One year follow-up of an emergency department protocol for abused women

Intimate partner violence screening in emergency department: a rapid review of the literature

AIMS AND OBJECTIVES

The aim of the review was to identify intimate partner violence screening interventions used in emergency departments and to explore factors affecting intimate partner violence screening in emergency departments.

BACKGROUND

Intimate partner violence against women is now clearly recognised as a global health and societal issue. Nurses working in emergency and urgent care settings can play a crucial role in identification, prevention and management of intimate partner violence. Research exploring optimal methods of intimate partner violence screening and factors affecting intimate partner violence screening in emergency departments are relatively limited.

DESIGN

Literature review: Rapid Evidence Synthesis.

METHODS

Literature published between 2000-2015 was reviewed using the principles of rapid evidence assessment. Six electronic databases: CINAHL, MEDLINE, EMBASE, Psych Info, the Cochrane Library and Joanna Briggs Library.

RESULTS

Twenty-nine empirical studies meeting the eligibility criteria were independently assessed by two authors using appropriate Critical Appraisal Skills Programme Checklists. Intimate partner violence screening in emergency departments is usually performed using electronic, face to face or pen- and paper-based instruments. Routine or universal screening results in higher identification rates of intimate partner violence. Women who screen positive for intimate partner violence in emergency departments are more likely to experience abuse in subsequent months. Factors that facilitate partner violence screening can be classified as healthcare professionals related factors, organisational factors and patient-related factors.

CONCLUSIONS

Emergency departments provide a unique opportunity for healthcare professionals to screen patients for intimate partner violence. Competence in assessing the needs of the patients appears to be a very significant factor that may affect rates of intimate partner violence disclosure.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of appropriate domestic violence screening methods and factors affecting intimate partner violence screening in emergency can help nurses, and other healthcare professionals provide patient-centred and effective care to victims of abuse attending emergency department.

Understanding sustained domestic violence identification in maternal and child health nurse care: process evaluation from a 2-year follow-up of the MOVE trial

AIM

To investigate factors contributing to the sustained domestic violence screening and support practices of Maternal and Child Health nurses 2 years after a randomized controlled trial.

BACKGROUND

Domestic violence screening by healthcare professionals has been implemented in many primary care settings. Barriers to screening exist and screening rates remain low. Evidence for longer term integration of nurse screening is minimal. Trial outcomes showed sustained safety planning behaviours by intervention group nurses.

DESIGN

Process evaluation in 2-year follow-up of a cluster randomized controlled trial.

METHODS

Evaluation included a repeat online nurse survey and 14 interviews (July-September 2013). Survey analysis included comparison of proportionate group difference between arms and between trial baseline and 2 year follow-up surveys. Framework analysis was used to assess qualitative data. Normalization Process Theory informed evaluation design and interpretation of results.

RESULTS

Survey response was 77% (n = 123/160). Sustainability of nurse identification of domestic violence appeared to be due to greater nurse discussion and domestic violence disclosure by women, facilitated by use of a maternal health and well-being checklist. Over time, intervention group nurses used the maternal checklist more at specific maternal health visits and found the checklist the most helpful resource assisting their domestic violence work. Nurses' spoke of a degree of 'normalization' to domestic violence screening that will need constant investment to maintain.

CONCLUSION

Sustainable domestic violence screening and support outcomes can be achieved in an environment of comprehensive, nurse designed and theory driven implementation. Continuing training, discussion and monitoring of domestic violence work is needed to retain sustainable practices.

The health-systems response to violence against women

Health systems have a crucial role in a multisector response to violence against women. Some countries have guidelines or protocols articulating this role and health-care workers are trained in some settings, but generally system development and implementation have been slow to progress. Substantial system and behavioural barriers exist, especially in low-income and middle-income countries. Violence against women was identified as a health priority in 2013 guidelines published by WHO and the 67th World Health Assembly resolution on strengthening the role of the health system in addressing violence, particularly against women and girls. In this Series paper, we review the evidence for clinical interventions and discuss components of a comprehensive health-system approach that helps health-care providers to identify and support women subjected to intimate partner or sexual violence. Five country case studies show the diversity of contexts and pathways for development of a health system response to violence against women. Although additional research is needed, strengthening of health systems can enable providers to address violence against women, including protocols, capacity building, effective coordination between agencies, and referral networks.

