Assessment of clinical partner violence screening tools

Abstract

To compare the Women's Experience with Battering Scale (WEB) with the Index of Spouse Abuse-Physical Scale (ISA-P) as screening tools to identify intimate partner violence (IPV).
We conducted a large cross-sectional survey of women age 18 to 65 attending one of two family practice clinics from 1997 to 1998. All women completed both the WEB and the ISA-P and a telephone interview. We figured agreement estimates between the two tools, used stratified analyses to evaluate attributes of those more likely to screen as battered or physically assaulted, and compared associations between the WEB and ISA-P and a range of mental and physical health indicators known to be associated with IPV.
18% of 1152 eligible women surveyed had experienced IPV in a current or most recent intimate relationship with a male partner; 17% had been battered (WEB+), and 10% had been physically assaulted (ISA-P+). Had we used the ISA-P alone to assess IPV, we would have missed almost 45% of IPV. As anticipated, the ISA-P was more strongly associated with IPV-associated injuries and number of physician visits in the last year. The WEB was more strongly associated with self-perceived mental health, anxiety, depression, drug abuse, and low social support.
Clinicians need validated screening tools to rapidly and reliably screen patients for IPV. Most screening tools assess physical violence and injury without considering the more chronic experience of battering and the psychological terror associated with this violence. The WEB may identify more abused women than tools measuring physical assaults.

Full text

Assessment of Clinical Partner Violence Screening Tools1
By: ANN L. COKER, PHD, BRIAN O. POPE, MPH, PAIGE H. SMITH, PHD, MAUREEN SANDERSON,
PHD, and JAMES R. HUSSEY, PHD
Coker, A.L., Pope, B.O., Smith, P.H. and Hussey, J.R. (2001). Assessment of clinical partner violence screening
tools. Journal of the American Medical Women’s Association. Winter: 19-23.
Made available courtesy of American Medical Women’s Association:
http://cpmcnet.columbia.edu/dept/sph/popfam/jamwa/
***Note: Figures may be missing from this format of the document
Abstract:
Objective: to compare the Women’s Experience with Battering Scale (WEB) with the Index of Spouse Abuse-
Physical Scale (ISA-P) as screening tools to identify intimate partner violence (IPV).
Methods: We conducted a large cross-sectional survey of women age 18 to 65 attending one of two family
practice clinics from 1997 to 1998. All women completed both the WEB and the ISA-P and a telephone
interview. We figured agreement estimates between the two tools, used stratified analyses to evaluate attributes
of those more likely to screen as battered or physically assaulted, and compared associations between the WEB
and ISA-P and a range of mental and physical health indicators known to be associated with IPV.
Results: 18% of 1152 eligible women surveyed had experienced IPV in a current or most recent intimate rela-
tionship with a male partner; 17% had been battered (WEB+), and 10% had been physically assaulted (ISA-P+).
Had we used the ISA-P alone to assess IPV, we would have missed almost 45% of IPV. As anticipated, the
ISA-P was more strongly associated with IPV-associated injuries and number of physician visits in the last year.
The WEB was more strongly associated with self-perceived mental health, anxiety, depression, drug abuse, and
low social support.
Conclusion: Clinicians need validated screening tools to rapidly and reliably screen patients for IPV. Most
screening tools assess physical violence and injury without considering the more chronic experience of battering
and the psychological terror associated with this violence. The WEB may identify more abused women than
tools measuring physical assaults.
Article:
Intimate partner violence (IPV) is a leading cause of injury among American women (nearly one million
incidents annually) and has been thought to affect as many as 25% of American families.1 Women who
experience IPV are more likely to report their physical and mental health as fair to poor2-7 and to have more
physician visits8-10; irritable bowel syndrome and frequent dyspepsia11-14; chronic pain 4,13-14; migraine and other
frequent headaches14-16; sexually transmitted infections; pelvic inflammatory disease; chronic pelvic pain; and
bladder, kidney, or other urinary tract infections 14,17-21 than women who do not experience IPV.
The Conflict Tactics Scale,22 the Index of Spouse Abuse ,23 the Severity of Violence Against Women Scale,24
HITS ,25 and the Woman Abuse Screening Tool26 are several scales used to identify women in abusive
relationships. They assess violence based on the frequency and severity of physical attacks, and although they
have subscales to assess threats of violence or psychological abuse, these are rarely used. Only one tool, the
Women’s Experience with Battering Scale, 27-28 assesses battering, which is distinguished from episodic
physical assaults by its continuous, chronic nature and by such other forms of abusive behavior as threatening
and humiliating, forcing and withholding sexual activity, and isolating women and restricting their access to
other people and important resources. We define battering here as the process through which one member of an
1This research was funded by a grant (R49 CCR412752) from the Centers for Disease Control and Prevention National Center for
Injury Prevention and Control and the Disabilities Prevention Program of the National Center for Environmental Health.

