Heidi D. Nelson, M.D., M.P.H.;a,b,c Peggy Nygren, M.A.;a,b Yasmin McInerney, M.D.;a,c Jonathan Klein, M.D., M.P.H.d
The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Address correspondence to: Heidi D. Nelson, M.D., M.P.H., Oregon Health & Science University, Mail Code BICC 504, 3181 SW Sam Jackson Park Road, Portland, OR 97201; E-mail: nelsonh@ohsu.edu.
Select for copyright information. The USPSTF recommendations based on this review are online.
The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evidence Reviews, which are used by the U.S. Preventive Services Task Force (USPSTF) to make recommendations.
Abstract
Introduction
Methods
Results
Conclusions
Acknowledgments
References
Notes
Background: Family and intimate partner violence commonly occurs in the U.S. and is often associated with acute and chronic health problems. Although the clinician's role in identification and intervention is considered a professional, ethical, and sometimes legal responsibility, the effectiveness of screening is uncertain.
Purpose: To examine evidence on the benefits and harms of screening women and elderly adults in health care settings for family and intimate partner violence.
Data Sources: MEDLINE®, PsycINFO, CINAHL, Health & Psychosocial Instruments, AARP Ageline®, Cochrane Controlled Trials Register, reference lists, and experts.
Study Selection: English-language studies that included original data focusing on the performance of screening instruments (14 studies for women, 3 for elderly) and the effectiveness of interventions based in health care settings (2 studies for women, none for elderly).
Data Extraction: Study design, patient populations and settings, methods of assessment or intervention, and outcome measures were extracted, and a set of criteria was applied to evaluate study quality.
Data Synthesis: No trials of the effectiveness of screening in a health care setting in reducing harm have been published. Several screening instruments have been developed; some have demonstrated fair to good internal consistency and some have been validated with longer instruments, but none have been evaluated against measurable violence or health outcomes. Few intervention studies have been conducted. Existing intervention studies focused on pregnant women; study limitations restrict their interpretation.
Conclusion: Although the literature on family and intimate partner violence is extensive, few studies provide data on its detection and management to guide clinicians.
Key words: screening, intervention, family violence, elder abuse, intimate partner abuse, domestic violence, systematic review, evidence-based medicine.
As many as 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners each year in the U.S.,1,2 with 31 percent of all women reporting lifetime abuse.3 Prevalence rates of abuse in clinical samples range from 4 percent to 44 percent within the past year and from 21 percent to 55 percent over a lifetime.4-14 The incidence of acute cases in emergency care settings ranges from 2 percent to 7 percent.15 Approximately 20 percent of female teenage survey respondents reported being physically and/or sexually abused by a dating partner.16 Although violence by women against men also occurs, women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner.17
Approximately 551,000 older adults in domestic settings were abused and/or neglected in 1996.18 A random-sample survey of a community population indicated a prevalence rate of 32 per 1000 for physical violence, verbal aggression, and neglect.19 Complicating these estimates, however, is the difficulty in defining and quantifying elder abuse. Abuse of the elderly takes many forms, including physical, sexual, psychological, and financial exploitation, and neglect.20 Available data indicate that the highest rates of elder abuse are among women and those aged 80 and older.18 In 90 percent of cases, the perpetrator is a family member, most often an adult child or spouse.18
Many health problems are associated with abuse and neglect at all ages. These include repercussions of acute trauma, including death, and unwanted pregnancy, as well as long-term physical and mental problems, such as depression, post-traumatic stress disorder, somatization, suicide, and substance abuse.16,21-30 Children who witness intimate partner violence are at risk for developmental delay, school failure, psychiatric disorders,31,32 and violence against others.33
The clinician's role in identification and intervention is considered a professional responsibility by physician and nursing organizations.34,35 Reporting child and elder abuse to protective services is mandatory in almost all states; 4 states (California, Colorado, Rhode Island, and Kentucky) have laws requiring mandatory reporting of intimate partner violence. Hospitals are also required to address abuse for accreditation.36
Whether screening leads to a decline in abuse is unknown. In the mid-1990s, after several medical organizations recommended screening for intimate partner abuse, rates of abuse declined.37 A systematic review reported that most studies of screening for intimate partner violence in health care settings found that screening detected more abused women than no screening.38 Surveys indicate that 43-85 percent of female respondents consider screening in health care settings acceptable, although only one-third of physicians and half of emergency department nurses favored screening.38 The evidence on how to screen and effectively intervene once problems are identified is limited, and few clinicians routinely screen patients who do not have apparent injuries.39-44
In 1996, the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to recommend for or against the use of specific screening instruments to detect family or intimate partner violence, although including questions about abuse in the routine history could be recommended based on prevalence of abuse among adult women and potential value of the information to clinicians.45 This report is an update of the current literature on family and intimate partner violence focusing on studies of the performance of screening instruments designed for the clinical setting and the effectiveness of clinical-based interventions for women and elderly adults. A separate report on screening for family violence in children is available elsewhere.46
The analytic framework and key questions guiding this review are detailed in Figure 1 (17 KB). Relevant studies were identified from multiple searches of MEDLINE® (1966 to December 2002), PsycINFO (1984 to December 2002), CINAHL (1982 to December 2002), Health & Psychosocial Instruments (1985 to December 2002), AARP Ageline (1978 to December 2002), and the Cochrane Controlled Trials Register (Appendix 1). Additional articles were obtained by reviewing 2 recent systematic reviews,38,47 reference lists of pertinent studies, and by consulting experts.