Measuring the effectiveness of an intensive IPV training program offered to Greek general practitioners and residents of general practice

BACKGROUND

The need for effective training of primary care physicians in the prevention, detection and handling of intimate partner violence (IPV) has been widely acknowledged, given its frequency in daily practice. The current intervention study aimed to measure changes in the actual IPV knowledge, perceived knowledge, perceived preparedness and detection ability of practicing general practitioners (GPs) and general practice residents, following an intensive IPV training program.

METHODS

A pre/post-test design with a control group was employed to compare changes in baseline measures of IPV at the post intervention stage and at 12 months. A total of 40 participants provided full data; 25 GPs (11 in the intervention and 14 in the control) and 15 residents (intervention only). Three scales of the PREMIS survey were used to draw information on the study outcomes.

RESULTS

The training program met high acceptance by both groups of participants and high practicality in clinical practice. The GPs in the intervention group performed better than the GPs in the control group on "Perceived preparedness" and "Perceived knowledge" in both the post-intervention (p= .012, r= .50 and p= .001, r= .68) and the 12-month follow-up (p= .024, r= .45 and p= .007, r= .54) as well as better than the residents in "Perceived preparedness" at post-intervention level (p= .037, r= .41). Residents on the other hand, performed better than the GPs in the intervention group on "Actual knowledge" at the 12-month follow-up (p= .012, r= .49). No significant improvements or between group differences were found in terms of the self-reported detection of IPV cases.

CONCLUSION

Further studies are needed to decide whether residency training could serve as an early intervention stage for IPV training.

An integrated health sector response to violence against women in Malaysia: lessons for supporting scale up

Background

Malaysia has been at the forefront of the development and scale up of One-Stop Crisis Centres (OSCC) - an integrated health sector model that provides comprehensive care to women and children experiencing physical, emotional and sexual abuse. This study explored the strengths and challenges faced during the scaling up of the OSCC model to two States in Malaysia in order to identify lessons for supporting successful scale-up.

Methods

In-depth interviews were conducted with health care providers, policy makers and key informants in 7 hospital facilities. This was complemented by a document analysis of hospital records and protocols. Data were coded and analysed using NVivo 7.

Results

The implementation of the OSCC model differed between hospital settings, with practise being influenced by organisational systems and constraints. Health providers generally tried to offer care to abused women, but they are not fully supported within their facility due to lack of training, time constraints, limited allocated budget, or lack of referral system to external support services. Non-specialised hospitals in both States struggled with a scarcity of specialised staff and limited referral options for abused women. Despite these challenges, even in more resource-constrained settings staff who took the initiative found it was possible to adapt to provide some level of OSCC services, such as referring women to local NGOs or community support groups, or training nurses to offer basic counselling.

Conclusions

The national implementation of OSCC provides a potentially important source of support for women experiencing violence. Our findings confirm that pilot interventions for health sector responses to gender based violence can be scaled up only when there is a sound health infrastructure in place – in other words a supportive health system. Furthermore, the successful replication of the OSCC model in other similar settings requires that the model – and the system supporting it – needs to be flexible enough to allow adaptation of the service model to different types of facilities and levels of care, and to available resources and thus better support providers committed to delivering care to abused women.

Universal screening for intimate partner violence: a systematic review

Intimate partner violence (IPV) is known to be prevalent among therapy-seeking populations. Yet, despite a growing understanding of the dynamics of IPV and of the acceptability of screening, universal screening practices have not been systematically adopted in family therapy settings. A rapidly growing body of research data-almost entirely conducted in medical settings-has investigated attitudes and practices regarding universal screening for IPV. This article is a systematic review of the IPV universal screening research literature. The review summarizes literature related to IPV screening rates and practices, factors associated with provider screening practice, the role of training and institutional support on screening practice, impact of screening on disclosure rates, client beliefs and preferences for screening, and key safety considerations and screening competencies. Implications for family therapy and recommendations for further inquiry and screening model development are provided.

Self-administered questionnaire versus interview as a screening method for intimate partner violence in the prenatal setting in Japan: a randomised controlled trial

Background

Intimate partner violence (IPV) is a serious social issue in Japan. In order to start effective interventions for abused women, the appropriate method of screening for IPV in healthcare settings needs clarifying. The objective of this study was to compare the effectiveness of a face-to-face interview with a self-administered questionnaire. We used the Violence Against Women Screen (VAWS), a Japanese screening instrument for intimate partner violence (IPV), for identifying pregnant women who have experienced abuse.

