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

DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16
follow-up (difference 21.4%, 95% confidence
interval 20.0–22.8).
Accident and emergency
department
In a before-and-after study with historical
controls, Ramsden and Bonner 173 evaluated the
implementation of screening by nursing staff of
all women aged over 15 years. The staff training
focused on partner violence, screening protocols
and a referral pathway. Information about
resources, including local services and contact
numbers, was also provided. Regardless of the
patient’s response, all screened women were
supposed to receive an information resource card.
The duration and frequency of training was not
stated. No data were presented on adherence to
the protocol or on identification rates. It was found
that the number of referrals to a social worker or to
the police nearly doubled (8 compared with 14) as
compared with preintervention numbers. However,
the authors did not report enough information
for referral rates to be calculated; neither did they
report the findings of any statistical analyses.
Home visit
The before-and-after study with historical controls
conducted by Shepard and colleagues 174 differed
from the others in that the health professionals who
were instrumental in the intervention were nurses
who routinely visited women in their own homes
as part of a maternal and child health programme.
For this project, the nurses received training in
partner violence, and a partner violence response
protocol was developed to increase referrals and
information-giving. The protocol included a
general question about the women’s history of
abuse. Two years after the protocol was introduced,
the authors reported that referral rates increased
from 3% at preintervention to 17%. This positive
trend was not statistically significant; however, the
data on referral before and after the intervention
were not fully comparable. Increases were found
in both information-giving by nurses following the
intervention (0.03% to 78%) and identification of
partner violence (6% to 9%), although only the
former was significant.
Sensitivity analyses
When considering outcomes by settings, systemlevel
screening interventions in primary care and
women’s health clinics are more effective than
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those within accident and emergency departments
and home visits. Some of the studies did not
adequately report data on referral outcomes, or
combined several different outcomes under one
category; thus it is hard to judge changes in these
outcomes.
In terms of study quality, only one study 169 had the
‘greatest’ strength of design and a ‘fair’ execution
rating. The other seven studies rated ‘poor’ for
execution and ‘moderate’ for strength of study
design, most using a before-and-after method.
Details of the assessment of execution of individual
studies are in Appendix 8.3. Due to all but one
of the studies having a poor execution rating,
there is insufficient evidence for system-centred
interventions increasing identification, referral and
other activities aimed at reducing morbidity and
mortality. The lack of variation in study quality
precludes a detailed sensitivity analysis by quality.
Yet it is striking that the highest quality study, 169
and the only randomised controlled trial, did not
find a significant increase in identification.
Strengths and limitations
By extending to proxy outcomes it was possible
to explore the potential benefit of system-based
screening interventions. For those studies where
no statistical analysis was given, we calculated
95% confidence intervals for differences in the
proportions if absolute numbers were reported,
thus allowing some assessment of the precision
of the comparisons reported by the authors. The
USPSTF quality appraisal criteria were used to
rate the primary studies. This not only gives us
a measure of internal and external validity, but
also the strength of evidence of the studies as a
whole. This review fulfils the relevant QUORUM
reporting criteria (see Appendix 11.6 for
QUORUM checklist and flowchart).
Limitations are twofold, those arising from
our review and those related to the primary
studies. Excluded studies included those that
only measured identification; it may well be that
an intervention could have excellent efficacy
in increasing detection rates, or improving
the rapport and communication skills of staff,
which improves patient disclosure. However,
identification is a necessary but not sufficient
condition of improved outcomes for women, and
the additional activity inclusion criterion brings
it further along a causal pathway towards patient
benefit. Limitations of some of the primary studies
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