Preventing intimate partner violence: screening is not enough.
Preventing intimate partner violence: screening is not enough.
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预防亲密伴侣暴力：筛查还不够。
DOI：
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发表时间：
2009
期刊：
影响因子：
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通讯作者：
T. B. Cole
中科院分区：
文献类型：
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作者：
Kathryn E. Moracco;T. B. Cole
女性遭受亲密伴侣的身体、性和心理虐待在世界各地都很普遍。为了应对这一普遍存在的公共卫生问题，包括美国医学协会和美国妇产科医师学会在内的医疗保健专业组织建议，所有成年女性患者都应认真询问有关虐待的情况，无论其表现出何种症状。然而，临床预防服务的循证指南，如美国预防服务工作组和预防保健工作组，得出结论认为，没有足够的证据表明虐待幸存者的健康益处，以建议或反对进行亲密伴侣暴力（IPV）筛查，主要是由于现有研究的方法学缺陷。在本期JAMA中，MacMillan等人在一项试验的报告中解决了这种缺乏证据的问题，该试验将在急诊科，家庭实践和产科/妇科诊所接受护理的随机妇女在看临床医生之前进行滥用筛查，或者由临床医生看到而不进行滥用筛查。然后由临床医生自行决定讨论滥用（如果存在）或转诊IPV服务。为了确保所有参与研究的妇女都能得到最低标准的护理，每个参与者，无论其筛查状况如何，都得到一张印有当地机构名称和电话号码以及遭受暴力妇女热线电话的卡片。筛查在初级保健机构进行，临床医生在应对IPV方面接受了标准化培训。随访18个月后，筛查组与未筛查组的IPV复发率差异无统计学意义，在使用多重插补技术解释研究参与者的失访后，筛查组生活质量评分的轻微改善不再具有统计学意义。因此，在这项研究中，普遍筛查，包括常规询问所有患者有关滥用的情况，并没有发现是有益的。应将普遍筛查与作为诊断测试的滥用评估区分开来，本研究未涉及这一问题。评估风险增加的妇女遭受虐待的情况不仅可以发现暴力行为，而且还可以更准确地诊断和治疗同时发生的健康问题。MacMillan等人对他们的研究未能证明暴露于IPV的普遍筛查对健康和生活质量的益处提供了2种可能的解释。首先，缺乏已证实的获益可能归因于研究方法和数据的局限性。这些局限性包括在衡量暴力方面的潜在错误，在暴力升级期间，即使没有筛查，妇女的入学率也可能随着时间的推移而下降（回归平均值），与研究人员随时间随访相关的筛查和未筛查女性的未测量获益（霍桑效应），向接受筛查和未接受筛查的妇女分发有关社区资源的信息（印有当地机构信息的卡片），两组对社区资源的使用大致相同，失访，筛查组为43%，未筛查组为41%。然而，作者进行了额外的分析，以评估他们的发现对这些限制的敏感性，这证实了他们调查的最有效结论是缺乏普遍筛查的健康益处。作者的另一种解释是，本研究中IPV筛查缺乏有效性可能是由于缺乏基于证据的有效IPV干预措施来伴随筛查。也就是说，如果临床医生有机会将受虐待的妇女转介到这种干预措施中，也许他们会有动力进行更多的转介。同样，如果研究参与者认为干预对IPV有潜在的好处，也许更多的女性会保持自己的意愿并留在研究中。最重要的是，如果干预可以有效地减少暴力并为研究参与者所接受，那么在筛查后测量的暴力可能比未筛查组减少得更多。虽然IPV的干预措施尚未在随机试验中一致证明是有效的，但至少有3种方法有望改善IPV的有害影响并防止暴力复发。首先，IPV幸存者最广泛使用的干预措施是转介到社区资源，如咨询，法律的服务，庇护所，以及其他临床和社会服务。在美国，以社区为基础的家庭暴力组织通常作为为IPV幸存者提供服务的中心，提供直接服务，如
PHYSICAL, SEXUAL, AND PSYCHOLOGICAL ABUSE OF WOMen by their intimate partners is common around the world. In response to this widespread public health problem,organizationsofhealthcareprofessionals, including the American Medical Association and the American College of Obstetricians and Gynecologists recommend that alladult femalepatientsbeaskedroutinelyaboutabuse, regardless of their presenting symptoms. However, evidence-based guides to clinical preventive services, such as the US PreventiveServicesTaskForce and theCanadianTaskForceonPreventive Health Care, have concluded that there is insufficient evidence of health benefits to abuse survivors to recommend fororagainstscreeningfor intimatepartnerviolence(IPV),primarily due to methodological weaknesses of available studies. In this issue of JAMA, MacMillan et al address this lack of evidence in the report of a trial that randomized women presenting for care in emergency departments, family practices, and obstetrics/gynecology clinics to be screened for abuse before seeing a clinician or to be seen by a clinician without being screened for abuse. It was then at the discretion of clinicians to discuss abuse (if present) or to make referrals for IPV services. To ensure a minimum standard of care for all women participating in the study, each participant, regardless of screening status, was given a printed card with names and telephone numbers of local agencies and telephone hotlines for women exposed to violence. Screening took place in primary care facilities where clinicians had received standardized training in responding to IPV. After 18 months of follow-up, the difference in recurrence of IPV for screened vs nonscreened women was not statistically significant, and a slight improvement in quality-of-life scores for the screened group was no longer statistically significant after a multiple imputation technique was used to account for loss to follow-up of study participants. Therefore, universal screening, which involves routinely asking all patients about abuse, was not found to be beneficial in this study. Universal screening should be distinguished from assessing abuse as a diagnostic test, which was not addressed in this study. Assessing abuse in women at increased risk may not only detect violence but may also lead to more accurate diagnosis and treatment of co-occurring health problems. MacMillan et al offer 2 possible interpretations for their study’s failure to demonstrate health and quality-of-life benefits of universal screening for exposure to IPV. First, the lack of demonstrated benefits may be attributable to limitations of the study methods and data. These limitations included potential errors in the measurement of violence, enrollment of women during an escalating period of violence that was likely to decrease over time even in the absence of screening (regression to the mean), unmeasured benefits to screened and unscreened women associated with being followed up by study personnel over time (Hawthorne effect), distribution of information about community resources to both screened and unscreened women (the printed card with local agencies’ information), approximately equal use of community resources by both groups, and loss to follow-up, which was 43% in the screened group and 41% in the nonscreened group. However, the authors conducted additional analyses to assess the sensitivity of their findings to these limitations, which confirmed that the most valid conclusion of their investigation was a lack of health benefits of universal screening. The authors’ alternative explanation is that the lack of efficacy of screening for IPV in this study may have been due to the lack of an evidence-based, effective intervention for IPV to accompany the screening. That is, if the clinicians had the opportunity to refer abused women to such an intervention, perhaps they would have been motivated to make more referrals. Similarly, if thestudyparticipantshadperceivedapotentialbenefit froman intervention for IPV,perhapsmorewomenwould havekept their appointmentsandremained in thestudy.Most important, if an interventionhadbeenavailable thatwaseffective in reducing violence and was acceptable to the study participants,measuredviolencesubsequenttoscreeningmighthave abated in thescreenedgroupmore thantheunscreenedgroup. Although interventions for IPV have not yet consistently been demonstrated to be effective in randomized trials, at least 3 approaches hold promise for ameliorating the deleterious effects of IPV and preventing recurrence of violence. First, the most widely used intervention for IPV survivors is referral to community resources, such as counseling, legal services, shelters, and other clinical and social services. In the United States, community-based domestic violence organizations usually serve as the hub for service provision for IPV survivors, offering direct services such as