Family Practice Advance Access originally published online on July 29, 2005
Family Practice 2005 22(6):617-623; doi:10.1093/fampra/cmi075
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Screening for domestic violence in a predominantly Hispanic clinical setting
Department of Family Medicine, University of Medicine and Dentistry of New Jersey—New Jersey Medical School, Newark, NJ, USA.
Correspondence to Ping-Hsin Chen, PhD, Department of Family Medicine, UMDNJ—NJMS, 185 S. Orange Avenue, MSB, B648 Newark, NJ, USA; Email: chenpi{at}umdnj.edu
Received 8 September 2004; Accepted 29 June 2005.
Chen P-H, Rovi S, Vega M, Jacobs A and Johnson MS. Screening for domestic violence in a predominantly Hispanic clinical setting. Family Practice 2005; 22: 617–623.
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Abstract |
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Background. Domestic violence is a public health problem that is common across ethnic groups. The utility of validated screening tools to detect abuse in diverse populations remains largely unknown.
Objective. The purpose of the study was to test the reliability and validity of a brief 4-question instrument, HITS, among predominantly Hispanic women.
Methods. We conducted a cross-sectional study in an urban clinical setting. Two hundred and two women completed HITS and two other previously validated tools, the Index of Spouse Abuse-Physical Scale (ISA-P) and the Woman Abuse Screening Tool (WAST). Instruments were prepared in English and translated to Spanish. Reliability and validity of HITS were compared with the ISA-P and WAST. Performance measures of HITS were compared with the ISA-P or WAST as a criterion standard.
Results. Cronbach's alphas were 0.76 and 0.61 for the English version and Spanish version of HITS, respectively. When administered first and analysed alone, the Spanish version of HITS had a reliability of 0.71. For both English and Spanish versions HITS was significantly correlated to ISA-P and WAST. The English HITS version had a sensitivity of 86% and a specificity of 99%. A cut-off score of 5.5 for Spanish HITS version achieved a sensitivity of 100% and a specificity of 86%.
Conclusions. HITS demonstrated good reliability and validity with ISA-P in English speaking patients. The Spanish version of HITS showed moderate reliability and good validity with WAST in Spanish speaking patients. HITS may help physicians detect abuse in predominantly Hispanic clinical settings.
Keywords. Battered women, domestic violence, spouse abuse.
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Introduction |
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It is estimated that 5.3 million domestic violence victimizations occur each year. Domestic violence leads to nearly 2 million injuries, and more than 550 000 of these injuries result in some type of medical treatment to the victim.1 The prevalence of current victims of domestic violence among patients in clinical settings ranges from 4 to 44%.2,3 Research has suggested that domestic violence is common across diverse populations with studies finding no difference in the severity of abuse and types of abuse across ethnic groups.4–7 Victims of domestic violence have poorer physical and mental health compared to non-victims.2,8–10 Furthermore, domestic violence is expensive with an annual cost of health care services for female victims of domestic violence of $1775 more than non-victims.11
Professional medical organizations have recommended that physicians routinely screen for, recognize, and document domestic violence.12–14 Recent surveys reported that 50–75% of physicians agreed that doctors should ask patients about the possibility of abuse.15,16 Surveys of patients in clinical settings also indicated that 43–85% of patients favour inquiries about abuse and 90% believed physicians can help with this problem.16,17 However, previous studies indicated that only 1.5% to 12% of women in primary care settings had been asked about domestic violence by their provider.2,3,15,18,19 Findings from previous studies have suggested that most of the common physician barriers to domestic violence screening concerned the implementation of screening tools.15,17,20–23 For example, a recent study that examined family physicians' perceptions of domestic violence indicated that limited time, forgetting to ask screening questions, and lack of response of patients to questioning are major barriers to screening.15 In addition, a qualitative study conducted on 51 battered women suggested that provider reluctance to ask about abuse is a significant barrier to patient disclosure of domestic violence,24 although other factors may also interfere with this process.2,5,7,20,25
Many established screening tools exist but they are not suitable for use in clinical settings because they are too detailed.23 For example, the Index of Spouse Abuse-Physical Scale (ISA-P) and the Conflict Tactics Scales (CTS),26,27 which are standard instruments for many studies,28 ask many questions and require multiple scoring procedures. In addition, CTS does not provide cut-off scores thus limiting their use for clinical identification of domestic violence.27 More recently, several brief screening tools have been developed for use in clinical settings.10,23,28,29 These instruments may help physicians and patients overcome the barriers to screening. However, the sensitivity and specificity of these brief instruments are often not reported.3 In addition, the ability of these brief instruments to detect domestic violence among diverse populations remains largely unexamined.
