Draft Recommendation Statement
Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening
April 24, 2018
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
IPV and abuse of older or vulnerable adults are common in the United States but often remain undetected. Although estimates vary, IPV (including sexual violence, physical violence, and stalking) is experienced by approximately 37% of U.S. women during their lifetime and 31% of U.S. men. Severe physical violence is experienced by 23% of U.S. women and 14% of U.S. men during their lifetime.1 Prevalence rates vary by age, race/ethnicity, and income. Less is known about the prevalence of abuse among noninstitutionalized older or vulnerable adults; a 2008 nationwide survey of U.S. adults age 60 years or older found that the prevalence of any abuse or potential neglect in the past year was 10%.2,3
In addition to the immediate effects of IPV, such as injury and death, there are other health consequences, many with long-term effects, including development of mental health conditions such as depression, posttraumatic stress disorder (PTSD), anxiety disorders, substance abuse, and suicidal behavior; sexually transmitted infections; unintended pregnancy; and chronic pain and other disabilities.4-6 Violence during pregnancy is associated with preterm birth and low birth weight7 and adverse effects on maternal and infant health, including postpartum mental health problems8 and hospitalization during infancy.9
There are a number of long-term negative health effects from elder abuse, including death,10,11 higher risk of nursing home placement12 among victims referred to Adult Protective Services, increased rates of hospitalization,13 and adverse psychological consequences (distress, anxiety, and depression).13
The USPSTF found adequate evidence that available screening instruments can identify IPV in women.
The USPSTF found inadequate evidence to assess the accuracy of screening instruments designed to detect elder abuse or abuse of vulnerable adults.
Benefits of Detection and Early Intervention
The USPSTF found inadequate direct evidence that screening for IPV can reduce violence, abuse, and physical or mental harms in adults and adolescents. However, the USPSTF found adequate evidence that effective interventions can reduce violence, abuse, and physical or mental harms in women of reproductive age.
The USPSTF found inadequate evidence that screening or early detection of elder abuse or abuse of vulnerable adults reduces exposure to abuse, physical or mental harms, or mortality in older or vulnerable adults.
Harms of Detection and Early Intervention
The USPSTF found inadequate evidence to determine the harms of screening or interventions for IPV. Limited evidence showed no adverse effects of screening or interventions for IPV. The USPSTF determined that the magnitude of the overall harms of screening and interventions for IPV could be bounded as no greater than small.
The USPSTF found inadequate evidence on the harms of screening or interventions for elder abuse or abuse of vulnerable adults.
The USPSTF concludes with moderate certainty that screening for IPV in women of reproductive age and providing or referring women who screen positive to ongoing support services has a moderate net benefit.
The USPSTF concludes that the benefits and harms of screening for elder abuse or abuse of vulnerable adults are uncertain and that the balance of benefits and harms cannot be determined.
This recommendation applies to asymptomatic women of reproductive age and older or vulnerable adults. The studies reviewed included women from adolescence to about age 40 years, with most research focusing on women age 18 years or older.
Definitions of IPV and Elder Abuse
The term “intimate partner violence” refers to physical violence, sexual violence, psychological aggression (including coercive tactics), or stalking by a person with whom one has a close personal relationship, such as a current or former boyfriend/girlfriend, dating partner, ongoing sexual partner, or spouse.1
The term “elder abuse” refers to either intentional or unintentional acts whereby a trusted person (e.g., a caregiver) causes or creates risk of harm to an older adult.14 According to the Centers for Disease Control and Protection (CDC), an older adult is considered to be age 60 years or older.14 The legal definition of “vulnerable adult” varies by State but is generally defined as a person who is or may be mistreated and who, due to age, disability, or both, is unable to protect him or herself.15 Types of abuse that apply to older or vulnerable adults include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial or material exploitation.
Primary care interventions for child maltreatment are addressed in a separate recommendation statement.16
Assessment of Risk
Although all women of reproductive age are at potential risk for IPV and should be screened, there are a variety of factors that increase the risk of IPV, such as exposure to violence as a child, young age, unemployment, substance abuse, marital difficulties, and economic hardships.17 However, the USPSTF did not identify any risk assessment tools that predict violence in populations with these risk factors.
