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

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Chapter 1 Background

Chapter 2 Objectives and the review questions

There are seven review questions. We have linked each of these to key NSC criteria for a screening programme. The figure in Appendix 2 places the criteria we are reviewing in an analytic framework for research on partner violence and health, and is adapted from a framework used by the Canadian Preventive Task Force. 18

Chapter 3 Review methods

Chapter 4 What is the prevalence of partner violence against women and its impact on health? (Question I)

Clinical populations

General practice

A study by Richardson et al. 41 measured the prevalence of partner violence in 1207 women attending a general practice, finding a 41% lifetime prevalence and a 17% 1-year prevalence of physical abuse by a partner. Prevalence was higher among women who were divorced or separated, and amongst women aged 16–24 years, and lower in women born outside the UK.

Antenatal/postnatal care

We found five papers (four studies) that estimated the prevalence of partner violence in women attending antenatal or postnatal clinics in the UK.

Bacchus and colleagues42 measured the lifetime prevalence and 1-year prevalence of physical, sexual and emotional abuse in a cohort of 892 women attending maternity services in south London; they asked about partner violence at booking, at 34 weeks of gestation and postpartum. The study reported a lifetime prevalence of 13% and prevalence (during the pregnancy) of 6.4%.

A second study conducted by Bacchus and colleagues43,44 measured a 23.5% lifetime prevalence of partner violence (physical, sexual and psychological) from a sample of 200 women receiving antenatal or postnatal care at a south London hospital.

In a study based on a cohort of 7591 women from 18 weeks’ gestation to 33 months postpartum, Bowen and colleagues45 found that the prevalence (during pregnancy and a 33-month postpartum period) of partner violence steadily increased through the second half of pregnancy and after delivery. At 18 weeks’ gestation, 5.1% of the women experienced some form of abuse (physical, sexual or emotional) and this increased to 11% at 33 months after the birth. However, this study had substantial limitations, including a high attrition rate (45%), which may result in an underestimated prevalence, because those experiencing partner violence were more likely to be lost to follow-up. Moreover, the questionnaires were posted to women, which may have discouraged some respondents from reporting abuse if they were still living with the abuser. A further complication of this study is that the women who completed the study differed from those lost to follow-up: they were more likely to have attended higher education, have fewer children, be married, be at least 25 years old when their first child was born, and be homeowners.

A questionnaire survey by Johnson and colleagues46 of 500 consecutive women in an antenatal booking clinic in a hospital in the north of England found a 17% lifetime prevalence of physical, sexual and emotional abuse in pregnant women. Abuse was most prevalent in women aged between 26 and 30 years.

Thus lifetime prevalence of partner abuse in women receiving antenatal or postnatal care in the UK ranges from 13% to 24%. One-year prevalence was estimated at 6.4% or 11% depending on the type of study and the stage of pregnancy at which women are asked about abuse.

Accident and emergency departments

We found three primary studies that measured the prevalence of partner violence in women attending accident and emergency departments in the UK.

In a study by Boyle and Todd,47 using randomly allocated time blocks, complete data were collected from 256 patients attending the emergency department of a Cambridge hospital. The study reported a 22.1% lifetime prevalence of physical, sexual and emotional abuse.

Sethi and colleagues48,49 purposefully sampled 22 nursing shifts, representative of day, night and weekend shifts. A questionnaire was administered to 198 women attending an inner city accident and emergency department. The study found a 34.8% lifetime prevalence of physical abuse. Prevalence was highest in women aged 30–39 and not in paid employment. A 6.1% 1-year prevalence of physical abuse in the past year was also reported. Neither this nor the Cambridge study reported which specific instrument was used to measure the rate of violence, so the difference in prevalence between the two studies might also be due to the use of different instruments in addition to population differences.

Wright and Kariya50 sought to ask consecutive assault victims attending a Scottish accident and emergency department over a 2-month period about partner violence. The paper reported that 41% of the 46 women asked had experienced partner violence in the past 2 months and that 63% of the women who were survivors of partner violence had experienced previous incidents. The paper did not define types of assault and probably only measured physical assault.

Among women attending accident and emergency departments in the UK, the prevalence of partner violence has been estimated between 22% and 35% depending on the definition adopted.

Gynaecology clinics

We found one study that examined the prevalence of partner violence in women attending gynaecology clinics in the UK. The study, by John and colleagues,51 reported a 21% lifetime prevalence of physical violence and a 1-year prevalence of 4%, with most abuse being perpetrated by ex-husbands or ex-boyfriends (32% and 29% respectively). Prevalence was highest in women aged 31–40 years.