intimate relationship experiences a loss of power and control due to the other member’s patterned use of
physical, sexual, and psychological force.29
Prior research with both clinical and population-based samples of women 6,30 suggests that battering and
physical assaults are both conceptually and empirically distinct. Consequently, it is important to identify the
various health consequences of each type of IPV. Physical assault results in such obvious outcomes as broken
bones, bruises, and head and facial injuries. However, the nonphysical forms of abuse battered women experi-
ence, and the coercive, disempowering relationships within which they live are likely to be associated with a
range of health problems.6,14
The purpose of this study was to compare two screening tools used to identify IPV: the Index of Spouse Abuse-
Physical (ISA-P), which measures physical abuse, and the Women’s Experience with Battering Scale29,30
(WEB), which measures battering, to determine whether one measure was more sensitive or more strongly
associated with the range of adverse mental and physical health outcomes known to be linked with IPV.
Methods
Sample. In this cross-sectional study, eligible women seeking medical care in one of two university-associated
family practice clinics were recruited and screened for IPV from February 1997 through January 1999. Eligible
women were those age 18 to 65 who were insured by a managed care organization or Medicaid and had ever
been in an intimate, sexual relationship with a man for at least three months. Interviewers invited women in the
clinic waiting room to discuss study participation and obtained their informed consent; for safety reasons, we
did not

attempt to recruit women whose partners would not leave them alone. Interviewers were female graduate
students who had received extensive training in asking these sensitive questions, in active listening, and in
providing women with community resources.
Study participation included a 5- to 10-minute in-clinic interview to screen for partner violence using both the
ISA-P and the WEB and a 30- to 45-minute telephone interview to assess medical history and current health
status. Subjects were reimbursed $5 for completing the in-clinic interview and $10 for the longer telephone
interview. As a safety measure, women currently in violent relationships were given the option of completing
the longer interview in the clinic. We used computer-assisted interviewing for both in-clinic and telephone

interviews to reduce errors and rapidly provide scale scores for IPV measures. We told all women about
community services for battered women, and we were more explicit in providing the local shelter hotline
number; talking about safety plans; and describing services for women, children, and batterers for women
screened as IPV positive.
The University of South Carolina Institutional Review Board approved this project.
Measures ofIPV. We used a modified version of the ISA-P,23 a 25-item scale designed to measure the severity
of physical violence inflicted on women by their current or most recent male partners. The Cronbach’s alpha
coefficient for the reduced 15-item scale was high (a=0.93). We used the recommended weighted scale score
and cutpoint.31
We used the 10-item WEB ,27,29-30 which measures battering by characterizing women’s perception of their
vulnerability to physical and psychological danger or loss of power and control in relationships with male
partners. Respondents indicated their level of agreement or disagreement using a six-point Likert scale. The
WEB has good construct validity, accurately discriminates battered from nonbattered women, and shows strong
internal consistency ((x=0.95 in current sample). Although the WEB and ISA-P were designed to be self-
administered, we used personal interviewers because of concern with literacy in our population.
The WEB and revised 15-item ISA-P are included as appendices.
We collected the following demographic characteristics: the woman’s marital status, age, race/ethnicity,
education, and usual occupation; whether she had an alcohol or drug problem; whether her father was either
emotionally or physically abusive toward her mother; her current male partner’s age, race/ethnicity, and occupa-
tion; and her perception of his drinking or drug problems, if any.
Injuries and Health Assessment. We assessed current mental and physical health status in the 45-minute
follow-up

