Definition of screening

1. Effectiveness of screening for GBVClaudia Garcia-MorenoWorld Health OrganizationIntegrating Gender-based violence in HIV programmesWorkshop: Nairobi, Kenya 30-31 July 2012

2. Definition of screening • Screening, in medicine, is a strategy used in a population to detect a disease in individuals without signs or symptoms of that disease. • Enables early identification of disease, enabling earlier intervention and management in the hope to reduce mortality and suffering from a disease. • Although screening may lead to an earlier diagnosis, not all screening tests have been shown to benefit the person being screened; overdiagnosis, misdiagnosis, and creating a false sense of security are some potential adverse effects of screening.

3. Barriers to screening - Health professionals • Limited knowledge on gender violence • Institutional constraints: lack of time, resources • Attitudes: fear to offend, blaming • No effective interventions • Lack of coordination between departments within the health sector (mental health, drugs & alcohol) • Lack of coordination between health services and other sectors that deal with gender violence (justice, welfare, NGO networks) Insert file name

4. “ Sometimes when I ask a woman about violence, she dissolves in a sea of tears… then I think “now how am I going to get rid of her? Doctor in El Salvador ” Insert file name

5. Barriers to screening in the health sector - women Women are not talking: • Shame, embarrassment • Lack of confidence in the health worker / system • Fear of more violence at home Insert file name

6. “ I said in the hospital that I had fallen, because if I told the truth he would kill me, and I was also ashamed that they would find out that it was my husband who had beaten me. ”

7. Systematic reviews • Ramsay, Richardson, Carter et al (2002) BMJ concluded that "Although domestic violence is a common problem with major health consequences for women, implementation of screening programmes in healthcare settings cannot be justified. Evidence of the benefit of specific interventions and lack of harm from screening is needed." • Feder et al Review against UK National Screening Committee criteria (2007) concluded thatCurrently there is insufficient evidence to implement a screening programme for partner violence against women either in health services generally or in specific clinical settings. It may be inappropriate to judge a policy of routine enquiry about partner violence by the NSC criteria, particularly as women perceive other valid purposes of screening besides identification. Even if the scope of routine enquiry is wider than screening, it is debatable whether that policy would be justified within health services.

8. UK review of IPV screening (2009) • Question I: What is the prevalence of partner violence against women and what are its health consequences? (NSC criterion 1) • Question II: Are screening tools valid and reliable? (NSC criteria 5 and 6) • Question III: Is screening for partner violence acceptable to women? (NSC criterion 7) • Question IV: Are interventions effective once partner violence is disclosed in a health-care setting? (NSC criteria 10 and 15) • Question V: Can mortality or morbidity be reduced following screening? (NSC criterion 13) • Question VI: Is a partner violence screening programme acceptable to health professionals and the public? (NSC criterion 14) • Question VII: Is screening for partner violence cost-effective? (NSC criterion 16)

9. WHO Systematic review 2011: Picot question What are the effects of interventions aimed at screening or identifying women survivors of intimate partner violence delivered at the health system level? • Population: Women (15 years of age or older) who experience(d) partner violence within last 5 years • Interventions: Screening for IPV of all women or subgroups of women by any method in any health setting • Comparator: Comparison between types of interventions or between intervention and no intervention. • Outcome: Health care provider giving related information or services, Referral rates (and uptake of referrals if documented), Partner violence recurrence, Physical, emotional, psychological and reproductive health including Health Functioning, Quality of Life, Safety behaviours (Proxy measure), Harm/adverse events, Use of health services (intermediate outcome), Economic wellbeing (e.g getting a job, increased benefit) (intermediate outcome)

10. Search methodology • Embase, Medline, Psych Info, Cumulative Index Nursing and Allied Health Literature (CINAHL), Dissertation/ Theses, Criminal Justice and Psych Books. • Search dates, Jan 1, 2009 through March 4, 2011, overlapped the 2010 WHO review by eight and one-half months (Feder et al 2010, search date ended August 14, 2009). • Initial search identified 6,195 potential studies. After removing duplicates, all remaining abstracts were reviewed of which 16 warranted review of the full publication. Of these 16, two met our criteria. • GRADE criteria were applied to the studies in the prior WHO review, as well as to new studies in the indexed literature (search dates January 1, 2009 to March 4 2011). Two reviewers appraised the new studies and applied GRADE criteria to the new studies and studies from the prior 2010 review when sufficient data was available.

11. Results • Review contains 4 studies (Macmillan et al, 2009; Koziol-Maclain, 2010; to provide evidence on screening plus health system level interventions. Of the 4 studies all were randomized controlled trials and all were conducted in resource rich settings: Canada (2), New Zealand (1) and USA (1). • WHO 2010 systematic review concluded there was insufficient evidence that screening for partner violence leads to a reduction in IPV or an improvement in quality of life or health outcomes. This review focused on screening plus an immediate action (referral, prompt in medical record). • Three of the 4 studies were in emergency department, two in family practice and one in gynaecology or antenatal clinical setting. • No studies demostrated a stratistically significant reduction in IPV recurrence.

12. Results continued…. • Only one study assessed health outcomes: quality of life and symptoms of depression and PTSD and found no difference at 18 months • Conclusion: In spite of new studies to date there is insufficient evidence that screening plus actions leads to a reduction in IPV recurrence or improvement in quality of life or other health actions. • There is now evidence of the lack of potential harms. • Screening still does not fulfill the public health criteria for implementation of a screening programmes with no evidence of improved outcomes. On the other hand no evidence that screening produces adverse outcomes. • Limitations of evidence: small number of trials with only 2 studies going beyond intermediate outcomes and other health outcomes. High proportion of potential participants declining and high loss to follow up.

13. WHO draft recommendations for health sector • 'Universal screening' or 'routine enquiry' (i.e. asking women in all healthcare encounters) is not recommended. • Healthcare providers, should ask about exposure to IPV when assessing conditions that may be caused or complicated by IPV (see Box 1 Clinical conditions where asking about IPV is recommended)and it is safe, in order to improve diagnosis/ identification and subsequent care- • Training should focus on enabling all primary health care providers to be aware of IPV and to know how to provide a first-line/support response to anyone who discloses IPV • Written information on IPV should be available in health care settings for women in the form of posters and pamphlets (with appropriate warnings about taking home if an abusive partner is there).

14. Considerations for WHO recommendation on screening • The high burden of universal screening where there is high prevalence, particularly in settings with limited referral options and overstretched resources/providers, which translates into limited capacity to respond to women who may be identified through screening, and where focusing on selective or clinical enquiry is more likely to benefit women. • Women may find it difficult being repeatedly asked, particularly if nothing is done. This may potentially reduce their uptake of health services. • The opportunity costs of over stretched healthcare providers • While screening increased detection it also tends to increase resistance from clinicians and rates fall off. It rapidly becomes a tick-box exercise carried out without due consideration or done in an ineffectual way. • Training providers on asking women when there were limited options to offer much else has an important opportunity cost. It is preferable to focus on enhancing providers' ability to respond adequately to those who disclose violence, or who are suffering from severe formsof abuse.

15. WHO Draft recommendations for health sector • Women who disclose any form of violence by an intimate partner (or other family member) or sexual violence should be offered immediate support. Health care providers should, as a minimum, offer first line support when women disclose violence. This includes: • ensuring consultation(s) is done in privacy • ensuring confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting) • providing practical care and support, which does not intrude • asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken with the use of interpreters for sensitive topics); • being non-judgmental, providing comfort and validating what the woman is saying • helping her access information about resources, including legal and other services;