Screening for Domestic Violence in Health Care Settings. Existing Evidence on Screening and Intervention

08/01/2013

The 2013 USPSTF recommendation supporting screening of all women of childbearing age for intimate partner violence was based on the 2012 Annals of Internal Medicine’s “Systematic Review of Evidence to Update the 2004 U.S. Preventive Services Task Force Recommendation” (Nelson et al. 2012). That review of 36 studies about IPV screening in health care settings concluded that there are effective screening tools, that screening tools do not cause significant harm, and that some interventions, primarily for pregnant or post-partum women, have had positive results.5
 
The review examined 15 studies that evaluated 13 existing screening instruments. Six screening instruments were found to be highly accurate, including: the Hurt, Insult, Threaten, and Scream (HITS) instrument; the Ongoing Violence Assessment Tool (OVAT); the Slapped, Threatened, and Throw (STaT) instrument; the Humiliation, Afraid, Rape, Kick (HARK) instrument; the Women Abuse Screening Tool (WAST); and the Partner Violence Screen (PVS) (Nelson et al., 2012). Fourteen studies included in the review determined that screening patients for IPV did not result in adverse outcomes (Nelson et al., 2012).
 
The review also looked at evidence related to interventions. An intervention is the response provided by the clinician or by a different service provider after a women discloses abuse through the screening process. The review included six studies that showed evidence that an intervention had a positive effect on reducing exposure to IPV, physical or mental harms, or mortality (Blair-Merritt et al., 2010; El-Mohandes et al., 2011; Kiely et al., 2010; McFarlane et al., 2006; Miller et al., 2011; Taft et al., 2009). Five of these six studies conducted interventions that targeted pregnant and postpartum women, and found modest improvements, including fewer episodes of IPV, reduction in reproductive coercion, and improved child gestational age and birth weight (Blair-Merritt et al., 2010; El-Mohandes et al., 2011; Kiely et al., 2010; Miller et al., 2011; Taft et al., 2009). One of the six studies assessed an intervention targeted to women in urban primary care public clinics and tested the difference between two intervention approaches (providing a wallet-sized referral card versus a 20-minute nurse case management session). The study found that both groups experienced a reduction in the number of threats of abuse, assaults, risks for homicide, and events of work harassment, and there was no statistically significant difference between the two interventions (McFarlane et al., 2006).
 
The systematic review also found one study that addressed the question of whether screening for IPV, without a follow-up intervention, reduced exposure to IPV, physical or mental harms, or mortality. Comparing outcomes for screened and non-screened women, the study found there was no statistically significant difference (MacMillan et al., 2009).
 
While the review provided sufficient evidence for the USPSTF to recommend universal IPV screening for all women of childbearing age, further research remains to be done to identify the most effective approaches to screening and to understand better the relationship between screening, intervention, and women’s health outcomes.

5 For a listing of studies and more detail on the evidence thresholds used to assess them, see Nelson et al., 2012.

 

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