Screening for Family and Intimate Partner Violence: Recommendation Statement

U.S. Preventive Services Task Force

doi:10.1370/afm.128

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Health system needs effectiveness research from clinical to intersectoral interventions.
Angela J Taft

Published on: 16 May 2004
We Need Effectiveness Research Concerning Family/Child/Intimate Partner Violence Screening and Interventions
Lorraine E Ferris

Published on: 05 May 2004
Thoughts from another perspective
Barbara A Elliott

Published on: 04 April 2004
Screening for Family and Intimate Partner Violence: A New Risk Factor for Future Analysis?
margaret b heldring

Published on: 02 April 2004

Published on: (16 May 2004)
Page navigation anchor for Health system needs effectiveness research from clinical to intersectoral interventions.
Health system needs effectiveness research from clinical to intersectoral interventions.
Angela J Taft, Melbourne, Australia
In 2004, there is no lack of evidence that intimate partner violence causes substantial health damage to women, children and their families and communities. Consequently, policymakers have recognised that health service providers are uniquely placed to intervene to reduce this harm and many are examining the potential of health system intervention. The USPSTF has wisely considered the evidence behind increased recommendatio...
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In 2004, there is no lack of evidence that intimate partner violence causes substantial health damage to women, children and their families and communities. Consequently, policymakers have recognised that health service providers are uniquely placed to intervene to reduce this harm and many are examining the potential of health system intervention. The USPSTF has wisely considered the evidence behind increased recommendations for screening or routine inquiry about family and intimate partner violence [1].
While acknowledging the limitations of evidence-based medicine, Lorraine Ferris questions why we haven't better advocacy and funding for effectiveness research of family violence/partner violence interventions. Elsewhere, old-fashioned clinical judgement and compassion is emphasised in the absence of evidence for effective interventions, because applying rigorous screening criteria in family violence is ‘a fool’s errand’ [2]. However, however previous research identified many barriers to compassionate clinical judgement [3]. This cannot be guaranteed and in family medicine can be complicated by the tensions of seeing all family members in family practice [4].
Ferris is right. We need evidence for intervention, but at every level in the health system. We need evidence at the individual clinician level for effective curriculum and training, which promotes compassionate attitudes, enhances clinical judgement and ensures a compassionate response when a clinician has a strong index of suspicion about family violence.
But we also need evidence at the institutional level. Previous research has recognised wider institutional barriers to good clinical judgement [5, 6]. What kind of quality assurance, in what kind of clinic or health maintenance organisation, or hospital accreditation, is required to promote good-quality clinical judgement? As Rodriguez etal (1999)argued, without structural changes, regular in service education and institutional policies, physician training is unlikely to be sufficient to change clinical practice [7].
Even more broadly, we need evidence of the most effective links between family practice and the wider family violence and community-based service system. Within each country, we need to know how best to promote effective intersectoral collaboration. However most importantly, when we evaluate family violence intervention at any level, the major outcome variable must be the victims’ long-term benefit and well-being from her own perspective. This, of all variables, is the one most critical and so often missing in almost all family violence effectiveness evaluation to date.
1. US Preventive Services Task Force, Screening for Family and Intimate Partner Violence, Recommendation Statement. Annals of Family Medicine, 2004. 2(2): p. 156-160. 2. Lachs MS, Screening for Family Violence: What's an Evidence Based Doctor To Do. Ann Intern Med, 2004. 140(5): p. 399-400. 3. Hegarty KL and Taft AJ, Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice. Aust NZ J Public Health, 2001. 25(5): p. 433-7. 4. Taft A, Broom DH, and Legge D, General practitioner management of intimate partner abuse and the whole family: a qualitative study. BMJ, 2004. 328: p. 618-621. 5. Warshaw, C. and E. Alpert, Integrating Routine Enquiry about Domestic Violence into Daily Practice. Annals of Internal Medicine, 1999. 131(8): p. 619-620. 6. Cohen, S., E. De Vos, and E. Newberger, Barriers to Physician Identification and Treatment of Family Violence: Lessons from Five Communities. Academic Medicine, 1997. 72(1 Supplement/January 1997): p. S19-S25. 7. Rodriguez MA, et al., Screening and Intervention for Intimate Partner Abuse: practices and attitudes of primary care physicians. JAMA, 1999. 282(5): p. 468-474.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (5 May 2004)
Page navigation anchor for We Need Effectiveness Research Concerning Family/Child/Intimate Partner Violence Screening and Interventions
We Need Effectiveness Research Concerning Family/Child/Intimate Partner Violence Screening and Interventions
Lorraine E Ferris, Toronto, Ontario
This issue of the Annals of Family Medicine (March/April 2004) contains two important articles concerning family/child/intimate partner violence screening<1,2>. Using an evidence-based medicine (EBM) <3> approach, this significant work reviews best evidence and renders resultant recommendations about the care of patients. EBM has influenced areas such as individual patient care, clinical guidelines and stan...
