Poster

etsu.edu

Poster

INTIMATE PARTNER VIOLENCE SCREENING TOOLS:

ARE THEY VALID FOR RURAL PREGNANT WOMEN?

TIFANI R. FLETCHER,

ANDREA D. CLEMENTS,

LANA MCGRADY,

BETH BAILEY


INTIMATE PARTNER VIOLENCE AND PREGNANCY

q Intimate partner violence is defined as physical, sexual, or psychological harm

by a current, or former, partner or spouse (Devi, 2012).

q IPV prevalence during pregnancy has been estimated from 1 – 80%, with

higher IPV rates being found in rural populations (Bailey & Daughtery, 2007).

q Why is IPV bad, especially during pregnancy?

q Pregnancy presents a unique opportunity to screen for IPV (Daviolio, 2001).

q Different rates of IPV likely due to different definitions/terminology,

measurements and methodologies (Martin, Mackie, Kupper, Buescher & Moracco, 2001.)

q Psychometric data are lacking on IPV screens, especially for pregnant

populations (USPSTF, 2012; Rabin, 2004).


SCREENING FOR INTIMATE PARTNER VIOLENCE DURING

PREGNANCY

q Accurately identifying women who have experienced or are at risk of

experiencing IPV is the main objective.

q IPV screening measures should have sound psychometrics.

q The unofficial “gold standard” of IPV assessment is the Revised Conflict

Tactics Scale (CTS2) (Bailey & Daughtery, 2007).

q Considerations for IPV screening in prenatal care settings require that the

screen also be brief (Brzoska & Razum, 2010), and methodologies standardized for

optimal effectiveness (Gerbert et al., 2002; Hindin, 2006).


CURRENT PROJECT: STUDY AIMS

q Compare IPV prevalence of 2 commonly used IPV screening tools to

a reference standard.

q Ascertain validity of the two IPV screening tools in a rural pregnant

population.

q Make recommendations for which IPV screen to use in this

population.


METHODS – PARTICIPANTS & PROCEDURE

q Participants were recruited from regional prenatal

clinics as part of the Tennessee Intervention for

Pregnant Smokers (TIPS) program.

q Participant characteristics: N = 540

q Procedure for TIPS


METHODS - MATERIALS

q A TIPS created background questionnaire was utilized for demographic

information.

q The Revised Conflict Tactics Scale (CTS2) was used as the reference

standard for the other IPV screens (Straus, Hamby, Boney-McCoy, & Sugarman, 1979).

q The Women Abuse Screening Tool (WAST) was developed because existing

IPV screens were too lengthy and intrusive (Brown, Lent, Brett, Sas, & Pederson , 1996).

q The Abuse Assessment Screen (AAS) is the only IPV screen created

specifically for, and validated in pregnant populations (McFarlane, Parker, Soeken &

Bullock, 1992; Parker & McFarlane, 1991).


CTS2: HOW OFTEN DID THIS HAPPEN?

1 = ONCE IN THE PAST YEAR 5 = 11-20 TIMES IN THE PAST YEAR

2 = TWICE IN THE PAST YEAR 6 = MORE THAN 20 TIMES IN THE PAST YEAR

3 = 3-5 TIMES IN THE PAST YEAR 7 = NOT IN THE PAST YEAR, BUT IT DID HAPPEN BEFORE

4 = 6-10 TIMES IN THE PAST YEAR 0 = THIS HAS NEVER HAPPENED

1. I showed my partner I cared even though we disagreed. 1 2 3 4 5 6 7 0

2. My partner showed care for me even though we disagreed. 1 2 3 4 5 6 7 0

3. I explained my side of a disagreement to my partner. 1 2 3 4 5 6 7 0

4. My partner explained his or her side of a disagreement to me. 1 2 3 4 5 6 7 0

5. I insulted or swore at my partner. 1 2 3 4 5 6 7 0

6. My partner did this to me. 1 2 3 4 5 6 7 0

7. I threw something at my partner that could hurt. 1 2 3 4 5 6 7 0

8. My partner did this to me. 1 2 3 4 5 6 7 0

9. I twisted my partner’s arm or hair. 1 2 3 4 5 6 7 0

10. My partner did this to me. 1 2 3 4 5 6 7 0

11. I had a sprain, bruise, or small cut because of a fight with my partner. 1 2 3 4 5 6 7 0

12. My partner had a sprain, bruise, or small cut because of a fight with me.1 2 3 4 5 6 7 0

13. I showed respect for my partner’s feelings about an issue. 1 2 3 4 5 6 7 0

14. My partner showed respect for my feelings about an issue. 1 2 3 4 5 6 7 0

15. I made my partner have sex without a condom. 1 2 3 4 5 6 7 0

16. My partner did this to me. 1 2 3 4 5 6 7 0


WAST

1. In general, how would you describe your relationship…

A lot of tension (2) Some tension (1) No tension (0)