interview. Measures included the Drug Abuse Screening Test32 ((C=0.76), the TWEAK33 to measure alcohol
abuse ((C=0.71), an injury frequency and severity scale specific to partner violence ((C=0.76), the Speilberger
State-Trait Personality Inventory34 to measure anxiety ((C=0.77), the Center for Epidemiologic Studies
Depression Scale35 to measure depressive symptoms in the past two weeks ((C=0.79), and the Social Support
Questionnaire-Short Form36 ((C=0.89) to measure current social support. Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV)37 criteria were used to assess symptoms of post-traumatic stress disorder
((C=0.87). We assessed current self- perceived mental and physical health with the following standard question:
“Compared to others your own age, do you consider your current mental/ physical health to be excellent, very
good, good, fair or poor?” We asked women the number of times they were seen by physicians and the number
of times they were hospitalized in the year before recruitment. All health indicators were dichotomized for
stratified analysis.
Statistical Analysis. All analyses were conducted in SAS version 6.12 .38 We compared women’s responses to
the WEB and the ISA-P using dichotomous cut-points (WEB >_20 and ISA-P >2).
We used Cohen’s kappa statistic to measure correlation between the two dichotomized measures, adjusting for
chance agreement and Pearson correlation coefficient for the continuous WEB and ISA-P scales.
We next assessed the association between the WEB and ISA-P and a range of current mental and physical
health indicators. We used stratified analyses to provide Mantel-Haenszel adjusted relative risk estimates for
each of the ten dichotomized health indicators as the dependent variables, adjusting for the confounders noted in
the table. Additionally, because there was overlap between the WEB and ISA-P, and because we wanted to
identify which of the two measures was more strongly associated with the health indicator of interest, we
included both the WEB and the ISA-P as dichotomous variables in stratified analyses. The referent group was
women who scored negative on both the WEB and the ISA-P.
Results
Forty women had never had intimate relationships with men and were thus ineligible. Of the 1503 eligible
women approached for participation, 174 refused (12%), 97 did not complete the health assessment interview
(6%), and 80 had missing data on several response variables (5%), leaving 1152 women for this analysis (77%).
Refusers (32%) were more likely than respondents (25%) to be Medicaid recipients; we have no additional
demographic data to compare refusers and respondents. Women who did not complete the health assessment
interview were younger and more likely to have recently experienced IPV than were women who completed the
health assessment.
Table 1 presents the demographic characteristics of the study participants. The mean age was 38.1 years
(SD±11.2). The majority (62%) of women screened were African American, insured by a managed care
provider (78%), and currently employed (86%). Almost one- third (32%) of women had been in physically
abusive intimate relationships in the past, and 30% had fathers who were abusive to the respondents’ mothers.
Table 2 provides the comparison of ISA-P and WEB scores. Eighty-two percent (946) of the 1152 women did
not test positive on either screening tool. The kappa statistic of 60% indicates good agreement between the two
measures. The Pearson correlation coefficient for the continuous WEB and ISA-P scales (r=0.67) also indicates
good agreement. The mean and standard deviation for continuous IPV scores were 15.4 ± 11.2 (range 10-60) for
the WEB and 1.7 + 6.8 (range 0-84) for the ISA-P.
Table 3 provides a summary of our analyses comparing the dichotomized ISA-P and WEB with a range of self-
reported dichotomous health indicators for all 1152 women in the study. Relative risk estimates (RR) and 95%
confidence intervals (CI) are presented. Prevalence of each health outcome is presented for those who were
currently experiencing IPV (IPV+) and those who had not experienced IPV (IPV–). When controlling for the
ISA-P, the WEB score was significantly associated with poor mental health, anxiety, depression, drug abuse,
post-traumatic stress disorder (PTSD), and low social support. When controlling for the WEB, the ISA-P score

was associated only with more physician visits. Among women currently experiencing physical IPV only
(n=154), the continuous ISA-P score (adjusting for the continuous WEB score) was significantly associated
with having an IPV- associated injury requiring medical care (RR=1.06), and the WEB was not (RR=0.99).
Among women reporting an event that could lead to PTSD (n=356), the WEB score was associated with higher
PTSD symptom scores (RR=2.02), and the ISA-P score was not (RR=0.93).
Discussion
This is the first study to evaluate how the WEB correlates with the ISA-P in terms of absolute frequency of IPV
and health indicators. Our findings indicate that the WEB may have greater clinical and public health relevance
because it is more strongly associated with the more prevalent IPV-associated health outcomes and may have
longer term health consequences. In short, these data provide support for the WEB Scale as a tool for IPV
screening and intervention alone or in combination with other measures of physical assault. Our assessment of a
range of health outcomes associated with IPV is important from a clinical and public health perspective.
Although injuries are frequently a result of IPV, IPV also has a negative impact on women’s physical and
mental health. Screening for battering using the WEB and intervening early could reduce the health impact of
this violence.
As do most studies, this one had limitations. Because our sample included insured women, we cannot generalize
to uninsured women. As is true for all cross-sectional studies, we cannot establish that IPV preceded the health
outcome. Because we were measuring current physical and mental health outcomes not routinely collected from
all patients, we could not rely on medical records to provide validation of health outcomes. Because we did not
have chart audit data for all women in the study and the agreement between our chart audit for 238 women and
their recall of number of clinic visits in the last year was good (r=0.69), we opted to use the self-report data.
Study strengths included the relatively large (n=1152) sample size, which provided us with sufficient power to
address the question. We controlled for potential confounding by including the identified covariates in all
stratified analyses.
We conclude that the WEB Scale may identify more women experiencing both physical and psychological
battering. Further, the WEB is more strongly associated with the wide range of health outcomes associated with
IPV. From a practical standpoint, the 10-item, self- administered WEB can be completed much more rapidly
than the 25-item ISA-P or the longer Conflict Tactics Scale without any loss of effectiveness. Clinicians in busy
primary care settings can provide the WEB to women in the private examination room, and it can be scored by
clinic staff to provide a rapid assessment of battering. Alternatively, the clinic assistant could administer the
WEB, calculate the score, and provide it to the clinician for follow-up and referral. We recommend that all
women be screened annually for battering independent of any clinical indicators. Clinicians must talk with each
woman who screens positive and offer resources. Expressing concern for her safety and well-being is an
important intervention and may help her seek services to address IPV.
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