Methods

We conducted a randomised controlled trial to screen participants at three points in time in a prenatal clinic in Tokyo, Japan. There were 328 consenting women between 14 and 25 weeks of pregnancy who were consecutively selected and randomly assigned to either the interview or self-administered questionnaire group. Both groups completed the same screening instrument three times during their pregnancy. The primary outcome was the total number of women identified by each screening method and the secondary outcome was the effect of the screening as measured by the women's comfort level and their expressed need to consult with the nurse.

Results

For all three screenings, the identification rate in the interview group was significantly lower than that for the self-administered questionnaire group (relative risk 0.66, 95% CI 0.46 to 0.97), even after controlling for smoking (adjusted odds ratio 0.59, 95% CI 0.35 to 0.98). The two groups did not differ for secondary outcomes.

Conclusions

The self-administered questionnaire identified more IPV than the face-to-face interview when screening pregnant women in a Japanese prenatal clinic.

Trial Registration

UMIN-CTRC000000353

Help-seeking behaviors and reasons for help seeking reported by a representative sample of women victims of intimate partner violence in New Zealand

Efforts to understand and support the process of help seeking by victims of intimate partner violence are of considerable urgency if we are to design systems and responses that are capable of actively and appropriately meeting the needs of victims. Using data from the New Zealand Violence Against Women Study, which drew from a representative general population sample of women aged 18 to 64 years, the authors report on the help-seeking behaviors of the women who had ever in their lifetime experienced physical and/or sexual violence by an intimate partner (n = 956). More than 75% of respondents reported that they had told someone about the violence, indicating that it is not necessarily a "secret and private" problem. However, more than 40% of women indicated that no one had helped them. Informal sources of support (family and friends) were most frequently told about the violence but not all provided helpful responses. Fewer women told formal sources of help such as police, health care providers, and not all provided helpful responses. Women's reasons for seeking help and for leaving violent relationships were similar and included "could not endure more," being badly injured, fear or threat of death, and concern for children. Women's reasons for staying in or returning to violent relationships included perception of the violence as "normal/not serious," her emotional investment in the relationship, or staying for the sake of the children. The findings suggest that broader community outreach is required to ensure that family and friends are able to provide appropriate support for women in abusive relationships who are seeking help. Continued improvement in institutional responses is also required.

Care provided in visits coded for intimate partner violence in a national survey of emergency departments

PURPOSE

This article describes the health status of and care provided to patients in visits coded to intimate partner violence (IPV) victims in a national survey of emergency departments (EDs). Visits coded for IPV were defined by International Classification of Diseases, 8th edition-Clinical Modification (ICD-9-CM) codes.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey for 1997-2001 were analyzed. The sample consisted of 111 ED visits with ICD codes for IPV (or 12 IPV visits per 10,000 ED visits, and 21 female IPV visits per 10,000 female ED visits).

FINDINGS

The majority of visits coded to IPV were for patients who presented with mild to moderate pain (86%), physical or sexual violence (50%), and injuries to the body (38%). The majority of patients in visits coded to IPV received radiologic testing, wound care, and pain medications (odds ratios [ORs], 1.6, 3.3, and 2.3 respectively). Disposition was mostly referral to another physician or clinic (42%) or return to the ED when needed (20%), but much less to nonphysician services such as social services, support services, and shelters (14%). Uninsured IPV patients were more likely to receive radiologic testing and pain medications (ORs 5.1 and 3, respectively). Patients seen by nurses were 9 times more likely to receive wound care.

CONCLUSION

Caution should be exercised when interpreting the study results because they reflect only coded IPV visits in the ED and these might be the most obvious IPV cases. The results signal the need for further studies to evaluate access to and the quality of care for IPV patients and to improve screening, documentation, coding, and management practices.

Visits coded as intimate partner violence in emergency departments: characteristics of the individuals and the system as reported in a national survey of emergency departments

INTRODUCTION

This study was conducted to explore the characteristics of intimate partner violence (IPV) victims whose visit was coded as IPV and the health care delivery system in emergency departments (ED).

METHODS

This study utilized a secondary data analysis of a national probability sample that comprised the National Hospital Ambulatory Medical Care Survey for 1997 to 2001.

