This review assessed screening and interventions in health care settings for reducing family and intimate partner violence. The evidence suggested that home nurse visits for parents during prenatal and postpartum periods may improve outcomes related to child abuse and neglect. Evidence related to women and elderly adults were limited. This was a relatively well-conducted review and the conclusions appear reliable.

To assess the benefits and harms of screening procedures and interventions in health care settings for reducing harm from family and intimate partner violence for children, women and elderly adults.

The authors searched MEDLINE, PsycINFO, CINAHL, Health and Psychosocial Instruments, ERIC and AgeLine from inception to December 2002 and the Cochrane Controlled Trials Register. They also reviewed the reference lists of pertinent studies, reviews and editorials, and contacted experts in the field. Only studies with English language abstracts were included in the review.

Study designs of evaluations included in the review

The intervention studies had to have a comparison group. No inclusion criteria relating to the study design were stated for studies of screening.

Specific interventions included in the review

Studies that evaluated the performance of verbal or written questionnaires, or other assessment procedures such as brief physical examinations in the primary care setting, and studies that assessed the effectiveness of an intervention to reduce harm from family and intimate partner violence, were eligible for inclusion in the review.

The studies had to be conducted in or linked to primary care, obstetrics or gynaecology or emergency department settings, and include a physician or other health provider in the process of assessment or intervention, to be eligible for inclusion. The studies also had to be applicable to United States clinical practice.

Studies that assessed the effectiveness of interventions to educate health care professionals about family violence or to increase screening rates were excluded, as were studies about mandatory reporting laws, descriptions of programmes, the accuracy of physician diagnosis and reporting of abuse, and physician factors relating to reporting.

The included studies of screening for child abuse used self-administered questionnaires, sometimes in conjunction with interviews and review of medical records, clinical staff interviews and clinical observation. None used specific physical examination protocols. The included studies of interventions for child abuse assessed support services, home visitation programmes and comprehensive services, including care by a multidisciplinary team for prenatal, postnatal and paediatric care.

The included studies of screening for intimate partner violence against women compared brief screening instruments against previously validated instruments, compared instruments against directed interview, measured inter-rater reliability and/or internal consistency, or compared methods of administration. The included studies of interventions for intimate partner violence against women assessed a wallet-sized card listing community resources, counselling, and counselling plus a 'mentor mother' in the community.

The included studies of screening for elder abuse assessed a caregiver abuse screening instrument and elder abuse screening instruments.

Reference standard test against which the new test was compared

The review did not include any diagnostic accuracy studies that compared the performance of the index test with a reference standard of diagnosis.

Participants included in the review

Studies of women, children and elderly adults were eligible for inclusion in the review. Studies of patients presenting with trauma were excluded.

The included studies of screening for child abuse primarily assessed parents, particularly pregnant women, rather than children directly. The included studies of interventions for child abuse were for pregnant and postpartum women and their infants, who were considered at high risk because of sociodemographic characteristics and/or additional risk factors.

The included studies of screening for intimate partner violence against women included women attending family practice clinics, prenatal clinics, a parenthood clinic, or emergency departments. The included studies of interventions for intimate partner violence against women included women attending prenatal clinics.

The included studies of screening for elder abuse included abusive and non-abusive caregivers, elderly victims of abuse, elderly adults referred to Adult Protective Services but found not to be abused, elderly adults from a family practice clinic, or a convenience sample of white minority elderly adults living in public housing.

Outcomes assessed in the review

Studies that assessed indicators of physical abuse, neglect, emotional abuse and/or sexual abuse, and related health outcomes were eligible for inclusion in the review.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

The studies were assessed for quality using criteria specific to different study designs that were developed by the U.S. Preventive Services Task Force. Separate criteria were used for diagnostic accuracy studies, randomised controlled trials (RCTs) and case-control studies. The studies were rated good, fair or poor. Two reviewers independently assessed study validity, and any disagreements were resolved through consensus.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

How were the studies combined?

