Karen Roush, MS, RN, FNP-C, AJN clinical managing editor
A recent study reported in JAMA, “The Effect of Screening for Partner Violence on Women’s Quality of Life” (abstract only), is being touted in overly simplistic headlines across the Web (the word “debunks” has been getting a lot of use) as further evidence that domestic violence screening doesn’t improve outcomes for women.
Don’t believe it.
The problem doesn’t lie with the researchers or with JAMA; they accurately reported just what they found. The problem lies with how it is being interpreted by others as further proof of the overall ineffectiveness of screening for intimate partner violence (IPV).
What the study actually found was that there was no difference in health outcomes between women who received computerized screening and a resource list and women who just received the resource list or women who received neither.
This is how it worked:
Women in primary care settings who agreed to participate and who were randomized to the screening group were seated in front of a computer and responded to the three questions in the partner violence screening (for example, “have you ever been hit, kicked, punched or otherwise hurt by someone within the past year?”) on the monitor. If they checked yes for any question, the computer played a short video of an IPV advocate who “provided support and information about the hospital-based IPV advocacy program and encouraged [them] to attend.”
So what’s wrong with this? True, this particular “screening” and “intervention” didn’t make a difference in the participants’ quality of life. The problem lies in the claims being made that this study proves that IPV screening doesn’t work. The reason this is a problem is not with the screening component. Research supports computer screening to improve disclosure rates—it’s one way to address the time burden that is often cited as a major barrier to screening, as well as the stigma attached to disclosure. So yes, further testing of this possible approach to screening is warranted.
The problem, as I see it, is with the approach taken with women who disclosed abuse. We know that women will disclose abuse and accept help if there is trust, the belief that you actually care about them, a nonjudgmental attitude and consideration for their safety. None of these things are present in this approach. In fact, it is the antithesis. What this approach tells women is that we cannot be bothered to actually talk to you in person—that would take more time, money, and actual empathy than we care to spend on you.
We also have evidence that a well-planned advocacy program with follow-up can work. This “intervention” doesn’t take into consideration the complexity of IPV. There are social, cultural, psychologic, economic, and physical factors involved. I don’t know what this computer-presented advocate says to the women watching. But even if it’s all the right things, she or he is still just an image on the screen.
And expecting women to take on all the emotional and practical challenges that disclosure and seeking help can entail, merely in response to a disembodied image on a screen, is a disservice to the women. Beyond the significant risk of increased violence and even death, there are so many other variables, such as fear of losing their children to protective services, or the difficulties involved in accessing resources when you are without transportation or funds.
Figuring out ways to provide care and support to women who experience IPV (and men who also experience it, though in much smaller numbers) is essential and long overdue. We are still not very good at it, and women continue to suffer and die. Yes, it’s time-consuming. Yes, it’s costly. But we are willing to spend great amounts of time and money in research, public awareness, and health care expenditures on other screening programs that have questionable benefits, such as mammograms for younger women without other risk factors, prostate cancer screening with PSA tests, electrocardiograms for people without a history of heart disease.
Consider the debate over IPV screening in terms of screening that is supported by strong evidence. For example, one in 20 women will be diagnosed with colorectal cancer in their lifetime—one in four women will experience IPV. Why do we as a society choose to focus massive efforts on one and not the other?
So, if you read that we now have more evidence that screening for domestic violence doesn’t work, don’t believe it. What we have is evidence that this one interventional approach used with screening doesn’t work. It shouldn’t stand as an indictment of screening overall or suggest the futility of intervening in domestic violence. It should cause us to continue to seek answers to the question of how to screen and intervene effectively.