Pregnancy counselling

A study by Keeling52 of women attending pregnancy counselling when seeking a termination reported a 35.1% lifetime prevalence for physical and emotional abuse, with 19.5% of the women having experienced abuse in the past year.

Family planning

A study by Keeling and Birch53 of women attending family planning clinics reported a 34.9% lifetime prevalence of physical, sexual, emotional and financial abuse, with a 1-year prevalence of 14%. Higher prevalence rates were observed in women aged 35–39 years and 45–49 years.

Figures 1 and 2 display the 1-year and lifetime prevalences (with 95% confidence intervals) of partner violence reported in the primary studies, in order of standard error. Table 3 lists the studies and the definitions of intimate partner violence (IPV) used.

FIGURE 1.

Plot of 1-year prevalence of partner violence with 95% confidence intervals. *See Table 3 for definitions of IPV used in these studies. Note: Bowen 200545 – 18 weeks’ gestation to 33 months’ postnatal prevalence; Wright 199750 – 2-month prevalence.

FIGURE 2.

Plot of lifetime prevalence of partner violence with 95% confidence intervals. *See Table 3 for definitions of IPV used in these studies.

TABLE 3 - Definitions of intimate partner violence (IPV) used in studies in Figures 1 and 2

Study	Definition of IPV	Study	Definition of IPV
Bacchus et al., 200442	Physical, sexual, emotional	Johnson et al., 200346	Physical, sexual, emotional
*Bacchus et al., 200444	Physical, sexual, psychological	Keeling, 200452	Physical, emotional
Bowen et al., 200545	Physical, sexual, emotional	*Keeling and Birch, 200453	Physical, sexual, emotional, financial
Boyle and Todd, 200347	Physical, sexual, emotional	Mirrlees-Black and Byron, 199940	Physical
Carrado, 199639	Physical	Richardson et al., 200241	Physical
Coid et al., 200354	Sexual	Sethi et al., 200448	Physical
Dominy and Radford, 199637	Physical, emotional, sexual and psychological	Walby and Allen, 200436	Physical, emotional, financial and threats
*Finney, 200638	Physical, emotional, financial and threats	*Walby and Allen, 200436	Sexual
*Finney, 200638	Sexual	Wright and Kariya, 199750	Physical
John et al., 200451	Physical

Table 4 shows the results of a logistic regression model testing whether the definition of IPV used in the studies or type of population (community versus clinical) is associated with variation in prevalence. We found that community populations have significantly lower prevalence, but there was no consistent relationship between the number of different types of IPV measured and the reported prevalence.

TABLE 4 - Logistic regression of population (community vs clinical) and definition of intimate partner violence (IPV; physical, emotional/psychological, threats, sexual an d/or financial) in relation to prevalence

Comparison	Incidence rate ratio	95% Lower confidence limit	95% Upper confidence limit	p-Value
Lifetime prevalence
Setting: community vs clinical	0.77	0.73	0.82	< 0.001
Count of 2 vs 1	1.22	1.18	1.25	< 0.001
Types of 3 vs 1	0.74	0.66	0.82	< 0.001
Violence 4 vs 1	1.27	1.04	1.56	0.02
One-year prevalence
Setting: community vs clinical	0.24	0.22	0.27	< 0.001
Count of 2 vs 1	1.83	1.70	1.96	< 0.001
Types of 3 vs 1	0.93	0.83	1.05	0.24
Violence 4 vs 1	1.19	0.86	1.65	0.30

Chapter 5 Are screening tools valid and reliable? (Question II)

Eighteen tools were assessed in 15 validation studies. The total number of participants was 10,289; studies reporting diagnostic accuracy comprised 8433 participants. The tools ranged from single questions to 30-item research inventories (see Appendix 5.1 for details of individual tools). Twelve tools were tested as index tools and eight as comparators; the Woman Abuse Screening Tool (WAST) and the Women’s Experience with Battering Scale (WEB) served in both capacities in different studies. Of the 15 studies, only 10 reported sufficient data to calculate diagnostic accuracy. The majority of studies were conducted in the USA (11), with two in Canada, and the remaining two in France and Brazil. Settings varied from general practice (six), accident and emergency departments (four), antenatal clinics (three), women’s health-care centres (two), women’s homes (two), domestic violence refuges (two) and an urgent care centre within a hospital (one). Publication dates ranged from 1992 to 2006. For details of primary studies see Appendix 5.3, and for detailed results by study see Appendix 5.4. Below we have presented the main findings in a narrative form.