RESULTS

There were 111 coded ED visits of IPV victims 16 years or older (equivalent of 482,979 out of 4 million national visits for the 5-year study period). Women (94%), African Americans (35%), those 25 to 44 years of age (64%), and uninsured patients (38%) were significantly more likely to be categorized as an IPV visit (odds ratios 14, 1.9, 2.7, and 2.4, respectively) compared with non-IPV visits. Characteristics of the health care delivery system (region, metropolitan vs. non-metropolitan, type of hospital, and type of health care provider) were not associated with IPV.

DISCUSSION

Caution should be implemented when interpreting the study results because they represent only coded IPV visits in the emergency department. The study findings suggest the critical need to improve identification, documentation, and coding of IPV visits.

Does screening in the emergency department hurt or help victims of intimate partner violence?

STUDY OBJECTIVE

Recent systematic reviews have noted a lack of evidence that screening for intimate partner violence does more good than harm. We assess whether patients screened for intimate partner violence on a computer kiosk in the emergency department (ED) experienced any adverse events during or subsequent to the ED visit and whether computer kiosk identification and referral of intimate partner violence in the ED setting resulted in safety behaviors or contact with referrals.

METHODS

We conducted a prospective, observational study in which a convenience sample of male and female ED patients triaged to the waiting room who screened positive (on a computer kiosk-based questionnaire) for intimate partner violence in the past year were provided with resources and information and invited to participate in a series of follow-up interviews. At 1-week and 3-month follow-up visits, we assessed intimate partner violence, safety issues, and use of resources. In addition, to obtain an objective measure of safety, we assessed the number of violence-related 911 calls to participant addresses within a call district 6 months before and 6 months after the index ED visit.

RESULTS

Of the 2,134 participants in a relationship in the last year, 548 (25.7%) screened positive for intimate partner violence. No safety issues, such as calling security or a partner's interference with the screening, occurred during the ED visit for any patient who disclosed intimate partner violence. Of the 216 intimate partner violence victims interviewed in person and 65 contacted by telephone 1 week later, no intimate partner violence victims reported any injuries or increased intimate partner violence resulting from participating in the study. For the sample in the local police district, there was no increase in the number of intimate partner violence victims who called 911 in the 6 months after the ED visit. Finally, 35% (n=131) reported they had contacted community resources during the 3-month follow-up period.

CONCLUSION

Among patients screening positive for intimate partner violence, there were no identified adverse events related to screening, and many had contacted community resources.

Improving detection and quality of assessment of child abuse and partner abuse is achievable with a formal organisational change approach

AIM

To improve detection and quality of assessment of child and partner abuse within a health service.

METHODS

A formal organisational change approach was used to implement the New Zealand Family Violence Intervention Guidelines in a mid-sized regional health service. The approach includes obtaining senior management support, community collaboration, developing resources to support practice, research, evaluation and training. Formal pre-post evaluations were conducted of the training. Barriers and enablers of practice change were assessed through 85 interviews with 60 staff. More than 6000 clinical records were audited to assess rates of questioning for partner abuse. Identifications of partner abuse and referrals made were counted through the Family Violence Accessory File. Referrals to the Department of Child, Youth and Family Services (CYFS) were recorded routinely by the CYFS. Audits assessed quality of assessment of child and partner abuse, when identified.

RESULTS

More than 700 staff were trained in dual assessment for child and partner abuse. Evaluations demonstrate improved confidence following training, though staff still need support. Barriers and enablers to asking about partner abuse were identified. Referrals from the health service to the CYFS increased from 10 per quarter to 70 per quarter. Identification of partner abuse increased from 30 to 80 per 6-month period. Routine questioning rates for partner abuse vary between services.

CONCLUSION

Achieving and sustaining improved rates of identification and quality of assessment of child and partner abuse is possible with a formal organisational change approach.

Domestic violence screening rates in a community health center urgent care clinic

We describe the screening rates obtained in the first year of implementation of a universal domestic violence screening protocol by nurses in the urgent care clinic of a Canadian community health center. Rates were calculated using data extracted from electronic patient health records, and a random patient chart pull. Qualitative methods provided additional information. Screening rates were considerably higher and were maintained longer than those recorded in similar settings reported in the literature. Leadership, including monitoring of documentation rates, was key to maintaining higher than average rates. Asking all patients in urgent care settings about domestic violence may improve overall screening rates and play an important role in public education.