2. Do you and your partner work out arguments with…

Great Difficulty (2) Some Difficulty (1) No difficulty (0)

3. Do arguments ever result in you feeling put down or bad about yourself?

Often (2) Sometimes (1) Never (0)

4. Do arguments ever result in hitting, kicking, or pushing?

Often (2) Sometimes (1) Never (0)

5. Do you ever feel frightened by what your partner says or does?

Often (2) Sometimes (1) Never (0)

6. Has your partner ever abused you physically?

Often (2) Sometimes (1) Never (0)

7. Has your partner ever abused you emotionally?

Often (2) Sometimes (1) Never (0)

8. Has your partner ever abused you sexually?

Often (2) Sometimes (1) Never (0)


AAS

Please circle YES or NO for each question.

1. Have you ever been emotionally or physically abused by your partner or someone

important to you?

YES (1) NO (0)

2. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by

someone?

YES (1) NO (0)

3. Since you have been pregnant, have you been hit, slapped, kicked, or otherwise

physically hurt by someone?

YES (1) NO (0)

4. By whom? (check all that apply)

____ Husband ____ Ex-husband ____ Boyfriend ____ Stranger ____ Other

5. Within the last year, has anyone forced you to have sexual activities?

YES (1) NO (0)

6. Are you afraid of anyone you have checked above?

YES (1) NO (0)


ANALYSIS

q IPV past year prevalence rates were determined for the CTS2,

WAST and AAS, for any IPV, and individual IPV categories

(physical, sexual, psychological or threat of physical or

psychological).

q Sensitivities and Specificities were determined for the WAST and

AAS, using the CTS2 as a reference standard.

IPV - Yes

IPV - No

IPV

IPV


CALCULATING SENSITIVITY AND SPECIFICITY

SENSITIVITY

If a person has

experienced IPV, how

often will the measure

be positive/yes (true

positive rate)?

SPECIFICITY

If a person has NOT

experienced IPV how

often will the screen be

negative/no (true

negative rate)?

Sensitivity= true positives/

(true positive + false

negative)

Specificity=true negatives/

(true negative + false

positives)


IPV PREVALENCE

IPV Type CTS2 WAST AAS

Any IPV 80% 74% 45%

Physical 21% 5% 12%

Sexual 19% 0.5% 0.5%

Psychological 76% 23% n/a


Figure 2. Profile of the CTS2 physical and sexual assault scales N = 540

Subscale Prevalence CTS2 item N

Physical minor 17.2% 93

my partner threw something at me that could hurt

55

my partner twisted my hair or my arm

35

my partner pushed or shoved me

53

my partner grabbed me

47

my partner slapped me

24

Physical severe 11.3% 61

my partner used a knife or gun on me

4

my partner punched or hit me with something that could hurt

21

my partner choked me

32

my partner slammed me up against the wall

41

my partner beat me up

13

my partner burned or scalded me on purpose

2

my partner kicked me

15

Physical total 21.3% 115

Sexual minor 17% 91

my partner made me have sex without a condom

47

my partner insisted on sex when I did not want to (no physical force) 43

my partner insisted I have oral sex (but did not use force)

27

Sexual severe 4.3% 23

my partner used force (like hiKng, holding down, or using a weapon)

to make me have oral or anal sex

6

my partner used force (like hiKng, holding down or using a weapon)

to make me have sex

14

my partner used threats to make me have oral or anal sex

9

my partner used threats to make me have sex

5

Sexual total 19.1% 103


RESULTS: SENSITIVITY (SE) AND SPECIFICITY (SP) OF THE

AAS AND WAST AS COMPARED WITH THE CTS2.

