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30 Review Question II tools were used. Prevalence rates varied between the two comparators: ISA-P gave a prevalence of 5.4%, the WAST 9.9%; overall, 10.9% screened positive on the ISA-P or WAST. Diagnostic accuracy analyses were computed for both English and Spanish populations. To assess the nature and extent of misclassifications, receiver operating characteristic (ROC) analyses were used, which also help derive cut-off scores that highlight the greatest sum of sensitivity and specificity. Minor differences emerged when looking at the two comparisons. Comparison of the English versions revealed good reliability (Cronbach’s alpha) for the HITS (0.76), ISA-P (0.80) and the WAST (0.78). English HITS total scores were also significantly correlated with ISA-P total scores (r = 0.76, p < 0.001) and WAST total scores (r = 0.75, p < 0.001).The area under the curve (AUC) for English HITS was 0.99, using ISA-P as the criterion. English HITS was effective as a screening tool for partner violence (p < 0.001). For those using the English language, HITS was compared with an English version of the ISA-P. A cut-off score of 10.5 created the greatest sum of sensitivity (86%) and specificity (99%). For the Spanish versions, reliability was slightly lower (HITS = 0.61, ISA-P = 0.77 and WAST = 0.80); however, correlations between the Spanish tools were slightly higher than those found between the English tools (HITS and ISA-P r = 0.81, p < 0.001; HITS and WAST r = 0.78, p < 0.001). This pattern of high correlations was also repeated for the total sample. For those answering in Spanish, the HITS was compared with a translated Spanish version of WAST. The AUC for the Spanish HITS was 0.95, and HITS was found to be effective as a screening tool (p < 0.001). A cut-off of 5.5 maximised sensitivity (100%) and specificity (86%). HITS has several advantages over WAST. It is an acronym (making it easier to remember the individual questions), its cut-off scores for identifying partner violence are easier to remember, and it has a simple scoring protocol compared with the WAST multiple scoring protocols. One limitation of HITS is that it is only validated for detection of current abuse. The different cut-off points for the HITS between English-speaking and Spanish-speaking populations may reflect different views about what constitutes abuse. Hispanic women may view certain types of abuse as less abusive than other cultural groups. Sherin and colleagues 82 used a modified version of the Conflict Tactics Scale (CTS) as a comparator against the HITS. In the first phase of the study, women were recruited from a family (general) practice setting in order to assess reliability and concurrent validity of the HITS. In the second phase the reliability and concurrent validity of the HITS were tested in self-identified survivors of partner violence from either a refuge or an accident and emergency department. The two groups were then compared to assess the construct validity of the HITS. In the first phase, HITS showed good reliability (Cronbach’s alpha = 80). The distribution of CTS and HITS scores suggests a low prevalence of partner violence in this population, although no prevalence figures were reported. Correlation between the two measures revealed a positive linear relationship (r = 0.85); the subscores for items measuring physical violence and verbal violence also showed a good positive association (0.82 and 0.81, respectively). No significant difference in scores was found due to presentation effects. In the second phase of the study, the scores from the practice population were compared with those of self-identified survivors and improvised diagnostic accuracy data were computed. With a cut-off score of 10.5 on the HITS, 96% of victims and 91% of non-victims were correctly identified (analogous to sensitivity and specificity analysis). This study provides good support for the use of HITS as a screening tool, although the accuracy analysis is contestable as a modified version of CTS (four reasoning items were removed) was employed. Abuse Assessment Screen (AAS) The Abuse Assessment Screen (AAS) has been tested against a number of tools, although only one study reported diagnostic accuracy data. Reichenheim and Moraes 83 validated the AAS against the Revised Conflict Tactics Scale (CTS2) in postnatal maternity wards in Brazil. Three case levels of partner violence were specified in this study: minor, major and overall. Minor cases were those where the participant answered ‘yes’ to at least one of five items asking about less severe physical acts such as being grabbed, pushed or slapped; major cases were defined as when at least one of seven more severe acts were reported, such as being choked, beaten up or kicked; overall cases were those that featured at least one positive response from both subsets. Prevalence of partner violence found with the CTS2 varied depending on the definition of cases used. Prevalence of
DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16 minor cases was 18%, for major cases it was 8%, and overall it was 19%. Diagnostic accuracy data for minor cases revealed a poor sensitivity at 32%, whereas specificity was very good (99%). Analysis of major cases showed an improved sensitivity of 61%, and specificity of 98%. Analysis of overall violence reduced sensitivity to 32%, with specificity at 99%. The AAS detects more major cases of abuse than either minor or overall violence. This observation is further supported by analysis of the false negatives; up to 50% of those who screened positive for ‘pushed or shoved’ or ‘grabbed’, and 60% of those who ‘had something thrown at them that could hurt’, were missed by the AAS. Partner Violence Screen (PVS) The Partner Violence Screen (PVS) has been tested against the ISA and CTS by Feldhaus and colleagues 84 in an accident and emergency department setting. The ISA revealed a current prevalence of abuse of 24% (95% confidence interval 19–30%) and the CTS showed a prevalence of 27% (95% confidence interval 22–34%). The study found reasonable diagnostic accuracy for the PVS. When compared with the ISA, the sensitivity of the PVS was 65% and specificity 80%. The physical violence item and two safety items of the PVS also showed moderate linear sensitivity (53% and 48%, respectively) and reasonable specificity (89% and 88%, respectively) when individually compared with the ISA. Similarly, comparison with the CTS gave reasonable results. Overall, sensitivity was 71% and specificity 84%; the physical violence item had greater sensitivity and specificity (68% and 95%) compared with the ISA, whereas the safety item showed slightly lower diagnostic values than the ISA (sensitivity was 40%, specificity was 87%). The single physical abuse question of the PVS was more sensitive and specific than the questions regarding safety. The negative predictive value was also good, with sensitivity of 88% and specificity of 89%. The PVS is a three-question tool that takes only 20 seconds to administer. About one in every four women who entered the emergency department had a history of physical or nonphysical partner abuse, and the PVS was able to detect between 65% and 71% of these women. MacMillan and colleagues 85 reported a validation of the PVS and WAST (see paragraph below) against the Composite Abuse Scale (CAS). Recruitment took place in two accident and emergency departments, two family practices and two women’s health clinics. The study’s original aim was to investigate the effects of presentation method of © 2009 Queen’s Printer and Controller of HMSO. All rights reserved. the two index tools; specifically computerised, faceto-face interview, or pencil and paper presentation. Prevalence of partner violence for the CAS was 10%. The PVS showed only moderate diagnostic accuracy, with a sensitivity of 49% and a specificity of 94%, although overall accuracy was stated as 89%, calculated as the number of true positives plus the number of true negatives divided by the total sample size. Woman Abuse Screening Tool (WAST) MacMillan and colleagues 85 validated the WAST against the CAS. Like the PVS, they found only moderate diagnostic accuracy data, with a sensitivity of 47% and a specificity of 96%, although the overall accuracy was 91%. Slapped, Threatened or Thrown (STaT) scale Paranjape and colleagues 86 validated the STaT against the ISA in an urgent care centre in an inner city hospital that provides primary care. For most recent relationships, the ISA revealed a lifetime prevalence of 33% and a current prevalence of 15%. Diagnostic accuracy data were computed for each STaT score. For scores ≥ 1, sensitivity was 95% (95% confidence interval 90–100%), specificity was 37% (95% confidence interval 29–44%); for scores ≥ 2, sensitivity was 85% (95% confidence interval 77–92%) and specificity was 54% (95% confidence interval 46–62%); and finally a score of 3 had a sensitivity of 62% (95% confidence interval 51–73%) and a specificity of 66% (95% confidence interval 59–73%). Although showing good sensitivity, the tool has only moderate specificity. Behavioural Risk Factor Surveillance Survey (BRFSS) Bonomi and colleagues 87 compared the Behavioural Risk Factor Surveillance Survey (BRFSS) against the WEB using a telephone survey of randomly selected women enrolled for at least three years in a Group Health Cooperative. Prevalence was found to be 7% using the WEB. The authors computed diagnostic accuracy data for various elements of the BRFSS. For any kind of abuse, good sensitivity and specificity were found (72% and 90%, respectively). Sensitivity for sexual abuse was 21% and specificity 99%, whereas sensitivity for physical abuse was 42% and the specificity 95%. For detecting fear due to threats, sensitivity was 48% and specificity 97%. Detection 31
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