Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: US Preventive Services Task Force Recommendation Statement
US Preventive Services Task Force
This guideline focuses on screening for intimate partner violence (IPV) and abuse of elderly and vulnerable adults. IPV commonly goes undetected, but it has several potential adverse consequences. Immediate effects include injury and death, whereas long-term health consequences range from unintended pregnancy to increased rates of chronic pain, neurological disorders, gastrointestinal disorders and migraine headaches1.
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen women of child-bearing age for IPV and provide or refer women who screen positive to intervention services (grade B recommendation)1.
Further, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (those with physical or mental dysfunction) for abuse and neglect (I statement)1.
According to police-reported data, Canadians’ risk of IPV (both spousal and dating partner violence) is higher than the risk of non-spousal family violence or violence committed by strangers2. In 2010, 363 women per 100,000 population reported IPV, representing over 102,500 Canadians2.
Little information is available on the prevalence of abuse among non-institutionalized elderly or vulnerable adults. In 2004, 3,370 incidents of violence against Canadians aged 65 years and over were reported to police3. Over one quarter (29%) of reported incidents against older people were committed by a family member3.
This guideline was developed in the United States by a broad range of experts and is targeted toward clinicians.
RELEVANCE TO CTFPHC MANDATE
All sections of this guideline are applicable to the CTFPHC mandate of prevention in primary care.
The target populations for screening are individuals presenting for health care, specifically adult women for IPV screening and elderly and vulnerable adults for screening for abuse and neglect.
EVIDENCE REVIEW METHODS
The National Library of Medicine’s Medical Subject Headings (MeSH) keyword nomenclature was used to search Ovid MEDLINE and PsycINFO (2002 to 9 January, 2012), the Cochrane Central Register of Controlled Trials (fourth quarter of 2011) and the Cochrane Database of Systematic Reviews (fourth quarter of 2011) for relevant English-language studies and systematic reviews. In addition, reference lists of papers were manually reviewed, and citations of key studies were searched using Scopus. A total of 8,368 abstracts were identified; 625 full-text articles were reviewed for relevance, of which 38 were included in the evidence synthesis.
The USPSTF assigns 1 of 5 letter grades to each recommendation: A, B, C, D or I4. These grades are based largely on the level of certainty of the net benefit associated with providing the service. For more information on the grading scheme, see Table 2 and Table 3.
The CTFPHC assessed the methodological quality of the guideline using the Appraisal of Guidelines Research & Evaluation (AGREE II) 5 criteria (Table 1).
|AGREE II domain||Domain score||Standard deviation|
|Scope and purpose||90%||0.6|
|Rigour of development||83%||1.0|
|Clarity of development||83%||1.3|
Overall, the objective, health questions and target population of this guideline are well defined and clearly presented. Further, a high level of rigour was used to develop this guideline. However, in the opinion of the CTFPHC, there is currently insufficient evidence to recommend screening the general Canadian population for IPV or elder abuse.
It is important to note that the guideline included data from only one study that directly addressed the benefit of screening, and that study found no effect of screening on outcomes. The recommendation for screening is based on indirect evidence with considerable limitations. In addition, some of the indirect evidence of benefit for screening appears to depend on follow-up programs for victims of IPV that may not be widely available in Canada, and/or rely on clinician knowledge of available referral pathways.
Implementation of this guideline would be challenging, since clinical criteria for identifying IPV and elder abuse have limitations; further, definitions of what constitutes abuse may vary between contexts, and the legal obligations of providers differ between jurisdictions. These potential barriers to implementation are mentioned by the developers, but no advice is given about how to address them.
Although IPV and elder abuse are both important societal problems, available evidence does not justify screening for these conditions in Canada. The World Health Organization recently came to the same conclusion, through publication of its guideline Responding to Intimate Partner Violence and Sexual Violence against Women5 which recommends against routine screening. Practitioners should remain alert to clinical clues of IPV or abuse and neglect of elderly and vulnerable adults and assess further when indicated on clinical grounds.
ORIGINAL GUIDELINE RECOMMENDATIONS
The full guideline can be found at uspreventiveservicestaskforce.org.
- Asymptomatic Women of Childbearing Age: Screen women for intimate partner violence (IPV), and provide or refer women who screen positive to intervention services. (Grade B)
- Elderly or Vulnerable Adults: No recommendation. (I statement)
- Moyer VA; U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478–486.
- Sinha M. Section 2. Violence against intimate partners. In: Family violence in Canada: a statistical profile, 2010. Ottawa, ON: Statistics Canada; 2012. Available at: http://www.statcan.gc.ca/pub/85-002-x/2012001/article/11643/11643-2-eng.htm. Accessed 2013 Apr 16.
- Elder abuse in Canada: a gender-based analysis—summary. Ottawa, ON: Public Health Agency of Canada; 2012. Available at: <http://www.phac-aspc. gc.ca/seniors-aines/publications/pro/abuse-abus/gba-acs/index-eng.php>. Accessed 2013 Apr 16.
- Grade definitions: grade definitions after July 2012. Rockville, Maryland: U.S. Preventive Services Task Force; 2012. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm. Accessed 2013 Jun 16.
- Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013. Available at: http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf. Accessed 2014 Jan 16.