Care for emergency department patients who have experienced domestic violence: a review of the evidence base

AIMS

A literature review was conducted to identify and evaluate the research base underpinning care for emergency department patients who have experienced domestic violence.

BACKGROUND

The extent of domestic violence in the general population has placed it high on health and social policy agendas. The Department of Health has recognized the role of health care professionals to identify and provide interventions for patients who have experienced domestic violence.

METHOD

Systematic review.

RESULTS

At least 6% of emergency department patients have experienced domestic violence in the previous 12 months although actual prevalence rates are probably higher. Simple direct questioning in a supportive environment is effective in facilitating disclosure and hence detecting cases of abuse. Although routine screening is most effective, index of suspicion screening is the current mode of practice in the UK. Index of suspicion screening is likely to contribute to under-detection and result in inequitable health care. Patients with supportive networks have reduced adverse mental health outcomes. Women will have negative perceptions of emergency care if their abuse is minimalized or not identified. Women want their needs and the needs of their children to be explored and addressed. Access to community resources is increased if patients receive education and information.

CONCLUSION

Domestic violence is an indisputable health issue for many emergency department patients. Practitioners face challenges from ambiguity in practice guidelines and the paucity of research to support interventions. Recommendations for practice based on the current evidence base are presented.

RELEVANCE TO CLINICAL PRACTICE

The nursing care for patients in emergency and acute health care settings who have experienced domestic violence should focus on three domains of: (1) Providing physical, psychological and emotional support; (2) Enhancing safety of the patient and their family; (3) Promoting self-efficacy.

"I am not frustrated anymore". Family doctors' evaluation of a comprehensive training on partner abuse

OBJECTIVE

The aim of this study was to discover the ways in which a training program on intimate partner abuse affected a doctor's daily practice.

METHODS

Eighteen family doctors who participated in a training program on partner abuse were interviewed.

RESULTS

The interviewees evaluated the training program to be useful in raising their awareness and suspect criteria on partner abuse. Any questions and frustrations they had concerning the subject were resolved. They felt more confident and equipped to discuss and aid abused patients after the training.

CONCLUSION

In order to improve doctors' awareness of partner abuse in daily practice, they must need first realize the scale of the problem and then become more comfortable in their own attitude and finally more confident in their ability to aid these patients.

PRACTICE IMPLICATIONS

Training on partner abuse should be specifically tailored to change awareness, attitudes and consultation skills.

Violence against women as a public health issue

Violence can be considered "infectious" in rape-prone cultures that celebrate violence and domination. The number of annual injuries and deaths due to violence against women and girls is high enough to demand the type of active interventions and public policies that have been targeted at infectious diseases by public health agencies. In this article, we review data on the physical and mental health effects that violence has on victims of domestic violence, rape, stalking, and sexual harassment. We also focus on the economic costs to the health care system, business and industry, families, and the broader society that accrue as a result of the widespread violence against women and girls. Victims' suffering can never be accounted for by economic data, but those data may be helpful in pushing governments to allocate funds and agencies to take preventive actions.

Successful integration and maintenance of screening for domestic violence in the health sector: moving beyond individual responsibility

Domestic violence (DV) screening and prevention interventions have been implemented in the health sector; however, few health care settings have successfully implemented protocols that have been fully integrated and sustained within the larger organization. Researchers have tended to focus on individual-level characteristics of health care providers to explain this. The authors argue that organizational, structural, social, and cultural factors, especially related to gender, also play roles in adoption and integration of these interventions. It is important for policy analysts and program evaluators to use this larger framework to ensure sustainable integration of DV screening programs within health care systems.

Physical violence against women: Evaluation of women assaulted by spouses

OBJECTIVE

To investigate the characteristic of physical violence against women sent to the Forensic Medicine Council for the forensic reports with a history of being assaulted by their spouses.

METHODS

One hundred and thirty five women attending judicial institutions from August 1st 2000 to January 31st 2001 were interviewed. The demographic characteristics of assaulted women and their spouses, time of violence, beginning and continuation of violence after marriage, frequency of violence, women's judgment of the reason for being assaulted, violence against children by the husbands, history of violence in the husbands' family, the husbands' manner at home, women' attitudes against violence, existence and type of physical trauma and injury severity according to Turkish Penalty Law were evaluated. The data were analyzed using chi(2) test and percent ratios.