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This issue of the Annals of Family Medicine (March/April 2004) contains two important articles concerning family/child/intimate partner violence screening<1,2>. Using an evidence-based medicine (EBM) <3> approach, this significant work reviews best evidence and renders resultant recommendations about the care of patients. EBM has influenced areas such as individual patient care, clinical guidelines and standards of practice, policy, and health care resources. EBM interprets best evidence to determine if health interventions are effective. For clinical care, EBM aims to increase the likelihood that interventions are offered where effective and not offered where ineffective or harmful. For system issues, EBM aims to increase the likelihood that guidelines, standards and policy as well as resources and services are informed by best evidence for effectiveness. EBM has its critics<4>, including those concerned about its reliance on rigid rules in determining “best evidence” (e.g., systematic reviews and randomized controlled trials) <5>, use of a population-based approach to direct clinical medicine <6>, uneven treatment of patients’ preferences <7>, and questionable applications in non-medical areas <8 >. It would be imprudent for EBM supporters not to recognize that it, like any other methods of synthesis, analyses and interpretation, has its limitations. Regardless of one’s position, it is clear that EBM is an influential force that has changed the landscape on which clinical and non-clinical health decisions are made.
While these articles contribute to the understanding of the effectiveness of family/child/intimate partner violence interventions, what is most striking is what they cannot tell us. The EBM approach shows, among other things, that there is a lack of effectiveness research in the area of family/child/intimate partner violence regardless of what rules are applied in determining “best evidence”. Not having effectiveness research is far different than having negative results from it. Unfortunately, negative results are easier to translate into clinical and non-clinical health decisions than no results.
Why is it that we lack effectiveness research in the area of family/child/intimate partner violence interventions? Is it that we cannot devise appropriate effectiveness studies? Are we reluctant to subject the issues to studies about effectiveness? Do we lack research funding? I believe it is a mixture of the difficulty (but not impossibility) in designing these types of effectiveness studies and the lack of funding to pursue them.
These articles ought to be credited for doing more than making sound recommendations based on available evidence, for they are a wake-up call. We need debate about how to design effectiveness studies in this area and advocacy for funding to conduct them.
References
1. U.S. Preventive Services Task Force. Screening for Family and intimate Partner Violence: Recommendation Statement. Annals of Family Medicine 2004; 2:156-160.
2. Nygren P, Nelson HD, Klein J. Screening Children for Family Violence: a Review of the Evidence for the US Preventive Services Task Force. Annals of Family Medicine 2004; 2:161-169.
3. Saskett David L. Evidence-Based Medicine. Spine 1998;23:1085- 1086.
4. Feinstein AR, Horwitz RI. Problems in the “evidence” of “evidence -based medicine” Am J Med 1997; 103:529-35.
5. Petticrew M. Why certain systematic reviews reach uncertain conclusions. BMJ 2003; 326:756-758.
6. Dickenson D, Vineis P. Evidence-Based Medicine and Quality of Care. Health Care Analysis 2002;10:243-259
7. Rogers WA. Is there a Tension Between Doctors’ Duty of Care and Evidence-Based Medicine? Health Care Analysis 2002; 10:277-287.
8. Lachs MS. Screening for Family Violence: What’s an Evidence- Based Doctor to Do? Annals of Internal Medicine 2004; 140:399-400.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (4 April 2004)
Page navigation anchor for Thoughts from another perspective
Thoughts from another perspective
Barbara A Elliott, Duluth, MN USA
Other Contributors:
These recommendations are both heartening and disheartening for me, as a teacher and researcher of family violence issues--as well as one who encounters them regularly in my clinical work as an ethicist and chaplain. I encounter my BELIEF that screening for issues of violence across the lifespan can and does make a difference in peoples' lives. This concensus statement makes very "black and white" the reality: our resea...
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These recommendations are both heartening and disheartening for me, as a teacher and researcher of family violence issues--as well as one who encounters them regularly in my clinical work as an ethicist and chaplain. I encounter my BELIEF that screening for issues of violence across the lifespan can and does make a difference in peoples' lives. This concensus statement makes very "black and white" the reality: our research base does not validate or negate my belief.
So--it motivates me to think hard about how to do the research that will test this assumption / belief.
These points are part of that thinking:
First, since there have been clear legal obligations about reporting abuse against minors, the assumption has been that the law was written with some information base supporting it. Clearly this is not true: this statment emphasizes that they have not been tested, either earlier, or in the meantime, with research.
