Heidi D. Nelson, MD, MPH; Christina Bougatsos, MPH; Ian Blazina, MPH
Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Tracy Dana, MLS, from Oregon Health & Science University, who conducted literature searches; and Shelley Selph, MD, MPH, from Oregon Health & Science University, and Laurie Hoyt Huffman, MS, provided who additional contributions to the report.
Grant Support: By AHRQ under contract HHSA-290-2007-10057-I-EPC3, Task Order 3. This work was contracted by AHRQ and used by the U.S. Preventive Services Task Force to determine its recommendation.
Potential Conflicts of Interest: Dr. Nelson: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ. Ms. Bougatsos: Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Other (money to institution): AHRQ. Mr. Blazina: Grant (money to institution): AHRQ. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2667.
Requests for Single Reprints: Heidi D. Nelson, MD, MPH, Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098; e-mail: firstname.lastname@example.org.
Current Author Addresses: Dr. Nelson, Ms. Bougatsos, and Mr. Blazina: Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.
Author Contributions: Conception and design: H.D. Nelson.
Analysis and interpretation of the data: H.D. Nelson, C. Bougatsos, I. Blazina.
Drafting of the article: H.D. Nelson, C. Bougatsos, I. Blazina.
Critical revision of the article for important intellectual content: H.D. Nelson.
Final approval of the article: H.D. Nelson, C. Bougatsos.
Provision of study materials or patients: H.D. Nelson.
Statistical expertise: H.D. Nelson.
Obtaining of funding: H.D. Nelson, C. Bougatsos.
Administrative, technical, or logistic support: H.D. Nelson, C. Bougatsos, I. Blazina.
Collection and assembly of data: H.D. Nelson, C. Bougatsos, I. Blazina.
Nelson H., Bougatsos C., Blazina I.; Screening Women for Intimate Partner Violence: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 2012;156:796-808. doi: 10.7326/0003-4819-156-11-201206050-00447
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Published: Ann Intern Med. 2012;156(11):796-808.
In 2004, the U.S. Preventive Services Task Force determined that evidence was insufficient to support screening women for intimate partner violence (IPV).
To review new evidence on the effectiveness of screening and interventions for women in health care settings in reducing IPV and related health outcomes, the diagnostic accuracy of screening instruments, and adverse effects of screening and interventions.
MEDLINE and PsycINFO (January 2002 to January 2012), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through fourth quarter 2011), Scopus, and reference lists.
English-language trials of the effectiveness of screening and interventions, diagnostic accuracy studies of screening instruments, and studies of any design about adverse effects.
Investigators extracted data about study populations, designs, and outcomes and rated study quality by using established criteria.
A large fair-quality trial of screening versus usual care indicated reduced IPV and improved health outcomes for both groups, but no statistically significant differences between groups. Fifteen fair- and good-quality studies evaluated 13 screening instruments, and six instruments were highly accurate. Four fair- and good-quality trials of counseling reported reduced IPV and improved birth outcomes for pregnant women, reduced IPV for new mothers, and reduced pregnancy coercion and unsafe relationships for women in family-planning clinics. Fourteen studies indicated minimal adverse effects with screening, but some women experienced discomfort, loss of privacy, emotional distress, and concerns about further abuse.
Trials were limited by heterogeneity, lack of true control groups, high loss to follow-up, self-reported measures, and lack of accepted reference standards.
Screening instruments accurately identify women experiencing IPV. Screening women for IPV can provide benefits that vary by population, while potential adverse effects have minimal effect on most women.
Agency for Healthcare Research and Quality.
This review is an update for the U.S. Preventive Services Task Force (USPSTF) recommendation on screening women for intimate partner violence (IPV). In 2004, the USPSTF found that evidence was insufficient to support a screening recommendation (1–3). This update focuses on IPV against women and includes studies published since the previous recommendation related to the effectiveness and adverse effects of screening and interventions and the diagnostic accuracy of screening instruments.
