Should all women be screened for domestic violence?

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Mar 26 2009

A screening programme which would require doctors and nurses to ask all women whether they have experienced domestic violence, whatever their reason for seeking medical attention, is not justified, according to a new report by researchers at the University of Bristol, funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme.

However, doctors and nurses need better training to respond to domestic violence and the NHS should consider commissioning specialist domestic violence services to which doctors can refer women, the lead author of the report says.

Domestic or partner violence affects at least one in four women at some point in their lives. It can do long-term damage to physical and mental health and causes two deaths a week in the UK. Although doctors and nurses deal all the time with the consequences of domestic violence, the health service has been slow to respond to the needs of women currently experiencing abuse.

One proposal for improving care has been a policy whereby all women, regardless of their reason for seeking medical attention, are asked by doctors and nurses if they have experienced domestic violence. This is called screening and has been effective in other areas, for example in detecting thyroid disease in babies and raised blood pressure in adults.

Gene Feder, Professor of Primary Health Care at the University of Bristol and colleagues in Bristol, London, Manchester and Australia reviewed research evidence for a domestic violence screening programme in the NHS.

They looked at all published studies of:

the prevalence of domestic violence against women in the UK population and among patients
the health consequences for women and their children
screening questions that can be used by doctors and nurses
the acceptability of screening to women and clinicians
the effectiveness of specific care for women once they have disclosed abuse
the cost-effectiveness of domestic violence screening programmes.

The overall conclusion of the review was that there was not enough evidence to justify asking all women about domestic violence when they consult a doctor or a nurse, whether this is in hospital or general practice.

Professor Feder said: "The debate over screening for domestic violence in health care settings has diverted attention away from the uncontroversial need to train doctors and nurses in asking patients about their experiences of abuse and in responding appropriately when women do disclose. This is largely neglected in undergraduate and postgraduate medical education.

"We need more research on how clinicians can best respond to this large public health problem. The evidence we have reviewed on effectiveness of specific care after disclosure of abuse, particularly domestic violence advocacy, supports a case for the NHS commissioning specialist domestic violence services to which clinicians can refer women."

Professor Feder has recently been appointed an expert advisor to the World Health Organisation on the development of guidance on the health sector response to violence against women.

The report was authored by researchers at the University of Bristol, Queen Mary, University of London, London School of Hygiene and Tropical Medicine, University of Manchester and Deakin University, Australia.

How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria by G Feder, J Ramsay, D Dunne, M Rose, C Arsene, R Norman, S Kuntze, A Spencer, L Bacchus, G Hague, A Taket, and A Warburton. Health Technology Assessment 2009; Vol. 13.17

The debate over screening for domestic violence in health care settings has diverted attention away from the uncontroversial need to train doctors and nurses in asking patients about their experiences of abuse and in responding appropriately when women do disclose. This is largely neglected in undergraduate and postgraduate medical education.

Professor Gene Feder