Risk factors for elder abuse include isolation and a lack of social support, functional impairment, and poor physical health.18,19 For older adults, lower income and living in a shared living environment with a large number of household members (other than a spouse) are associated with an increased risk of financial and physical abuse.20
Several screening instruments can be used to screen women for IPV. The following instruments have reasonable accuracy to detect IPV in the past year among adult women: Humiliation, Afraid, Rape, Kick (HARK); Hurt/Insult/Threaten/Scream (HITS); Extended Hurt/Insult/Threaten/Scream (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST).
HARK includes four questions that assess emotional and physical IPV in the past year. HITS includes four items that assess the frequency of IPV and E-HITS includes an additional question to assess the frequency of sexual violence. PVS includes three items that assess physical abuse and safety. WAST includes eight items that assess physical and emotional IPV.
The USPSTF found no valid, reliable screening tools to identify abuse of older or vulnerable adults in the primary care setting.
The USPSTF found no evidence on appropriate intervals for screening. Randomized, controlled trials of screening and IPV interventions often screen for current IPV or IPV during the past year.
Intervention characteristics varied across studies and appeared to be important to the effectiveness of reducing violence, abuse, and physical or mental harms. The more effective studies generally involved ongoing support services, which included multiple visits with patients, addressed multiple risk factors (not just IPV), and provided a range of emotional support and behavioral and social services (Table). Studies that only included brief interventions and provided information about referral options were generally ineffective.
No studies were able to definitively prove which intervention components resulted in positive outcomes. However, based on the evidence from three studies,21-23 effective interventions generally included ongoing support services that focused on counseling and home visits, addressed multiple risk factors (not just IPV), or included parenting support for new mothers. See the Table for more information about the components of effective ongoing support services.
Suggestions for Practice Regarding the I Statement and Other Populations
Potential Preventable Burden
Older or vulnerable adults. Less is known about the prevalence of abuse among noninstitutionalized older or vulnerable adults, and reported rates vary and likely underestimate prevalence. A 2008 nationwide survey of U.S. adults age 60 years or older found that the prevalence of any abuse or potential neglect in the past year was 10%.2 Elder abuse has a number of long-term negative health effects, including death,10 higher risk of nursing home placement12 among victims referred to Adult Protective Services, increased rates of hospitalization,13 and adverse psychological consequences (distress, anxiety, and depression).13
Women not of reproductive age. Approximately 4% of women ages 45 to 54 years and more than 1% of women age 55 years or older have experienced rape, physical violence, or stalking by an intimate partner in the past 12 months.24
Men. One study reported that more than 30% of men have experienced sexual violence, physical violence, or stalking by an intimate partner in their lifetime.1 Almost half of men report any psychological aggression by an intimate partner in their lifetime. Among men who experience sexual violence, physical violence, or stalking, 35.7% experience at least one form of an IPV-related impact, such as feeling fearful, feeling concerned for safety, PTSD symptoms, missing days of work/school, needing legal services, and needing medical care.1
Some potential harms of screening in older or vulnerable adults, women not of reproductive age, and men are shame, guilt, self-blame, retaliation or abandonment by perpetrators, partner violence, and the repercussions of false-positive results (e.g., labeling and stigma).
Older or vulnerable adults. Limited evidence suggests screening is not commonly occurring in practice; one study found that more than 60% of clinicians have never asked their older adult patients about abuse.25
Women not of reproductive age. While not specific to age, evidence suggests that screening for IPV is not commonly occurring in practice. A recent systematic review found that rates of routine screening vary and are typically low, ranging from 2% to 50% of providers reporting “always” or “almost always” routinely screening for IPV.26
Men. No data are available on current screening practice among in men.
Additional Approaches to Prevention
The Health Resources and Services Administration (HRSA) Strategy to Address Intimate Partner Violence (2017–2020) identifies priorities for reducing IPV, including training the Nation’s health care and public health workforce to address IPV.27 The strategy includes a toolkit for providers to help implement IPV screening that was funded by the Department of Health and Human Services, HRSA, and the Administration for Children and Families.
The CDC,28 Substance Abuse and Mental Health Services Administration (SAMHSA)-HRSA Center for Integrated Health Solutions,29 and Administration on Aging’s National Center for Elder Abuse30 also have additional resources available for clinicians.