Chapter 6 Is screening for partner violence acceptable to women? (Question III)

Chapter 7 Are interventions effective once partner violence is disclosed in a health-care setting? (Question IV)

We found 33 studies measuring the effectiveness of interventions for women who have experienced partner violence and their children. Nineteen of these studies were examined in a previous systematic review,11 and have been summarised below with the new studies. Publication dates of the 14 studies not included in the previous review range from 2000 to 2006. The majority of these new studies were conducted in the USA, a few were conducted in Canada, two in Spain, one in Mexico and one in Hong Kong. The settings varied and included refuges, community settings, women’s homes, antenatal clinics, a methadone maintenance programme and primary care ‘public health’ clinics. Study designs included nine randomised controlled trials, two case–control studies and two before-and-after studies. For details of the included studies see Appendix 7.1. For results and quality scores of studies see Appendix 7.2. The assessments of individual studies using the USPSTF criteria and the Jadad tool are detailed in Appendices 7.3 and 7.4, respectively.

No qualitative studies were found that explored what outcomes abused women want for themselves and their children from programmes that include screening or other health-care based interventions.

Chapter 8 Can mortality or morbidity be reduced following screening? (Question V)

We identified eight studies of interventions to implement screening with a total patient sample of 16,272 (one study did not report the number of participants). Publication dates ranged from 1998 to 2006, and the majority of studies were based in the USA. One study was conducted in Australia. Settings varied and included family practice sites and community clinics, health maintenance organisations (HMOs), women’s health clinics, and accident and emergency departments. One study trained nurses who visited vulnerable women in their homes. Experimental designs included seven before-and-after studies with varying follow-up periods (6 months to 2 years), and one randomised controlled trial. For further details of the design of included studies see Appendix 8.1. Results of included studies and quality scores are detailed in Appendix 8.2.

Morbidity and mortality are central to this NSC criterion, but we found no studies that measured these outcomes. Therefore we have included studies with proxy outcomes: identification of women experiencing partner violence after a system-based intervention to implement screening plus one other activity (such as referral to partner violence advocacy, or full documentation of the abuse). Studies that only reported one proxy outcome were excluded, unless this was referral to expert partner violence services. The justification for including identification plus another activity as relevant outcomes is that there is evidence that these additional activities may be associated with improved morbidity or mortality. As we discussed in Chapter 7, advocacy improves outcomes for survivors of partner violence and this may also be the case for psychological interventions.

The other specific outcome in our review protocol was harm associated with screening, but no studies reporting evidence of harms were found during this review.

The sections below are organised by health-care setting.

Chapter 9 Is screening for partner violence acceptable to health-care professionals? (Question VI)

Chapter 10 Is screening for partner violence cost-effective? (Question VII)

In this chapter we investigate whether screening for partner violence in any health-care settings is cost-effective. First, we conducted a systematic review of the primary studies that reported the cost-effectiveness of partner violence screening. Second, a cost-effectiveness model was constructed based on a pilot trial of a system-based intervention to implement routine enquiry about partner violence in a primary care setting.

Cost-effectiveness model of PreDoVe: a pilot trial of a primary care-based system-level intervention to improve identification and referral of women experiencing partner violence

The pilot study investigated a general practice-based intervention in the UK and tested the feasibility of this intervention in four general practices (three acting as an intervention and one as a control). The multifaceted, system-based intervention aimed to change the behaviour of clinicians towards women experiencing partner violence, and was designed to increase routine enquiry about partner violence and thereby disclosure of current partner violence. Following disclosure, clinicians were prompted to refer women to an advocate based in a domestic violence specialist agency or to a psychologist with specific training related to partner violence. The system-based intervention included initial educational sessions for all clinicians within the practice, which emphasised a pragmatic approach to enquiry and referral and also gave an overview of the wider community response. The referral component of the intervention was supported by a direct referral pathway to a domestic violence advocate and a psychologist, both of whom were involved in the initial training. In addition, prompts in the electronic medical record were used to probe for partner violence during routine consultations based on a four-item screening tool termed HARK (an acronym based on the dimensions of abuse, i.e. Humiliation, Afraid, Rape and Kick) linked to a range of coded diagnoses such as depression, insomnia, sexually transmitted infections and fatigue. 209 The HARK questions and a prompt to refer women to the advocate or psychologist were installed as a template onto the electronic medical record in the practices. Although the aim of the intervention was not a comprehensive screening programme for all women, it aimed to implement screening or routine enquiry for women presenting with other problems. We maintain that an economic analysis of this intervention is relevant to the question of whether screening for domestic violence could be cost-effective.