RESULTS

The majority of both women and their husbands had been born in rural areas (73.3% and 71.1%, respectively). Approximately three quarters of the men and women had secondary school or lower education levels (80.7% and 81.5%, respectively). Most women (63.7%) and 17.8% of men were unemployed. For the most part, women were assaulted between 18.01 and 06.00 h (73.3%). Nearly 80% of husbands had at least one 'bad' habit such as alcohol intake and gambling. 60.7% of the assaulted women did not react to their spouses' violence. The most frequently encountered result of violence was soft tissue lesions (91.9%). After being assaulted nearly all of the women (91.9%) were provided with forensic reports advising of between 1 and 7 days of inability to follow ordinary pursuits.

CONCLUSION

Women from all socioeconomic-cultural levels reported a history of partner violence. Routine screening with structured questions during visits to doctors is necessary in order to identify assaulted women so as to prevent potential violence and to interrupt existing violence.

A randomised controlled trial of empowerment training for Chinese abused pregnant women in Hong Kong

OBJECTIVE

To evaluate the effectiveness of an empowerment intervention in reducing intimate partner violence (IPV) and improving health status.

DESIGN

Randomised controlled trial.

SETTING

Antenatal clinic in a public hospital in Hong Kong.

SAMPLE

One hundred and ten Chinese pregnant women with a history of abuse by their intimate partners.

METHODS

Women were randomised to the experimental or control group. Experimental group women received empowerment training specially designed for Chinese abused pregnant women while the control group women received standard care for abused women. Data were collected at study entry and six weeks postnatal.

MAIN OUTCOMES MEASURES

IPV [on the Conflict Tactics Scale (CTS)], health-related quality of life (SF-36) and postnatal depression [Edinburgh Postnatal Depression Scale (EPDS)].

RESULTS

Following the training, the experimental group had significantly higher physical functioning and had significantly improved role limitation due to physical problems and emotional problems. They also reported less psychological (but not sexual) abuse, minor (but not severe) physical violence and had significantly lower postnatal depression scores. However, they reported more bodily pain.

CONCLUSION

An empowerment intervention specially designed for Chinese abused pregnant women was effective in reducing IPV and improving the health status of the women.

Domestic violence: an approach to identification and intervention

DV encompasses a wide variety of actions that coerce, control, or demean the victim. Victims of DV suffer many physical and mental health consequences that cause emergency physicians to encounter them knowingly or unknowingly in the medical setting. Physicians who are aware of the prevalent problem of DV are able to help victims the most. A physician should be educated to recognize the physical and emotional presentations of victims, but, more importantly, the physician should be knowledgeable about the need for screening of all patients to reach the greatest number of victims. Victims often are not ready or able to disclose DV because of patient and physician barriers. Clinicians should work to overcome these barriers by initiating screening, ensuring patient comfort and safety, and understanding the many stages involved in behavioral change that a victim must traverse. The emergency physician would experience less frustration and more success if he or she would change their role from problem solver to listener and empowerer. This approach allows the survivor to make informed choices. Patients who are ready to make changes must be provided with protection,treatment, resources, and support. Informed, active physicians have great potential for improving DV victims' lives, reducing the effects of violence,and facilitating the patient's progression from victim to survivor.

Screening for partner violence: direct questioning or self-report?

OBJECTIVE

To compare the effectiveness of a self-report checklist with a standard set of direct questions in identifying women who are experiencing domestic partner violence.

METHODS

Medical records were reviewed for evidence of positive partner violence for women attending the Royal Brisbane and Women's Hospital prenatal clinic between August and September 2002.

RESULTS

Records (n = 1,596) were audited, and 937 (58.7%) contained both forms. The self-report check list identified a greater number of "cases" of partner violence (151) than the direct questions (66), with the level of agreement between the two instruments being only "fair" (Kappa coefficient.34). Each of the methods identified 7 cases of major abuse, which would have been missed if only 1 instrument had been used. All cases where women stated that they were afraid of their partner using the direct questions were also identified using the self-report checklist.

CONCLUSION

A self-report checklist is an effective alternative to direct questioning in detecting women who are experiencing partner violence and is acceptable to women.

