Domestic Violence: Does Universal Screening Help?

Troy Brown

August 14, 2012

August 14, 2012 — When women were screened for domestic violence and given a health resource list of domestic violence services, their health-related quality of life was similar at baseline and 1 year compared with women who were given the same list without screening and a control group of women who received no screening and no resource list, according to a study published in the August 15 issue of JAMA.

Joanne Klevens, MD, PhD, an epidemiologist in the Division of Violence Prevention at the Centers for Disease Control and Prevention in Atlanta, Georgia, and colleagues conducted a 3-group blinded randomized controlled trial of 2708 women treated at 10 primary healthcare centers in Cook County, Illinois.

Women were randomly assigned to 1 of 3 groups. One group (n = 909) completed a computerized partner violence screen. If the screen was positive, they watched a short video that offered support and urged them to contact a hospital-based partner violence service. They also received a list of partner violence resources that were part of a larger list of general health resources.

A second group (n = 893) was given the same list without screening, and the control group (n = 898) was neither screened nor given the resource list.

Women were contacted for follow-up at 1 year. The primary outcome was quality of life (QOL) during the past 4 weeks, based on a physical health composite scale and a mental health composite scale that were each standardized with a mean (SD) of 50 (10) for the US population. The possible range was 0 to 100, with higher scores representing a more favorable health state.

Secondary outcomes were days lost from work or household activities, use of health or partner violence services, and partner violence recurrence.

Mean scores on QOL components and subscales among all women ranged from 44 to 52.

There were no significant differences between groups in number of days lost from work (0.7; 95% confidence interval [CI], 0.5 - 0.8 days) or household activities (2.0 days; 95% CI, 1.8 - 2.2 days), or in mean number of hospitalizations (0.2; 95% CI, 0 - 0.3), emergency department visits (0.3; 95% CI, 0.2 - 0.4), or ambulatory care visits 5.7; 95% CI, 4.1 - 7.2).

At 1 year, 66.5% (1574/2364) of the women recalled receiving the resource list. Of those, 32.9% (519/1574) reported sharing it with someone, but only 6.3% (100/1574) contacted services on the list, and fewer than 4.4% (106/2362) of all women contacted a partner violence resource.

Partner violence at baseline as well as in the previous year was experienced by 9.9% (235/2362) of the women, with no significant differences between the groups.

A total of 14.6% (346/2364) of the women had experienced partner violence at baseline, with no significant differences between groups.

Compared with the overall sample, women with a history of partner violence had lower baseline scores for "mental health composite (45.7 vs 41.5; P < .001), role limitations due to emotional problems (42.8 vs 40.1; P < .001), social functioning (44.7 vs 41.5; P < .001), mental health (46.2 vs 42.6; P < .001), and vitality subscales (49.9 vs 48.2; P = .003)," the authors write.

Adjusted mean scores on the QOL components and subscales were between 41.9 and 49.4.

Women in this subgroup lost 0.9 days of work (95% CI, 0.5 - 1.2) and 2.5 days of housework (95% CI, 1.9 - 3.1) in the past 4 weeks and had a mean number of 0.1 (95% CI, 0 - 0.3) hospitalizations, 0.3 (95% CI, 0.2 - 0.4) emergency department visits, and 5.0 (95% CI, 3.3 - 6.7) ambulatory care visits in the past year. There were no significant differences between groups.

In this subgroup, 72% (249/345) of the women recalled receiving the resource list. Of those, 33% (81/249) reported sharing the list with someone, but only 9% (23/249) contacted listed services, and 14% (49/346) contacted a resource for victims of partner violence.

The recurrence rate was 68% (235/345), and there were no statistically significant differences between the groups.

The authors note that repeated screening may be more effective than a single screening, and a stronger intervention than the video and referral list may also be more effective than the study intervention.

"[T]he results of this study suggest providing a partner violence resource list with or without computerized screening of female adult patients in primary care settings does not result in significant benefits in terms of general health outcomes," conclude the authors.

C. Nadine Wathen, PhD, an associate professor in the LIS program in the Faculty of Information and Media Studies at Western University in London, Ontario, Canada, and Harriet L. MacMillan, MD, FRCPC, a professor in the Department of Psychiatry and Behavioural Neurosciences and the Department of Pediatrics at McMaster University in Hamilton, Ontario, commented on the study in an accompanying editorial.

"Identification of abuse alone has been shown to be insufficient and ineffective in the absence of evidence-based clinical services that are acceptable to abused patients and their families," they write.

"[T]here are now 2 large-scale trials specifically evaluating partner violence screening that have remarkably consistent results: universal screening does not improve women's health or life quality or reduce reexposure to partner violence. It is time to enact an approach in which individual women are assessed according to their presenting histories, which include symptoms and risks. With exposure to partner violence being understood in the context of its health-relevant consequences, clinical teams may more effectively be able to address these issues," the editorialists conclude.

One author received consultancy fees from the World Health Organization. The other authors and the editorialists have disclosed no relevant financial relationships.

JAMA. 2012;308:681-689, 712-713.

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