Should health professionals screen women for domestic violence? Systematic reviewBMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7359.314 (Published 10 August 2002) Cite this as: BMJ 2002;325:314
- Jean Ramsay, senior research officera,
- Jo Richardson, research fellowa,
- Yvonne H Carter, professor of general practice and primary carea,
- Leslie L Davidson, directorb,
- Gene Feder, professor of primary care research and development ()a
- aDepartment of General Practice and Primary Care, Barts and the London, Queen Mary's School of Medicine and Dentistry, London E1 4NS
- bNational Perinatal Epidemiology Unit, Institute of Health Sciences, Oxford OX3 7LF
- Correspondence to: Gene Feder
- Accepted 1 May 2002
Objective: To assess the evidence for the acceptability and effectiveness of screening women for domestic violence in healthcare settings.
Design: Systematic review of published quantitative studies.
Search strategy: Three electronic databases (Medline, Embase, and CINAHL) were searched for articles published in the English language up to February 2001.
Included studies: Surveys that elicited the attitudes of women and health professionals on the screening of women in health settings; comparative studies conducted in healthcare settings that measured rates of identification of domestic violence in the presence and absence of screening; studies measuring outcomes of interventions for women identified in health settings who experience abuse from a male partner or ex-partner compared with abused women not receiving an intervention.
Results: 20 papers met the inclusion criteria. In four surveys, 43-85% of women respondents found screening in healthcare settings acceptable. Two surveys of health professionals' views found that two thirds of physicians and almost half of emergency department nurses were not in favour of screening. In nine studies of screening compared with no screening, most detected a greater proportion of abused women identified by healthcare professionals. Six studies of interventions used weak study designs and gave inconsistent results. Other than increased referral to outside agencies, little evidence exists for changes in important outcomes such as decreased exposure to violence. No studies measured quality of life, mental health outcomes, or potential harm to women from screening programmes.
Conclusion: Although domestic violence is a common problem with major health consequences for women, implementation of screening programmes in healthcare settings cannot be justified. Evidence of the benefit of specific interventions and lack of harm from screening is needed.
What is already known on this topic
Around one quarter of women in the United Kingdom have been physically assaulted by a current or former male partner
Screening for domestic violence in healthcare settings is the policy of many health professional bodies in the United States
The Department of Health recommends that health professionals should consider “routine enquiry” of women patients about whether they have experienced domestic violence
What this study adds
Screening by health professionals increases the identification of domestic violence, and many women do not object to being asked
Most health professionals surveyed do not agree with screening of women in healthcare settings
Insufficient evidence exists to show whether screening and intervention can lead to improved outcomes for women identified as abused
Implementation of screening programmes in healthcare settings is not justified by current evidence
Violence against women by male partners and ex-partners is a major public health problem, resulting in injuries and other short term and long term health consequences, including mental illness and complications of pregnancy. Exposure of children to domestic violence results in emotional, behavioural, and health problems.1 The response of health services to domestic violence is an international priority.2 In the United Kingdom many organisations of health professionals have published guidelines or recommendations.3–8 These guidelines are not identical, but they all emphasise the prevalence of domestic violence and advocate recognition, assessment, and referral within and beyond the health service. The Department of Health in England now recommends that health professionals should consider “routine enquiry” of some or all women patients for a history of domestic violence.9 This is essentially a recommendation to screen women for domestic violence in healthcare settings and echoes longstanding recommendations of organisations and accreditation bodies in North America.10
Implicit in these recommendations to undertake screening is the assumption that this will increase identification of women who are experiencing violence, lead to appropriate interventions and support, and ultimately decrease exposure to violence and its detrimental health consequences, both physical and psychological. These assumptions underlie the justification for conventional screening for the premorbid or early stage of a disease. A further assumption of the recommendations is that health professionals and female patients alike will not object to the screening process. In this review we test these assumptions.
We evaluated the evidence for screening for domestic violence in health service settings for the United Kingdom National Screening Committee.11 In reviewing the evidence, we chose to focus on three of the committee's criteria for a screening programme: firstly, that the screening test should be acceptable to the population; secondly, that there should be evidence that the complete screening programme is acceptable to health professionals (although the review focused only on the screening test); and, thirdly, that there should be an effective treatment or intervention for the problem. We also reviewed evidence on whether screening programmes increase the proportion of women identified.
Identification of primary studies
We used medical subject headings and text words to search for studies on three bibliographic databases: Medline, Embase, and CINAHL (from the start of the databases to February 2001). The specific search terms differed between the databases, but were comparable. Box 1 shows the search strategy for Medline. Limiting the results of the search to papers published in English and with online abstracts available yielded a total of 2520 potentially relevant studies. In addition to searching bibliographic databases we checked personal bibliographies, consulted other health service researchers studying domestic violence, and checked references from relevant reviews.
