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

DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16
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Chapter 11
Conclusions of the reviews and implications for
health care
On the basis of our review findings, we believe
that the NSC criteria are not fulfilled for a
policy of screening women in health-care settings
for partner violence. The main unmet criterion
is evidence of improved morbidity and mortality
from screening programmes (Question V).
Notwithstanding the poor methodological quality
of most studies of screening interventions, there
is a trend for increased identification and referral
to partner violence advocacy services. However,
the strength of this evidence is insufficient as
there is only one randomised controlled trial
of a screening intervention showing a limited
impact on the identification of partner violence.
More importantly, there is no robust evidence
that screening for partner violence has any direct
benefits in terms of reducing levels of abuse or in
improving the physical and psychological health
of abused women. A further gap in the evidence
base is that none of the screening studies has
measured whether screening is associated with
an increase in potential harm for abused women.
Those that measured health outcomes for women,
such as the cluster randomised controlled trial of
Thompson and colleagues, 169 would have been able
to detect harm if the participants in the control
group had better outcomes than those in the
intervention group, but would not have been able
to detect adverse events that were not outcome
measures. We do know that two of the intervention
studies (Question IV) found increases in bodily
pain in treatment arms, although this may have
been a temporary state, and arguably part of the
therapeutic process. 210 The question of potential
harm from a screening programme was also
raised by survivors of partner violence in interview
and focus group studies reported in Chapter 6,
although the breaches in confidentiality they were
particularly concerned about are not specific to
screening. The risk of breaches of confidence
should be negligible if health-care professionals
have adequate training in appropriate and safe
responses to disclosure of partner violence. 211
Health-care professionals also were concerned
about adverse effects of screening, although the
worry about offending patients raised in some
of the studies reviewed in Chapter 9 was not
confirmed by the survivors participating in the
interviews and focus group studies or the surveys.
To what extent are the
NSC criteria fulfilled?
Question I: What is the prevalence of partner violence
and its health consequences?
NSC criterion 1, that the condition should be an
important health problem, is met. Abuse of women
by their partners or ex-partners is widespread
internationally212 and there is no longer any debate
about the large public health impact of partner
violence, although prevalence rates and the
magnitude of health sequelae vary depending on
population and study design. However, even based
on the lower estimates for prevalence, morbidity
and mortality, it is clear that partner violence is a
potentially appropriate condition for screening and
intervention.
Question II: Are screening tools valid and reliable?
A variety of partner violence screening tools are
available, ranging from single-question tools
to 30-item research inventories. We limited our
review to screening tools comprising 12 items or
less, for ease of administration in busy healthcare
environments. NSC criterion 5 states that
the screening test should be simple, safe, precise
and validated, the distribution of test values in
the target population should be known, and a
suitable cut-off level defined and agreed. We
reviewed the diagnostic accuracy of 12 screening
tools, none of which had been evaluated in terms
of the subsequent safety of women following their
administration. Overall, the 4-item HITS (Hurts,
Insults, Threatens and Screams) screening tool
demonstrates the best predictive power, concurrent
and construct validity and reliability, with a suitable
cut-off score. It fulfils the NSC criterion and could
be used to screen for partner violence in a variety
of health-care settings. However, it does not ask
about sexual abuse or ongoing violence, and so it
may need to be administered alongside another
screening tool to detect these forms of abuse.
Alternative short screening tools, such as the WAST
and the AAS, perform almost as well as the HITS in
the health-care settings in which they were tested.
The North American context of diagnostic accuracy
studies of screening tools requires extrapolation of
these findings to the NHS, but there is no a priori
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