Screening women for intimate partner violence in healthcare settings

Background

We carried out this review to find out if asking (screening) all women attending healthcare settings about their experience of domestic violence from a current or previous partner helps to recognise abused women so that they may be provided with a supportive response and referred on to support services. We were also interested to know if this would reduce further violence in their lives, improve their health, and not cause them any harm compared to women's usual healthcare.

Women who have experienced physical, psychological, or sexual violence from a partner or ex-partner suffer poor health, problems with pregnancy, and early death. Their children and families can also suffer. Abused women often attend healthcare settings. Some people have argued that healthcare professionals should routinely ask all women about domestic violence. They argue that 'screening' might encourage women who would not otherwise do so, to disclose abuse, or to recognise their own experience as 'abuse'. In turn, this would enable the healthcare professional to provide immediate support or refer them to specialist help, or both. Some governments and health organisations recommend screening all women for domestic violence. Others argue that such screening should be targeted to high-risk groups, such as pregnant women attending antenatal clinics.

Study characteristics

We examined research up to 17 February 2015. We included research studies that had women over 16 years of age attending any healthcare setting. Our search generated 12,369 studies and we eventually included 13 studies that met the criteria described above. In all, 14,959 women had agreed to be in those studies. Studies were in different healthcare settings (antenatal clinics, women's health/maternity services, emergency departments, and primary care centres). They were conducted in mainly urban settings, in high-income countries with domestic violence legislation and developed support services to which healthcare professionals could refer. Each of the included studies was funded by an external source. The majority of the funding came from government departments and research councils, with a small number of grants/support coming from trusts and universities.

Key results and quality of the evidence

Eight studies with 10,074 women looked at whether healthcare professionals asked about abuse, discussed it, and/or documented abuse in participating women's records. There was a twofold increase in the number of women identified in this way compared to the comparison group. The quality of this evidence was moderate. We looked at smaller groups within the overall group, and found, for example, that pregnant women were four times as likely to be identified by a screening intervention as pregnant women in a comparison group. We did not see an increase in referral behaviours of healthcare professionals but only two studies measured referrals in the same way and there were some shortcomings to these studies. We could not tell if screening increased uptake of specialist services and no studies examined if it is cost-effective to screen. We also looked to see if different methods were better at picking up abuse, for example, you might expect that women would be more willing to disclose to a computer, but we did not find one method to be better than another. We found an absence overall of studies examining the recurrence of violence (only two studies looked at this, and saw no effect) and women's health (only one study looked at this, and found no difference 18 months later). Finally, many studies included some short-term assessment of adverse outcomes, but reported none.

There is a mismatch between the increased numbers of women picked up through screening by healthcare professionals and the high numbers of women attending healthcare settings actually affected by domestic violence. We would need more evidence to show screening actually increases referring and women's engagement with support services, and/or reduces violence and positively impacts on their health and wellbeing. On this basis, we concluded that there is insufficient evidence to recommend asking all women about abuse in healthcare settings. It may be more effective at this time to train healthcare professionals to ask women who show signs of abuse or those in high-risk groups, and provide them with a supportive response and information, and plan with them for their safety.

Authors' conclusions: 

The evidence shows that screening increases the identification of women experiencing IPV in healthcare settings. Overall, however, rates were low relative to best estimates of prevalence of IPV in women seeking healthcare. Pregnant women in antenatal settings may be more likely to disclose IPV when screened, however, rigorous research is needed to confirm this. There was no evidence of an effect for other outcomes (referral, re-exposure to violence, health measures, harm arising from screening). Thus, while screening increases identification, there is insufficient evidence to justify screening in healthcare settings. Furthermore, there remains a need for studies comparing universal screening to case-finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing in order to inform IPV identification policies in healthcare settings.

Read the full abstract...
Background: 

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for IPV rather than asking only women with symptoms (case-finding). Here, we examine the evidence for whether screening benefits women and has no deleterious effects.

Objectives: 

To assess the effectiveness of screening for IPV conducted within healthcare settings on identification, referral, re-exposure to violence, and health outcomes for women, and to determine if screening causes any harm.

Search strategy: 

On 17 February 2015, we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, six other databases, and two trial registers. We also searched the reference lists of included articles and the websites of relevant organisations.

Selection criteria: 

Randomised or quasi-randomised controlled trials assessing the effectiveness of IPV screening where healthcare professionals either directly screened women face-to-face or were informed of the results of screening questionnaires, as compared with usual care (which could include screening that did not involve a healthcare professional).

Data collection and analysis: 

Two authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the odds ratio (OR). For continuous data, either a mean difference (MD) or standardised mean difference (SMD) was calculated. All are presented with a 95% confidence interval (CI).

Main results: 

We included 13 trials that recruited 14,959 women from diverse healthcare settings (antenatal clinics, women's health clinics, emergency departments, primary care) predominantly located in high-income countries and urban settings. The majority of studies minimised selection bias; performance bias was the greatest threat to validity. The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision.

We excluded five of 13 studies from the primary analysis as they either did not report identification data, or the way in which they did was not consistent with clinical identification by healthcare providers. In the remaining eight studies (n = 10,074), screening increased clinical identification of victims/survivors (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence).

Subgroup analyses suggested increases in identification in antenatal care (OR 4.53, 95% CI 1.82 to 11.27, two studies, n = 663, moderate quality evidence); maternal health services (OR 2.36, 95% CI 1.14 to 4.87, one study, n = 829, moderate quality evidence); and emergency departments (OR 2.72, 95% CI 1.03 to 7.19, three studies, n = 2608, moderate quality evidence); but not in hospital-based primary care (OR 1.53, 95% CI 0.79 to 2.94, one study, n = 293, moderate quality evidence).

Only two studies (n = 1298) measured referrals to domestic violence support services following clinical identification. We detected no evidence of an effect on referrals (OR 2.24, 95% CI 0.64 to 7.86, low quality evidence).

Four of 13 studies (n = 2765) investigated prevalence (excluded from main analysis as rates were not clinically recorded); detection of IPV did not differ between face-to-face screening and computer/written-based assessment (OR 1.12, 95% CI 0.53 to 2.36, moderate quality evidence).

Only two studies measured women's experience of violence (three to 18 months after screening) and found no evidence that screening decreased IPV.

Only one study reported on women's health with no differences observable at 18 months.

Although no study reported adverse effects from screening interventions, harm outcomes were only measured immediately afterwards and only one study reported outcomes at three months.

There was insufficient evidence on which to judge whether screening increases uptake of specialist services, and no studies included an economic evaluation.

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