The IfWH Sexual and Reproductive Health team hold a monthly journal club. Today my colleagues and I critically appraised this recently published paper:
The World Health Organisation report that IPV is “one of the most common forms of violence against women and includes physical, sexual, and emotional abuse and controlling behaviours by an intimate partner.”
In response, many healthcare services have been undertaking screening to identify IPV and refer cases to appropriate support. However neither NICE nor WHO guidelines recommended screening, and the evidence to date has been unclear as to whether screening is worthwhile.
Screening is the identification of people without symptoms who are at risk of harm. Its really important that any form of screening is assured of doing more good than harm, and the good ‘ol Wilson and Junger criteria can be a helpful guide for this.
The criteria can be difficult to apply to complex social phenomenon, such as IPV. I’ve given it a go anyway – here is my take on the evidence provided in the above paper:
The case for IPV screening
|The disease||Is it an important health problem?||Yes; 1 in 3 women are globally affected.|
|Is the natural history well understood?||No; no ‘natural history’ as complex social phenomenon!|
|Is there a long time between the presence of risk factors/sub-clinical disease to overt disease?||Unclear; frequency of recurrent IPV is variable|
|Does early intervention improve clinical/public health outcome?||No; review evidence shows no benefit to women’s health|
|Screening test||Is the test valid (sensitivity and specificity)?||Unclear; range of different tests used, no superior test has been identified|
|Is the test simple, reliable and affordable?||Unclear; range of different tests used, no superior test has been identified|
|Is the test acceptable to patient and staff?||Unclear; review suggests paper/computer test more acceptable/reliable than clinician-led testing|
|Diagnosis and treatment||Is access to diagnostic facilities available and rapid?||Unclear; not known what support is most effective, resources varied across studies|
|Is treatment effective and accessible?||No; interventions did not impact on violence reduction|
|Is it cost-effective?||No evidence|
|Is it sustainable?||No evidence|
|Does benefit outweigh the harm?||Currently there is insufficient evidence of benefit derived to the women screened|
Agreed that choosing to only include studies which separated the screening test from other clinic activities was sensible. This helped to ensure the the effect of the screening was less likely to be influenced by other activities/interventions.
The finding that disclosure to sensitive questions was more likely when using self interview techniques (whether computer assisted or paper based) correlates with findings from other sexual health research, such as Natsal.
The paper reported a higher number of IPV reports in antenatal clinics. This may be due to the higher prevalence of IPV amongst pregnant women as highlighted by other research.
It was a shame that no research has been conducted in sexual health clinics (yet!) as these would be good healthcare locations to identify women at risk of sexual-related and other violence.
Although only ‘high income countries’ were included, there was some discussion regarding whether it was appropriate to compare different healthcare systems. For example – the cost of healthcare is likely to be compounded by social class and likely to influence access to services.
We agreed with the authors recommendation that process evaluation is needed. For example it would be useful to understand what patients think about the ‘screening test’, onward referral, and whether any different or additional support would have been beneficial.
Although the number of women identified with IPV was 2.33 times more than from the control groups (risk ratio 2.33, 95% confidence interval 1.39 to 3.89); the number of people identified was still tiny. This was evident by the wide forest plot confidence intervals also. It may be appropriate to consider means of targeting high-risk individuals rather than adopting a population approach (or do bigger trials!)
We agreed with the authors conclusion that there is currently insufficient evidence to support screening for IPV. We agreed that this was likely to be due to an absence of evidence (i.e. we need to do more research) rather than evidence of absence.
Concerns were raised regarding what happens once women of high risk are identified. A discussion of local practice revealed that many sexual health clinics in London are asking patients about violence and typically followed up with a safeguarding assessment, however little is known about what is effective. We thought it would be useful to conduct an audit to find out what happens to women following assessment.
NICE Guidance [PH50] Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively (February 2014)
Thank you to Professor Judith Stephenson, Dr Hannat Akintomide, Dr Jenny Hall, Dilisha Patel, Elissa Cannon, Debbie Holland, Bola Grace and Dr Sue Mann for contributing to the Journal Club discussion.