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Nelson HD, Bougatsos C, Blazina I. Screening Women for Intimate Partner Violence and Elderly and Vulnerable Adults for Abuse: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 May. (Evidence Syntheses, No. 92.)

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Screening Women for Intimate Partner Violence and Elderly and Vulnerable Adults for Abuse: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation [Internet].

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1INTRODUCTION

Purpose of Review and Prior USPSTF Recommendation

This systematic evidence review is an update for the U.S. Preventive Services Task Force (USPSTF) recommendation on screening women for intimate partner violence (IPV) and elderly and vulnerable adults for abuse and neglect. The USPSTF defines screening as obtaining information about abuse from individuals in health care settings who do not have complaints or obvious signs of abuse, such as physical injuries. This information would be obtained from surrogates for individuals who are unable to provide it themselves. Individuals with signs, symptoms, or complaints of IPV or abuse or neglect would undergo evaluations outside the scope of screening recommendations. (Abbreviations are listed in Appendix A.)

In 2004, based on results of a previous review,13 the USPSTF found insufficient evidence to recommend for or against routine screening of women for IPV or of older adults or their caregivers for elder abuse (I Statement).4,5 The USPSTF could not determine the balance between the benefits and harms of screening because of the lack of critical evidence, particularly the lack of trials of the effectiveness of screening in health care settings and the effectiveness of interventions to reduce harm from abuse. The USPSTF reviewed several existing screening instruments that demonstrated adequate internal consistency and were validated with longer instruments. However, none were evaluated against measurable violence or health outcomes. Also, despite reviewing an extensive literature on IPV, few studies provided data on screening and management to guide clinicians in practice, and there was little to no evidence from studies of elder abuse or neglect.

This update focuses on new studies and evidence gaps that were unresolved at the time of the 2004 recommendation.

Condition Definitions

Intimate Partner Violence

The Centers for Disease Control and Prevention (CDC)6 recognizes four categories of IPV, including physical violence, sexual violence, threat of physical or sexual violence, and psychological or emotional abuse.7

Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to, scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person.

Sexual violence is divided into three categories: 1) use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed; 2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act (e.g., because of illness, disability, or the influence of alcohol or other drugs or because of intimidation or pressure); and 3) abusive sexual contact.

Threats of physical or sexual violence use words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm.

Psychological or emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. Psychological or emotional abuse can include, but is not limited to, humiliating the victim, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. In addition, stalking is often included among the types of IPV. Stalking generally refers to “harassing or threatening behavior that an individual engages in repeatedly, such as following a person, appearing at a person’s home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing a person’s property.”8

Abuse and Neglect of Elderly and Vulnerable Adults

For this review, abuse and neglect of vulnerable adults is also considered with elder abuse. A vulnerable adult is a person age 18 years or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to a mental, emotional, long-term physical, or developmental disability or dysfunction, or brain damage.9 Definitions vary by State, and sometimes included in the definition is the receipt of personal care services from others. Types of elder abuse that also apply to vulnerable adults include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self neglect.1012 Elder abuse is defined in various ways for research as well as for legal purposes.13 The CDC provides the following specific definitions.12

Physical abuse occurs when an individual is injured (e.g., scratched, bitten, slapped, pushed, hit, or burned), assaulted or threatened with a weapon (e.g., knife, gun, or other object), or inappropriately restrained.

Sexual abuse or abusive sexual contact is any sexual contact against an individual’s will. This includes acts in which the elderly person is unable to understand the act or is unable to communicate. Abusive sexual contact is defined as intentional touching (either directly or through the clothing) of the genitalia, anus, groin, breast, mouth, inner thigh, or buttocks.

Psychological or emotional abuse occurs when an elder experiences trauma after exposure to threatening acts or coercive tactics. Examples include humiliation or embarrassment, controlling behavior (e.g., prohibiting or limiting access to transportation, telephone, or money or other resources), social isolation, disregarding or trivializing needs, or damaging or destroying property.

Neglect is the failure or refusal of a caregiver or other responsible person to provide for an elder’s basic physical, emotional, or social needs, or failure to protect an elder from harm. Examples include not providing adequate nutrition, hygiene, clothing, shelter, or access to necessary health care, or failure to prevent exposure to unsafe activities and environments. Abandonment is the willful desertion of an elderly person by a caregiver or other responsible person.