Box 1: Search strategy for primary studies in the review
For #1 through to #4 the “focus” facility was used. For #6 through to #47 the “explode” facility was used
#1 domestic violence
#2 battered women
#3 partner abuse
#4 spouse abuse
#5 #1 or #2 or #3 or #4 or #5
#6 communication or communication barriers or emergency medical service communication systems or hospital communication systems or persuasive communication
#7 clinical protocols
#8 diagnosis or nursing diagnosis
#9 diagnostic tests, routine
#10 evaluation studies
#11 health services accessibility
#12 education, medical or education, nursing, continuing
#13 inservice training
#14 intervention studies
#16 confidentiality or mandatory reporting
#17 mass screening
#18 medical history taking
#19 program evaluation
#21 referral and consultation
#22 self disclosure
#23 #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22
#24 attitude or attitude of health personnel or attitude to health
#25 nurse-patient relations
#26 physician-patient relations
#27 professional-patient relations
#28 knowledge, attitudes, practice
#29 perception or social perception
#30 #12 or #13 or #24 or #25 or #26 or #27 or #28 or #29
#31 adaptation, psychological
#32 consumer advocacy
#33 patient advocacy
#37 follow up studies
#38 housing or public housing
#39 nursing care
#40 community mental health services
#41 crisis intervention
#42 police or social control, formal or social work
#43 quality of life
#45 decision support systems, clinical or decision support techniques or financial support or health planning support or life support care or social support or support, non-u.s., gov't or support, u.s. gov't, non-p.h.s. or support, u.s. gov't, p.h.s
#46 stress or stress disorders, post-traumatic or stress, psychological
#47 wounds and injuries
#48 #7 or #10 or #12 or #13 or #14 or #19 or #21 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45 or #46 or #47
#49 #5 and #23
#50 #5 and #30
#51 #5 and #48
#52 #49 or #50 or #51
The above relates to the Medline search. Slightly amended versions were used for searching Embase and CINAHL
One of the reviewers applied the study inclusion criteria (table 1) to the 2520 abstracts; 2228 abstracts did not meet the criteria and were excluded at this early stage. Any abstracts that potentially fulfilled the criteria, that the reviewer was uncertain about, or that had insufficient detail went forward to the next stage of selection. Two reviewers independently read and judged the remaining 292 abstracts against the inclusion criteria. When reviewers differed, this was resolved by discussion or by a third reviewer. We obtained all papers that met the inclusion criteria or for which insufficient detail existed for inclusion or exclusion of the study. We retrieved 112 full papers: 53 reported studies of attitudes towards screening for domestic violence; 32 reported evaluations of screening programmes to increase identification of domestic violence; 23 reported intervention studies to improve outcomes related to domestic violence; and four were relevant to both the questions about increased identification and improved outcomes. Four reviewers then assessed the papers, with each paper being assessed independently by at least two reviewers. A third reviewer resolved any differences through discussion. Twenty papers (reporting on 17 studies) met the inclusion criteria12–31; we excluded the remaining 92 papers (table 2).
Data extraction and analysis
Four reviewers extracted data from the papers; two reviewers worked independently on each paper and then amalgamated the results. Discrepancies were resolved by referral back to the original papers and discussion. Data extracted included characteristics of the samples, interventions (where relevant), and design features that affected the quality of the study and the validity of the results. We applied the results of the studies to three review questions: Do women patients and health professionals find screening for domestic violence acceptable? Do screening programmes increase the identification of women who are experiencing domestic violence? Do interventions with women identified in healthcare settings improve outcomes? We did not combine the results of the studies because of the heterogeneity of interventions, outcomes, and populations. In our narrative analysis we consider the results in relation to the design and quality of the studies.
We found few good quality studies that addressed our review questions. Weaknesses in study design were common and included lack of justification for sample size, unclear sampling strategies, lack of comparability between study groups, and no monitoring of the quality of extraction of data from medical records. Some of the screening studies 18 22 23 25 and intervention studies 27 29–31 did adjust for potential confounding factors or for differences in baseline rates when comparing groups. Generally, details of methods, interventions, and results were poorly described in the papers we reviewed. We did not find any randomised controlled trials of interventions based in healthcare settings to improve outcomes. The range of outcomes was limited, and no studies measured potential risk to women of identification from screening in healthcare settings and subsequent management by health professionals. Another potential limitation of the primary studies, from the perspective of European healthcare policy, is their geographical distribution: most were from North America, with three papers from Australia or New Zealand.