We defined screening as an assessment of current harm or risk for harm from family and intimate partner violence in asymptomatic persons in a health care setting. Universal screening means assesses everyone; selective screening assesses only those who meet specific criteria. The target populations for this review are women and elderly victims of abuse, where abuse is directed towards them by family members, intimate partners, caretakers, or others with similar relationships. The USPSTF focused this review on these populations because they are the largest at-risk groups in general primary care settings.
Studies included in this review had English-language abstracts; were applicable to U.S. clinical practice; described abuse and violence against women or elderly adults; were conducted in or linked to primary care (i.e., family practice, general internal medicine), obstetrics/gynecology, or emergency department settings; and included a physician or other health care provider in the process of assessment or intervention. We excluded studies about patients presenting with trauma. All eligible studies were reviewed, including those published prior to the 1996 USPSTF recommendation.
Assessment studies were included if they evaluated the performance of verbal or written questionnaires or other assessment procedures, such as physical examinations, that were brief and applicable to the primary care setting. Included studies described the study sample, the screening instrument or procedure, the abuse or neglect outcome, and the collection of data. Outcomes included indicators of physical abuse, neglect, emotional abuse, and/or sexual abuse and any reported related health outcomes (i.e., depression).
Intervention studies were included if they measured the effectiveness of an intervention in reducing harm from family and intimate partner violence compared with nonintervention or usual care groups. We excluded studies that tested the effectiveness of interventions to educate health care professionals about family violence or to increase screening rates in institutions. We also excluded studies about mandatory reporting laws, descriptions of programs, the accuracy of physician diagnosis and reporting of abuse, and physician factors related to reporting.
From each included study, we abstracted the study design, number of participants, setting, length and type of interventions, length of followup, outcomes, methods of outcome measurement, and study duration, among others. Two reviewers independently rated each study's quality using criteria specific to different study designs developed by the USPSTF (Appendix 2).48 When reviewers disagreed, a final score was reached through consensus.
This research was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to support the work of the USPSTF. Agency staff and Task Force members participated in the initial design of the study and reviewed interim analyses and the final manuscript. Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript. The authors are responsible for the content of the manuscript and the decision to submit it for publication.
Of 806 abstracts identified by database searches, 14 met inclusion criteria. These included 6 studies that compared one instrument with another, 3 that compared an instrument to a directed interview, 2 that measured inter-rater reliability and/or internal consistency, and 3 that compared methods of administration. None evaluated the performance of a screening instrument or procedure using verified abuse outcomes. Screening instruments are described in Appendix 3.49-61
Six studies compared brief screening instruments with previously validated instruments and were rated good or fair in quality (Table 1).15,53,54,56,57,62 Brief instruments were generally correlated to longer instruments and in some cases performed better.
The Hurt Insulted Threatened or Screamed at (HITS) instrument includes 4 questions.54 When administered to 259 women in family practice clinics, it demonstrated fair internal consistency (Cronbach's alpha = 0.80), and its results correlated with the previously validated 19-item Conflict Tactics Scales (CTS) (r = 0.85). In urban emergency department settings, the Partner Violence Screen (PVS), consisting of 3 questions, was compared with the 30-item Index of Spouse Abuse (ISA) (sensitivity 64.5 percent; specificity 80.3 percent) and the CTS (sensitivity 71.4 percent; specificity 84.4 percent).53 However, the CTS may not have undergone sufficient testing of its validity to qualify as a gold standard in these studies.
A study of 1,152 predominantly African American women presenting for care at university-affiliated family practice clinics found that the 10-item Women's Experience with Battering (WEB) Scale had a higher detection rate (16 percent) than the 15-item ISA-Physical Scale (10 percent).56 Another trial studying predominantly white women in family practice clinics found that the 8-item Woman Abuse Screening Tool (WAST) was correlated to the 25-item Abuse Risk Inventory (r = 0.69).57 A study of pregnant women in public prenatal clinics tested the 3-item Abuse Assessment Screen (AAS) against the ISA.62 Women identified as abused on the AAS also scored significantly higher on the ISA than non-abused women.