Financial abuse or exploitation is the unauthorized or improper use of an elder’s resources for monetary or personal benefit, profit, or gain. Examples include forgery, misuse or theft of money or possessions, use of coercion or deception to surrender finances or property, or improper use of guardianship or power of attorney.

Prevalence and Health Burden

Intimate Partner Violence

Estimates of the prevalence of IPV range widely, due to nonstandardized definitions, variations in reporting, and undisclosed or undiagnosed abuse. Annual estimates for women in the United States range from 1.3 to 5.3 million annually.14,15 The prevalence of lifetime history of IPV for women was reported as 23.6 percent in the 2005 Behavioral Risk Factor Surveillance System dataset for 18 States (N=10,243).16 Among pregnant women in the United States during 2008, physical abuse during the 12 months prior to becoming pregnant varied by State, from 1.8 to 6.0 percent, and rates for physical abuse during pregnancy ranged from 1.3 to 4.6 percent.17 Among postmenopausal women from the Women’s Health Initiative study, 11 percent reported abuse during the prior year, of which 2.1 percent was physical abuse, 89.1 percent was verbal abuse, and 8.8 percent was both physical and verbal abuse (N=91,749).18 Among patients at the Group Health Cooperative, a large nonprofit health maintenance organization serving a predominantly white, middle-class population, Thompson and colleagues reported prevalence of IPV of 7.9 percent in the preceding year and 14.7 percent in the preceding 5 years.19

These estimates likely underrepresent the true rates of abuse because it is often underreported for many reasons,20 including shame, fear, and reprisal.21 For example, only 35.6 percent of women injured during their most recent rape and 30.2 percent of women injured during their most recent physical assault received medical treatment.14

Health consequences of IPV include immediate effects, such as injuries22 and death23 from physical and sexual assault, as well as long-term effects. IPV increases sexually transmitted infections, including HIV,24 pelvic inflammatory disease,25 and unintended pregnancy.26 Assaults during pregnancy adversely affect the health of pregnant women and newborns,27,28 and IPV is associated with preterm birth, low birth weight, and decreased mean gestational age.2931

Chronic mental health conditions related to IPV include post-traumatic stress disorder (PTSD), depression, anxiety disorders, substance abuse, and suicide.3236 Physical conditions resulting from IPV include chronic pain, neurological disorders resulting from injuries, gastrointestinal disorders such as irritable bowel syndrome, migraine headaches, and other disabilities.34,37,38 Physical and sexual abuse during adolescence and young adulthood have been associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, suicidality, and other conditions.39,40

Abuse and Neglect of Elderly and Vulnerable Adults

The prevalence of abuse and neglect among elderly and vulnerable adults is unknown because of the nonstandardized definitions of abuse and neglect, differences in reporting, and undisclosed or undiagnosed abuse.41 A recent study estimated that 14 percent of noninstitutionalized older adults had experienced physical, psychological, or sexual abuse; neglect; or financial exploitation during the past year.42 In a survey, 52 percent of family caregivers of individuals with dementia reported abusive behavior towards them.43 Women with disabilities are four times more likely to experience sexual assault in the past year than women without disabilities.44 A comprehensive literature review utilizing studies of self-report, caregiver and professional support, and objective measures found that overall, one in four vulnerable elders are at risk for abuse, but only a small proportion are identified.45

Elder abuse is associated with higher mortality. In a large, long-term prospective cohort study in New Haven, Connecticut, mistreated elders had an increased risk for death compared with nonmistreated elders (odds ratio [OR], 3.1 [95% CI, 1.4–6.7]) after adjustment for demographic characteristics, chronic diseases, functional status, social networks, cognitive status, and depression.46

