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Opinion Piece
Screening for Domestic Violence
The evidence dilema
Joan Webster
Nursing Director, Research, Royal Brisbane and Women's Hospital, Brisbane QLD
Article Text
Initial calls for universal screening for domestic violence by health care workers date back over two decades (Hillard 1985). During the early 1990's the agenda was subsequently driven by the introduction of medical and nursing guidelines supporting the procedure (Braham et al. 1992; ACOG Technical Bulletin 1995). These guidelines provided a health related rationale for screening and screening methods and tools that were tailored for use in health care settings. Since that time and despite a general reluctance by health care providers, the momentum for routine screening has increased. This is partly because governments, both state and national, have made domestic violence prevention a major priority and have supported the introduction of screening programs into health care facilities (Webster et al. 1994) and partly due to a changing cultural perception of domestic violence as both an important criminal and public health issue (Webster et al. 1996).
However, as the momentum for universal screening increased, questions began to surface about its effectiveness. Underpinning screening is an assumption that women experiencing violence will be identified, referred to an appropriate agency and receive support that would lead to a reduction in violence, yet several systematic reviews have now been published that challenge these assumptions (Ramsay 2002; Nelson 2004). The most influential of these concludes that 'implementation of screening programs in health care settings cannot be justified.' (Ramsay 2002: 314) The conclusion is based on the absence of any high quality evidence of benefit and a similar lack of evidence that screening causes no harm.
There are at least two possible responses to this information. The first concerns whether asking questions about domestic violence during a health care contact constitutes 'screening'. The argument suggests that whilst the term 'screening' is used it will always fail to meet the requirements of a screening test. These include the ability of the test to correctly identify those with the problem (sensitivity), how good the test is at identifying those without the problem (specificity), what the chances are that the test will predict those who will get the problem (positive predictive value) or correctly predict those who will not get the problem (negative predictive value). We run into difficulties immediately with these demands if we apply them to a domestic violence screen; it is well known that most women who are experiencing domestic violence will deny it if asked and there are no well conducted studies that have established the predictive ability of any of the many screens that are in current use. A further requirement of universal 'screening' is that an effective treatment or intervention should be available to alleviate the problem and again, we run into difficulties as the systematic reviews clearly demonstrate. On the other hand, if we do not call routine enquiry about domestic violence 'screening', we avoid some of these difficulties. The argument here is that domestic violence is not a disease, so screening for it is inappropriate. What we are really doing is asking questions about a potential health-related risk factor in same way we ask about smoking or diet. In support of this approach is that women do not object to being asked (Webster et al. 2001) and screening provides an opportunity for disclosure and referral to specialised services. It also acknowledges to the women that someone is prepared to listen, to take her situation seriously and provide information to her which may be of assistance.
The second response to the systematic reviews is to take the results on board and use the information to determine future directions. We need to start by accepting that there is insufficient evidence to demonstrate the effectiveness of screening as an intervention to reduce domestic violence to be but we also need to acknowledge that nor is there any evidence of ineffectiveness. We just do not know. The Ramsay review clearly identifies research questions requiring answers and these should form the basis for the development of rigorous research programs. Moreover, if reducing the incidence of domestic violence is a public health priority, the argument for government funding to test the effectiveness of interventions they have supported is very strong.
In the meantime, while we wait for the evidence we need, we have to choose whether or not to continue screening. We can either err on the side of screening and risk finding at some future date that this approach was harmful, or we could discontinue screening and then discover that our patients were disadvantaged by that choice. We could argue that there are many areas in medicine and nursing where there is insufficient evidence to support one intervention or another but taking no action is usually not a choice. I believe screening faces the same dilemma and until there is evidence of harm, universal domestic violence screening should continue, as long as a sustainable education program is in place and there are options available for referral.
References
ACOG technical bulletin. Domestic violence. Number 209, American College of Obstetricians and Gynecologists. (1995) International Journal of Gynaecology and Obstetrics 51(2): 161-70.
Braham R, Furniss KK and Holtz H (1992) Nursing protocol on domestic violence. Nursing Practice 17(11): 24, 27, 31.
Hillard PJ (1985) Physical abuse in pregnancy. Obstetrics and Gynecology 66(2):185-90.
Nelson HD, Nygren P, McInerney Y and Klein J (2004) US Preventive Services Task Force. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine 140(5): 387-96.
Ramsay J, Richardson J, Carter YH, Davidson LL and Feder G (2002) Should health professionals screen women for domestic violence? Systematic review, British Medical Journal 325(7359): 314-326.
Webster J, Sweett S and Stolz T (1994) Domestic violence in pregnancy: A prevalence study. Medical Journal of Australia 161(8): 466-470
Webster J, Chandler J and Battistutta D (1996) Pregnancy outcomes and health care use: Effects of abuse. American Journal of Obstetrics & Gynecology 174(2):760-767
Webster J, Stratigos SM and Grimes KM (2001) Women's responses to screening for domestic violence in a health-care setting. Midwifery 17(4): 289-94.
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