1. Effectiveness of screening for GBV Claudia Garcia-Moreno World Health Organization Integrating Gender-based violence in HIV programmes Workshop: Nairobi, Kenya July 2012
The presentation today will focus on 2 things. The first is a systematic review commissioned by WHO in 2010 and updated in 2012 to identify effective interventions to jointly address gender-based violence and HIV. The systematic review is being finalized as an article for peer-reviewed submission – it is being prepared by Kristin Dunkle and Sara Head from the Emory University, School of Public Health
The second part of the talk will build on the evidence from the systematic review on GBV and HIV plus other systematic and literature reviews to present a draft of a tool that WHO is developing to help HIV programme managers identify and develop evidence-based interventions to jointly address GBV and HIV. The tool is being finalized for a launch in December 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.
Screening, in medicine, is a strategy used in a population to detect a disease in individuals without signs or symptoms of that disease.
The intention of screening is to identify disease in a community early, thus 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. For these reasons, a test used in a screening program, must have good sensitivity in addition to acceptable specificity.[1]
Several types of screening exist: universal screening involves screening of all individuals in a certain category (for example, all children of a certain age). Case finding involves screening a smaller group of people based on the presence of risk factors (for example, because a family member has been diagnosed with a hereditary disease).

3. Disadvantages of screening
Screening involves cost and use of medical resources on a majority of people who do not need treatment.
Adverse effects of screening procedure (e.g. stress and anxiety, discomfort, radiation exposure, chemical exposure).
Stress and anxiety caused by a false positive screening result.
Unnecessary investigation and treatment of false positive results.
Stress and anxiety caused by prolonging knowledge of an illness without any improvement in outcome.
A false sense of security caused by false negatives, which may delay final diagnosis.
Screening involves cost and use of medical resources on a majority of people who do not need treatment.
Adverse effects of screening procedure (e.g. stress and anxiety, discomfort, radiation exposure, chemical exposure).
Stress and anxiety caused by a false positive screening result.
Unnecessary investigation and treatment of false positive results.
Stress and anxiety caused by prolonging knowledge of an illness without any improvement in outcome.
A false sense of security caused by false negatives, which may delay final diagnosis.

4. Principles of screening
The condition should be an important health problem.
There should be a treatment for the condition.
Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
There should be a test or examination for the condition.
The test should be acceptable to the population.
The natural history of the disease should be adequately understood.
There should be an agreed policy on whom to treat.
The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
Case-finding should be a continuous process, not just a "once and for all" project.

5. 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)
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6. “
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 ”
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7. 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
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8. “
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. ”

9. What women experiencing violence need from health workers
To be listened to
A compassionate response
Privacy and confidentiality
Danger assessment and safety planning
Appropriate medical care and documentation
Information about rights
Referral

10. 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 that Currently 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.

11. 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)
Results from UK review of studies against the criteria of the UK national screening committee
Question I: The prevalence in the UK of partner violence against women and the magnitude of health sequelae vary with study design and population. In samples drawn from the general population, lifetime prevalence ranged from 13% to 31%, and in samples from clinical populations it ranged from 13% to 35%. One-year prevalence ranged from 4.2% to 6% in the general population studies. Even the lower estimates for prevalence, morbidity and mortality show that partner violence against women is a major public health problem and potentially an appropriate condition for screening and intervention.
Question II: Several short screening tools are relatively valid and reliable for use in health-care settings. The HITS (Hurts, Insults, Threatens and Screams) scale had the best predictive power (sensitivity ranged from 86% to 100%, specificity ranged from 86% to 99%), concurrent and construct validity (r ranged from 0.75 to 0.85, p < 0.001) and reliability (Cronbach’s alpha ranged from 0.61 to 0.80), with a suitable cut-off score.
Question III: Most women patients considered screening acceptable (range 35–99%), although they identified potential harms, particularly with regard to stigmatisation and breach of confidentiality. Informants thought that, besides identifying women experiencing partner violence, the aims of screening should also include information giving and signalling willingness for clinicians to talk about partner violence.
Question IV: Effect sizes for post-traumatic stress disorder (PTSD) ranged from 0.10 (an individual psychological intervention) to 1.23 (an individual psychological intervention); depression ranged from 0.16 (an individual psychological intervention) to 1.77 (an individual psychological intervention); self-esteem ranged from 0.10 (an individual psychological intervention) to 2.55 (an individual psychological intervention); and physical abuse ranged from 0.02 (advocacy) to 0.48 (advocacy). The evidence for effectiveness of advocacy is growing, particularly for women who have actively sought help or are in a refuge. The two studies of advocacy interventions in women identified through screening in health-care services were based in antenatal clinics. Psychological interventions and work with survivors and their children may be effective, but not necessarily for women identified through screening.
Question V: There were no trials of screening programmes measuring morbidity and mortality. The proxy outcome measure of referral rates ranged widely from a difference of 4% to 67% between control and intervention sites. The proxy outcome measure of identification showed little change, ranging from 25% to 3% between control and intervention sites. Studies using proxy outcome measures generally had weak designs and execution.
Question VI: There was heterogeneity in the outcomes of qualitative and survey studies about the acceptability to health-care professionals of partner violence screening. The acceptability of partner violence screening among health-care professionals ranged widely from 15% to 95%, but overall the evidence showed that this NSC criterion is not met.
Question VII: There were no cost-effectiveness studies of partner violence screening interventions. A Markov model of a pilot intervention to increase identification of survivors of partner violence in general practice found that such an intervention was potentially cost-effective.
Conclusions
Implications for health care
Currently 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.

