Screening Women and Elderly Adults for Family and Intimate Partner Violence: A Review of the Evidence for the U.S. Preventive Services Task Force

As many as 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners each year in the United States (1, 2), and 31% of all women report abuse in their lifetime (3). Prevalence rates of abuse in clinical samples range from 4% to 44% within the past year and from 21% to 55% over a lifetime (4-14). The incidence of acute cases in emergency care settings ranges from 2% to 7% (15). Approximately 20% of female teenage survey respondents reported being physically or sexually abused by a dating partner (16). Although women also commit violence against men, women are 7 to 14 times more likely to sustain severe physical injury from an assault by an intimate partner (17). Approximately 551 000 older adults in domestic settings were abused or neglected in 1996 (18). A random-sample survey of a community population indicated a prevalence rate of 32 per 1000 for physical violence, verbal aggression, and neglect (19). Complicating these estimates, however, is the difficulty in defining and quantifying elder abuse. Abuse of elderly persons takes many forms, including physical, sexual, psychological, and financial exploitation as well as neglect (20). Available data indicate that the highest rates of elder abuse are among women and those 80 years of age and older (18). In 90% of cases, the perpetrator is a family member, most often an adult child or spouse (18). Many health problems are associated with abuse and neglect at all ages. These include repercussions of acute trauma, including death and unwanted pregnancy, as well as long-term physical and mental problems, such as depression, post-traumatic stress disorder, somatization, suicide, and substance abuse (16, 21-30). Children who witness intimate partner violence are at risk for developmental delay, school failure, psychiatric disorders (31, 32), and violence against others (33). Physician and nursing organizations consider the clinician's role in identification and intervention to be a professional responsibility (34, 35). Reporting child and elder abuse to protective services is mandatory in almost all states; 4 states (California, Colorado, Rhode Island, and Kentucky) have laws requiring mandatory reporting of intimate partner violence. Hospitals are also required to address abuse in order to maintain accreditation (36). Whether screening leads to a decline in abuse is unknown. In the mid-1990s, after several medical organizations recommended screening for intimate partner abuse, rates of abuse decreased (37). A systematic review reported that most studies of screening for intimate partner violence in health care settings found that screening detected more abused women than no screening (38). Surveys indicate that 43% to 85% of female respondents consider screening in health care settings acceptable, although only one third of physicians and half of emergency department nurses favored screening (38). The evidence on how to screen and effectively intervene once problems are identified is limited, and few clinicians routinely screen patients who do not have apparent injuries (39-44). In 1996, the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to recommend for or against the use of specific screening instruments to detect family or intimate partner violence, although including questions about abuse in the routine history could be recommended on the basis of prevalence of abuse among adult women and the potential value of the information to clinicians (45). This report is an update on the current literature on family and intimate partner violence. It focuses on studies of the performance of screening instruments designed for the clinical setting and the effectiveness of clinical-based interventions for women and elderly adults. A separate report on screening for family violence in children is available elsewhere (46). Methods The analytic framework and key questions guiding this review are detailed in the Figure. Relevant studies were identified from multiple searches of MEDLINE (1966 to December 2002), PsycINFO (1984 to December 2002), CINAHL (1982 to December 2002), Health & Psychosocial Instruments (1985 to December 2002), AARP Ageline (1978 to December 2002), and the Cochrane Controlled Trials Register (Appendix). Additional articles were obtained by reviewing 2 recent systematic reviews (38, 47), by reviewing reference lists of pertinent studies, and by consulting experts. Figure. Analytic framework and key questions ( KQs ). We defined screening as an assessment of current harm or risk for harm from family and intimate partner violence in asymptomatic persons in a health care setting. Universal screening assesses everyone; selective screening assesses only those who meet specific criteria. The target populations for this review were women and elderly victims of abuse from family members, intimate partners, caretakers, or others with similar relationships. The USPSTF focused this review on these populations because they are the largest at-risk groups in general primary care settings. Studies included in this review had English-language abstracts; were applicable to U.S. clinical practice; described abuse and violence against women or elderly adults; were conducted in or linked to primary care (for example, family practice or general internal medicine), obstetrics and gynecology, or emergency department settings; and included a physician or other health care provider in the process of assessment or intervention. We excluded studies about patients presenting with trauma. All eligible studies were reviewed, including those published before the 1996 USPSTF recommendation. Assessment studies were included if they evaluated the performance of verbal or written questionnaires or other assessment procedures, such as physical examinations, that were brief and applicable to the primary care setting. Included studies described the study sample, the screening instrument or procedure, the abuse or neglect outcome, and the collection of data. Outcomes included indicators of physical abuse, neglect, emotional abuse, or sexual abuse and any reported related health outcomes (for example, depression). Intervention studies were included if they measured the effectiveness of an intervention in reducing harm from family and intimate partner violence compared with nonintervention or usual care groups. We excluded studies that tested the effectiveness of interventions to educate health care professionals about family violence or to increase screening rates in institutions. We also excluded studies about mandatory reporting laws, descriptions of programs, the accuracy of physician diagnosis and reporting of abuse, and physician factors related to reporting. From each included study, we abstracted the study design, number of participants, setting, length and type of interventions, length of follow-up, outcomes, methods of outcome measurement, and study duration, among other variables. Two reviewers independently rated each study's quality using criteria specific to different study designs developed by the USPSTF (Appendix) (48). When reviewers disagreed, a final score was reached through consensus. This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the USPSTF. Agency staff and Task Force members participated in the initial design of the study and reviewed interim analyses and the final manuscript. Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript. The authors are responsible for the content of the manuscript and the decision to submit it for publication. Data Synthesis Intimate Partner Violence against Women Screening Of 806 abstracts identified by database searches, 14 met inclusion criteria. These included 6 studies that compared one instrument with another, 3 that compared an instrument with a directed interview, 2 that measured interrater reliability or internal consistency, and 3 that compared methods of administration. None evaluated the performance of a screening instrument or procedure by using verified abuse outcomes. Screening instruments are described in Appendix Figures 1 and 2 and Appendix Tables 1 and 2 (49-61). Appendix Figure 1. Screening instruments for intimate partner violence against women Appendix Figure 2. Screening instruments for elder abuse and neglect. Six studies compared brief screening instruments with previously validated instruments and were rated as good or fair in quality (Table 1) (15, 53, 54, 56, 57, 62). Brief instruments were generally correlated with longer instruments and in some cases performed better. Table 1. Studies of Screening Instruments about Intimate Partner Violence against Women The Hurt, Insulted, Threatened, or Screamed at (HITS) instrument includes 4 questions (54). When administered to 259 women in family practice clinics, it demonstrated fair internal consistency (Cronbach statistic = 0.80), and its results correlated with the previously validated 19-item Conflict Tactics Scales (CTS) (r = 0.85). In urban emergency department settings, the Partner Violence Screen (PVS), consisting of 3 questions, was compared with the 30-item Index of Spouse Abuse (ISA) (sensitivity, 64.5%; specificity, 80.3%) and the Conflict Tactics Scales (sensitivity, 71.4%; specificity, 84.4%) (53). However, the validity of the Conflict Tactics Scales may not have been tested sufficiently to qualify it as a gold standard in these studies. A study of 1152 predominantly African-American women presenting for care at university-affiliated family practice clinics found that the 10-item Women's Experience with Battering (WEB) Scale had a higher detection rate (16%) than the 15-item Index of Spouse AbusePhysical Scale (10%) (56). Another trial studying predominantly white women in family practice clinics found that the 8-item Woman Abuse Screening Tool