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

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Conclusions and implications for health care
reason why the tools should perform substantially
worse in a UK setting.
Question III: Is screening for partner violence
acceptable to women?
NSC criterion 7 is that the screening test should
be acceptable to the population. We therefore
evaluated both the quantitative and qualitative
evidence eliciting the views of women. In general,
the evidence from the survey studies of women
patients in health-care settings shows that most
agree with screening or being asked routinely about
partner violence. However, from the qualitative
studies, it is also clear that women perceive the
purpose of screening as lying outside the public
health screening framework and differently from
health-care professionals. On the whole, healthcare
professionals see screening as a method for
obtaining disclosure of abuse, which then leads
to appropriate care being offered. By contrast,
women tend to view screening as a method of
raising awareness rather than eliciting disclosure of
abuse. Thus, even though abused women may not
disclose immediately, screening may facilitate later
disclosure when the women feel more comfortable
with the health-care professional, or when their
circumstances change and they feel the need to get
help. This has implications for health service policy
in relation to screening and the training of healthcare
professionals in relation to partner violence,
as we discuss further below. Although only 2 out of
the 18 surveys were based in UK populations, their
results are consistent with the range of opinion in
the totality of studies.
Question IV: Are interventions effective once partner
violence is disclosed in a health-care setting?
NSC criterion 10 is that there should be an
effective intervention for patients identified
through early detection, with evidence of early
treatment leading to better outcomes than late
treatment. Further, the benefit from the screening
programme should outweigh the physical and
psychological harm caused by the test, diagnostic
procedures and treatment. We reviewed studies that
have evaluated the effectiveness of interventions
for women who have disclosed abuse, including
evidence from an increasing number of randomised
controlled trials. Most were targeted at women who
had already disclosed abuse, many from refuge
populations, so extrapolation to women identified
through screening is problematic. None of the
studies tested whether early detection of partner
violence leads to better outcomes. The evidence of
effectiveness of advocacy interventions is growing,
although using the USPSTF criteria for sufficiency
of evidence for policy, it is on the borderline
between insufficient and sufficient. As we discuss
in Chapter 7, this is probably too conservative a
judgment. On the whole, well-designed studies
show improvements in outcomes for women
receiving advocacy, but the evidence is strongest
for women who have actively sought help or are
already in a refuge. This evidence has informed
UK central government funding of specialist
independent domestic violence advocates (IDVAs)
attached to both statutory and voluntary agencies.
The only studies of advocacy interventions in
women identified through screening in health-care
services were based in antenatal clinics. 121,131–133 The
evidence for individual psychological interventions
is sufficient according to the USPSTF criteria,
but this is based on only three studies and, more
so than the advocacy studies, the interventions
are very heterogeneous. The evidence for
group psychological interventions and that for
mother and child programmes is insufficient as
a basis for policy. Overall, considering all types
of interventions that women might be offered
following disclosure, there is still uncertainty about
their effectiveness. However, there is little evidence
that they are ineffective. As none of the controlled
studies of interventions was based in the UK, the
uncertainty about their effectiveness within the
NHS is even greater.
Question V: Can mortality or morbidity be reduced
following screening?
This question addresses NSC criterion 13,
that there must be evidence from high-quality
randomised controlled trials that the screening
programme is effective in reducing mortality or
morbidity. We extended the review to include proxy
outcomes for improved morbidity and mortality,
particularly referral to partner violence advocacy
and other community support agencies following
screening. We found no studies that directly
measured morbidity and mortality. Although
most of the studies measuring proxies showed
improvements in these outcomes, study design and
execution were generally poor. The most robust
study methodologically showed the least effect on
identification rates. There was no measurement of
potential harms of screening, although these were
raised by women and health-care professionals
in the qualitative studies. Criterion 13 remains
unfulfilled. As none of the studies was based in the
UK, this is even more the case for NHS policy than
it is for US health-care policy.