Some research has suggested that cultural factors may affect the disclosure of domestic violence by patients.5,7,25 For example, Mexican-American women, who conceptualize domestic violence differently, were found to be less likely to report abuse than White women.7 Nonetheless, except for a few notable exceptions,25,30 most research has largely failed to consider the impact of cultural factors on the ability of screening tools to detect domestic violence. A study that compared the accuracy of the Spanish version of the Woman Abuse Screening Tool (WAST) with the English version of WAST suggested that different screening questions should be used to accurately detect domestic violence in the two groups.25 More research is needed to test the use of screening tools with diverse populations and the accuracy of their translated versions.
In this study, we compared the use of a four-item brief instrument, HITS (Hurt, Insulted, Threatened with harm and Screamed at), with two other previously validated tools, ISA-P and WAST in predominantly Hispanic clinical settings. All three instruments were primarily developed for use in clinical settings.23,25,26,29 The objectives of this study were twofold: (1) to assess whether the English version of HITS is useful in predominantly Hispanic clinical settings; (2) to validate a Spanish version of HITS and determine the cut-off scores of HITS for differentiating between victims and non-victims among non-English speaking women.
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Methods |
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Participants
We collected cross-sectional data using a structured interview conducted at an urban family practice site with 7 family physicians and 27 residents who see approximately 1700 patients per month, of whom approximately 70% are Hispanic. The target population was women who were 18 years or older, and were currently involved with a partner in an ongoing relationship.
Prior to the start of the study, three medical students fluent in Spanish received two weeks of intensive training by the investigators and a domestic violence specialist on domestic violence preventions, interventions, interviewing techniques, and administration of the instruments to increase standardization. During June through August 2001, the three medical students screened all female patients for eligibility, and because of safety and confidentiality concerns for the victims they made no reference to domestic violence. Recruited patients were seen alone in a private room where medical students advised the patient that the topic of the study was domestic violence and obtained informed consent. Medical students then administered all the instruments in English or Spanish depending on patient choice. Patients were provided a stipend of $10 for their participation. For women who screened positive for domestic violence, the medical students made appropriate referrals.
Survey instrument
The structured interview included questions from HITS, ISA-P, and WAST. Demographic data on all participants was also collected. The questionnaires were initially developed in English. The pre-existing Spanish version of WAST was used.25 Translation and back-translation were used to produce the Spanish version of HITS and ISA-P.25 One of the investigators (MV), a certified translator, translated HITS and ISA-P into Spanish. The translated HITS and ISA-P were reviewed by the 3 bilingual medical students, and the translator made modifications as needed. A bilingual staff member who did not participate in the study conducted back-translation of the translated HITS from Spanish back to English to ensure accuracy.
HITS is comprised of the following four items: (1) "How often does your partner physically hurt you?" (2) "How often does your partner insult you or talk down to you?" (3) "How often does your partner threaten you with harm?" and (4) "How often does your partner scream or curse at you?" Participants answered each of these questions using a 5-point scale from never to frequently. Answers were summed to form an interval scale of the total HITS score. Using a cut-off score of 10.5 Sherin et al. found that HITS accurately classified 91% of non-victims and 96% of victims.23
The ISA-P measures the severity of physical abuse by the partner (11 items, alpha = 0.91).26 Women were asked to indicate the frequency of behaviours with a 5-point scale. The 11 items are weighted, summed, and standardized to form an interval scale. A cut-off score of 10 has been developed to classify women as victims or non-victims.26 Previous studies have more often used the English version of the ISA-P as a comparison than the English version of the WAST, therefore we used the English version of the ISA-P as the criterion to determine the accuracy of the English version of the HITS in this study.