The studies were combined in a narrative.

How were differences between studies investigated?

The studies were grouped according to the participants (children, women or elderly adults) and the type of intervention (screening or intervention).

A total of 42 studies were included in the review.

Child abuse and neglect.

Screening (6 studies).

Few studies evaluated the performance of screening assessment procedures for predicting child abuse and neglect outcomes. Instruments designed to screen for child abuse had poor to fair sensitivity and specificity depending on the instrument and population. None of the instruments had been widely tested.

Intervention (17 studies).

A good-quality RCT with 15 years' follow-up found that nurse home visits during pregnancy and for 2 years postpartum for low-income women improved abuse and neglect outcomes for children, and also improved related outcomes such as criminal activity, perpetrator status and drug use. Eight lower quality RCTs were also identified; these did not indicate improved child abuse and neglect outcomes, but did report improved related outcomes.

Intimate partner violence against women.

Screening (14 studies).

Several brief instruments designed to screen for intimate partner abuse against women compared well with longer, previously validated instruments. However, none of the instruments had been evaluated against measurable intimate partner violence outcomes. The optimal methods of administration have not been determined.

Intervention (2 studies).

Both studies were of abused pregnant women and reported lower levels of violence after delivery of the intervention, based on scores on questionnaires. However, neither study had a non-intervention control group.

Elder abuse and neglect.

Screening (3 studies).

Few studies were identified that assessed instruments designed to screen for elder or caregiver abuse. The instruments assessed performed fairly well, but had not been tested in the primary care setting.

No studies of interventions for elder abuse and neglect were identified.

No studies assessed the adverse effects of screening and interventions for children, women and elderly adults.

Screening and interventions for child abuse are directed at parents during prenatal and postpartum periods; one trial of home nurse visits during and after pregnancy indicated reduced violence measures, whilst other studies of home nurse visits reported improved outcomes related to violence. Several brief screening instruments for intimate partner violence against women have been tested, with fair to good correlation with longer instruments, but interventions are lacking; two small trials suggest benefit using self-reported outcomes. Few screening instruments and no interventions were identified for elderly adults.

The review question was clear in terms of the interventions, participants and outcomes of interest. The authors searched several relevant electronic databases, reviewed reference lists and contacted experts in the field, thus reducing the potential for publication bias. However, only studies reported in English were eligible for inclusion, which increases the potential for language bias. The validity of the studies was assessed using appropriate criteria and by two independent reviewers, thus reducing the potential for reviewer bias and error. However, for some studies few details of the quality assessment results were reported, therefore readers cannot assess their importance. The authors did not report the process used to select studies or extract the data, so the potential for reviewer bias and error cannot be assessed. Adequate details of individual studies were provided. In view of the differences between the studies, a narrative synthesis was appropriate. The authors' conclusions follow from the evidence presented. This was a relatively well-conducted review and the conclusions appear reliable.

Practice: The authors did not state any implications for practice.

Research: The authors stated that future research should use standardised definitions and measures of abuse and neglect, and consider the influence of observer or surveillance bias. Interventions should be defined in a more complete, standardised way and be assessed in broader populations and special populations, such as cultural groups and military families, rather than just high-risk populations. Instruments should be validated in languages other than English and in various medical settings, including the primary care setting. Further research is required to develop, test and implement effective screening instruments and interventions for elder abuse and neglect; to evaluate barriers to screening; to develop instruments and procedures to be used with children aged 5 to 18 years; and to better understand pregnancy-related violence. Studies of effectiveness of treatment programmes for abused victims are also required. These should measure outcomes such as improved quality of life, mental health and social support, as well as measures of reduced violence.

Agency for Healthcare Research and Quality, contract number 290-97-0018.

1. Nelson HD, Nygren P, McInerney Y, Klein J. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:387-96. 2. Nygren P, Nelson HD, Klein J. Screening children for family violence: a review of the evidence for the US Preventive Services Task Force. Ann Fam Med 2004;2:161-9.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.