Second, The research questions that this raises include: a) How can we do this screening well (and safely)? b) How does screening affect Dr-patient/family relationships? c) Why are we not asking older youth or parents about abuse? (We know that the average age for physical abuse is three years of age and for sexual abuse is nine years of age... and in my work with homeless teen agers and those who are parenting, most have run from home because of abuse...) d) What outcomes would be positive outcomes?! How do we document prevented deaths? Increased safety? The role of family re-configurations? etc.
This recommendation is actually a good wake up call from my perpective...
Competing interests: None declared
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Competing Interests: None declared.
Published on: (2 April 2004)
Page navigation anchor for Screening for Family and Intimate Partner Violence: A New Risk Factor for Future Analysis?
Screening for Family and Intimate Partner Violence: A New Risk Factor for Future Analysis?
margaret b heldring, washington dc, usa
Supported principally by The Robert Wood Johnson Foundation, America's HealthTogether leads a national initiative investigating the health and mental health impacts of exposure to terrorism and other disasters, especially as symptoms of adverse impact surface in primary care settings. This initiative is known as Mental Health and Primary Care in a Time of Terrorism: Facing Fear Together and is a partnership of the natio...
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Supported principally by The Robert Wood Johnson Foundation, America's HealthTogether leads a national initiative investigating the health and mental health impacts of exposure to terrorism and other disasters, especially as symptoms of adverse impact surface in primary care settings. This initiative is known as Mental Health and Primary Care in a Time of Terrorism: Facing Fear Together and is a partnership of the nation's leading physician, nurse practitioner, public health and mental health groups (www.facingfeartogether.org).
We are currently in a second year of research. Our methodology has included 1)structured interviews with national and inernational experts in disaster mental health and the epidemiology of mental health disorders (such as depression and post traumatic stress disorder) in primary care; 2) 21 focus groups of primary care providers and,one-third of the time, mental health professionals at strategically chosen urban, rural, and suburban locations; 3) February 2003 online survey of health care providers; and, 4) review and update of the literature post 9/11.
Preliminary findings suggest that exposure to terrorist events may be a "new" risk factor for violence. Norris et al (2002) reviewed disaster mental health literature prior to 9/11 and found that mass violence is the most impactful disaster and that reports ofdomestic conflict and violnce do increase following espoxure. Studies pre and post 9/11 identify women, girls, motherhood, low SES, impoverished social support, and prior exposure to trauma as significant predictor variables of post disaster/terrorist distress and impairment. Clearly, these are similar to predictor variables for family and intimate partner violence.
Norris comments: "Two questions require attention when considering the implications of domestic violence for postdisaster recovery. The first question is whether domestic violence increases in prevalence after disasters. There are only minimal data that are relevant to this question. Mechanic et al. (2001) undertook the most comprehensive examination of intimate violence in the aftermath of a disaster after the 1993 Mid-western flood. A representative sample of 205 women who were either married or cohabitating with men and who were highly exposed to this disaster acknowledged considerable levels of domestic violence and abuse. Over the 9-month period after flood onset, 14% reported at least one act of physical aggression from their partners, 26% reported emotional abuse, 70% verbal abuse, and 86% partner anger. Whether these rates of physical aggression are greater than normal is not known because studies of domestic violence from previous years and under normal conditions have showed the existence of rates of violence as low as 1% and as high as 12%. A few studies have produced evidence that supports the above. Police reports of domestic violence increased by 46% following the eruption of the Mt. St. Helens volcano (Adams & Adams, 1984). One year after Hurricane Hugo, marital stress was more prevalent among individuals who had been severely exposed to the hurricane (e.g., life threat, injury) than among individuals who had been less severely exposed or not exposed at all (Norris & Uhl, 1993). Within 6 months after Hurricane Andrew, 22% of adult residents of the stricken area acknowledged having a new conflict with someone in their household (Norris et al., 1999). In a study of people directly exposed to the bombing of the Murrah Federal Building in Oklahoma City, 17% of noninjured persons and 42% of persons whose injuries required hospitalization reported troubled interpersonal relationships (Shariat et al., 1999)." (comments prepared by Fran H. Norris for the National Center for Post Traumatic Stress Disorder.http://www.ncptsd.org/facts/disasters/fs_domestic.html)
Our survey research suggests similar trends. From NYC to Fargo, ND to Miami, FL, primary care providers are noting increased psychological stress, somatization and potential for violence among their patients and families. As we continue to encouter and live with the possibility of additional homeland terrorist events, primary care providers should be alert to possible increases in family and intimate partner violence. The next iteration of the U.S. Preventive Services Task Force may well need to assess terrorism as a risk factor.
Competing interests: None declared
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Competing Interests: None declared.