LEVEL OF EVIDENCE

II-3

Interventions for violence against women: scientific review

CONTEXT

Intimate partner violence is prevalent and is associated with significant impairment, yet it remains unclear which interventions, if any, reduce rates of abuse and reabuse.

OBJECTIVE

To systematically review, from the perspective of primary health care, the available evidence on interventions aimed at preventing abuse or reabuse of women.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, HealthStar, and Sociological Abstracts were searched from the database start dates to March 2001 using database-specific key words such as domestic violence, spouse abuse, partner abuse, shelters, and battered women. References of key articles were hand searched. The search was updated in December 2002.

STUDY SELECTION

Both authors reviewed all titles and abstracts using established inclusion/exclusion criteria. Twenty-two articles met the inclusion criteria for critical appraisal.

DATA EXTRACTION

Following the evidence-based methods of the Canadian Task Force on Preventive Health Care, both authors independently reviewed the 22 included studies using an established hierarchy of study designs and criteria for rating internal validity. Quality ratings of individual studies--good, fair, or poor--were determined based on a set of operational parameters specific to each design category developed with the US Preventive Services Task Force.

DATA SYNTHESIS

Screening instruments exist that can identify women who are experiencing intimate partner violence. No study has examined, in a comparative design, the effectiveness of screening when the end point is improved outcomes for women (as opposed to identification of abuse). No high-quality evidence exists to evaluate the effectiveness of shelter stays to reduce violence. Among women who have spent at least 1 night in a shelter, there is fair evidence that those who received a specific program of advocacy and counseling services reported a decreased rate of reabuse and an improved quality of life. The benefits of several other intervention strategies in treating both women and men are unclear, primarily because of a lack of suitably designed research measuring appropriate outcomes. In most cases, the potential harms of interventions are not assessed within the studies reviewed.

CONCLUSIONS

Much has been learned in recent years about the epidemiology of violence against women, yet information about evidence-based approaches in the primary care setting for preventing intimate partner violence is seriously lacking. The evaluation of interventions to improve the health and well-being of abused women remains a key research priority.

Should health professionals screen women for domestic violence? Systematic review

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. SESRCH 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.

Missed opportunities: intimate partner violence in family practice settings

BACKGROUND

For women experiencing partner violence, women health care visits represent opportunities for physicians and patients to address intimate partner violence (IPV), a significant health threat for women.

OBJECTIVES

The objectives were to estimate rates of physician documentation of IPV in medical records; characterize IPV+ women most likely to have IPV documented; and determine whether IPV screening increased IPV documentation.

METHODS

Subjects were women ages 18-65 receiving primary care in two large family practice clinics. All were screened for IPV by study staff using a modified Index of Spouse Abuse and the Women's Experience with Battering scales. We selected and abstracted medical records for all women experiencing current IPV (N = 144) and a random sample of women never experiencing IPV (N = 147).

RESULTS

Of 144 women screened as currently experiencing IPV, 14.7% were documented. Women most likely to have IPV documented were Caucasian, with higher WEB scores, and more likely to have an event that could trigger posttraumatic stress syndrome. Although the majority (41/56) of women currently in physically violent relationships did not plan to disclose IPV, those disclosing were significantly more likely to have IPV documented and documentation occurred after screening for 60% of women experiencing IPV.

CONCLUSION

IPV screening increased documentation. IPV screening can provide the opportunity for patients to disclose IPV. Physicians then have the opportunity to compassionately connect patients with appropriate resources.

Improving the emergency department detection rate of domestic violence using direct questioning

The purpose of this study was to compare the domestic violence (DV) rate identified with simple direct questioning to a historical cohort of patients receiving routine emergency department (ED) care. One thousand ED charts of female patients were retrospectively reviewed. Each patient in the prospective cohort was asked five DV specific questions. The historical cohort revealed a DV prevalence rate of 0.4%. The prospective study group of 302 patients identified 11 (3.6%) patients who admitted to acute DV on direct questioning. Ten of these patients accepted help. Twenty (6.6%) were identified as probable DV and 12 (4%) admitted to past violence. The total number of victims of DV, past, present, and probable was 43 (14.2%). This increase in detection from 0.4% (4/1000) to 14.2% (43/302) is significant at p < 0.001. Only 1.3% of patients refused to participate in the DV specific questions. The conclusion of the study indicated that the use of simple, direct questioning significantly improves the detection rate of DV in the ED.