The Joint Commission on Accreditation of Healthcare Organizations now mandates that all hospitals screen patients for domestic violence.33 Educating health care providers about domestic violence and screening improves their self-reported ability to identify and manage abuse victims.34,35 In addition, screening for domestic violence increases the rate of referrals to community resources.34,35 Administrative changes, guidelines, protocols, and changes to standardized medical record forms to assist screening for domestic violence increase identification of victims35-37 and help maintain sustained change in screening behavior over more than 12 months.1
TABLE 1
History and physical findings suggestive of abuse
2 Useful screening instruments
New screening tools are briefer and more efficient than earlier devices.
The HITS Scale38 (Hurt, Insult, Threaten, Scream; Table 2) is a practical 4-item scale. It has been validated in the family practice setting in a study that compared 160 family practice patients whose abuse status was unknown with 99 selfidentified victims of abuse.
The Woman Abuse Screening Tool (WAST; Appendix A, available online at http://www.jfponline.com) was developed for the family practice setting. It was validated by a study comparing the responses between 24 self-identified abused women from shelters and 24 nonabused women recruited from the principal investigator’s professional contacts.39
The first 2 questions of the WAST screen make up the WAST-short questions:
- In general, how would you describe your relationship? (A lot of tension; some tension; no tension)
- Do you and your partner work out arguments with…? (great difficulty; some difficulty; no difficulty)
These questions assess the degree of relationship tension and the amount of difficulty the patient and her partner have in working out arguments. If a patient answers affirmatively to these 2 questions, then the physician can use the remaining WAST questions to elicit more information about the patient’s experience of abuse. A Spanish version of the WAST has been shown to be successful as well.40
The WAST and HITS scales need to be further evaluated prospectively in larger populations with a high prevalence of abuse. In addition, nonbiased samples need to be recruited and the tests need to be validated against a criterion standard.
The HITS scale has been tested in English-speaking populations only. The ability to screen different ethnic groups and ask sensitive questions across cultural barriers is important and should be studied further.
The Women’s Experience with Battering Scale41 (Table 3) is a series of 10 questions tested in a large cross-sectional survey of women (n=1152) attending 1 of 2 family practice clinics. It has been validated in a study using the Index of Spouse Abuse as a reference standard (18% of the women surveyed had experienced violence in a current or most recent intimate relationship with a male partner). For every 100 female patients seen, a physician will correctly identify 16 of 18 abuse victims and will incorrectly label 7 nonabused women as victims. For this reason, a positive screen using any instrument must be followed-up by a careful interview before further intervention.
Unlike other tests, the Women’s Experience with Battering Scale was conducted in a relatively larger, unbiased, sample population, had good accuracy, and is recommended. The only drawback is the length, but it can be self-administered as part of a routine intake for an annual health maintenance examination.
TABLE 2
The HITS screen
| Hurt | How often does your partner physically hurt you? |
| Insult | How often does your partner insult or talk down to you? |
| Threaten | How often does your partner threaten you with physical harm? |
| Scream | How often does your partner scream or curse at you? |
| Each question is answered on a 5-point scale: 1 = never, 2 = rarely, 3 = sometimes, 4 = fairly often, 5 = frequently. | |
| The score ranges from 4 to a maximum of 20. A score of 10 is considered diagnostic of abuse. | |
TABLE 3
Women’s Experience with Battering Scale
| Description of how your partner makes you feel | Agree strongly | Agree somewhat | Agree a little | Disagree a little | Disagree somewhat | Disagree strongly | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. He makes me feel unsafe even in my own home | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 2. I feel ashamed of the things he does to me | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 3. I try not to rock the boat because I am afraid of what he might do | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 4. I feel like I am programmed to react in a certain way to him | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 5. I feel like he keeps me prisoner | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 6. He makes me feel like I have no control over my life, no power, no protection | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 7. I hide the truth from others because I am afraid not to | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 8. I feel owned and controlled by him | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 9. He can scare me without laying a hand on me | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| 10. He has a look that goes straight through me and terrifies me | 6 | 5 | 4 | 3 | 2 | 1 | |||||
| To score this scale, add the responses for items 1 through 10. The score range is 10 to 60. A score of 20 or higher is a positive screening test for battering. | |||||||||||