Abstract
BackgroundFamily physicians and other primary care practitioners are encouraged or expected to screen for an expanding array of concerns and problems including intimate partner violence (IPV). While there is no debate about the deleterious impact of violence and other adverse psychosocial exposures on health status, the key question raised here is about the value of routine screening in primary care for such exposures.DiscussionSeveral characteristics of IPV have led to consideration for routine IPV screening in primary care and during other healthcare encounters (e.g., emergency room visits) including: its high prevalence, concern that it may not be raised spontaneously if not prompted, and the burden of suffering associated with this exposure. Despite these factors, there are now three randomized controlled trials showing that screening does not reduce IPV or improve health outcomes. Yet, recommendations to routinely screen for IPV persist.Similarly, adverse childhood experiences (ACEs) have several characteristics (e.g., high frequency, predictive power of such experiences for subsequent health problems, and concerns that they might not be identified without screening) suggesting they too should be considered for routine primary care screening. However, demonstration of strong associations with health outcomes, and even causality, do not necessarily translate into the benefits of routine screening for such experiences. To date, there have been no controlled trials examining the impact and outcomes – either beneficial or harmful - of routine ACEs screening. Even so, there is an expansion of calls for routine screening for ACEs.SummaryWhile we must prioritize how best to support and intervene with patients who have experienced IPV and other adverse psychosocial exposures, we should not be lulled into a false sense of security that our routine use of “screeners” results in better health outcomes or less violence without evidence for such. Decisions about implementation of routine screening for psychosocial concerns need similar rigorous debate and scrutiny of empirical evidence as that recommended for proposed physical health screening (e.g., for prostate and breast cancer).
Highlights
Physicians and other primary care practitioners are encouraged or expected to screen for an expanding array of concerns and problems including intimate partner violence (IPV)
There is no debate about the deleterious impact of violence and other adverse psychosocial exposures on health status, but the critical question remains: what is the value of routine screening in primary care for such exposures? The need to examine the evidence for this type of screening is just as critical as the ongoing research about the effectiveness of routine prostate specific antigen screening for prostate cancer or mammography screening for breast cancer
There are three randomized controlled trials showing that routine IPV screening does not reduce IPV or improve health outcomes; one conducted in Canada with patients recruited from 26 health care settings followed for 18 months; a second carried out in a New Zealand emergency department with a three-month follow-up and the most recent, a US trial conducted in 10 primary health care centers with a 1 year follow-up [10,11,12]
Summary
The World Health Organization (WHO) defines IPV as behaviour by a current or former intimate partner that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviours [9]. In the American Academy of Pediatrics’ call for an expanded role for pediatricians in addressing ACEs, there is an acknowledgement that there is “relatively limited availability of evidence-based strategies ...shown to reduce sources of toxic stress in the lives of young children or mitigate their adverse consequences” (p.e226) and that “routine screening for increased vulnerability is useful only if collaborative relationships exist with local services to address the identified concerns...it is essential that those services demonstrate evidence of effectiveness” (p.e227) [23] They appropriately call for prioritizing investment in evaluation of promising interventions [23], hopefully as a pre-requisite to routine screening. In the case of IPV, international guidelines from the WHO have moved beyond the concept of screening to instead focus on safe, caring and effective case finding linked to available services [24]
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