State and local reporting requirements vary from one jurisdiction to another, with differences in definitions, whom and what should be reported, who should report, and to whom. Some States require clinicians (including primary care physicians) to report abuse to legal authorities, and most require reporting of injuries resulting from firearms, knives, or other weapons.31 For elder abuse specifically, mandatory reporting laws and regulations also vary by State; however, most require reporting.32
The USPSTF has several recommendations that may be relevant, including screening for depression in adolescents, adults, and pregnant women,33 screening for alcohol misuse (update in progress),34 and screening for drug misuse (update in progress).35
There are several key research gaps related to IPV. The USPSTF recognizes that a significant body of evidence is lacking for men. The CDC has conducted studies demonstrating the prevalence and importance of IPV against men. Research is needed in all areas related to the accuracy of screening tools for men, and trials are needed that examine the effectiveness of screening for and interventions to prevent IPV in men in the primary care setting.
More research is also needed on the most effective characteristics of ongoing support services for reducing IPV. In particular, more RCTs that compare screening (plus an ongoing support service or referral for women who screen positive) versus no screening are needed, where support services may include more frequent and intensive interventions such as home visits, cognitive behavioral therapy, or other forms of ongoing support services that address multiple risk factors. These trials should also enroll pregnant and nonpregnant women. These types of trials will help with understanding the types of postscreening, ongoing support services that can be most effective and for whom they are most effective.
More research is also needed in all areas related to the accuracy of screening tools for abuse of older or vulnerable adults, as well as the effectiveness of screening for and interventions to prevent such abuse in the primary care setting.
Burden of Disease
IPV is a significant public health problem. According to the CDC, 37.3% of U.S. women and 30.9% of U.S. men experience sexual violence, physical violence, or stalking by an intimate partner during their lifetime.1 The prevalence of lifetime psychological aggression is higher (47.1% of women and 47.3% of men). Lifetime severe physical violence is experienced by 23.2% of women and 13.9% of men. The most commonly reported effects of IPV include feeling fearful (61.9% of women and 18.2% of men), concern for safety (56.6% of women and 16.7% of men), and symptoms of PTSD (51.8% of women and 16.7% of men).1 Both women and men with a history of sexual violence, stalking, or physical violence committed by an intimate partner were more likely to report experiencing asthma, irritable bowel syndrome, frequent headaches, chronic pain, difficulty sleeping, and limitations in their activities (vs. women and men without a history of such violence).
IPV is more common in younger adult women; thus, women of reproductive age have a higher prevalence of IPV than older women. Approximately 14.8% of women ages 18 to 24 years have experienced rape, physical violence, or stalking by an intimate partner in the past 12 months, compared with 8.7% of women ages 25 to 34 years, 7.3% of women ages 35 to 44 years, 4.1% of women ages 45 to 54 years, and 1.4% of women age 55 years or older.24 IPV during pregnancy can have significant negative health consequences for women and children, including depression in women, low birth weight and preterm birth, and perinatal death.36
Abuse of older or vulnerable adults is also a significant public health problem. Estimates of prevalence vary. A nationally representative survey (N=3,005) of community-dwelling adults ages 57 to 85 years estimated that 9% had experienced verbal mistreatment, 3.5% percent financial mistreatment, and 0.2% physical mistreatment by a family member.18 Among older adults, intimate partners constitute a minority of perpetrators in substantiated reports of elder abuse; according to data from a national survey of Adult Protective Services agencies, across all substantiated abuse reports involving a known perpetrator among adults older than age 60 years (N=2,074), approximately 11% of reports involved a spouse or intimate partner.37 The most common perpetrators of elder abuse are adult children (about 33% of cases) and other family members (about 22% of cases).37
Less is known about the prevalence of abuse among populations of vulnerable adults. The 1995–1996 National Violence Against Women Survey (N=6,273) found that women with severe disability impairments were 4 times more likely to experience sexual assault in the past year than women without disabilities.38
Scope of Review
The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on screening for the prevention of IPV, elder abuse, and abuse of vulnerable adults. The scope of this review was similar to the prior systematic review, but in the current review,39 the USPSTF also examined the evidence on men and adolescents as victims of IPV.
