How far does screening women for domestic (partner) - NIHR Health ...

DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16
© 2009 Queen’s Printer and Controller of HMSO. All rights reserved.
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.
Health-care setting
Primary care, community
clinics and health maintenance
organisations
Harwell and colleagues 168 used a before-and-after
design with a 3-month follow-up at community
health centres in the USA. The effects of the
RADAR (Routine screening; Ask direct questions;
Document your findings; Assess patient safety;
Review patient options and referrals) training
project was assessed via medical chart reviews,
extracting data that allowed calculation of relative
risk for screening being performed, suspicion
and identification of partner violence, safety
assessment, documentation of abuse, and referral
to internal and external partner violence services.
Training of all community health centre staff in the
intervention group was 3–6 hours. Using trauma
theory as a framework, it included a video on the
emotional impact of partner violence, introduction
to the use of and modelling of RADAR, and a
survivor’s story. Follow-up support tailored to the
needs of the centre staff continued for 2 years
after training. Baseline measurements taken at
pretraining for both phases were used as control
data. During the intervention period women were
more likely to have partner violence suspected
(2% versus 6%, relative risk 1.49, 95% confidence
interval 1.13–1.99), to have a safety assessment
performed (5% versus 17%, relative risk 1.65, 95%
confidence interval 1.39–1.97) and to be referred
to an outside agency (0% versus 4%, relative risk
1.81, 95% confidence interval 1.45–2.28) compared
with women in the baseline period. The authors
state no differences were found for confirmation
of partner violence; however, reported confidence
intervals suggest a significant effect (2% versus 5%,
relative risk 1.49, 95% confidence interval 1.08–
1.97). This study showed improved proxy outcomes
after implementation of RADAR.
Thompson and colleagues 169 studied the impact
of a system-based intervention to implement
screening and effective responses to disclosure
of partner violence in an HMO, recruiting five
59