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26 Review Question I problems in social functioning, the relationship between witnessing partner violence and the social functioning of these children remains unclear, with the majority of recent studies finding no significant relationship. Eight studies assessed cognitive functioning; three of these had been conducted since the previous review. Except for the findings of Christopoulos and colleagues, 74 the recently conducted studies all found that children who witness abuse are at risk for problems in cognitive functioning. However, the limited number of recent studies makes it difficult to draw firm conclusions of a cause–effect relationship, and no mention is made of the quality of these studies. Ten of the studies examined physical health. One of the only two studies using standardised measures suggested a causal relationship after finding clinical levels of somatic complaints among witnesses of abuse. The second study did not find any neurological deficit among such children, and evidence of a causal link between exposure to violence and health problems remains equivocal. The reviewers concluded that although there is still some uncertainty about the magnitude and consistency of detrimental effects on children’s social, cognitive and physical development, the evidence for effects on children’s emotional and behavioural development is far less equivocal. Strengths and limitations The strengths of this review of prevalence and health impact studies include the independent quality appraisal of primary studies by two reviewers (using the STROBE quality appraisal tool for prevalence studies and the CASP systematic review tool for health impact reviews) and the sensitivity analysis based on study quality. These reviews fulfil the QUORUM and most of the MOOSE reporting criteria lines (see Appendix 11.1 for MOOSE criteria and Appendix 11.2 for a flowchart of this review). Limitations of this review include the small number (six) of databases searched for studies, and the exclusion of reviews of health impact conducted prior to 1990 and prevalence studies conducted prior to 1995. Limitations of the primary prevalence studies include investigators’ modification of instruments to measure partner violence without reporting how, or if, the adapted version of the instrument was validated. Comparisons between the studies were problematic because of different definitions of partner violence, different questions to establish the presence of partner violence and different questionnaire administration methods. Limitations of the reviews of health impact studies include a lack of detailed reporting of search strategies, no quality appraisal of primary studies and no pooling of data. A major limitation in the field of domestic violence research is the absence of systematic reviews of physical consequences synthesising primary studies. Discussion The reviews provide strong evidence that partner violence can have a substantial detrimental effect on mental health. Evidence for the impact on pregnancy is more equivocal, but it is likely that low birthweight is a consequence of abuse during pregnancy. Recent studies on the impact on children show a greater prevalence of behavioural and mental health problems among children who witness partner violence, as well as diminished educational attainment. When the betterquality systematic reviews are considered, the findings on mental health, pregnancy and child health consequences are similar to the overall findings, although comparison between reviews is problematic because they report different outcomes. Synthesis of prevalence and health impact studies Differences in definition, methodology, sampling and assessment make it difficult to estimate precisely the prevalence of partner violence in the UK. Nonetheless, the studies reported here delineate the lower boundaries of partner violence prevalence, although possibly not the upper limit as under-reporting is likely. It is unarguable that partner violence against women is a common problem. To fulfil the NSC screening criterion for an important health problem, it also has to have a substantial impact on health. The reviews of health impact that we have considered, notwithstanding heterogeneity of morbidity estimates associated with partner violence, demonstrate that partner violence significantly increases the risk of mental illness and substance abuse and is likely to increase the risk of pregnancy complications. We have not systematically reviewed individual studies of other health problems associated with partner violence, but they probably support the conclusion that partner violence has a substantial and persistent detrimental effect on the health of women. The most consistent and largest physical health difference between abused and non-abused
DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16 women is in the prevalence of gynaecological problems. 75 Population-based studies from the USA show that the likelihood of abused women having gynaecological symptoms is three times greater than average. 76 Other conditions include chronic pain and neurological symptoms, 75 gastrointestinal © 2009 Queen’s Printer and Controller of HMSO. All rights reserved. disorders 77 and self-reported cardiovascular conditions. 78 The evidence for the substantial effect of partner violence on population health includes the results from the systematic reviews of outcomes on children that we have reported here. 27
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