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

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Review Question V
primary care clinics in a cluster randomised trial
design. Utilising the Precede/Proceed model, the
intervention focused on changing practitioner
predisposing factors (such as knowledge and
attitudes), enabling factors (environmental
and infrastructure processes supporting the
intervention) and reinforcing factors (i.e. the use
of feedback). Staff attended two separate halfday
training sessions, targeting skills building
and empowering practice teams to ask about
partner violence. Additionally, four educational
sessions on skills improvement, community
resources and early results were attended, with
opinion leaders attending three extra training
sessions. In intervention sites, posters about
partner violence were displayed, cue cards given
to clinicians, and screening questionnaires and
newsletters periodically sent to participating
health-care professionals. Identification of women
experiencing partner violence at the intervention
sites had increased at 9 months’ follow-up,
although this was not significant (2% at baseline
to 4% at follow-up, odds ratio 1.5, 95% confidence
interval 0.73–3.17). At the intervention sites, the
morbidity outcomes depression and physical injury
did not improve and pelvic pain actually showed a
significant increase (from 4% to 8%, odds ratio 3.8,
95% confidence interval 1.1–12.5).
McCaw and colleagues 101 conducted a before-andafter
study with historical controls within various
departments of an HMO. Although the paper
reporting the study was entitled ‘Beyond screening
for domestic violence’, increased screening by
clinicians was an aim of the intervention. The
intervention was designed to take advantage
of existing infrastructures and to avoid taking
clinicians away from their clinical practice.
Several brief training and information sessions
were delivered to clinical staff and receptionists.
Additionally, using a systems model approach,
the HMO actively sought to improve its links
with community services, inform patients about
partner violence and appropriate services, provide
clinicians with information and prompts, and
employ an on-site domestic violence specialist.
Nine months after training started, referrals had
increased from 51 to 134. Unfortunately there was
insufficient information to determine referral rates
and no statistical analysis.
Coyer and colleagues 170 conducted a before-andafter
study in a rural, nurse-managed US healthcare
centre, testing whether the addition of a
screening protocol into the clinic would increase
the identification of violence against women. The
system-centred intervention was relatively informal
and involved discussions with nursing staff, which
identified a need for improving their knowledge
of local community resources. Due to staff interest,
two local agencies that support women in violent
situations visited the members of the clinic in order
to provide background information, local statistics,
information about the resources available and the
processes of referrals, and a strategy on how to
manage patients who gave a ‘yes’ response to the
question ‘Is anyone hurting you?’. An audit of the
medical notes 12 months prior to the intervention
revealed no notation of abuse or use of partner
violence services in any of the records. During
the 12 months after the intervention, chart audit
showed six women had notation of abuse in their
medical records, and of these, four were referred
to domestic violence refuges or the local drug
treatment facility, and one was provided with the
abuse hotline telephone number.
Women’s health services
In a parallel group study in an antenatal setting,
Wiist and McFarlane 171 provided clinic staff with
a single session of 90 minutes of didactic training
about screening for partner abuse and associated
procedures, including making referrals to an onsite
bilingual counsellor. This was supplemented
with a protocol and with weekly visits by the trainer
to provide support and for training any new staff.
Referrals at follow-up showed an increase from 0%
to 67% of women disclosing abuse at 3 months, and
53% at 12 months.
Ulbrich and Stockdale 172 used a before-and-after
design with historical controls to evaluate the
implementation, in rural family-planning clinics,
of ‘routine screening’ for partner violence. All staff
were given didactic core training, pocket cue cards
and a protocol to follow; key staff also received
intensive follow-on training over 2 years. As part
of the intervention, community-based domestic
violence agencies provided advocates. At three of
the clinics, the advocates worked mostly off-site
but attended the clinics in emergency situations;
at the fourth clinic, an on-site service was available
for 1 day per week. Due to the low numbers in the
study, only descriptive statistics were reported. For
nurse-practitioners and registered nurses, a trend
for discussing partner violence with patients on a
weekly basis increased from 19% at pretraining to
57% at the 6-month follow-up (difference 38.3%,
95% confidence interval 37.0–39.6). Self-reported
referrals over the past 3 months increased from 0%
for four or more referrals to 21% at the 6-month