Intimate partner violence includes a range of abusive behaviors perpetrated by someone who is or was involved in an intimate relationship with the victim. Although IPV affects both men and women as victims and perpetrators (4), more women experience IPV and most studies about screening and interventions for IPV enroll women. Approximately 1.3 to 5.3 million women in the United States experience IPV each year (5, 6). Lifetime estimates range from 22% to 39% (7, 8). The National Intimate Partner and Sexual Violence Survey indicated that 30% of women experience physical violence, 9% rape, 17% sexual violence other than rape, and 48% psychological aggression from their intimate partners over their lifetimes (4). Costs related to IPV are estimated to be between $2 and $7 billion each year (9).
Intimate partner violence has immediate health effects, such as injuries (10) and death (11) from physical and sexual assault; sexually transmitted infections, including HIV (12); pelvic inflammatory disease (13); unintended pregnancy (14); and psychological distress. Assaults during pregnancy adversely affect the health of pregnant women and newborns (15, 16), and IPV is associated with preterm birth, low birthweight, and decreased mean gestational age (17–19). Long-term conditions that are associated with IPV include chronic pain, neurologic disorders, gastrointestinal disorders, migraine headaches, and other physical disabilities (20–22), as well as posttraumatic stress disorder, depression, anxiety disorders, substance abuse, and suicide (22–26).
Routine screening for IPV in health care settings could identify women at risk and lead to interventions that reduce violence and improve health outcomes. New recommendations from the Institute of Medicine (27), as well as from professional organizations (28–30), support screening. Screening by health care professionals is generally acceptable to women under conditions that are perceived as private and safe and when women are asked questions in a comfortable manner, although there is no consensus about the optimal screening setting or method (31).
We developed and followed a standard protocol. A technical report that details methods and includes search strategies and additional evidence tables is available at www.uspreventiveservicestaskforce.org(32). This report also includes our review of screening elderly and vulnerable adults for abuse and neglect that is not presented in this article.
The USPSTF and Agency for Healthcare Research and Quality (AHRQ) determined the focus, scope, target population, and key questions for this review. Investigators created an analytic framework, incorporating the key questions and outlining patient populations, interventions, outcomes, and adverse effects of the screening process (Appendix Figure 1).
Analytic framework and key questions for screening women for IPV.
ED = emergency department; IPV = intimate partner violence.
* Including reduction in the level of violence or abuse and leaving an unsafe situation.
† Including physical trauma (fractures, dislocations, and brain injury); unwanted pregnancy and sexually transmitted diseases; mental trauma and its repercussions, such as depression, anxiety, and posttraumatic stress; social isolation; quality of life; and chronic medical conditions, among others.
The target population included women presenting for health care without problems directly related to abuse, such as physical injuries. Presumably, women with these problems would have evaluations outside the scope of screening. Health care settings included primary care clinics, emergency departments (EDs), and student health centers, among others. Screening techniques included self-administered as well as person-to-person methods. Outcomes included reduced exposure to IPV, physical or mental harms, or mortality related to IPV.
In conjunction with a research librarian, we used the National Library of Medicine's Medical Subject Headings (MeSH) keyword nomenclature to search Ovid MEDLINE and PsycINFO (2002 to 9 January 2012), Cochrane Central Register of Controlled Trials (fourth quarter of 2011), and Cochrane Database of Systematic Reviews (fourth quarter of 2011) for relevant English-language studies and systematic reviews. We also manually reviewed reference lists of papers and used Scopus to search citations of key studies.
Investigators developed inclusion and exclusion criteria for abstracts and articles on the basis of the target population and key questions. We included research conducted in the United States or in similar populations that received services and interventions applicable to medical practice in the United States published in 2003 or later. After an initial review of abstracts, investigators retrieved full text articles and conducted a second review to ensure eligibility (Appendix Figure 2).
Summary of evidence search and selection.
RCT = randomized, controlled trial.
* Cochrane databases include the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews.