Risk Factors

Intimate Partner Violence

The CDC lists a broad array of risk factors for victimization or perpetration of IPV, categorized by individual, relationship, community, and societal factors.47 The CDC’s individual risk factors apply predominantly to perpetrators. Relationship risk factors include marital conflict, tension, and other struggles; marital instability, including divorces or separations; dominance and control of the relationship by one partner over the other; economic stress; and unhealthy family relationships and interactions. Community risk factors include poverty and associated factors such as overcrowding; low social capital such as lack of institutions, relationships, and norms that shape a community’s social interactions; and weak community sanctions against IPV. Societal risk factors include traditional gender norms, such as women staying at home, not entering the workforce, and being submissive, while men support the family and make the decisions. In a large observational study of Kaiser Permanente members, the highest predictor of undiagnosed IPV for women was violence that occurred during the 5 years prior to the patient visit for health care (OR, 7.8 [95% CI, 5.3–11.4]).48 In this study, complications during pregnancy was another predictor for pregnant women.

Abuse and Neglect of Elderly and Vulnerable Adults

The CDC also categorizes risk for elder abuse by individual, relationship, community, and societal levels.49 Individual risk factors apply mostly to perpetrators, who are often caregivers, and include mental illness, alcohol abuse, hostility, poor or inadequate preparation or training for caregiving responsibilities, assumption of caregiving responsibilities at an early age, inadequate coping skills, and exposure to maltreatment as a child.

The CDC’s relationship risk factors include high financial and emotional dependence upon a vulnerable elder, past experience of disruptive behavior, and lack of social support. Community risk factors include limited, inaccessible, or unavailable supportive services, such as respite care for caregivers. Societal risk factors include cultures in which there is high tolerance and acceptance of aggressive behavior; health care personnel, guardians, and other agents are given greater freedom in routine care provision and decisionmaking; family members are expected to care for elders without seeking help from others; persons are encouraged to endure suffering or remain silent regarding their pains; and there are negative beliefs about aging and elders.

Risk factors for victims of elder abuse determined from research studies include dementia, living in a care facility, advanced age, female sex, widowed marital status, physical and mental disabilities, behavioral problems, substance abuse, psychological factors, economic factors, dependency, and social isolation.13,18,50,43

Rationale for Screening

Routine screening among asymptomatic individuals for IPV and elder and vulnerable adult abuse and neglect could identify abuse not otherwise known, prevent future abuse from occurring, and reduce morbidity and mortality. Because of fear, intimidation, and lack of support, many individuals do not disclose abuse unless directly questioned, and many who are directly questioned will not disclose. Prevention, identification, and stopping abuse is important to avert both short- and long-term serious health outcomes.15,5153

Screening for IPV by health care professionals is generally acceptable to women under conditions that are perceived as private and safe, and when questions are asked in a comfortable manner. There is no consensus regarding the most acceptable screening setting or modality.54 While screening is generally acceptable to the majority of women surveyed,54 some patients may experience feelings of being judged by care providers, and may have increased anxiety, feelings of intrusion, and disappointment in provider responses.55 Some women also raise concerns about increased risk for abuse associated with both screening and mandatory reporting.56 Studies suggest that victims of elder abuse and neglect may not tell anyone about their experiences.57,58 Many victims do not seek help from the police, Adult Protective Services (APS), or social and health service providers, especially when the perpetrators are their children.57,5961 Some victims may view abuse as normal behavior,61 and some may blame themselves for the abusive situation.58,60,62,63

Interventions

Intimate Partner Violence

There are several types of services for women subjected to IPV that vary by community and accessibility. These include hotlines, shelters, inpatient services, counseling, and advocacy programs. Identification of IPV in health care settings can lead to a referral to social services to help identify appropriate resources or a direct referral to services, or it can provide an opportunity to present information and discuss options for future consideration.

Some States require physicians to report abuse to legal authorities, and most require reporting of injuries resulting from firearms, knives, or other weapons.64 By federal law, through the passage of the 1994 Violence Against Women Act and the 2005 reauthorization,65 shelter workers and other advocates are not mandatory reporters, unless they hold a clinical license that otherwise requires them to report abuse, thereby making it easier for women to seek refuge from abuse without fear of losing their children. There is significant controversy in the field over whether legal reporting for IPV should be mandatory to assure victim safety.

