
the analysis (Ta bl e 1 .) Example, paraphrased
reections are reported in Box1.
Theme Outcome
Clinician underlying anxiety Training reduced clinician anxiety
Patients’ experience Clinicians are able to understand
Timing of training sessions Important to schedule at a time of best convenience for sta
Behaviour change Training led to an increased awareness of DVA, increased
knowledge of DVA and positive attitude
Tipping point for patient disclosure of DVA Clinicians’ understanding increased
Training sessions time Requested reduced time and/or combine two sessions into a
single session
Training reinforcement Request for regular updates
DVA awareness and knowledge Clinicians’ increased awareness and knowledge
Safe environment Clinicians’ recognised utility of dental surgery for disclosure
Named advocate educator Not necessarily important
Table 1 Qualitative interviews identied underlying themes
952 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 |
Stakeholder workshops also discussed
the relevant dierences of GDPs to GMPs.
ese were: no unied IT system in dental
practices; payment systems’ time for training
constraints; patients are customers and are a
mix of NHS and private; corporate practices;
more sta in attendance with patients, private
space?; building trust and condence so that
disclosure can be made; and some preference
for no waiting area posters aboutDVA.
Results relating to feasibility of a
denitive cluster randomised trial
Willingness of GDPs to be randomised
All six dental practices provided written
informed consent to be randomised to the
study to intervention or usual practice (no
intervention). ere were no issues with the
randomisation. All six practices were oered a
small research expense fee. ere was limited
contract with the three ‘usual practice’ sites;
however, all declined accepting this fee. e
principal of one of these practices commented
that he had never come across patients with
DVA experience in his dental practice, that
is, no suspicious or unexplained dental injury
and no disclosures.
DVA identication and referral data
capture
Between September 2018 and October
2019, clinical staff across the three dental
practices had domestic violence-focused
enquiries (conversations) with 11 adult
patients who had presented with injuries
that were suspected to have been as a result
of domestic abuse. Ten patients were women
and one was a man. Of the eleven patients,
four disclosed historical cases of domestic
abuse. Two patients were referred to the
named advocate educator. Although some of
the identified patients could not be directed
or supported as part of this study, all patients
were given the contact details of the DVA
advocate educator.
In addition, practice managers from the
intervention practices reported that patients
regularly took the contact details of the
advocate educator from tear-off strips on
study posters that had been placed in the
practice patient toilets.
Feasibility of a denitive cluster
randomised trial design
We looked at the feasibility of undertaking
a fully powered cluster randomised trial
to evaluate the adapted IRIS in GDPs. We
were unable to satisfy our objectives, as we
did not collect sucient quantitative data.
However, ndings from our qualitative study
and the narrative provided by the advocate
educator suggests that the research has
started the process that may, potentially,
change current practice and service provision
within dentistry for adult patients with lived
experience of domesticabuse.
We were unable to calculate health economics
costs to inform the cost-eectiveness analysis in
a denitive trial, as we did not collect sucient
empirical data. We did, however, est imate excess
treatment costs involved in identication and
referral of an individual patient to constitute
30-minute patient contact instead of a ten-minute
check-up, that is, 20minutes of additional time,
equivalent to two lost units of dental activity:
2x (£28+on-costs)=2x£33=£66 per patient.
Applying this to three study intervention
practices over the course of12months with one
patient identied per month would equate to a
cost of £2,376.00. Training time would also need
to be considered.
Discussion
Intervention
e sta training was delivered by an advocate
educator and general practitioner duo in the
IRIS model and we replicated this with an
advocate educator and dentist duo. is is seen
to be an important feature of the intervention,
likely because the doctor or dentist is
persuaded that the DVA role is an important
aspect of their professional responsibility. We
also established a referral pathway to a named
advocate educator from the collaborating
agency (Manchester Women’s Aid).
We were not able install soware in the
electronic medical system of the three dental
practices. Prompts for the dental team
members could not be used, as IT systems in
GDPs are not unied. Similarly, soware used
by dental practices for record keeping couldn’t
be used for study data collection as these are
not unied and also because coding is not
developed. Coding for dental procedures,
disease or condition (for example, trauma)
and clinical patient recorded outcome
measures is embryonic in the UK. is severely
limited our ability to collect meaningful data
eectively. One practice used SOE, another
Bridge-IT, and the other, R4 Soware. e
lack of unied systems for recording DVA to
allow data collection is a signicant problem
for dentistry. We understand that NHS
Digital is committed to introducing a novel
and consistent coding system across primary
healthcare, including dental practice, in both
the NHS and privateGDPs.