Model

A Markov model was developed to combine the intervention costs and benefits. It was fitted comparing the PreDoVe programme with usual care and used the differences between the two simulations to calculate the incremental net benefit. The model evaluated the impact of increased assessment and referral rates upon further violence and quality of life over a 10-year period. Partner violence affects several public services as women experiencing such violence come into contact with, for example, local authority housing departments and social services. Women experiencing violence who come into contact with the criminal justice system are now routinely recorded. Taking a societal perspective permitted a wide range of data from sources to be incorporated into the model. See Appendix 10.1 for summary of data sources for the model.

The model defines six health states in which women can find themselves (Figure 3). Following assessment, women experiencing partner violence can (1) remain unidentified, or are (2) identified and subsequently referred and treated, or (3) identified but decline referral to advocacy or psychology services. Women who receive treatment following disclosure during assessment can (4) drop out without improvement, or (5) enter a state of medium-term improvement where they can stay or move to the no-abuse or identified/untreated state. Women can also (6) die of non-related causes or specifically from partner violence. The transition probabilities for movement between these states were taken from the literature or in discussion with partner violence researchers. See Appendix 10.2 for details of transition probabilities. The average length of time a woman remains in contact with advocacy services is 6 months, and therefore the model cycle length was set to 6 months with a time horizon of 10 years. Following the approach suggested by the National Institute for Health and Clinical Excellence (NICE), we discounted both costs and outcomes at 3.5% per annum. The reason for this is that it is the approach most commonly taken in UK cost-effectiveness analyses, facilitating comparison of our results with other studies.

FIGURE 3.

Diagram of Markov model states of PreDoVe intervention.

Costs associated with advocacy and/or psychological interventions were collated for each woman in the PreDoVe pilot trial, and averaged across all women in the arm. These directly recorded pilot data were used to populate the model with the number of women attending the practices, the number who were asked about partner violence by GPs or practice nurses, the number of women disclosing partner violence, the number of subsequent referrals to the advocate or psychologist, and the number of women who declined to take up the referral to these services.

Simplifying assumptions about current abuse incidence included: 16 years as a woman’s minimum age for first experiencing partner violence; a lifetime prevalence of 40%; and that moving to a state of abuse occurs at a constant rate over a woman’s lifetime. Assessment rates at intervention and control practices were assumed to be 10.7% of abused women and 7.1% of non-abused women, based on actual rates of asking and extrapolation from the prevalence of partner violence found in east London general practices.

Costs comprised health-care use in terms of assessment, mental health and treatment costs as well as other social costs. Social costs included criminal justice costs, civil justice costs and cost of divorce involving children, societal employment loss, temporary housing costs and costs of social services.

Quality of life was based on survey data using the Short Form 12 (SF-12) measurement tool. SF-12 data were converted into quality of life utilities between 0 (equivalent to death) and 1 (equivalent to optimal health) for those with less severe and more severe violence, based on the US study by Wittenberg and colleagues. 272 See Appendix 10.3 for a summary of treatment cost sources, and Appendix 10.4 for other costs and QALYs per woman per year for each state.

The majority of women in the model are likely to be in ‘No abuse’ (State 1) although a flow of women will become ‘Abuse unidentified’ (State 2). Following assessment, women experiencing partner violence can remain unidentified (State 2), or be referred to a psychologist and/or advocate (States 3 and 4), or disclose abuse to a health-care professional but not be seeking intervention (State 5). If the psychologist and/or advocate intervention is successful, the women can be termed as ‘Medium-term improvement’ (State 6) and, if this does not worsen, can return to the ‘No abuse’ category.

Results

Univariate sensitivity analysis was carried out, and model parameters were both increased and decreased by 25%, unless these figures were internally invalid (such as if probabilities were less than zero or greater than one). For transition probabilities for which the intervention was assumed to be preferable to the control, the sensitivity analysis was constrained to assume the transition probabilities were at worst equal. In addition, the sensitivity analysis used an upper and lower confidence interval for the impact of abuse on health.

Combining net benefits and net costs in the model resulted in an incremental cost-effectiveness ratio (ICER) of £2450 per QALY. This result would be considered cost-effective had a service use perspective been applied under the implicit willingness-to-pay threshold applied by NICE. Including costs from a societal perspective will result in lower costs per QALY. The estimated cost-effectiveness was most sensitive to women taking up an intervention and the success of these interventions ‘downstream’ from disclosure to a health-care professional (in PreDoVe this entailed partner violence advocacy and a psychological intervention), and to the likelihood that medium-term improvement will continue into living outside of an abusive relationship. Most ICERs did not increase above £5000 per QALY and only one was greater than the £30,000 notional threshold for cost-effectiveness in the UK. For details of the sensitivity analysis results, see Appendix 10.5.