The previously validated AAS was modified to detect ongoing abuse, rather than abuse within the previous 12 months, for use in the emergency department setting, and was renamed the Ongoing Abuse Screen (OAS).15 Women presenting to an emergency department were screened with both instruments as well as with a single question about present abuse. The AAS was positive in 59 percent of women screened, and the OAS was positive in 16 percent. Asking the single question, "Are you presently a victim of intimate partner violence?" was positive in 3 percent of women.
Three studies comparing a screening instrument to an interview were rated as poor quality.51,52,55 The major limitation of these studies was that no protocol for the directed interview was identified. These studies reported higher detection rates with questionnaires than with interviews.
Two fair-quality studies measured the internal consistency of screening instruments. The Partner Abuse Interview, an 11-item questionnaire modified from the CTS, showed fair internal consistency (Cronbach's alpha = 0.82) when tested in 90 women at a suburban family practice clinic and university hospital.49 The WEB Scale, which was tested in primary care clinics and community groups, showed good internal consistency (Cronbach's alpha = 0.99).63
Three fair-quality studies compared methods of administration of screening instruments.42,50,58 A study of 4,641 women presenting to 11 community emergency departments found that the prevalence of past-year and lifetime violence was significantly higher when a questionnaire containing items from the AAS was self-administered than when it was administered by a nurse.42 In another study conducted in an emergency department, reports of abuse were similar when a questionnaire was given as part of a face-to-face-interview (16 percent) and when a taped-recorded questionnaire with a written self-reported answer sheet was provided (15 percent).58 In a study at a Planned Parenthood clinic using 4 questions, rates of reported abuse were higher on a nurse-conducted interview (29 percent) than by self-report (7 percent).50
Of 667 abstracts identified by database searches, only 2 met inclusion criteria (Table 2). These fair-quality studies evaluated interventions for abused, pregnant women and reported lower levels of violence after delivery even when a minimal or "brief" intervention was performed. Neither study had a nonintervention control group.64,65
In 1 study, 329 pregnant Hispanic women in a prenatal clinic who tested positive for abuse on a screening questionnaire (AAS) were randomized into 1 of 3 groups: "brief" (given wallet-sized card listing community resources); "counseling" (unlimited access to counselor in the clinic); or "outreach" (counseling plus a "mentor mother" in the community).64 At 2-month followup, violence scores measured using the Severity of Violence Against Women Scale were significantly lower in the outreach group compared with the counseling group, but not compared with the brief group. However, at the 6-, 12-, and 18-month followup, violence scores were decreased in all groups without statistically significant differences between groups.
In another study of pregnant women in prenatal clinics with positive results on the AAS, 132 received 3 counseling sessions and 67 were offered wallet-sized cards listing community resources.65 At 6 and 12 months post delivery, less violence occurred in the intervention group, as measured by the ISA and Severity of Violence Against Women Scale (P = 0.052).
Of 1,045 abstracts identified by database searches, 3 studies of elder abuse screening instruments met modified inclusion criteria (Table 3).60,61,66 None were developed or tested in traditional clinical settings. However, because the care of elderly adults occurs largely outside these settings, studies were included if it appeared that they could be adapted to clinical settings.
A screening instrument for caregivers was tested in 3 groups: abusive and non-abusive caregivers from a social service agency, and non-abusive caregivers from the community.61 The Caregiver Abuse Screen (CASE) is based on yes or no responses to 8 items. Scores on the CASE distinguished abusers from non-abusers (Cronbach's alpha = 0.71), and correlated with the previously validated Indicator of Abuse (IOA) (r = 0.41; P < 0.001), and Hwalek-Sengstock Elder Abuse Screening Test (HSEAST) (r = 0.26; P < 0.025).
Two studies described screening elderly adults. One study evaluated 3 groups: victims of abuse, individuals who were referred to adult protective services and were found not to be abused, and non-abused elderly adults from a family practice clinic.60 The 15-item HSEAST was administered to all groups and correctly classified 67-74 percent of cases (P < 0.001). The HSEAST was also evaluated in a study of elderly adults living in public housing in Florida.66 Abuse status (past abuse or none) was reported by participants and verified by a social worker reviewing their records at the housing authority. Scores for the abused and non-abused were significantly different (mean total score, 4.01 for abused group vs 3.01 for non-abused group; P = 0.049). This study also indicated that a 9-item model, rather than 15, performed as well as the longer version, correctly identifying 71.4 percent of abuse cases with 17 percent false-positive and 12 percent false-negative rates.
Of 1,084 abstracts identified by database searches, 72 articles were retrieved for further review; however, none provided data about effective interventions. Some papers provided descriptions of individual elder abuse programs, but none included comparison groups or health outcome measures.