† Identified from reference lists and suggested by experts.
‡ Includes search results for child, adult, and elderly populations. Studies of children and elderly populations are included in separate reports.
§ Studies that meet inclusion criteria for key questions, some studies apply to more than 1 key question.
To evaluate the effectiveness of IPV screening or interventions, we included randomized, controlled trials (RCTs) that compared treatment and control groups and reported IPV or health outcomes, as defined by the key questions. Studies of screening or referral rates, attitudes about screening, or plans or intentions related to screening, or studies reporting other types of intermediate outcomes, were not included. To measure the performance of screening techniques, we included diagnostic accuracy studies of screening instruments that reported sensitivity, specificity, or other accuracy measures (Appendix Table 1). We excluded studies that lacked a validated reference standard or assessed instruments not feasible for screening. To evaluate adverse effects, we included several study designs that reported adverse effects of screening and interventions. Studies that enrolled both men and women were included if most participants were women or results were reported separately.
Appendix Table 1.
Measures of Diagnostic Accuracy
An investigator abstracted data on study design and setting; participant characteristics; data collection procedures; numbers enrolled and lost to follow-up; methods of exposure and outcome ascertainment; analytic methods, including adjustment for confounders; and outcomes. A second investigator confirmed its accuracy.
We used criteria developed by the USPSTF to assess study quality (33–37). We assessed the applicability of studies by using the population, intervention, comparator, outcome, timing, and setting (PICOTS) framework (38) adapted to this topic. We considered applicability in determining quality ratings for studies of the diagnostic accuracy of screening instruments because it was relevant to evaluating the patient spectrum. Two investigators independently rated the quality and applicability of each eligible study (good, fair, or poor). Final ratings were determined by consensus.
We assessed the aggregate quality of the body of evidence for each key question (good, fair, or poor) by using methods developed by the USPSTF on the basis of the number, quality, and size of studies and consistency of results between studies (33). Studies were considered consistent if outcomes were generally in the same direction of effect and ranges of effect sizes were narrow. Consistency was determined by consensus of the investigators.
The study was funded by AHRQ under a contract to support the work of the USPSTF. Staff at AHRQ and members of the USPSTF developed the scope of the work and reviewed the draft manuscript. The draft report was reviewed by content experts, USPSTF members, AHRQ program officers, and collaborative partners. Approval from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it for publication.
Does screening asymptomatic women in health care settings for current, past, or increased risk for IPV reduce exposure to IPV, physical or mental harms, or mortality?
One large cluster RCT met inclusion criteria (39). The trial included 6743 women aged 18 to 64 years who were randomly assigned to screening or nonscreening groups. The primary outcomes were exposure to abuse and quality of life in the 18 months after screening. Secondary outcomes included depression, posttraumatic stress disorder, alcohol and drug abuse, global mental and physical health, and use of health and social services. Adverse effects of screening were actively monitored.
Participants were recruited when they presented for a health care visit at 1 of 12 primary care, 11 acute care, and 3 obstetrics and gynecology clinic sites in Ontario, Canada. Clinicians at all sites received standardized training in responding to IPV. All women had universal access to health care in accordance with local practice. Participants were given information cards of locally available resources for women with IPV.
On screening days, before seeing their clinicians for the intended health care visit, participants completed the Woman Abuse Screening Tool, an 8-item self-administered instrument measuring physical, sexual, and emotional abuse in the past 12 months (score ≥4 was a positive response). Results were provided to the clinicians before the health care visit for women with positive scores. Discussion of positive findings, referrals, or treatment was left to the treating clinician's discretion. After their visits and regardless of their scores on the screening tool, all women completed the Composite Abuse Scale, a 30-item self-administered validated research instrument to measure IPV (score ≥7 indicated exposure to IPV). The same procedures were followed for nonscreening days, except that participants completed both the screening tool and the abuse scale at the end of the visit. Clinicians could inquire about abuse during the clinic visit if there were indications to do so.