CTS2

CTS2

+ -­‐ + -­‐

CTS2 subscale*

AAS

+ a b Sensi\vity † Specificity‡

WAST

+ a b Sensi\vity † Specificity‡

-­‐ c d % (95% CI) % (95% CI) -­‐ c d % (95% CI) % (95% CI)

Physical 40 24

34.8% (30.8 to 38.8) 94.4% (92.5 to 96.3)

22 4

75 401 146 360

45.5% (41.3 to 49.7) 98.9% (98 to 99.8)

Sexual 2 1

2% (.8 to 3.1) 99.8% (99.4 to 100)

1 1

100 435 97 433

1% (.2 to 1.9) 99.8% (99.4 to 100)

Psychologica

l

118 4

283 127

29.3% (25.6 to 33.3) 96.9% (95.5 to 98.4)

Notes: Figure format adapted from Reichman and Moraes

(2004).

*Pos\ve events were defined as at least one posi\ve item

in the (sub)scale.

† Se = a/(a + c); ‡ Sp = d/(d+b)


IMPLICATIONS

q Information on IPV prevalence during pregnancy is necessary to make

informed recommendations for healthcare practice, policy and research.

q This requires data from accurate, brief screening instruments.

q Screening and estimates of IPV prevalence both often involve the use of an

imperfect measurement for identifying those likely to be current or former

victims of IPV.

q High sensitivity should be paramount when choosing an IPV screen.

q These results suggest that the WAST should be used with

caution as a stand-alone assessment of IPV, and that the AAS

should not be used as a stand-alone assessment for physical

or sexual violence in this pregnant population.


LIMITATIONS AND FUTURE RESEARCH

q The results of the study should be generalized with caution. A

relatively homogenous sample was used from a specific region of

the United States.

q IPV measurements were self-reported, and “true” IPV status was

not established.

q Different wording on the measurements likely contributed to

some of the differences in responses.

q Future research will examine data from more women, and also

include an additional measure of IPV (HITS), as well as examine

IPV throughout pregnancy.


QUESTIONS OR COMMENTS?

Thank you! A

special thanks to the TIPS

participants, the doctors and staff

at the prenatal care clinics, and the

TIPS staff and research assistants.

Funding for this project was provided by the Tennessee Governor's office of Children’s Care Coordination.


REFERENCES

American Congress of Obstetricians and Gynecologists (2012). ACOG Committee Opinion No. 518: Intimate

partner violence, 119, 412-417.

Bailey, B. A., & Daugherty, R. (2007). Intimate partner violence during pregnancy: Incidence and associated

health behaviors in a rural population. Maternal and Child Health Journal, 11(5), 495-503.

Brzoska, P. & Razum, O. (2010). Validity issues in quantitative migrant health research: The example of illness

perceptions. In Series: Challenges in Public Health –Volume 58. New York: Peter Lang.

D'Avolio, D., Hawkins, J. W., Haggerty, L. A., Kelly, U., Barrett, R., Toscano, S., & ... Bell, M. (2001). Screening for

abuse: Barriers and opportunities. Health Care For Women International, 22(4), 349-362.

Devi, S. (2012). US guidelines for domestic violence screening spark debate. The Lancet, 379 506-507.

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violence against pregnant women. JAMA, 275(24), 1915-1920.

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reproductive health: Current knowledge and future research directions. Maternal and Child Health Journal, 4,

79-84.

Gerbert, B., Moe, J., Caspers, N., Salber, P., Feldman, M., Herzig, K., & Bronstone, A. (2002). Physician’s

response to victims of domestic violence: Toward a model of care. Women’s Health, 35(2-3), 1-22.

Hindin, P. K. (2006). Intimate partner violence screening practices of certified nurse- midwives. Journal of

Midwifery & Women's Health, 51(3), 216-221.

McFarlane, J., Parker, B.,Soeken, K., Bullock, L. (1992). Assessing for abuse during pregnancy: Severity and

frequency of injuries and associated entry into prenatal care. Journal of the American Medical Association,

267(23), 3176-3178.


REFERENCES

Martin, S. L., Mackie, L., Kupper, L. L., Buescher, P. A., & Moracco, K. E. (2001). Physical abuse of women

before, during, and after pregnancy. JAMA: Journal Of The American Medical Association, 285(12),

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Parker, B., & McFarlane, J. (1991). Nursing assessment of the battered pregnant women. Maternal-Child

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Journal of Interpersonal Violence, 20 501-506.


HITS

Please respond to the questions below using the following scale:

1=Never

2=Rarely

3=Sometimes

4=Fairly often

5=Frequently

Since you were pregnant, has a partner or ex-partner

_____ 1. Physically hurt you?

_____ 2. Insulted you fairly often?

_____ 3. Threatened you?

_____ 4. Screamed at you fairly often?

_____ 5. Forced unwanted sexual activity?

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