The WAST is an eight-item questionnaire which has been administered to samples of both English and Spanish speaking women. Women responded to these items with a 3-point response set. Answers were summed to form an interval scale. Different scoring criteria were used for English and Spanish WAST.25,29 For the English version of WAST, the two least threatening questions were selected to form a short version of the scale (WAST-Short) as a more rapid clinical diagnostic tool. Scores are summed to form an interval scale. A cut-off score of 1 correctly classified 92% of the victims and 100% of the non-victims.29 For the Spanish version of WAST, the two most reliable questions were used to form WAST-Short. A cut-off score of 2 is used to determine the victim status of domestic violence, achieving a sensitivity of 89% and a specificity of 94%.25 The Spanish version of the ISA-P has not been validated with other established instruments, therefore we used the Spanish version of the WAST as a criterion to determine the accuracy of the Spanish version of HITS.
We estimated that a sample size of 200 women in which at least 3% are victims would be needed to detect an 11 versus 5-point difference in total HITS scores between abused and non-abused women, at the 5% significance level with more than 90% power, assuming SD of 2 for the two groups. To control for presentation effects, half of the participants completed the ISA-P followed by HITS and WAST, and the other half completed HITS and WAST followed by the ISA-P. Institutional Review Board approval was secured.
Statistical analysis
We performed all tests using SPSS for the total sample and the English and Spanish questionnaires separately. For sample characteristics comparisons, we conducted chi-square and ANOVA analyses. Cronbach's coefficient alpha was used to compare the reliability of HITS with the ISA-P and WAST. Correlations among HITS, ISA-P, and WAST were calculated to determine the concurrent validity of HITS. To test for presentation effects, we conducted separate analyses to compare the reliability of instruments in women who completed HITS and WAST first and women who completed ISA first. In addition, we conducted linear regression analysis to assess the association between the presentation method and the total scores of the three instruments, respectively, controlling for demographic characteristics. For construct validity analysis, we conducted linear regression analysis to assess the relation of ISA-P victim status and WAST victim status to the total scores of HITS, respectively, controlling for demographic characteristics. We conducted Receiver Operating Characteristic (ROC) curve analysis to assess the overall accuracy of HITS, using ISA-P as the criterion for the English version and Spanish WAST for the Spanish version. The ROC curve displays the possible values of sensitivity as a function of the false–positive rate for the tested instrument.31 The area under the ROC curve ranges from 0.5 to 1.0, with higher values indicating better accuracy. We performed sample size calculations to determine adequate power for ROC curve analysis.32 A sample of 200 women in which at least 3% are victims will achieve over 90% power to detect a 90% (i.e., excellent tool) and 50% (i.e., worthless tool) difference in the area under the ROC curve, using a 2 sided test at a significance level of 5%. In addition, we used the ROC curve to find a cut score that achieves optimal sensitivity and specificity of the Spanish version of HITS.
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Results |
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Participants
During the course of six weeks at the clinic, 386 women were eligible to participate in the study. Of these, 56 did not complete the questionnaire due to the long waiting period for an available private room and 128 women refused to participate. Therefore, 202 (52%) of the eligible patients participated in the study. We did not collect demographic background data for non-respondents. Therefore, we are not able to compare characteristics between respondents and non-respondents.
Table 1 presents the demographic characteristics of the study participants. Fifty six percent of the participants (n = 113) chose to complete the interview in English and of those, 50% were Hispanic. Forty four percent of the women (n = 89) chose to complete interviews in Spanish.
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Compared to those who completed the interview in English, participants who completed the interview in Spanish tended to be older (P < 0.001), to have lower incomes (P < 0.001), to be married (P < 0.001), to have longer relationships (P < 0.01), and to be pregnant (P < 0.05).
Hispanics and non-Hispanics were similar in all demographic characteristics (not shown). However, Hispanic women who completed the interview in Spanish compared to Hispanic women who completed the interview in English were less likely to be Puerto Rican and other Latin American, and more likely to be Cuban and Cuban American (P < 0.001), tended to be older (P < 0.001), to have lower incomes (P < 0.01), and to be married (P < 0.01) (not shown).