Women with positive scores on both the screening tool and the abuse scale in the screened and nonscreened groups were followed for 18 months. Interviewers who were blinded to group assignment met with participants within 14 days of the initial clinic visit for a baseline interview, and again at 6, 12, and 18 months. At follow-up, participants completed several instruments, including the Composite Abuse Scale. Additional services included visits to physicians, nurses, psychologists, or social workers; use of crisis hotlines, sexual assault crisis centers, advocacy or counseling services, or women's shelters; or other types of services.
The 12-month prevalence of IPV at the initial clinic visit was 13% and 12% in the screened and nonscreened groups, respectively. During the initial clinic visit, 44% of screened women and 8% of nonscreened women discussed IPV with their clinicians. During follow-up, women in both groups accessed additional health care services; had reduced IPV recurrence, posttraumatic stress disorder symptoms, and alcohol problems; and had improved scores for quality of life, depression, and mental health. None of these results were statistically significantly different between groups.
We rated the trial as fair rather than good quality because loss to follow-up was high (43% of screened and 41% of nonscreened participants). Women lost to follow-up had lower levels of education, had higher scores on the Woman Abuse Screening Tool and Composite Abuse Scale, and were more likely to be married than women retained in the trial. Women lost to follow-up in the screened group had the highest Woman Abuse Screening Tool and Composite Abuse Scale scores among trial participants.
How effective are screening techniques in identifying asymptomatic women with current, past, or increased risk for IPV?
Fifteen studies (40–54) that evaluated the diagnostic accuracy of 13 screening instruments met inclusion criteria (Table 1). Instruments included the Abuse Assessment Screen (49); Partner Violence Screen (44, 45); Hurt, Insult, Threaten, and Scream tool (40); Woman Abuse Screening Tool (40, 45, 52); Humiliation, Afraid, Rape, Kick tool (50); Ongoing Abuse Screen and Ongoing Violence Assessment Tool (42, 53); Slapped, Threatened, and Throw tool (46, 47); Childhood Trauma Questionnaire–Short Form (51); Secure, Accepted, Family, Even, Talk survey (43); Parent Screening Questionnaire (41); 1 personal safety question (48); and 5 items with nongraphic language (54). Five instruments and their modifications were used as reference standards, including the Index of Spouse Abuse (40, 42, 47, 53); Woman Abuse Screening Tool (40); Conflict Tactics Scale (41, 44, 48, 49, 54); Partner Violence Screen (43); and Composite Abuse Scale (45, 50, 52). Structured (51) and semistructured interviews (46) were used as reference standards in 2 studies (Appendix Table 2, includes additional descriptions.)
Studies of Diagnostic Accuracy of Screening Instruments for IPV
Appendix Table 2.
Instruments Used in Studies of IPV Screening
Three studies were rated as good quality (45, 51, 52) and 12 as fair quality (40–44, 46–50, 53, 54). Methodological limitations included narrow patient spectrums with limited applicability to the target population (40–42, 44, 46–50, 53), selected (that is, not randomly assigned or not consecutive) or inadequately described sampling methods (43, 54), reference standards that were not credible or replicable or were unclear (43, 46, 48), combined results for men and women (42, 53), and high attrition rates (>30%) (44). All studies applied their reference standards to all participants, although only 2 (44, 51) indicated that reference standards were independently interpreted.
Five screening instruments designed to detect current or recent IPV demonstrated high diagnostic accuracy. Both English and Spanish versions of the 4-item Hurt, Insult, Threaten, and Scream instrument had sensitivity and specificity greater than 85% when evaluated in a study of predominantly Hispanic primary care patients, although cut points differed for each version (40). The Ongoing Violence Assessment Tool had higher diagnostic accuracy than either the Ongoing Abuse Screen or Abuse Assessment Screen when evaluated in men and women in an ED (53). The Slapped, Threatened, and Throw instrument showed different results depending on the reference standards and cut points in 2 studies (46, 47). Sensitivity and specificity were maximized when patients reported 2 or more positive responses on this 3-item scale. The Humiliation, Afraid, Rape, Kick instrument showed sensitivity of 81% and specificity of 95% among women in general practice settings in the United Kingdom (50). The Woman Abuse Screening Tool had sensitivity of 88% and specificity of 89% in a study of 5607 women (52) who were enrolled in the previously described screening trial (39). However, a separate evaluation of 2461 women in the same trial indicated sensitivity of 47% and specificity of 96% (45).