We have made a number of simplifying assumptions in our model that could be addressed with more research. We considered the possibility that women may relapse into an abusive relationship, but we did not capture the fact that women with past histories of partner violence have a greater likelihood of entering into another abusive relationship. We also did not differentiate between women in a relatively new abusive relationship and those in longer-standing relationships or long-term harassment after they have left an abusive relationship. The latter group may take longer to change their situation. Our model draws upon the available evidence for the effect of partner violence programmes but these studies are based upon different populations and this may affect the accuracy of our findings. For instance, the main intervention effects were based on data from the PreDoVe pilot trial, based in inner city general practices with multiethnic, relatively deprived populations in the UK. The population targeted in PreDoVe were patients in primary care, and the majority of referrals were women who had not previously disclosed abuse. By contrast, our estimate of effect of advocacy came from a US study126 focused on a refuge population who had already self-identified and sought help, not necessarily in the context of health care. There is considerable uncertainty regarding both the modelling of partner violence, and the costs and quality of life for the women involved.

A limitation of the model for estimating the cost-effectiveness of screening is that the intervention was aimed at implementing routine enquiry of women presenting with a range of specific conditions, rather than a comprehensive screening programme within a health-care setting.

Chapter 11 Conclusions of the reviews and implications for health care

On the basis of our review findings, we believe that the NSC criteria are not fulfilled for a policy of screening women in health-care settings for partner violence. The main unmet criterion is evidence of improved morbidity and mortality from screening programmes (Question V). Notwithstanding the poor methodological quality of most studies of screening interventions, there is a trend for increased identification and referral to partner violence advocacy services. However, the strength of this evidence is insufficient as there is only one randomised controlled trial of a screening intervention showing a limited impact on the identification of partner violence. More importantly, there is no robust evidence that screening for partner violence has any direct benefits in terms of reducing levels of abuse or in improving the physical and psychological health of abused women. A further gap in the evidence base is that none of the screening studies has measured whether screening is associated with an increase in potential harm for abused women. Those that measured health outcomes for women, such as the cluster randomised controlled trial of Thompson and colleagues,169 would have been able to detect harm if the participants in the control group had better outcomes than those in the intervention group, but would not have been able to detect adverse events that were not outcome measures. We do know that two of the intervention studies (Question IV) found increases in bodily pain in treatment arms, although this may have been a temporary state, and arguably part of the therapeutic process. 210 The question of potential harm from a screening programme was also raised by survivors of partner violence in interview and focus group studies reported in Chapter 6, although the breaches in confidentiality they were particularly concerned about are not specific to screening. The risk of breaches of confidence should be negligible if health-care professionals have adequate training in appropriate and safe responses to disclosure of partner violence. 211 Health-care professionals also were concerned about adverse effects of screening, although the worry about offending patients raised in some of the studies reviewed in Chapter 9 was not confirmed by the survivors participating in the interviews and focus group studies or the surveys.

Acknowledgements

We would like to thank all the investigators who responded to our queries about their studies, or to our request for additional studies, or provided us with copies of their papers: Arshiva Baig, Megan Bair-Meritt, Adrian Boyle, Petra Brzank, Cheryl Buehler, Jacqueline Campbell, M. Denise Dowd, Kerstin Edin, Prem Fry, Barbara Gerbert, Felicity Goodyear-Smith, Jeanne Hathaway, Katrina Hurley, Kim Jaffe, Ellen Jamieson, Jane Knapp, Cheryl Koopman, Alice Kramer, Harriet MacMillan, Randy Magen, Brigid McCaw, Renee McDonald, Judith McFarlane, Christina Nicolaidis, Chen Ping-Hsin, Stacey Plichta, Elizabeth Powell, Gail Robinson, Judy Rollins, Lynda Sagrestano, Debra Salmon, Daniel Saunders, Amer Shakil, Kevin Sherin, Vanja Stenius, Kristina Stenson and Robert Thompson.

We would also like to thank Marie Westwood for her guidance on the assessment of screening tools, the UK Domestic Violence and Health Research forum for their comments on our preliminary review findings, and Stephen Bremner for plotting prevalence rates and the logistic regression model in Chapter 4.

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Appendix 1 Previous systematic reviews of partner violence screening

Appendix 2 Mapping of selected NSC criteria onto analytic framework for research on partner violence screening

FIGURE 4.

Adapted from Macmillan et al. , 2001. 18

Appendix 3 Quality appraisal

Appendix 4 Prevalence and health impact studies

Appendix 5 Screening tool studies