Prevalence of domestic violence
The mean total score for ISA-P for the total sample was 2.1 (SD = 5.3). Eleven women (5.4%) screened positive for domestic violence on the ISA-P. The mean total score for WAST for the total sample was 10.3 (SD = 2.5). Twenty women (9.9%) were categorized as abused using WAST. Overall, 22 women (10.9%) were screened positive for domestic violence on the ISA-P or WAST.
Reliability and concurrent validity of HITS
Table 2 presents reliability estimates (in parentheses) and intercorrelations for instruments. Cronbach's alpha was 0.76, 0.80, and 0.78 for the English version of HITS, ISA-P, and WAST, respectively. The Spanish version of HITS had lower internal consistency than ISA-P and WAST (0.61, 0.77, 0.80, respectively). However, when administered first and analysed alone, the Spanish version of HITS had a reliability of 0.71. For the total sample, all three instruments showed good reliability.
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The correlation of English HITS total scores with ISA-P total scores was 0.76 (P < 0.001), and with WAST total scores it was 0.75 (P < 0.001). Similarly, Spanish HITS total scores were significantly correlated with ISA-P total scores (P < 0.001), and with WAST total scores (P < 0.001). For the total sample, HITS total scores remained highly correlated with ISA-P and WAST total scores.
Presentation effects of instruments
The English interviews had similar reliability of all instruments regardless of whether participants completed HITS and WAST or ISA-P first. The Spanish interviews revealed that both presentations were similar in the reliability of ISA-P and WAST. However, compared to those who first answered the ISA-P, the reliability of HITS was higher for those who first answered HITS and WAST (Cronbach's alpha = 0.71 and 0.49, respectively). Presentation method was not significantly associated with total scores of HITS, ISA-P, and WAST, after controlling for demographic characteristics.
Results from subgroup analysis indicated that the presentation effect for the Spanish version of HITS did not change the construct validity and accuracy of the Spanish version of HITS. Specifically, total scores of HITS and WAST, and the accuracy of HITS were similar between those who first answered the Spanish version of HITS and WAST and those who first answered the Spanish version of ISA-P (P > 0.05). Therefore, the results of construct validity and accuracy of the Spanish version of HITS were based on all participants who completed the Spanish version of HITS.
Construct validity of HITS
ISA-P victim status was significantly associated with HITS total scores for those who completed the interview in English, controlling for demographic characteristics. Victims identified by the English version of the ISA-P had significantly higher HITS total scores than non-victims (12.0 and 5.2, respectively; P < 0.001). For those who completed the interview in Spanish, WAST was strongly related with HITS total scores, taking into account demographic characteristics. Victims identified by the Spanish version of WAST had significantly higher HITS total scores than non-victims (8.6 and 4.6, respectively; P < 0.001).
Table 3 shows the overall accuracy of HITS. ROC analysis was used to assess the nature and extent of misclassifications. The area under the curve (AUC) for English HITS was 0.99, using ISA-P as the criterion. English HITS was effective as a screening tool for domestic violence (P < 0.001). To maximize the sum of sensitivity and specificity, cut-off scores were derived through ROC analysis. Using a cut-off score of 10.5 suggested by previous research,23 English HITS accurately categorized 86% of the victims and 99% of non-victims. With the use of this cut-off, a true victim would be 90.86 times more likely than a true non-victim to be classified as a victim. A true non-victim would be only 0.14 times more likely to be classified as a victim. Using WAST as a criterion, the area under the ROC curve was 0.95 for the Spanish HITS. Spanish HITS was effective as a screening tool for domestic violence (P < 0.001). A cut-off score of 5.5 appeared to maximize the sum of sensitivity and specificity, which correctly discriminated 100% of the victims and 86% of the non-victims. True victims would be 7.27 times more likely than true non-victims to be classified as victims, whereas true non-victims would be 0.00 times more likely to be classified as a victim.
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Discussion |
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This is one of only a few studies to assess the use of a brief screening tool with diverse populations and the accuracy of its translated versions. This study extends previous studies in that we include a larger sample of adult women based on power calculations, and we control for demographic confounders in the validity analysis.
