Women favor self-completed screening methods for intimate partner violence compared with direct questioning by clinicians, regardless of how the self-report approach is administered, according to a study in the August 2 JAMA.

Harriet L. MacMillan, MD, MSc, Professor of Psychiatry and Behavioral Neurosciences and Pediatrics at McMaster University in Hamilton, Ontario, and colleagues randomized 2,461 women ages 18 to 64 to receive one of three screening methods—a face-to-face interview with a physician or nurse, a written self-completed questionnaire, or a computer-based self-completed questionnaire. The researchers evaluated intimate partner violence using the Partner Violence Screen (PVS) and the Woman Abuse Screening Tool (WAST) and compared these two screening instruments with the Composite Abuse Scale (CAS).

Depending on the method and instrument used for screening, as well as the participant’s original health care setting (primary, acute, or specialty), 12-month disclosure of intimate partner violence prevalence ranged from 4.1% to 17.7%. Women reported that both written and computerized self-report methods were preferable, easier, and gave more privacy than did face-to-face questioning.

Dr. MacMillan pointed out that recent studies support this finding. For example, Bair-Merritt et al found no statistically significant differences in intimate partner violence disclosures between audiotaped and written screenings in a pediatric emergency department. However, Dr. MacMillan’s group found "several patterns in women’s preferences. Specifically, women found the audiotaped method to be less risky and more private than the written approach, and among both the entire sample and the subgroup of women disclosing abuse, the written and audiotaped methods were significantly preferred to the idea of disclosing intimate partner violence directly to a health care provider."

These results, along with the findings of Glass et al, point to "emerging evidence that direct questioning by clinicians is less favored by women compared with self-report versions, whether delivered by computer, audiotape, or written questionnaire," stated Dr. MacMillan and colleagues.

SCREENING METHODS AND INSTRUMENTS

While screening method or instrument had no statistically significant main effects on disclosed prevalence, a significant interaction was found between method and instrument. On the written WAST, disclosure of intimate partner violence prevalence was lower compared with disclosed prevalence on the written PVS. This finding suggests that "the written format of the WAST may lead to some underestimation of disclosure," Dr. MacMillan’s team noted. "In theory, sensitivity of the WAST could be improved by changing the scoring criteria to include more items."

In addition, there were significantly fewer missing data using the WAST and the written method compared with the quantity of missing data from the PVS and the combined use of the face-to-face and computer-based methods. The researchers pointed out that this result "is worth noting, especially for research applications, but also when considering clinical policies for intimate partner violence detection and intervention. Prevalence, missing data, and preference are all important considerations for both clinical and research efforts in intimate partner violence screening."

With respect to screening instrument accuracy and precision, the PVS and WAST had sensitivities of 49.2% and 47.0%, respectively, and specificities of 93.7% and 95.6%, respectively. "The estimated sensitivities and specificities of both instruments in relation to the CAS were remarkably similar; the low sensitivity means that a sizeable proportion of women who disclosed exposure to intimate partner violence on the CAS were not identified on either the WAST or the PVS," Dr. MacMillan and colleagues commented. "This is likely because the CAS includes many more questions covering a broad range of abusive behaviors in several domains, including harassment."

STUDY LIMITATIONS

The researchers pointed out several limitations to their study. Health care providers administering the face-to-face screening method knew the women’s responses; this "could have influenced women’s willingness to disclose, although interestingly, there were no consistent patterns in disclosure by method," Dr. MacMillan’s group stated. These participants were also asked questions from either the WAST or the PVS, but not both, in the interest of limiting clinician and participant strain from having to verbally administer and answer, respectively, more than one similarly designed questionnaire. In addition, the researchers acknowledged that CAS, used as the criterion standard for WAST or PVS in the study, "is not free of error."

However, Dr. MacMillan and colleagues emphasized, "In screening for intimate partner violence, women preferred self-completed approaches over face-to-face questioning; computer-based screening did not increase prevalence; and written screens had fewest missing data. These are important considerations for both clinical and research efforts in intimate partner violence screening."

—John Merriman

Suggested Reading
Bair-Merritt MH, Feudtner C, Mollen CJ, et al. Screening for intimate partner violence using an audiotape questionnaire: a randomized clinical trial in a pediatric emergency department. Arch Pediatr Adolesc Med. 2006;160:311-316.
Glass N, Dearwater S, Campbell J. Intimate partner violence screening and intervention: data from eleven Pennsylvania and California community hospital emergency departments. J Emerg Nurs. 2001;27:141-149.
MacMillan HL, Wathen CN, Jamieson E, et al. Approaches to screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2006;296:530-536.

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