The only study evaluating risk for future IPV indicated that positive responses on the Partner Violence Screen predicted verbal aggression (relative risk, 7.3 [95% CI, 3.2 to 16.2]) and violence (relative risk, 11.3 [CI, 4.8 to 26.3]) during the 4 months after screening (44). A study determining childhood physical and sexual abuse among adult women in an HMO found that a positive response to 1 of 2 questions on the modified Childhood Trauma Questionnaire–Short Form had a sensitivity of 85% and specificity of 88% (51). Two instruments evaluated in mothers in pediatric settings had relatively low sensitivity but high specificity (Parent Screening Questionnaire, 19% to 29% sensitivity and 91% to 93% specificity ; Zink and colleagues' 5 questions, 40% sensitivity and 91% specificity ).
For screen-detected women with current, past, or increased risk for IPV, how well do interventions reduce exposure to IPV, physical or mental harms, or mortality?
Six RCTs reported in 8 publications met inclusion criteria (Table 2) (17, 18, 55–60). Three trials evaluated interventions targeted to pregnant and postpartum women (17, 18, 55–57). Three trials that enrolled women without regard to pregnancy status were conducted in primary care settings (58, 60, 61); Women, Infants, and Children clinics (58); and family-planning clinics (59). One trial met criteria for good quality (17, 18, 57), whereas 4 were rated fair (55, 58–60) and 1 poor (56). Trials were limited by enrollment of dissimilar groups at baseline (55, 56, 58–60), high or differential loss to follow-up or inadequately described follow-up (55, 56), lack of intention-to-treat or unclear analyses (55, 56, 58), and inadequately described randomization methods (56). All trials had limitations inherent in IPV research, including use of self-reported measures, lack of blinding, and lack of true control groups. Trials enrolled narrowly defined patient populations that may not be applicable to broader populations.
Randomized Trials of IPV Interventions
The National Institutes of Health–DC Initiative to Reduce Infant Mortality in Minority Populations was a good-quality RCT of counseling interventions during pregnancy and the postpartum period compared with usual care (17, 18, 57). The trial enrolled 1044 black pregnant women at 6 prenatal care sites in Washington, DC. Screening for cigarette smoking, environmental tobacco smoke exposure, depression, and IPV with the Abuse Assessment Screen was done by using an anonymous computer interview. Additional and follow-up information was collected by a telephone interviewer who was blinded to randomization group designations at baseline, 22 to 26 weeks' gestation, 34 to 38 weeks' gestation, and an average of 10 weeks after birth. Exposure to IPV was determined by using scores from the Conflict Tactics Scale, which was also used to categorize women as having minor or severe and physical or sexual IPV. Birth outcomes were determined by reviewing participants' medical charts.
Women assigned to the intervention group received prenatal behavioral counseling for 2 to 8 sessions with up to 2 postpartum sessions. The intervention was delivered during routine prenatal care visits at the clinics by social workers or psychologists trained to respond specifically to each identified risk and averaged 35 minutes in length. Counseling for IPV emphasized danger assessment, safety behaviors, and information on community resources. Smoking and depression were also addressed for participants with these problems.
At baseline, approximately one third of the women in both groups reported IPV in the previous year. At follow-up, women in the intervention group had fewer recurrent episodes of IPV during pregnancy and the postpartum period than women receiving usual care (adjusted odds ratio, 0.48 [CI, 0.29 to 0.80]) (17, 18). Reduction in IPV was confined to minor physical violence but not severe or sexual violence. Alcohol use and depression at baseline were associated with recurrent episodes of IPV (18).