Accuracy of Screening Tests
This review identified 15 fair-quality studies (n=4,460) assessing the accuracy of a total of 12 screening tools for IPV. All studies enrolled adults, and most enrolled only women or a majority of women; one study included only men.40 The recruitment settings varied across the studies; five recruited from emergency departments, four from primary care practices, one from urgent care, and three recruited women by telephone or mail survey. Most studies assessed a tool designed to identify persons exposed to IPV within the past year; however, six studies reported on the accuracy of a tool for identifying current (ongoing) abuse, two assessed the accuracy of detecting lifetime abuse, and one assessed the accuracy of a tool for predicting future (3 to 5 months) abuse.
Of the studies reporting on the accuracy of detecting past-year IPV, five reported on the accuracy of five different screening tools (HARK, HITS, E-HITS, PVS, and WAST) for detecting past-year IPV exposure in adult women. Across all screening tools, sensitivity ranged from 64% to 87% and specificity ranged from 80% to 95%. Most were assessed by only one study.
One study enrolling men only from an emergency department reported on the accuracy of the PVS and HITS for detecting past-year IPV; sensitivity was low for both PVS and HITS for detecting psychological abuse (30% and 35%, respectively) and physical abuse (46% for both).
Two studies reported on the accuracy of three screening tools in identifying ongoing or current relationship violence in populations enrolled from emergency departments; one study found a sensitivity of 86% and specificity of 83% for the Ongoing Violence Assessment Tool (OVAT) compared with the Index of Spouse Abuse (ISA). The second study found relatively poor accuracy for the Abuse Assessment Screen (AAS) and Ongoing Abuse Screen (OAS).
The review identified one fair-quality study assessing the accuracy of screening for abuse in older adults.41 No studies were found on the effectiveness of screening questionnaires or tools in identifying abuse and neglect of vulnerable adults. Screening was conducted using the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST), which includes 15 items. Compared with the Conflict Tactics Scale (CTS) (violence/verbal aggression scales combined), the H-S/EAST had a sensitivity of 46% (95% confidence interval [CI], 32 to 59) and specificity of 73.2% (95% CI, 62 to 82).
Effectiveness of Early Detection and Treatment
Overall, three RCTs (n=3,759) found no direct benefit of screening for IPV in adult women (mean age range, 34 to 40 years) when screening was followed by brief counseling or referral. There were no significant differences between screening and control groups over 3 to 18 months for IPV, quality of life, depression, PTSD, or health care utilization outcomes. The RCTs compared universal screening for IPV in a health care setting with no screening; one enrolled participants from 10 U.S. primary care clinics, one from a single New Zealand emergency department, and one from a variety of Canadian clinical settings (12 primary care sites, 11 emergency departments, and three obstetrics-gynecology clinics). There were no RCTs enrolling men or adolescents, and none that focused on pregnant women or reported outcomes separately by pregnancy status. Women who screened positive in these three trials received brief counseling and referral; the trials did not directly provide ongoing support services, and the proportion of women who received more intensive services following referral was not reported.
Eleven RCTs (n=6,740) evaluated an IPV intervention in adult women with screen-detected IPV or women who were considered at risk for IPV. Five RCTs enrolled women during the perinatal period; all reported on IPV exposure outcomes. Of these, the studies that were effective generally involved ongoing support services, which included multiple visits with patients, addressed multiple risk factors (not just IPV), and provided a range of emotional support and behavioral and social services. Two home-visit interventions22,23 found lower IPV exposure in women assigned to the intervention group than in those assigned to the control group; however, the difference between groups was small (standardized mean difference, -0.04 and -0.34, respectively), and only one study found a statistically significant difference (standardized mean difference, -0.34 [95% CI, -0.59 to -0.08]).22
Of the three RCTs enrolling pregnant women with screen-detected IPV that evaluated a counseling intervention, two found benefit in favor of the intervention.21,42 One trial only reported on subtypes of violence; the benefit was significant for some subtypes of violence (psychological and minor physical abuse) but not others (severe physical and sexual abuse).42
One RCT assessing an integrated behavioral counseling intervention in women with one or more risk factors (smoking, environmental tobacco smoke exposure, depression, and IPV) reported on birth outcomes among the subgroup who had IPV at baseline; significantly fewer women in the intervention group had very preterm neonates (≤33 weeks’ gestation) and very low birth weight neonates (<1,500 g).21,43 Many women with IPV at baseline (62%) also screened positive for depression and received counseling for depression in addition to counseling for IPV. Two RCTs reported on depression and both found benefit in favor of the intervention (only one found a statistically significant benefit42); one of these also reported on PTSD symptoms and found similar scores in both groups.44
Six RCTs enrolled nonpregnant women; four measured changes in overall IPV exposure and found no significant difference between groups in rates of overall IPV exposure45,46 or combined physical and sexual violence;47,48 measures of IPV exposure were either similar between groups or slightly higher in the intervention group. Two RCTs measured changes in quality of life following an IPV intervention; in both trials, scores were similar between intervention and control groups and differences were not statistically significant.45,49 The interventions in nonpregnant women primarily included brief counseling, provision of information, and referrals; they did not directly provide ongoing support services, and the proportion of women who received more intensive services following referral was not reported.
