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Healthcare screening for domestic abuse

Impact on crime
Evidence quality 4
Effect
How it works
cog full Evidence quality 1
Mechanism
Where it works
where full Evidence quality 2
Moderator
How to do it
what full Evidence quality 1
Implementation
What it costs
cost empty Evidence quality 0
Economic cost

What is the focus of the intervention?

The use of screening tools to identify women attending healthcare settings who have experienced domestic abuse (defined broadly as any behaviour within an intimate relationship that causes physical, psychological or sexual harm). Screening tools range from face-to-face screening by a clinician to self-completed screening forms. All women over the age of 16 attending primary (for example General Practitioner) and secondary healthcare settings (for example antenatal clinics, women’s health/maternity services, emergency departments) are subject to screening. For those women that disclose experiencing domestic violence or abuse, screening results are assessed by the consulting healthcare professional who uses their clinical judgement as to how to respond. Universal screening is intended to increase the identification of violence and abuse and to provide further support and access to services.

This narrative is based on 13 studies covered by the review, 8 of which were included in the meta-analysis. Of those included in the meta-analysis, 4 were conducted in the United States, 3 in Canada, and 1 in Portugal.

EFFECT

How effective is it?

Overall, the evidence suggests that universal screening for domestic violence and abuse in healthcare settings has been effective.

A meta-analysis covering 8 studies found that universal screening in healthcare settings led to an increase in the identification of domestic violence and abuse victims compared to healthcare settings where no screening was conducted or where screening was undertaken but results were not passed onto a healthcare practitioner.
 
Women who were screened were almost three times as likely to mention their experience of domestic violence or abuse compared to those who were not screened. The findings were based on a total of 10,074 women across 8 studies.

How strong is the evidence?

The review was sufficiently systematic that most forms of bias that could influence the study conclusions can be ruled out. 

The evidence is taken from a systematic review covering 13 studies, 8 of which were included in the meta-analyses. The review demonstrated a high quality design in terms of having a transparent and well-designed search strategy, featuring a valid statistical analysis, sufficiently assessing the risk of bias in the analysis, and attention to the validity of the outcome constructs, with only comparable outcomes combined. However, the review did not sufficiently consider unanticipated outcomes.

Biases remain within the included primary studies. All studies were judged to have high or unclear potential for performance bias (blinding of participants and personnel).

MECHANISM

How does it work?

The review suggests that the main assumption underpinning the use of universal screening is that routinely asking women in healthcare settings about their experience of domestic abuse from a current or previous partner will increase its identification, improve access to services and support, and ultimately decrease exposure to violence/abuse and detrimental health consequences. These presumed mechanisms were not tested in the review.

MODERATORS

In which contexts does it work best?

The review examined whether the type of screening technique used or the particular healthcare setting affected the impact of universal domestic violence/abuse screening for women in healthcare settings.

  • An analysis of 4 studies suggested that the level of disclosure did not vary by screening technique (health professional/face-to-face screening or written/computer-based screening). 
  • Analysis of 2 studies suggested that the effect of universal screening on the identification of domestic violence and abuse varied considerably by health care setting. The odds of identifying victims/survivors of domestic abuse in antenatal settings were four and a half times higher in screened women compared to those who received usual care (i.e. the control group) (2 studies). There were also higher identification rates in emergency departments (over two and a half times higher than control, 3 studies) and maternal health services (two times higher than control, 1 study), but not in hospital-based primary care.

IMPLEMENTATION

What can be said about implementing this initiative?

The studies included in the review employed different screening methods; screening was either conducted directly by a healthcare professional or indirectly through a self-completion questionnaire with a healthcare professional informed of results. Screening also varied in terms of the approach used; some studies included the use of screening tools or alternatively clinicians may ask one or a range of questions related to domestic violence/abuse either at one point in time or at several points.

ECONOMIC CONSIDERATIONS

How much might it cost?

No studies included in the Review reported any data on cost-benefit or any other economic evaluation of this intervention.

General considerations

  • The studies included in the review only considered evidence from healthcare settings in high income countries.
  • Most of the studies used in the meta-analyses were conducted in either the United States or Canada and therefore caution should be taken when applying findings to other geographical contexts.
  • The authors of the review highlight that the numbers and proportions of women identified by the screening intervention were modest when considered against the estimated prevalence of domestic abuse among women in healthcare settings.
  • The review reported on referral rates for other services as one of its primary outcome measures however these have not been reported in this synthesis which focuses on crime outcomes only.
  • The review does not include crime outcomes other than the identification of domestic violence and abuse. Therefore it is not possible to report on the effect the intervention has on future experiences of abuse (i.e. whether the intervention impacts on offending behaviour).

Summary

There is evidence that universal healthcare screening for domestic violence and abuse improves levels of victim identification. The Review is based on the assumption that routinely screening women in healthcare settings will increase the identification of domestic violence and abuse. No difference in impact was detected according to the particular screening technique used (health professional/face-to-face screening or written/computer-based screening). However, healthcare setting did influence the identification of domestic violence and abuse, with the highest level of identification in antenatal settings. Additional evidence is required in relation to cost-effectiveness of universal screening in healthcare settings.

Ratings for Individual Reviews

Review 1

How it works
cog full Evidence quality 1
Mechanism
Where it works
where full Evidence quality 2
Moderator
How to do it
what full Evidence quality 1
Implementation
What it costs
cost empty Evidence quality 0
Economic cost

Resources

​Review 1: O'Doherty, L., Hegarty, K., Ramsay, J., Davidson, L.L., Feder, G. & Taft A. (2015) 'Screening women for intimate partner violence in healthcare settings (Review)', The Cochrane Collaboration

Uploaded 21/11/2017

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