12. 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)
PICOT Question
8. What are the effects of interventions aimed at screening or identifying women survivors of intimate partner violence delivered at the health system level?
We were particularly interested in identifying studies with the following characteristics:
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 healthcare provider or any
other 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)
Note: IPV detection rate are noted in narrative of eligible studies
Note: If results of sexual violence screening are present, they are reported separately
Timescale: No minimum nor maximum follow up

13. 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 ). 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.

14. 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.
The previous WHO 2010 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. We recognize that the pathway between screening and an improvement in health outcomes or reduction in IPV recurrence is complex with multiple steps. In this review we identified studies that evaluated screening implemented in various ambulatory clinical settings that included an immediate action related to the screening result, such as a prompt in the medical record to the HCP or referral to social worker or advocacy professionals. Of the four studies in this review, three were conducted in an Emergency Department setting (Rhodes, MacMillan, Koziol-Mclean) two were conducted in family practice ambulatory settings (Ahmad, MacMillan) and one was conducted in gynaecology or antenatal clinic settings (MacMillan ). In this review we found no studies demonstrating an important or statistically significant reduction in IPV recurrence. The MacMillan and Koziol-McLean randomised efficacy trials had similar findings of a small effect size (Odds ratio of 0.82 and 0.86, not statistically significant) in two settings, the Emergency Department of an urban hospital in New Zealand and various outpatient clinics and Emergency Departments and primary care settings in Ontario, Canada.
We found only one study,  an RCT, that assessed multiple health outcomes : quality of life, and symptoms of depression and PTSD (MacMillan). At 18 months there were no important differences in these health outcomes. Thus, similar to the findings of the previous WHO review, in spite of new studies, to date there is insufficient evidence that screening plus action leads to a reduction in IPV recurrence or an improvement in quality of life or other health outcomes. Perhaps the action following a positive screen needs to be more extensive than a prompt in the medical record or referral.
Since prior reviews there is now evidence of the (lack of) potential harms and adverse events  of IPV screening (See Harms section 1.5.3).  
Overall, screening women in health care settings for IPV still does not fulfill the public health criteria for implementation of a screening programme, with no evidence of improved outcomes beyond interventions in health care settings not based on screening (i.e. based on selective or clinical enquiry). On the other hand there is no evidence that screening produces adverse outcomes and, indeed, evidence from the MacMillan trial shows that it does not.  
 What about uptake of other services found in the Rhodes study?
 In the service delivery section we refer to the article by Bachus and Bewley which documented harms. Even though not quantitative data should we not refer to that here as well?
 ?seems duplicative with below.
 idem

15. 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.
We found only one study,  an RCT, that assessed multiple health outcomes : quality of life, and symptoms of depression and PTSD (MacMillan). At 18 months there were no important differences in these health outcomes. Thus, similar to the findings of the previous WHO review, in spite of new studies, to date there is insufficient evidence that screening plus action leads to a reduction in IPV recurrence or an improvement in quality of life or other health outcomes. Perhaps the action following a positive screen needs to be more extensive than a prompt in the medical record or referral.
Since prior reviews there is now evidence of the (lack of) potential harms and adverse events  of IPV screening (See Harms section 1.5.3).  
Overall, screening women in health care settings for IPV still does not fulfill the public health criteria for implementation of a screening programme, with no evidence of improved outcomes beyond interventions in health care settings not based on screening (i.e. based on selective or clinical enquiry). On the other hand there is no evidence that screening produces adverse outcomes and, indeed, evidence from the MacMillan trial shows that it does not.  
Limitations of Research
The main limitation of evidence on the effectiveness of screening is the small number of trials, with only two studies going beyond intermediate outcomes to measure recurrence of violence and only one that measures other outcomes that matter: mental health and quality of life. Limitations of those trials include a high proportion of potential participants declining in one [Koziol-Maclean] and high loss to follow up in the other [MacMillan].

16. WHO draft recommendations for health sector
'Universal screening' or 'routine enquiry' (i.e. asking women in all
health care 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).

17. 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.

18. 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;