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.