Focus of the intervention
This intervention involves the use of screening tools to identify women attending healthcare settings who have experienced domestic abuse.
Domestic abuse is defined broadly as any behaviour within an intimate relationship that causes physical, psychological or sexual harm.
Screening tools range from face-to-face screening by a clinician to self-completed screening forms.
All women over the age of 16 attending primary (for example, GP surgeries) and secondary healthcare settings (for example, antenatal clinics, women’s health and maternity services, emergency departments) are subject to screening.
For those women that disclose experiencing domestic violence or abuse, screening results are assessed by the consulting healthcare professional who uses their clinical judgement as to how to respond.
Universal screening is intended to increase the identification of violence and abuse and to provide further support and access to services.
This narrative is based on 13 studies covered by the review, eight of which were included in the meta-analysis. Of those included in the meta-analysis, four were conducted in the USA, three in Canada and one in Portugal.
Effect – how effective is it?
Overall, the evidence suggests that universal screening for domestic violence and abuse in healthcare settings has been effective.
A meta-analysis covering eight studies found that universal screening in healthcare settings led to an increase in the identification of domestic violence and abuse victims compared to healthcare settings where no screening was conducted or where screening was undertaken but results were not passed onto a healthcare practitioner.
Women who were screened were almost three times as likely to mention their experience of domestic violence or abuse compared to those who were not screened. The findings were based on a total of 10,074 women across eight studies.
How strong is the evidence?
The review was sufficiently systematic that most forms of bias that could influence the study conclusions can be ruled out.
The evidence is taken from a systematic review covering 13 studies, eight of which were included in the meta-analyses. The review demonstrated a high-quality design in terms of having a transparent and well-designed search strategy, featuring a valid statistical analysis and sufficiently assessing the risk of bias in the analysis.
Biases remain within the included primary studies. All studies were judged to have high or unclear potential for performance bias (blinding of participants and personnel).
Mechanism – how does it work?
The review suggests the main assumption underpinning the use of universal screening is that routinely asking women in healthcare settings about their experience of domestic abuse from a current or previous partner will:
- increase its identification
- improve access to services and support
- ultimately decrease exposure to violence and abuse and detrimental health consequences
These presumed mechanisms were not tested in the review.
Moderators – in which contexts does it work best?
The review examined whether the type of screening technique used or the particular healthcare setting affected the impact of universal domestic violence and abuse screening for women in healthcare settings.
- Four of the 13 studies investigated the impact of screening techniques and found that detection of domestic violence between partners did not differ between face-to-face screen and computer or written assessment.
- Analysis suggested that the effect of universal screening on the identification of domestic violence and abuse varied considerably by healthcare setting. The two studies found that the odds of identifying victims or survivors of domestic abuse in antenatal settings were four and a half times higher in screened women compared to those who received usual care (the control group). There were also higher identification rates in emergency departments (over two and a half times higher than control, three studies) and maternal health services (two times higher than control, one study), but not in hospital-based primary care.
Implementation – what can be said about implementing this initiative?
The studies included in the review used different screening methods. Screening was either conducted directly by a healthcare professional or indirectly through a self-completion questionnaire with a healthcare professional informed of results.
Screening also varied in terms of the approach used. Some studies included the use of screening tools. In other studies, clinicians asked one or a range of questions related to domestic violence and abuse, either at one point in time or at several points.
Economic considerations – how much might it cost?
No studies included in the review reported any data on cost-benefit or any other economic evaluation of this intervention.
- The studies included in the review only considered evidence from healthcare settings in high income countries.
- Most of the studies used in the meta-analyses were conducted in either the USA or Canada. Caution should therefore be taken when applying findings to other geographical contexts.
- The authors of the review highlight that the numbers and proportions of women identified by the screening intervention were modest when considered against the estimated prevalence of domestic abuse among women in healthcare settings.
- The review reported referral rates for other services as one of its primary outcome measures. However, these have not been reported in this synthesis which focuses on crime outcomes only.
- The review does not include crime outcomes other than the identification of domestic violence and abuse. Therefore it is not possible to report on the effect the intervention has on future experiences of abuse and whether the intervention impacts on offending behaviour.
There is evidence that universal healthcare screening for domestic violence and abuse improves levels of victim identification.
The review is based on the assumption that routinely screening women in healthcare settings will increase the identification of domestic violence and abuse.
No difference in impact was detected according to the particular screening technique used (healthcare professional/face-to-face screening or written/computer-based screening).
However, healthcare setting did influence the identification of domestic violence and abuse, with the highest level of identification in antenatal settings.
Additional evidence is required in relation to cost-effectiveness of universal screening in healthcare settings.
Summary prepared by
This narrative was prepared by UCL Jill Dando Institute and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant reference: ES/L007223/1.