No studies were identified that provide data about the adverse effects of screening or interventions. No screening instrument demonstrated 100 percent sensitivity and specificity. False-negative tests may hinder identification of those who are truly at risk. False-positive tests, most common in low-risk populations, can lead to inappropriate labeling and punitive attitudes. Additional possible adverse effects include psychological distress, escalation of abuse and family tension, loss of personal residence and financial resources, erosion of family structure, loss of autonomy for the victim, and lost time from work. Women who leave an abuser can become the target of retaliatory responses that can lead to homicide.67
There has been concern that patients may feel uncomfortable or threatened if asked questions about family and intimate partner violence. Most women in a study of screening in antenatal clinics believed it was a good idea (98 percent) and felt "ok" during the process (96 percent) when asked at a subsequent visit.68 In another study, only 3 percent of women found 3 screenings, during and after pregnancy, with the AAS unacceptable.69 Although most women presenting with their children to a pediatric emergency department believed screening for intimate partner violence was appropriate, many indicated their willingness to disclose might be affected by fear of being reported to child protective services.70 This concern was confirmed by clinicians in the study who indicated that they would feel obligated to report a child if violence was present in the home.
A telephone survey of abused and non-abused women in 11 U.S. cities indicated that abused women were less likely to support mandatory reporting compared with non-abused women (59 percent vs 73 percent; P < 0.01). Respondents believed victims would be less likely to disclose abuse, would resent someone else having control of the situation, and reporting would increase the risk for perpetrator retaliation.71,72
We identified no studies that directly addressed the effectiveness of screening in a health care setting in reducing harm from family and intimate partner violence or the adverse effects of screening and interventions.
Several instruments have been developed for intimate partner violence screening; some have demonstrated fair to good internal consistency, and some have been validated with longer instruments, although none have been evaluated against measurable violence or health outcomes. The optimal methods of administration have not been determined. Few intervention studies have been conducted, and these focused on pregnant women. Outcomes were based on scores on questionnaires and suggest benefit; however, study limitations restrict interpretation.
Few screening instruments have been developed to identify potential elderly victims of abuse or their perpetrators. These instruments performed fairly well when administered in studies, but have not been tested in health care settings. We found no studies of interventions in the elderly.
Other systematic reviews of interventions for victims of intimate partner violence found few studies with outcomes other than the health outcomes we sought.38,47 Referrals to community resources, shelters, social workers, and police often increased when abused women were identified. However, it is not known if these interventions improved violence or health outcomes because the studies had inadequate study designs to answer these questions and provided inconsistent results.38,47
The prevalence of abuse and the sensitivity and specificity of screening instruments depend on definitions of abuse (physical, sexual, emotional, combinations) and acuity (current, past, any). These definitions are not standardized across instruments. Performance characteristics of screening instruments are difficult to determine because comparisons of scores from instruments with actual episodes of abuse are lacking and the accuracy of self-report varies widely. The effectiveness of specific screening methods and interventions could also vary by setting, delivery, culture, and population.
Self-reported abuse by the elderly may be compromised by cognitive impairment and overshadowed by other medical problems addressed in health care settings. A more comprehensive approach, including physical examination, caretaker and home evaluations, as well as direct questioning, may be more effective.
There are many gaps in the evidence.73 Definitions and measures of abuse, neglect, severity, and chronicity need to be standardized across studies. Existing screening instruments require more testing and validation in medical settings and in languages other than English.74 Little is known about the course of violence during pregnancy and postpartum periods, health implications for the mother and child, the role of violence on reproductive decisionmaking, and what screening and intervention strategies are most effective for pregnant women.
Studies of the effectiveness of treatment programs for abused victims, as well as for perpetrators,75-77 would provide needed evidence that identification and intervention can lead to improved health outcomes. These outcomes should include not only measures of reduced violence, but also improved quality of life, mental health, social support, self-esteem, productivity, and others.
The feasibility of screening procedures and interventions in health care settings requires evaluations that consider costs, time, resources, clinician consistency, barriers, and patient compliance. Strategies enlisting and evaluating health systems and community programs are needed.78
Although the literature on family and intimate partner violence is extensive, there are few studies providing data on its detection and management to guide clinicians. As a result, clinicians confront difficulties fulfilling their role in prevention and treatment of the adverse health effects of violence.
The authors thank members of the USPSTF and reviewers of the full evidence report for their contributions to this project. Patty Davies conducted library searches and Miranda Norbraten helped prepare the manuscript.
This study was conducted by the Oregon Evidence-based Practice Center for the Agency for Healthcare Research and Quality under Contract No. 290-97-0018, Task Order No. 2. Dr. McInerney was supported by the Veterans Affairs Special Fellowship in Health Issues of Women Veterans.