Sta engagement
Not all sta attended all training sessions or
all of each one. e practices were members
of a research network and had agreed to take
part and were being remunerated by National
Institute for Health and Care Research
(NIHR) to do so. It may be that sta did not
value the intervention suciently, were not
paid enough, or perhaps the sessions were
not scheduled at convenient times. Clinical
dentistry cannot be expected to run perfectly
Box 1 Example paraphrased comments from qualitative interviews
1. Dentist had a conversation with a patient as part of a clinical enquiry about their dental trauma. The
patient disclosed it was from domestic abuse but she was already in touch with social services, as her
kids had been removed. No further action with respect to DVA was undertaken by the dentist
2. Dentists had a conversation about the dental trauma a female patient presented with. The clinician
perceived that the explanation the patient gave was inconsistent with the injuries and asked the patient
made to the named advocate educator for the study
3. A dental nurse shared a previous experience of having a patient disclose they were experiencing
domestic abuse. The dental nurse recorded this information and passed it on to the advocate educator
4. Two full-time dentists had conversations with patients about domestic abuse. The conversations were
informed by the facial injuries the patients had sustained. Both patients said their injuries were not
as a result of domestic abuse
5. A patient attended with a black eye and had attended a few weeks earlier with bruising to the cheek
and said she had fallen. The reception team who had received the training booked the patient in and
then informed the dentist of their DVA concerns. The dentist then had a conversation with the patient
BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 | 953
to time and inevitably there is unpredictability
that impacts on training sessions booked over
lunchtime. ere may be holiday and sickness
that also prevents attendance. Alternatively, it
may have reected the absence of continuing
professional development reward, or another
reason. In general, we had good engagement.
Focus groups and individual qualitative
interviews
The qualitative data showed that study
participants found the modified IRIS
intervention very acceptable and that
attending the training raised their awareness
of domestic abuse among the general
population and among their adult patient
population. Participants volunteered that
the training empowered them to be able
to have conversations with patients about
DVA that they previously would not have
had. They were now aware of DVA signs to
look out for and had an improved level of
confidence, such that they could speak in a
reassuring manner with the patient about
DVA. They reported that they understood
and were confident of the referral pathway
to the DVA advocate.
There were mixed views about the
pertinent role and importance of having a
named DVA advocator, who was the same
individual who provided the training,
someone known to the dental practice, as
a key indicator in making a referral and
the subsequent uptake of a referral. Some
study participants suggested that having
a named advocate educator known to the
dental practice may not necessarily influence
them to make a referral to the collaborating
agency, as what was more important to them
was knowing what to do when a patient
discloses domestic abuse during a dental
appointment consultation.
Not all study participants had made a
referral to the advocate educator during
the follow-up period. Staff members who
had used the referral pathway reported that
being trained and having met the named
advocate educator were crucial factors
in their response. For study participants
who were yet to have a conversation with
patients or use the referral pathway, they
reported concerns, such as the need for more
professional experience and the amount of
paperwork that could potentially be involved
in making a referral. All study participants
identified the need for reinforcement to
enable them continue to engage with the
subject area. The suggested duration of
interval between reinforcement ranged from
often to once in sixmonths.
Willingness of GDPs to be randomised
All six dental practices provided written
informed consent to be randomised to the
study to intervention or usual practice (no
intervention). It is of note that the principal
of one of the practices randomised to ‘usual
practice’ denied the likelihood of any patient
attending with injury caused byDVA.
Planning of denitive study
We looked at the feasibility of undertaking
a fully powered cluster randomised trial to
evaluate the adapted IRIS in GDPs. While we
recruited six GDPs for this feasibility study, the
parameters used in deciding the sample size of
six GDPs for the denitive trial would include:
information obtained from our research;
taking into consideration the variation of
settings (for example, practice size, location,
etc); and comparable evidence from cluster
randomised trials in primary medical care, to
aid in estimating the intracluster correlation
coecient.
e size of the cluster would vary, depending
on the number of sta in the practices. However,
we envisaged that there would be a minimum
of six participants (two dentists, one practice
manager, one reception sta, one dental nurse/
hygienist and one practice safeguarding lead)
per cluster.