Attitudes of women and health professionals to screening
Table 3 shows the main characteristics of the five studies assessing attitudes to screening, table 4 shows their designs, and table 5 summarises the results.12–16 All of the studies were conducted in the United States. Four studies elicited the views of women patients about screening.12–15 In two of these studies three quarters or more of the respondents thought that routine screening was acceptable, with no significant difference between abused and non-abused respondents. 12 13 In the other two studies just under half of all women found screening acceptable, 14 15 with abused women in one of the studies being one and a half times more likely to favour this course of action.14 The heterogeneity of these results may be partly explained by the wording of the question about screening in the different surveys. In particular, the two studies reporting lower acceptability asked if screening at all consultations was acceptable, 14 15 whereas the studies reporting a higher acceptability asked a more general question. 12 13 As far as health professionals are concerned, one study of primary care physicians in New England found one third to be in favour of routine screening.12 In a study of emergency department nurses 53% responded that nurses should routinely screen all women for a history of domestic violence.16
Identification of women experiencing domestic violence
Our conclusions regarding identification of women experiencing domestic violence are drawn from nine studies (10 papers).17–26 Tables 6, 7, and 8 show the characteristics, design, and results of these studies. The studies were mostly based in the United States, with one each in Australia, New Zealand, and Canada. Most of the studies tested the effect of applying a screening protocol containing up to five questions about abuse to all women presenting in emergency departments, primary care facilities, or antenatal clinics. Baseline rates of identification were mostly in a range of 0-3%.
Screening produced an increase in rates of identification in eight of the studies, but not in the study with the strongest design.18 This cluster randomised controlled trial in primary care did not show a significant difference in identification rates between clinics using a screening protocol and those not using a protocol. This is not explained by less education of clinicians compared with other screening programmes or by differences in the numbers of screening questions asked. Screening typically resulted in doubling of identification rates, but larger effect sizes were detected in three of the studies. 17 24 26 The most robust of the parallel group studies measured a sevenfold increase in the identification of abused women, although the small sample size resulted in wide confidence intervals for this estimate (odds ratio 6.78, 95% confidence interval 2.5 to 14.6).26 Most of the studies did not monitor identification rates beyond an initial measurement after the screening protocol or programme had been implemented. One study that did measure identification rates in an emergency department one year after implementation of a protocol found that an initial improvement in comparison with a control department was not sustained.23 Screening programmes that provided substantial additional educational and training sessions for staff did not identify a higher proportion of women experiencing abuse. 18 22 23 Programmes with multiple screening questions did not produce larger effects than those using single questions. 18 24–26
Interventions for women experiencing domestic violence
Tables 9, 10, and 11 summarise the characteristics, design, and results of the primary studies investigating interventions for women experiencing domestic violence. Six studies (nine papers) fulfilled our criteria—five from the United States 19 26–31 and one from New Zealand. 22 23 None was a randomised controlled trial, the method least prone to bias for testing the effectiveness of a health service intervention. The interventions in antenatal clinics, 26 29–31 primary care, 19 27 and emergency departments 22 23 28 included advice about services, advocacy, and counselling. We found no relation between type of intervention or type of healthcare setting and the effect of the intervention on measured outcomes.
Only two of the studies measured rates of domestic violence as outcomes. 28 31 The more robust of these, which used a parallel group design and adjusted for differences in baseline rates and potential confounding factors, detected a reduction of physical and non-physical abuse with counselling and advocacy support for women identified in antenatal clinics.31 The other study that measured violence as an outcome was based in an emergency department.28 The investigators used a weaker (time series) design and measured visits to an emergency department for injury from domestic violence rather than reports from participants. The study did not detect a reduction in violence to participants after an advocacy based intervention.
Five studies measured referral to other agencies, 19 22 26 27 and all but one found increased referral. The study that detected no difference in referral rates was similar in design to those that did but tested a different intervention entailing home visits by public health nurses rather than interventions based in a heath facility.27 Two studies measured actual use of other services by women. 28 29 One study, with a weak design (see above), detected increased use of shelter services after an advocacy based intervention in an emergency department.28 The other study, evaluating a counselling and advice intervention in antenatal clinics, with a parallel group design and adjustment for baseline differences, found no difference in use of community resources.29
We found that about half to three quarters of women patients in primary care responding to surveys think that screening for domestic violence in healthcare settings is acceptable, with a higher proportion among women who have experienced abuse. In two surveys of health professionals only a minority of doctors and half of nurses were in favour of screening. A recent study in the United Kingdom, published after the time limit of this review, also found that a minority of health professionals wish to screen women for a history of domestic violence.32 A systematic review of studies of barriers to screening for domestic violence found that healthcare professionals gave a range of reasons for not routinely asking women about domestic violence: lack of education in or experience of screening, fear of offending or endangering patients, lack of effective interventions, patients not disclosing or not complying with screening, and limited time.10
In our review we found that screening programmes generally increased rates of identification of women experiencing domestic violence in antenatal and primary care clinics and emergency departments. This concurs with Waalen et al's review of studies evaluating interventions designed to increase screening for domestic violence.10 That review also included interventions that consisted solely of education of professionals, without specific screening protocols or questions; educating professionals about domestic violence did not result in increased identification of women experiencing abuse. On the whole, the magnitude of improved identification as a result of a screening programme was modest, and we found no evidence that the improvements were sustained, as most of the studies did not measure rates beyond initial implementation.