Women in the intervention group had better birth outcomes, including fewer very preterm neonates (≤33 weeks) (1.5% vs. 6.6%; P = 0.03), lower rates of very low birthweight (<1500 g) (0.8% vs. 4.6%; P = 0.052), and increased mean gestational age (38.2 weeks vs. 36.9 weeks; P = 0.016).
A fair-quality RCT of home visitation compared with usual care enrolled women in hospitals in Hawaii who gave birth to infants at risk for maltreatment (55). The intervention group received home visitation by paraprofessionals for 3 years and were followed for an additional 6 years. During the program, the intervention group had lower rates of IPV victimization (incidence rate ratio, 0.86 [CI, 0.73 to 1.01]) and perpetration (incidence rate ratio, 0.83 [CI, 0.72 to 0.96]) than the usual care group. Although rates of overall IPV victimization and perpetration also decreased after 6 years of follow-up, there were no statistically significant differences between groups.
A fair-quality cluster RCT of pregnant women and mothers of children aged 5 years or younger evaluated the effectiveness of mentor support compared with usual care in reducing IPV and depression (60). The trial enrolled women in primary care clinics in Australia who disclosed IPV or had behavioral symptoms suggestive of abuse. Scores on the Composite Abuse Scale were reduced in the intervention compared with the usual care group. Differences between groups in depression, physical well-being, mental well-being, and parenting stress scores were not statistically significant.
A fair-quality cluster RCT evaluated a counseling intervention compared with usual care in reducing abuse related to pregnancy coercion (59). Investigators defined coercion as a lack of control over a woman's reproductive health, including compromised decision making or limited use of contraception and family planning. Women who were randomly assigned to the intervention who reported recent IPV at baseline had decreased pregnancy coercion at follow-up (adjusted odds ratio, 0.29 [CI, 0.09 to 0.91]). Women in the intervention group were also more likely to discontinue an unhealthy or unsafe relationship, regardless of recent IPV status.
Two trials indicated no statistically significant differences between intervention and control groups, including a 2-group RCT comparing the use of a wallet-sized referral card with a nurse management protocol in reducing IPV (58) and a trial comparing nursing care management during pregnancy with usual care (56).
What are the adverse effects of screening for IPV and of interventions to reduce harm from IPV?
Adverse effects related to IPV screening and interventions were reported in 3 trials (39, 55, 58) and 11 descriptive studies (62–72) (Table 3) and were included in 2 systematic reviews (31, 73).
Studies of Harms of IPV Screening
Adverse effects were actively monitored in the Canadian trial of 6743 women that evaluated screening compared with nonscreening in primary care, acute care, and obstetrics and gynecology sites (39). Results of the analysis of a measure developed to monitor adverse effects for this trial (Consequences of Screening Tool) showed no adverse effects with screening. A trial of a 3-year home visitation intervention for at-risk newborns and their mothers suggested increased verbal abuse victimization and perpetration in the intervention group over long-term follow-up compared with a usual care control group, although differences were not statistically significant (55). A randomized, 2-group trial of women receiving either a wallet-sized referral card or a 20-minute nurse management protocol to address IPV found no adverse effects as a result of the intervention (58).
Descriptive studies generally indicated low levels of harm related to IPV screening and interventions, but study populations and methods varied widely. In a study of women receiving services in an urban ED in the United Kingdom, 24% indicated discomfort with screening, particularly women with previous IPV (68). Issues voiced by a few respondents in the various surveys and interviews included loss of privacy (71); worries about provoking abuse by disclosing IPV (69, 71); feelings of sadness, depression, or emotional distress (63, 69); feeling judged by the provider (62) or disappointed in the provider's response (62, 70); and general concerns with IPV screening (62, 64, 68, 72).