Our objectives were those of ‘objectives two’
above, that include measurement of recruitment
rates, testing the feasibility of data collection
for a trial in primary care dental practices,
articulating the health economics costs that can
be measured directly and estimating the sample
size for an adequately powered denitive trial.
We were unable to satisfy these objectives, as
we did not collect sucient quantitative data.
Since the overarching aim of this research was
to explore the feasibility of developing a training
and support practice-level intervention in
improving the health and social care outcomes
of adult patients with lived experience of DVA
utilising primary care dental practices, it was
not our intention to measure or demonstrate
impact. However, ndings from our qualitative
study and the narrative provided by the advocate
educator suggests that the research has started
the process, which may potentially change
current practice and service provision within
dentistry for adult patients with lived experience
of domesticabuse.
Conclusion
We found that it was feasible to adapt
elements of the IRIS intervention used in
GMPs for a GDP setting, in terms of the
training presentation and establishing a
referral pathway to a designated advocate
educator. We were not, however, able to use
dental practice IT soware prompts and data
collection as for general practitioners because
there is no unied IT system and also because
coding in dentistry is not developed.
We also have evidence from the feasibility
study to show that GDPs were keen to adopt
the intervention, sta felt empowered to have
conversations with patients when presented
with the opportunity that they previously
would not have had, and were confident
and able to utilise a referral pathway to a
DVA advocate. Practice managers from the
intervention practices reported that patients
regularly took the contact details of the
advocate educator from tear-off strips on
study posters that had been placed in the
practice patient toilets.
However, we were unable to resolve all
the existing uncertainties documented in
the objectives of the feasibility studies to
plan a denitive large cluster randomised
trial design to evaluate the IRIS-dentistry
intervention within the primary care dental
setting.
Acknowledgements
anks to Lucy Makin, advocate educator from
Manchester Women’s Aid’s IRIS team, who provided
the training, and to Vanessa Flanders of Manchester
Women’s Aid. anks to Ben Squires, Head of
Primary Care Operations, Greater Manchester Health
and Social Partnership, for his support of this study
and invaluable advice on costs. anks also to Dr
Alice Malpass and Professor Stephen Morris who
contributed to the studydesign.
Ethics declaration
Armitage is supported by NIHR Manchester
Biomedical Research Centre and NIHR Greater
Manchester Patient Safety Translational Research
Centre. e views expressed are those of the authors
and not necessarily those of the NIHR or Department
of Health and Social Care. e authors declare no
other conicts of interest.
Ethical approval (227059) was obtained 1 June
2018 and the study was approved by the University
of Manchester Research Ethics Committee. Written
consent to participate was obtained.
IRAS ref: 2018–4254-6223.
954 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 |
and health service research. Steering Committee
member. Martin Tickle: extensive expertise in
conducting NIHR trail in oral health. Steering
Committee member. Omolade Femi-Ajao: research
co-ordinator for eective study management.
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Funding information
is study was funded through the Research for
Patient Benet programme of the NIHR (ref: PB-PG-
0416-20015).e study was registered as per funder’s
requirement (ISRCTN11636488). e sponsor
was initially the University of Manchester and
later moved to Queen Mary University of London.
Collaborators were the Manchester University NHS
Foundation Trust, University of Bristol, University
College London, e Pankhurst Trust (Incorporating
Manchester Women’s Aid and IRISi]National
Coordinating Centre for IRIS]).
Author contributions
Paul Coulthard: principal investigator. Gene
Feder: global expertise in conducting and
implementing research on domestic violence.
Advised on developing and implementing the IRIS
care pathway, study design and results. Maggie A.
Evans: widespread experience in leading qualitative
studies in the eld of IRIS and domestic violence
and health service research. Steering Committee
member. Medina Johnson: IRIS chief executive with
extensive knowledge of implementing the IRIS care
pathway. Advised on developing and implementing
the IRIS care pathway, study design and results.
Tanya Walsh: statistician for the research project
and played a central role in design of the cluster
randomised controlled trials. Peter G. Robinson:
extensive expertise in evaluating oral health services.
Advised on developing and implementing the study
and results. Christopher J. Armitage: expert in the
science of behaviour change with dentists and dental
care professionals. Steering Committee member.
Estela Barbosa: widespread experience in leading
qualitative studies in the eld of domestic violence
Open Acces s.
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BRITISH DENTAL JOURNAL | VOLUME 233 NO. 11 | 955