We found little evidence for the effectiveness of interventions in healthcare settings with women who are identified by screening programmes. Randomised controlled trials are lacking, as are studies that measure important outcomes for participants, such as quality of life or mental health status. Rates of referral to outside agencies are not a convincing proxy. The primary studies we reviewed did not measure possible harm that may result from interventions initiated in healthcare settings.33
Quality of primary studies
The screening studies and intervention studies that we reviewed had substantial methodological weaknesses. All but one relied on parallel group or longitudinal designs. Most were underpowered, with only five out of nine identification studies and one out of six intervention studies justifying their sample size. No study considered possible bias in measuring outcomes. Generally, papers gave insufficient detail about data collection and analysis and about the content of the screening programme or intervention. Despite these weaknesses in the primary studies, we can still conclude that a screening protocol or programme will probably increase identification, at least in the short term, and that little evidence exists for the effectiveness of interventions.
Limitations of the review
Although our search of the three bibliographic databases was inclusive and was supplemented by personal bibliographies, references in reviews, and contact with other investigators, we may have missed relevant primary studies for several reasons: not ordering papers without abstracts on the databases, limiting the language to English, and not searching for unpublished reports. Is it likely that our review would have different conclusions if we had accessed this potentially wider pool of studies? This would only be the case if we might have found additional good quality studies from healthcare settings. We think it unlikely that those studies would be published in journals not covered by the three databases we searched.
Another limitation of our review is not extending it to the large qualitative literature on screening for domestic violence. This type of research can help to explain the attitudes of women patients and health professionals towards screening and, potentially, the variable effect of screening on identification and the variation in effect on outcomes of different interventions. Qualitative research could also help to improve the design of new interventions for responding effectively to domestic violence in healthcare settings.
In terms of developing policy for health services in the United Kingdom, our review has another potential limitation—all the studies were from North America, Australia, and New Zealand. Cultural differences may make extrapolation of the attitude surveys difficult to generalise. But our findings on the effects of screening and interventions in healthcare settings can probably be extrapolated to the United Kingdom, despite differences in the organisation and funding of health services.
From the studies we reviewed, even without considering all the criteria for a screening programme, we conclude that it would be premature to introduce a screening programme for domestic violence in healthcare settings. We know that introducing a programme is likely to increase the number of women experiencing domestic violence who are identified by health professionals, but not that subsequent interventions are effective. In order to base healthcare policy for domestic violence on evidence of safety and effectiveness we need to answer several research questions (box 2). In particular, research funders should give priority to randomised controlled trials of interventions in healthcare settings to test their effectiveness and safety for women and their families.
Box 2: Research questions
What are the benefits and risks to women of screening for domestic violence in healthcare settings?
What is the most effective screening interval?
What is the effect of participation in interventions such as provision of advocacy support on women experiencing domestic violence identified in healthcare settings?
What are the training needs of health professionals in relation to domestic violence?
How can we promote better multi-agency working in this area?
Our conclusions about the effectiveness of screening should not be interpreted as a denial of domestic violence as an important issue for healthcare providers.34 Debate is taking place among physicians in the United States regarding the validity of policies on domestic violence, partly because of lack of evidence for the effectiveness of screening.35 However, a strong consensus exists among healthcare organisations internationally that doctors and nurses should not abandon the goal of identifying and supporting women experiencing domestic violence. The high prevalence and severity of the problem and the views of women themselves require a response from health services. Health professionals need education and training to remain aware of the problem if they are to recognise women who experience domestic violence.36–40 Health services, local authorities, and the police need to coordinate their responses to domestic violence, but research is essential to develop and evaluate interagency policies. Finally, women's organisations have been instrumental in raising public and institutional awareness of domestic violence. These organisations should be involved in future policy decisions and the development of health service based interventions.
Contributors: J Ramsay performed the searches, selected papers, extracted data, and constructed the tables. J Richardson selected papers and extracted data. YHC selected papers and extracted data. GF designed the review, selected papers, and extracted data. LLD advised on the scope and design of the review. All the authors contributed to the analysis of the primary studies and the drafting and editing of the paper. GF is the guarantor.
Funding The National Screening Committee funded part of the original review on which this paper is based.
Competing interests None declared.