Time to Screen Routinely for Intimate Partner Violence?
Yes, according to the USPSTF, which says a systematic review has tipped the scale in favor of regular screening.
One good-quality RCT comparing prenatal behavioral counseling by psychologists or social workers with usual care found that the intervention led to decreased IPV up to 10 weeks postpartum and improved birth outcomes. These included a reduction in preterm births, increased mean gestational age, and decreased rates of very low birth weight, although the difference for very low birth weight was not statistically significant.
One fair-quality trial comparing home visitation by paraprofessionals with usual care for postpartum women led to lower rates of IPV for those in the home visitation group three years after the intervention.
Another study compared a counseling intervention with usual care for women who had reported recent IPV. The intervention led to a decrease in pregnancy coercion—being physically or verbally threatened with pregnancy or prevented from using contraception—and an increase in the likelihood of ending an unsafe relationship.
Two trials evaluating counseling versus wallet-sized referral cards and nurse management versus usual care during pregnancy showed improved outcomes in both the intervention and control groups, with no statistically significant difference between them.
Question 4: What are the adverse effects of screening for IPV and interventions to reduce harm? There are few—if any—adverse effects, according to three RCTs and several descriptive studies. The RCTs found no adverse effects of screening or IPV interventions. Descriptive studies showed low levels of harm among a wide range of study populations and a variety of methods. However, some women experienced loss of privacy, emotional distress, and concerns about further abuse.
WHAT’S NEW
B recommendation finalized
Given the relative safety of screening, the potential benefits of interventions for women who have positive screens, and the availability of accurate screening instruments, the USPSTF disseminated a draft recommendation that health care providers screen all women between ages 14 and 46 for IPV. (The recommendation was finalized in late January 8).
CAVEATS
Universal screening questions remain
While the findings from this systematic review led the USPSTF to upgrade its recommendation for IPV screening from a rating of I (insufficient evidence) to a rating of B (moderate to substantial benefit of screening), additional high-quality studies are needed to definitively reveal the benefit of screening.
The validity of the large multicenter RCT that found no benefit from IPV screening was compromised by high dropout rates and, potentially, by the fact that women in the control group had access to materials that increased IPV awareness. Overall, the trials included in this review ranged from fair to good quality and had relatively high and differential rates of loss to follow-up, enrollment of dissimilar groups, and concern for the Hawthorne effect (in which participants change their behavior simply as a result of being involved in a study).
What’s more, some trials used narrowly defined populations, which could limit applicability. And, while some earlier studies had found higher rates of IPV disclosure using self-administered instruments compared with face-to-face questioning, more research is needed to identify the optimal screening method.9
CHALLENGES TO IMPLEMENTATION
The right screen—and reliable follow-up
Five of the screening instruments used in studies included in this systematic review accurately identified women with past or present IPV. Three of these are suitable for use in primary care:
•
HARK, a self-administered screen (available on the Internet at www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1)
• HITS, a face-to-face screen
•
WAST, a self-administered screen
More information about the latter two screens is available at www.cdc.gov/ncipc/pub-res/images/ipvandsvscreening.pdf.
After deciding which instrument to use, primary care clinicians still must determine how to incorporate screening into a busy practice.
Finally, clinicians should not screen for IPV until reliable procedures and resources for follow-up of patients who screen positive have been identified. Resources are readily available through local and national hotline numbers. The number of the National Domestic Violence Hotline is (800) 799-SAFE.
REFERENCES
1. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the US Preventive Services Task Force recommendation. Ann Intern Med. 2012;156:796-808.
2.
National Center for Injury Prevention and Control. Costs of intimate partner violence against women in the United States. March 2003. www.cdc.gov/violenceprevention/pdf/IPVBook-a.pdf. Accessed November 7, 2012.
3. Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med. 2002;23:260-268.
4. Committee on Preventive Services for Women, IOM. Clinical preventive services for women: closing the gaps. July 2011. www.iom.edu/Reports/2011/Clinical-Preventive-Services-for-Women-Closing-the-Gaps.aspx. Accessed November 7, 2012.
5. AMA, National Advisory Council on Violence and Abuse. Policy compendium. April 2008. www.ama-assn.org/ama1/pub/upload/mm/386/vio_policy_comp.pdf. Accessed November 7 2012.
6. American College of Obstetricians and Gynecologists. Screening tools—domestic violence. www.acog.org/About_ACOG/ACOG_Departments/Violence_Against_Women/Screening_Tools__Domestic_Violence. Accessed November 7 2012.
