To our knowledge, this is the first nationally representative study of screening for domestic violence by health care providers among United States women. Studies in particular practice settings mainly reported low lifetime screening rates21–23
although a recent study found higher rates (42% among women who reported recent domestic violence and 28% among women not reporting recent domestic violence).1
Our finding of very low rates of domestic violence screening is consistent with the earlier studies. We found these low rates even after major groups began advocating for screening.14–16
It is likely that uncertainty about how to respond, provider discomfort,13,24,25
and the lack of evidence-based guidelines contributed to the low rates.
We found similar rates of screening across ethnic, educational, and income groups. Thus, we did not corroborate the concern in the literature that health care providers are more likely to screen poor or non-white women.2,11–13
Lower rates of access to care among poor or non-white women could obscure high rates of screening for those in care, but the persistence of our findings among the subset of women who had seen a primary care provider in the past year supports the main conclusion that provider screening rates are similar across ethnic and socioeconomic groups. Thus, the larger issue is the low rate of screening overall.
We found that reported lifetime domestic violence screening was more likely among women who had characteristics associated with higher risk for domestic violence: being younger,1,33
or living unmarried with a partner;1
having chronic medical conditions,33–35
mental health problems,23,33–35
or drug abuse problems;33
having recently ended a relationship;36
or having children living in the home.36
In addition, screening was much more likely among women who had witnessed someone being beaten or killed in the past 12 months, which may be a marker for being a victim of violence. These findings suggest that providers may be picking up on risk factors and screening women based on these known factors. An alternative explanation is that persons at higher risk are more likely to remember having been screened.
Even among women with risk factors, the percent reporting screening is low. The bivariate analysis showed that only 23% of women with drug problems, 18% of women with a probable mental disorder, and 21% of women who recently ended a relationship reported ever being screened for domestic or family violence. Only among women who reported witnessing someone being beaten or killed in the past year did a substantial proportion (40%) report lifetime domestic violence screening. Hamberger and colleagues23
previously suggested that provider inquiries reached only one-tenth of the observed victimization rate.
Nearly half (46%) of all women who reported being asked about domestic or family violence said that they were asked in a primary care setting and 24% said that they were asked in a specialty mental health setting. Although much has been written about routine screening in emergency departments, 36–38
only 11% of the women reported that they were asked about domestic violence in emergency rooms.
This study has some important limitations. We obtained a moderate response rate, compounded by nonresponse to the CTS survey. We created nonresponse weights, which may only partially account for nonresponse bias. We rely on self-report measures that deal with lifetime recall, and we have no measures of actual victimization although having witnessed someone being beaten or killed in the past 12 months may serve as a proxy measure. Our measure of domestic violence screening is broad and might include screening for child or elder abuse. In addition, it is possible that some women might not recognize questions about being hit or hurt as questions about domestic or family violence. We also do not know if women who were screened presented with signs of abuse that cued the provider to ask about abuse. Thus, we may be overestimating the amount of routine screening that takes place.
Despite these limitations, the study’s findings are important for health care professionals and policymakers. To our knowledge, this study provides the first nationally representative data on domestic violence screening in health care settings. Such screening is important because health care settings are the only places that many victims seek help.39
Moreover, the identification of domestic violence is clinically important because violence is prevalent and its presentation varied, and it may influence the evaluation of presenting complaints as well as the outcomes of care.9,10
Screening can have other advantages as well, such as reducing the stigma associated with being a victim of domestic violence and promoting access to needed services.21
These are important issues for future research and clinical practice guideline development.