HITS appears to have some advantages compared to WAST, a commonly used screening tool for both English-speaking and Spanish-speaking women. The four-item HITS questions form an acronym, thereby possibly increasing the chances that the questions will be remembered by clinicians. Although the English and Spanish versions of WAST-Short each have only two items, different questions are used for English-speaking and Spanish-speaking women. HITS has the same questions in both languages, and the cut-off scores for English and Spanish HITS are easy for physicians to remember. The cut-off score for the Spanish HITS is half of the cut-off score for English HITS to account for cultural differences. Patients who have an English HITS score greater than 10, or a Spanish HITS score greater than 5, are identified as victims of domestic violence. HITS has a simple scoring protocol, while WAST has multiple scoring protocols and different scoring criteria for English and Spanish WAST. Overall, HITS accurately classified 94% of the abused women and 94% of non-abused women, which is comparable to WAST.
The significant differences in demographic characteristics between women who completed English interviews and those who completed Spanish interviews provide some evidence that different screening criteria are needed for the two populations. Previous research has also indicated that Hispanic women may view certain types of abuse as less abusive than did other ethnic groups.7 Our results suggest that a cut score of 5.5 for the Spanish version of HITS successfully classified 100% of abused women and 86% of non-abused women, using the Spanish version of WAST as a criterion.
Although this study shows moderate reliability with the Spanish version of HITS, the reliability may increase when HITS is administered first and analyzed alone in clinical settings. It appears that the Spanish version of HITS has presentation effects, and that for those who completed HITS and then WAST, the reliability was 71%. Given that no other screening tools will be used before HITS in actual screening protocols, HITS may achieve a reliability of higher than 70%.
The prevalence rate of domestic violence using ISA-P or WAST in our study is similar to findings from studies by Sherin et al.23 and Brown et al.33 However, the rate is somewhat lower than those reported in other studies.2 Perhaps the measurement of domestic violence varies across studies. In this study, women reported domestic violence only in their current relationship. Research has suggested that past experience of domestic violence is associated with current victim status and poorer health status.1,8–10 Further research is needed to examine whether HITS is able to detect past history of domestic violence.
Our study has several limitations. First, our response rate is lower than previous studies.10,28,33 Nonparticipants and participants might have differed in demographic characteristics and in abuse. There is a possibility that the prevalence rate of domestic violence is higher in the non-respondents. The victims may be more likely to refuse to participate in the study. It is also likely that non-victims chose not to participate because they felt that the issue does not pertain to them. Therefore our relatively low response rate may not effect the outcomes. Second, HITS does not ask about sexual abuse, and it is an important aspect of domestic violence. Further research is needed to assess whether HITS is able to detect victims of sexual abuse. Third, patients' disclosure of domestic violence might be affected by the screening method (e.g. medical staff interview, physician interview, or self-report). One study found that a nurse interview identified 4 times as many abused women than did a written history form (29% and 7%, respectively).34 Another study revealed that self-report increased detection of domestic violence in clinical settings.35 Further research is needed to address this issue. Fourth, information on the level of acculturation is not available. Additional research is needed to explore the association between acculturation and domestic violence disclosure among Hispanic women. Finally, this study was in one urban clinical setting, and may not be generalizable to clinical settings in other regions. Future research should continue to investigate screening for domestic violence in more diverse geographic areas.
In summary, findings from this study showed that HITS is a reliable and valid screening tool for use in predominantly Hispanic clinical settings with both English and Spanish speaking patients. The four-item HITS is shorter than most of the other instruments and its items form an easily remembered acronym.23 HITS may help physicians successfully detect women experiencing abuse and explore the severity of the abuse in diverse populations, and intervene appropriately to try to prevent further abuse.
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Declaration |
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Funding: preparation of this paper was supported by a grant from the American Academy of Family Physicians Foundation (#G0211RS).
Ethical approval: Institutional Review Board approval was secured.
Conflicts of interest: none.
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Acknowledgments |
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The authors thank the departmental writing group and Mindy Smith, MD for their comments on an earlier version of this manuscript. An earlier version of this manuscript was presented at the North American Primary Care Research Group (NAPCRG) 30th Annual Meeting, November 2002, New Orleans, LA, USA.
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