Table 4 summarizes the evidence reviewed for this update. The effectiveness of IPV screening was evaluated in a single large, fair-quality RCT of women who were randomly assigned to screening or nonscreening groups. Although results indicated that women in both groups had reduced IPV recurrence, posttraumatic stress disorder symptoms, and alcohol problems and improved scores for quality of life, depression, and mental health, differences were not statistically significant between groups (39). More women in the screened group initiated discussions about IPV with their clinicians, indicating at least a change in the clinic visit related to screening.
Summary of Evidence for IPV Screening
Several issues should be considered when interpreting the results of the screening trial. Women with positive screenings were not offered a specific intervention and few screen-positive women had discussions about IPV with their clinicians during their clinic visits. Women who were randomly assigned to the nonscreening group were provided with information cards of locally available resources for women with IPV, which, in itself, is an intervention in other studies. Women in the nonscreening group had extensive questioning about IPV over the 18 months of the trial. These experiences could increase their self-awareness of IPV, affect their utilization of services, and influence outcomes of the trial by creating a substantial Hawthorne effect (that is, the phenomenon that study participants change their behavior as a result of being involved in the study).
Fifteen studies evaluated the diagnostic accuracy of 13 screening instruments. Overall, studies were consistent, applicability was high, and quality was fair to good. Five instruments demonstrated high accuracy in identifying women with current or recent IPV, and an instrument with 2 questions accurately identified women with histories of childhood abuse. Positive responses on the Partner Violence Screen predicted verbal aggression and violence during the 4 months after screening.
Six trials evaluated interventions to reduce IPV. Although trials were heterogeneous, results were largely consistent for indicating that counseling interventions provided benefits. These include reducing IPV and improving birth outcomes for pregnant women, reducing IPV for new mothers, and reducing pregnancy coercion and unsafe relationships for women in family-planning clinics. Applicability of trial data was limited, and quality was fair to good.
Few studies reported adverse effects of screening and interventions. A large RCT of screening indicated no differences in adverse effects for women who were either exposed or not exposed to IPV (39). Descriptive studies generally indicated low levels of adverse effects related to IPV screening, but study populations and methods varied. Overall results were consistent, applicability was unclear because most studies were based on small selected samples, and overall quality was fair.
Limitations of this review include using only English-language publications and studies applicable to U.S. screening populations and practice. These inclusion criteria improved applicability but may have also excluded important research. However, our extensive literature review and content experts did not identify critical non–English-language studies. This review also focused exclusively on IPV victimization in women and did not consider studies of women as perpetrators or men as victims. A comprehensive review of these studies would probably provide additional insights for IPV screening among these populations.
Our inclusion criteria targeted specific study designs and health outcomes that disqualified most research in this field. Although RCTs are the gold standard for evaluating efficacy and effectiveness, IPV research does not readily fit this standard because of its unique methodological challenges and ethical issues. These include providing intervention services to study participants in control groups who require them; inability to conduct double-blind trials; use of self-reported measures; lack of accepted reference standards and outcome measures; loss to follow-up; and confidentiality, reporting, and safety concerns with enrolling and following study participants, among others. How well the results of studies translate to clinical practice is also not clear, although most studies were conducted in health care settings and enrolled patients from actual practices. The positive predictive value of screening, as well as potential effects of interventions, would be expected to be greatest in populations with the highest IPV prevalence rates.
Several evidence gaps could be addressed by emerging research. Women have higher rates of IPV disclosure using self-administered methods than face-to-face questioning (45, 74). Computerized screening increases rates of IPV discussion, disclosure, and service provision (75–77) and is more acceptable for patients (78, 79). Patients also perceived use of an audio questionnaire as more private and less likely to increase risk for abuse (80). Further evaluation of the accuracy, as well as efficiency and acceptability, of these methods could lead to improvement in screening processes.
