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

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32 Review Question II of controlling behaviour was slightly better, with a sensitivity of 65% and specificity of 94%. The difference between these two tools is based on their conceptual framework; the BRFSS is based upon behavioural acts of abuse, whereas the WEB employs a more consequence-orientated approach. Single question The use of a single question was investigated by Peralta and Fleming, 88 who asked women within a family (general) practice setting ‘Do you feel safe at home?’ and compared this with a modified version of the CTS (six items instead of 19, five of which related to psychological and one to physical violence). Period prevalence (90 days) of abuse was high at 44%, as measured by the modified CTS. The researchers examined diagnostic accuracy for the single question in three ways: (1) any violence, (2) physical violence with or without psychological violence, and (3) psychological violence with or without physical violence. For any violence, sensitivity was very poor at 9%, whereas specificity was high at 96%. For physical violence with or without psychological abuse, sensitivity was slightly improved at 15% and specificity was 95%. For psychological violence with or without physical violence, sensitivity was 9% and specificity was 96%. These results suggest that a single question about safety is a poor screening tool for partner violence. Studies that did not assess the diagnostic accuracy data of index tools Abuse Assessment Screen (AAS) McFarlane and colleagues 89 tested the AAS against the CTS, ISA and the Danger Assessment Scale (DAS) in antenatal clinics. The population was ethnically heterogeneous: African Americans 39%, Hispanics 34% and whites 27%. Prevalence measured with the AAS was 26% within the last year, 17% during pregnancy and 55% when these two were combined. When the physical abuse (ISA-P) and non-physical abuse (ISA-NP) scores were compared against AAS scores, those positively screened with the AAS were more likely to have a significantly higher score on the ISA. This study showed physical abuse during pregnancy to be more than twice as high as reported in previous literature. A possible explanation for the increased rates may be due to the primary care provider, rather than a researcher, asking the questions. Another explanation may be that a woman was assessed three times in pregnancy; abuse may not have occurred until the third trimester or women who at first did not want to disclose abuse did so when asked again. Although the prevalence of abuse in pregnancy was similar for the AAS and both parts of the ISA, the absence of reliability or diagnostic accuracy data makes it hard to draw any conclusions on the validity and reliability of the AAS from this study. Perinatal Self-Administered Inventory (PSAI) Sagrestano and colleagues 90 administered the Perinatal Self-Administered Inventory (PSAI) and the CTS to women in antenatal clinics. Based on the CTS, the prevalence of verbal aggression was 84%, and 17% of women had experienced physical violence in the past year. During the current pregnancy, the prevalence of verbal aggression was 68% and that of physical violence was 13%. From the PSAI, the question ‘Are you experiencing severe conflicts with anyone at home?’ did not correlate with measures of verbal aggression, and there were no significant differences in scores of verbal or physical violence between those who endorsed the single question and those who did not. The other partner violence-related question of the PSAI, ‘Are you suffering from mental or physical violence abuse right now?’, was not correlated with either verbal or physical abuse as determined by the CTS, nor were there any significant differences in verbal aggression scores between those who did and did not respond in the affirmative to the suffering abuse question. For the violence subscale, paradoxically, those who responded in the affirmative to the single question (only 3% of the sample) scored significantly lower than those who did not. From these findings, the abuse questions of the PSAI are unlikely to be reliable screening tools for either verbal or physical violence within an antenatal setting; however, there are no diagnostic accuracy data to support this conclusion. Woman Abuse Screening Tool (WAST) Brown and colleagues 91 conducted a validation study in a Canadian family (general) practice setting comparing the WAST with the Abuse Risk Inventory (ARI). Prevalence detected with the WAST was 9%. The WAST showed good internal consistency (coefficient alpha = 0.75) and was significantly correlated with the ARI (r = 0.69, p = 0.01). In 2001, Brown repeated the study in a French-speaking population in a domestic violence refuge and private homes setting, and reported good internal consistency. As neither study
DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16 reported diagnostic accuracy no conclusion about construct validity can be drawn. Single question Connelly and colleagues 92 used the CTS as a comparator to test a single question incorporated into a hospital admission protocol: ‘Are you in a relationship in which you have been threatened, scared or hurt by someone? If yes, whom? [sic]’ The specific clinical setting in which the protocol was administered is not clear. The CTS gave a prevalence of 18%. No diagnostic accuracy data were reported. Diagnostic accuracy The data for diagnostic accuracy are summarised in Table 5. The sensitivity of partner violence screening tools ranges from poor to good (9–100%). Tools that scored sensitivity greater than 85% include the HITS (both Spanish and English versions), STaT, WEB and OVAT. Specificity was good across all but one of the tools, ranging from 83% to 99%. The one outlier was the STaT scale, with a specificity of 37%. Index tools with a specificity greater than 85% included the AAS, HITS, single question ‘Are you safe at home?’, WAST, PVS, WEB and the BRFSS. © 2009 Queen’s Printer and Controller of HMSO. All rights reserved. The relatively small number of studies for each index tool and the heterogeneity of settings, demography of participants and comparator tools precluded pooling of the diagnostic accuracy data. Concurrent validity Five studies reported concurrent validity (Table 6); generally this was high, the exception being the PSAI. Reliability Six primary studies reported two types of reliability data (Table 7): (1) internal consistency, a measure based on the correlations between different items on the same test (coefficient alpha and Cronbach’s alpha); and (2) inter-rater reliability, the degree of agreement among scorers (Cohen’s kappa). Most studies reported good reliability of the tools that were tested. Sensitivity analyses If we exclude studies with three or more areas of bias as determined by the QUADAS appraisal tool, four studies remain, as shown in Table 8. Table 5 Ranked scores of sensitivity, specificity and summed sensitivity plus specificity for each index tool in order of decreasing predictive power Decreasing predictive power Sensitivity Specificity Overall (Sen + spec) ↓ HITS (Spa) HITS (imp) STaT 100 96 94.9 AAS HITS (Eng) Single question 99.2 99 HITS (imp) HITS (Spa) 187 186 a HITS (Eng) WEB 86 85.9 WAST PVS 95.8 95.6 HITS (Eng) WEB 185 177 b OVAT BRFSS PVS 85.7 72.4 68 WEB HITS (imp) BRFSS 93.7 91.1 91 89.7 OVAT BRFSS PVS PVS 168.8 162.1 150.3 b 142.9 PVSb 49.2 HITS (Spa) 86 WAST 142.6 WAST 47 PVS 82.3 STaT 131.6 AAS 31.7 OVAT 83.1 AAS 130.9 Single questiona 8.8 STaT 36.6 Single questiona 104.6 Computation of diagnostic accuracy data (Sherin et al., 1998 82 ). Spa, Spanish language (Chen et al., 2005 81 ); Eng, English language (Chen et al., 2005 81 ); imp, improvised. a Single question: ‘Do you feel safe at home?’ b MacMillan et al., 2006. 85 33
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