Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review

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Abstract

We undertook a synthesis of existing studies to re-evaluate the evidence on program mechanisms of intimate partner violence (IPV) universal screening and disclosure within a health care context by addressing how, for whom, and in what circumstances these programs work. Our review is informed by a realist review approach, which focuses on program mechanisms. Systematic, realist reviews can help reveal why and how interventions work and can yield information to inform policies and programs. A review of the scholarly literature from January 1990 to July 2010 identified 5046 articles, 23 of which were included in our study. We identified studies on 17 programs that evaluated IPV screening. We found that programs that took a comprehensive approach (i.e., incorporated multiple program components, including institutional support) were successful in increasing IPV screening and disclosure/identification rates. Four program components appeared to increase provider self-efficacy for screening, including institutional support, effective screening protocols, thorough initial and ongoing training, and immediate access/referrals to onsite and/or offsite support services. These findings support a multi-component comprehensive IPV screening program approach that seeks to build provider self-efficacy for screening. Further implications for IPV screening intervention planning and implementation in health care settings are discussed.

Highlights

► Screening for and identification of intimate partner violence can facilitate victims’ access to services and resources. ► This realist-informed systematic review evaluated universal screening programs for IPV within health care settings. ► This study differs from prior reviews in this area by evaluating how screening programs work as well as whether they work. ► More successful screening programs incorporated multiple program components and had support at the institutional level.

Introduction

Intimate partner violence (IPV) – a pattern of coercion, physical abuse, sexual abuse or threat of violence in intimate relationships – is a serious public health issue (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). The World Report on Violence and Health documented the prevalence of lifetime physical assault for women in the range of 22–30% for the United States, Canada and United Kingdom (Krug et al., 2002). Due to high rates of injury, mental health morbidity (Campbell, 2002, Campbell et al., 2002), and health care utilization resulting from IPV (Day, 1995, O’Campo et al., 2008, Snow-Jones et al., 2006, Bonomi et al., 2009) and because of the high levels of support for IPV screening among patients (Gielen et al., 2006, Ramsay et al., 2002), there have been widespread calls to address IPV within the health care system through vigilant (U.S. Preventive Services Task Force, 2004, Wathen and MacMillan, 2003b) or routine inquiry (AmericanAcademy of Family Physicians, 2005, American Medical Association, 2000, Cherniak et al., 2005a).Victims interact with the health care system for both routine and abuse-related health care, and providers in all settings should be prepared to identify, support, and refer these individuals.

Evaluation of IPV screening programs in health care settings is growing, including several systematic reviews. Previous reviews have been equivocal in terms of locating strong evidence to recommend universal screening in health care settings (Anglin and Sachs, 2003, Feder et al., 2009, Nelson et al., 2004, Spangaro et al., 2009, Stayton and Duncan, 2005, U.S. Preventive Services Task Force, 2004, Waalen, 2000), and there remains a lack of understanding about the determinants of successes and failures in the implementation of screening programs (MacMillan et al., 2009, Spangaro et al., 2009). Previous reviews have also failed to acknowledge the variation in contexts for screening and have often combined results from disparate settings, which may blur the evidence for whether or not screening programs are successful.

Previous studies and reviews suggest that IPV screening should be evaluated according to how well it reduces IPV (Anglin and Sachs, 2003, Nelson et al., 2004, Wathen and MacMillan, 2003a). However, as we depict in Fig. 1, a change or reduction of IPV may not be the most appropriate outcome for screening. Intervention for IPV is a complex, multi-step process. Given the numerous steps and intervening factors between screening and IPV reduction, not all of which are under the control of the health care system or health care providers, a more productive strategy would be to consider the program’s sequence of outcomes along this process. In this review, we focused on the initial steps of the IPV clinical management process: screening and risk assessment and identification of IPV victims (Fig. 1).

There are two approaches to screening: screening all women or patients regardless of presumed risk (a universal, routine screening approach) or screening only those individuals suspected to be most at risk (a non-universal, case-finding approach). The debate about whether IPV screening programs should or should not be universal has been addressed in the literature (Cherniak et al., 2005b, Janssen et al., 2006, Lachs, 2004, McFarlane et al., 2006, Taket et al., 2003, Taket et al., 2004); however, this is not a topic that we are able to address in this review. In order to ensure that we reviewed comparable screening programs, and since most guidelines recommend routine screening, we chose to focus on only programs that adopted a universal, routine screening approach.

A realist review “unpacks” the inner mechanisms of interventions by making explicit the underlying theories about how programs work (Pawson, Greenhalgh, Harvey, & Walshe, 2004), and then systematically gathering evidence to test these theories. More specifically, a realist review uses the contextual characteristics of programs to help explain program success or failure. Diverse evidence is included and examined (e.g., scholarly literature, key documents, interviews with key informants) to help reveal why and how interventions work. This approach to evaluating existing evidence is explanatory (i.e., how “x” works) rather than judgmental (i.e., how well did “x” work) because it combines both theoretical thinking and empirical evidence about program workings and context.

Realist review methodology has recently been used to evaluate complex health-related interventions including housing and mental health programs, smoking cessation programs, and school feeding programs (Greenhalgh et al., 2007, Kaneko, 1999, O’Campo et al., 2009) and has been specifically mentioned as an approach for examining IPV screening (Spangaro et al., 2009). We conducted a realist-informed systematic review to determine why and how universal IPV screening programs in health care settings are effective.

Section snippets

Search strategy

The search was limited to articles published in English, in both industrialized and non-industrialized countries, between January 1990 and July 2010. Search terms included: intimate partner violence and its synonyms, screen, model, program, intervention, best practice, innovation, success, health service, program evaluation, program development, referral, and consulation. Search terms were entered into medical and social sciences databases using Boolean operators: MEDLINE, EBM Reviews,

“Comprehensive” program approach

During the evidence extraction and synthesis, a pattern emerged where programs that incorporated numerous screening components at multiple levels and had institutional support tended to have more successful outcomes. These programs were labeled “comprehensive” for the purposes of our review. We considered programs “non-comprehensive” if they did not broadly incorporate multiple screening components or if they were lacking institutional support.

Six programs took a “comprehensive” approach to IPV

Discussion

We present findings from a realist-informed systematic review of IPV screening. Unlike previous systematic reviews that combined routine and universal screening programs with case-finding approaches or that included programs in both health care and non-health care settings, we focused specifically on universal screening efforts occurring in health care settings. We chose the realist approach for two reasons. First, IPV screening and identification is a complex intervention that often includes

Acknowledgments

The Centre for Research on Inner City Health gratefully acknowledges the support of the Ontario Ministry of Health and Long-Term Care. Patricia O’Campo was supported by the Alma and Baxter Ricard Chair in Inner City Health. The authors’ work was independent of the funders. The views expressed in this article are those of the authors and do not necessarily reflect the views of the above-named organizations or of the institutions with which they are affiliated.

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