The review identified no eligible studies on the abuse of older or vulnerable adults.
Potential Harms of Screening and Treatment
Two fair-quality RCTs reported on harms of screening, and no adverse effects of screening were identified. In one RCT, authors developed a specific tool, the Consequences of Screening Tool (COST), to measure the consequences of IPV screening, such as “Because the questions on partner violence were asked, I feel my home life has become (less difficult... more difficult).” Results indicated that being asked IPV screening questions was not harmful to women immediately after screening. Scores were similar across groups.
Five good- or fair-quality RCTs assessing IPV interventions reported on harms. No study found significant harms associated with the interventions. One RCT45 assessing a brief counseling intervention surveyed women at 6 and 12 months about survey participation (including potential harms); there was no difference between groups in the percentage of women who reported potential harms, and the authors concluded no harms were associated with the intervention. Among women who reported that their abusive partner was aware of their trial participation, the number of negative partner behaviors (e.g., got angry, made her more afraid for herself or her children, or restricted her freedom) was not significantly different between groups.
The review identified no eligible studies on the abuse of older or vulnerable adults.
Estimate of Magnitude of Net Benefit
The USPSTF concludes with moderate certainty that screening for IPV in women of reproductive age and providing or referring women who screen positive to ongoing support services has a moderate net benefit. There is adequate evidence that available screening instruments can identify IPV in women. The evidence does not appear to support the effectiveness of brief interventions or the provision of information about referral options in the absence of ongoing supportive intervention components. The evidence demonstrating benefit of ongoing support services is predominantly found in studies of pregnant or postpartum women. Studies that demonstrated no clear benefit in nonpregnant women, however, did not directly provide ongoing support services. Therefore, the USPSTF extrapolated the evidence pertaining to interventions with ongoing support services from pregnant and postpartum women to all women of reproductive age. More research that includes ongoing support services for women who are not pregnant or postpartum are needed.
Due to the lack of evidence, the USPSTF concludes that the benefits and harms of screening for abuse in older or vulnerable adults are uncertain and that the balance of benefits and harms cannot be determined. More research is needed.
This recommendation replaces the 2013 USPSTF recommendation. It is consistent with the 2013 USPSTF recommendation, which was a B grade for women of childbearing age and an I statement for abuse in older or vulnerable adults. It incorporates new evidence since 2013 and provides additional information about the types of ongoing support services that appear to be associated with positive outcomes.
The American Academy of Family Physicians,50 American College of Obstetricians and Gynecologists (ACOG),51,52 American Academy of Neurology,53 American Academy of Pediatrics,54 and Institute of Medicine Committee on Preventive Services for Women55 are in favor of screening for IPV. The American Academy of Family Physicians recommends screening for IPV in all women of childbearing age and providing interventions for those who screen positive. ACOG recommends screening all pregnant women and offering ongoing support services. The American Medical Association Code of Medical Ethics says that clinicians should routinely ask about physical, sexual, and psychological abuse.56 The Canadian Task Force on Preventive Health Care57 and the World Health Organization58 indicate that current evidence does not justify universal screening for IPV. The American Academy of Neurology53 and ACOG59 recommend screening for elder abuse. The Canadian Task Force on Preventive Health Care57 concluded that the current evidence is insufficient to warrant a recommendation for screening.
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