Abuse and Neglect of Elderly and Vulnerable Adults

In cases of suspected or known elder abuse, health care workers are required to contact their local APS office, Area Agency on Aging office, or another social service for further investigation. The Social Security Act of 1974 authorized States to create APS offices. The Older Americans Act established local Ombudsman offices and other agencies dedicated to protecting the rights of elderly Americans. Mandatory reporting laws and regulations of elder abuse by physicians and other licensed individuals vary by State; however, most require reporting.66 If abuse is found, interventions vary and could include services such as advocacy, counseling, money management, out-of-home placement, or conservatorship, among others. Cases of abuse and interventions for vulnerable adults are also handled by local APS offices or other social services, and interventions are implemented on a case-by-case basis.

Current Clinical Practice

Intimate Partner Violence

Screening practices are inconsistent for several reasons, including the existence of a variety of screening instruments, a lack of consensus on which instrument to use, the nonspecificity of risk factors, lack of training, lack of effectiveness studies about what to do if IPV is identified, discomfort with screening, and time constraints. While screening protocols have been implemented in some health systems, screening practices are low in others. While 43 to 85 percent of women considered screening for abuse acceptable when surveyed, only one third of physicians and half of emergency department nurses favored screening.67

Abuse and Neglect of Elderly and Vulnerable Adults

Current screening practices for elder and vulnerable adult abuse and neglect are also limited for many reasons.50 These include varying definitions of abuse, the wide variety of types of elder abuse, lack of an agreed-upon screening method, wide-ranging risk factors, lack of training, unclear guidance about who to screen and what to do if abuse is identified, physician discomfort with screening, uncertainty about the ramifications of identifying abuse or making allegations, lack of physician control or ability to decide what is in the best interest of the patient,68 and time constraints. Also, in a recent survey of U.S. physicians, only a quarter were aware that the American Medical Association has guidelines on screening for elder abuse.69 Identifying abuse and neglect for elderly or vulnerable adults also raises legal issues about mandatory reporting.

Recommendations of Other Groups

Intimate Partner Violence

Recommendations of other groups about screening for IPV in health care settings are summarized in Table 1. The Canadian Task Force on Preventive Health Care found insufficient evidence to recommend for or against screening women for IPV.70 A report by the Health Technology Assessment Program in the United Kingdom also concluded that evidence is insufficient to implement a screening program for partner violence against women either in health services generally or in specific clinical settings.54

Table 1. Screening Recommendations for Intimate Partner Violence.

Table 1

Screening Recommendations for Intimate Partner Violence.

The American Medical Association recommends that physicians routinely inquire about physical, sexual, and psychological abuse as part of the medical history, and consider abuse as a factor in the presentation of medical complaints because patients’ experiences with interpersonal violence or abuse may adversely affect their health status.71 The Institute of Medicine recently recommended screening and counseling for interpersonal and domestic violence for women and adolescent girls,72 and this recommendation was incorporated into the Affordable Care Act as a preventive health service. The American Congress of Obstetricians and Gynecologists recommends that physicians screen all patients for IPV, and that screening should occur during routine visits and over the course of pregnancy.73 The American Academy of Pediatrics also recommends screening, stating that pediatricians are in a position to recognize abused women in pediatric settings.74 Other groups, such as Futures Without Violence (formerly the Family Violence Prevention Fund),75 Council of International Neonatal Nurses,76 Emergency Nurses Association,77 and American College of Emergency Physicians78 also recommend that health care providers screen patients for IPV. The American Academy of Family Physicians79 also suggests that physicians be aware of signs of IPV during each patient encounter.

Abuse and Neglect of Elderly and Vulnerable Adults

Recommendations of other groups about screening for elder abuse in health care settings are summarized in Table 2. The American Medical Association,80 American College of Emergency Physicians,78 and Emergency Nurses Association77 specifically suggest screening for elder abuse. The American Congress of Obstetricians and Gynecologists,73 American Academy of Pediatrics,74 Emergency Nurses Association,77 Council of International Neonatal Nurses,76 and Futures Without Violence75 all recommend in more general statements that care providers screen patients for family violence (Table 1).

Table 2. Screening Recommendations for Elder Abuse and Neglect.

Table 2

Screening Recommendations for Elder Abuse and Neglect.

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