How far does screening women for domestic (partner) - NIHR Health ...

DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16
© 2009 Queen’s Printer and Controller of HMSO. All rights reserved.
Chapter 5
Are screening tools valid and reliable?
(Question II)
Eighteen tools were assessed in 15 validation
studies. The total number of participants was
10,289; studies reporting diagnostic accuracy
comprised 8433 participants. The tools ranged
from single questions to 30-item research
inventories (see Appendix 5.1 for details of
individual tools). Twelve tools were tested as
index tools and eight as comparators; the Woman
Abuse Screening Tool (WAST) and the Women’s
Experience with Battering Scale (WEB) served
in both capacities in different studies. Of the 15
studies, only 10 reported sufficient data to calculate
diagnostic accuracy. The majority of studies were
conducted in the USA (11), with two in Canada,
and the remaining two in France and Brazil.
Settings varied from general practice (six), accident
and emergency departments (four), antenatal
clinics (three), women’s health-care centres (two),
women’s homes (two), domestic violence refuges
(two) and an urgent care centre within a hospital
(one). Publication dates ranged from 1992 to 2006.
For details of primary studies see Appendix 5.3,
and for detailed results by study see Appendix 5.4.
Below we have presented the main findings in a
narrative form.
The screening tools
Women’s Experience with
Battering Scale (WEB)
Coker and colleagues 79 tested the WEB against
the Index of Spouse Abuse-Physical (ISA-P) in
two university-associated family (general) practice
clinics. The original ISA-P has 25 items assessing
physical abuse; the investigators used a modified
version consisting of 15 items. Prevalence was
reported as 11% with the ISA-P. Reliability was
good: Cohen’s kappa was 60% between the two
measures, and a Pearson correlation of 0.67
between the two continuous measures supports the
kappa statistic. Sensitivity was 86% and specificity
91%. The scores for each tool were compared with
partner violence-associated injuries, adverse mental
health outcomes, and perceived levels of health
and health-care utilisation. Because the contents
of each tool overlap and the authors wanted to
identify which tool was more strongly associated
with the health outcomes of interest, they
performed a stratified analysis. Controlling for the
ISA-P, WEB was found to be significantly associated
with poor mental health, anxiety, depression, drug
abuse, PTSD and low social support, whereas the
ISA-P was only significantly associated with more
physician visits when controlling for the WEB. In
women currently experiencing physical partner
violence only, the continuous ISA-P score (adjusting
for continuous WEB score) was significantly
associated with having a partner violence-related
injury requiring medical care (relative risk 1.06);
the WEB was not (relative risk 0.99). Amongst
women reporting an event that could lead to PTSD
(n = 356), the WEB score was associated with higher
PTSD symptom scores (relative risk 2.02) and the
ISA-P score was not (relative risk 0.93). The authors
conclude that the WEB may identify more women
experiencing both physical and psychological
battering and thus increase its clinical value. The
study has shown the positive scores on the WEB to
be strongly associated with partner violence-related
health outcomes.
Ongoing Violence
Assessment Tool (OVAT)
In an accident and emergency department, Ernst
and colleagues 80 tested the OVAT against the
Index of Spouse Abuse (ISA). The ISA detected a
prevalence of 21% in women and 20% when both
men and women were included. Reliability was
reasonable, with a Cronbach’s alpha of 0.6 and a
kappa of 0.58 (95% confidence interval 0.53–0.63).
Similar to the WEB, the OVAT showed reasonable
diagnostic accuracy: a sensitivity of 86% and
specificity of 83%.
‘Hurts, Insults, Threatens and
Screams at her’ (HITS) scale
The HITS scale has been compared with a number
of tools in different cultural settings. Chen and
colleagues 81 trained medical students to administer
the HITS alongside the ISA-P and WAST in an
urban family (general) practice site. Approximately
70% of the practice population was of Hispanic
origin; thus English and Spanish versions of the
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