Research evaluating health system approaches to screening and intervention could improve quality, standardization, and rates of screening compared with approaches that depend on individual clinics or practitioners to implement. Methods could include using diagnostic codes to guide screening in ED settings (81), or screening during the hospital admissions process, for example. Coupled with the systems approach to screening, systems-based protocols for further evaluation and referral for persons with positive screening results could increase screening effectiveness. Studies that evaluate the feasibility, acceptability, and outcomes of these approaches would provide valuable guidance to health systems interested in implementing them.
In conclusion, screening instruments designed for health care settings can accurately identify women experiencing IPV. Screening women for IPV could reduce IPV and improve health outcomes depending on the population screened and outcome measured, although effectiveness trials have important limitations. Screening has minimal adverse effects, but some women experience discomfort, loss of privacy, emotional distress, and concerns about further abuse.
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Harriet L., MacMillan, Professor, Gene Feder, Professor
McMaster University and University of Bristol
May 18, 2012
Link between evidence and conclusion unclear in USPSTF IPV screening systematic review
As two clinician-researchers involved in the intimate partner violence (IPV) screening trial (1) that featured prominently in the recent US Preventive Services Task Force (USPSTF) systematic review on screening women for IPV (2), we were perplexed by the authors' conclusion that IPV screening can provide benefits that vary by population. This was the only trial identified as meeting the inclusion criteria to address question 1 of the review: "Does screening asymptomatic women in health care settings for current, past, or increased risk for IPV reduce exposure to IPV, physical or mental harms, or mortality?" Given that the trial results showed no differences between groups and the overall quality of the study was considered "fair", presumably the answer to question 1 would be "no" - which is what the trial authors concluded. Even taking into account the limitations of the trial, at most one would expect the answer to be "unknown". Yet the review authors concluded that IPV screening can provide benefits, extrapolating from trials of IPV interventions recruiting all participants via screening. These trials do not provide evidence for the effectiveness of screening in comparison to other methods of identifying survivors of IPV, such as clinical enquiry or case finding. Educational interventions in primary care that increase IPV disclosure rates and referral for advocacy support do not require implementation of screening (3).
We were concerned by the recent recommendation on IPV screening from the Institute of Medicine (4), given the lack of evidence of screening effectiveness and even more so by the conclusions of this USPSTF review. Previous systematic reviews have consistently found that there is insufficient evidence to justify screening women for IPV in health care settings. One of the most recent UK reviews assessed research findings against nine criteria for a public health or health care based screening program (5). The IPV screening trial that formed the basis for answering question 1 of the updated USPSTF review has provided further evidence that IPV violence screening is not justified. This is not simply an intellectual debate; the over-emphasis on means of identifying women experiencing abuse and the promotion of screening distracts attention and resources from further development of safe and effective interventions for women after disclosure of violence. We hope that the USPSTF Recommendation statement on IPV screening that is presumably forthcoming will reflect the scientific evidence and acknowledge the lack of evidence to support IPV screening.
(1) MacMillan HL, Wathen CN, Jamieson E, Boyle MH, Shannon HS, Ford- Gilboe M et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA 2009;302:493-501.
(2) Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendations. Ann Int Med 2012;156: May 7 [Epub ahead of print].
(3) Feder G, Davies RA, Baird K, Dunne D, Eldridge S, Griffiths C et al. Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011; 378:1788- 1795.
(4) National Research Council. Clinical Preventive Services for Women: Closing the Gaps. Washington DC: National Academies Pr; 2011.
(5) Feder G, Ramsay J, Dunne D, Rose M, Arsene C, Norman R et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess 2009;13:iii-iv, xi-xiii, 1-113, 137-347.
H MacMillan (as principal investigator) and G Feder (as Chair of Data Monitoring Committee) were both involved in a trial of IPV screening included in the review. Both are involved in the WHO Policy and Clinical Practice Guidelines for Responding to Violence against Women (G Feder as Chair and H MacMillan as a member) and G Feder chairs the UK National Institute of Health and Clinical Excellence Domestic Violence Program Development Group.
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