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Obstetrics & Gynecology 2004;103:299-303
© 2004 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Screening for Partner Violence: Direct Questioning or Self-Report?

Joan Webster, RN and Victoria Holt

From the Royal Brisbane and Women’s Hospital, Herston, Australia.

Address reprint requests to: Joan Webster, Level 6, Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston QLD 4029, Australia; e-mail: joan_webster{at}health.qld.gov.au.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: To compare the effectiveness of a self-report checklist with a standard set of direct questions in identifying women who are experiencing domestic partner violence.

METHODS: Medical records were reviewed for evidence of positive partner violence for women attending the Royal Brisbane and Women’s Hospital prenatal clinic between August and September 2002.

RESULTS: Records (n = 1,596) were audited, and 937 (58.7%) contained both forms. The self-report check list identified a greater number of "cases" of partner violence (151) than the direct questions (66), with the level of agreement between the two instruments being only "fair" (Kappa coefficient .34). Each of the methods identified 7 cases of major abuse, which would have been missed if only 1 instrument had been used. All cases where women stated that they were afraid of their partner using the direct questions were also identified using the self-report checklist.

CONCLUSION: A self-report checklist is an effective alternative to direct questioning in detecting women who are experiencing partner violence and is acceptable to women.

LEVEL OF EVIDENCE: II-3

Domestic partner violence is an important public health problem in many countries and is associated with maternal morbidity,1,2 mortality,3 and adverse fetal events.2,4 Routine screening for violence has been promoted as an important component of intervention programs5,6 in the belief that screening will improve maternal and fetal outcomes. Various assessment tools have been developed for this purpose7–9; however, health care providers remain reluctant to incorporate universal screening into their practice.10 One of the reasons for this is that emphasis has been placed on direct questioning as the method of choice for universal screening. This approach is supported by women who have experienced partner violence11,12 but resisted by physicians and nurses, who feel underequipped or embarrassed about raising the issue.13 An alternative to direct questioning is to provide the woman with an opportunity to self-disclose partner violence using a checklist. The purpose of the present study was to determine whether direct questioning is more effective than self-reporting in assisting women to disclose domestic violence.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The Royal Brisbane and Women’s Hospital is 1 of 3 major public hospitals in Queensland and has a birth rate of approximately 4,000 births annually. Inpatient and outpatient care is provided to women from local areas as well as to women with high-risk pregnancies from throughout the state and from northern New South Wales. The maternity clinic population is predominantly Caucasian women (86.0%) from a lower socioeconomic background, most of whom have no medical insurance. Approximately 1% of the population does not speak English, but translators are available.

All new obstetric patients are asked to complete a 6-item, self-report Maternity Social Support Scale14 as part of their registration process. It includes 2 items relating to partner violence: "I feel controlled by my husband/partner" and "there is conflict with my husband/partner" (Figure 1Go). The scale is completed while the woman is separated from her partner, at a time when other preliminary tests are being conducted. Later in the same visit, while the medical history is being taken, a midwife asks a standard set of questions on partner abuse, including items regarding physical and emotional violence and fear. These questions are part of Queensland Health’s Domestic Violence Initiative, a statewide project aimed at reducing the health impact of domestic violence on women.11 Responses are recorded on the Domestic Violence Initiative form, which is filed in the patient’s medical record (Figure 2Go). These questions are not asked if the partner is in the room during the consultation. If it is safe to do so, educational materials on domestic violence are provided to women with positive results, and they are offered referral to a support agency. Screening for domestic violence occurs only at the initial visit.



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  		Figure 1. The Maternity Social Support Scale. Webster and Holt. Domestic Violence Screening. Obstet Gynecol 2004.

 


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  		Figure 2. The Domestic Violence Initiative questions. Webster and Holt. Domestic Violence Screening. Obstet Gynecol 2004.

 
The inclusion criteria for this study were women registered for delivery at the hospital and who had an active medical record in the clinic during the audit period between August 2002 and September 2002. A research assistant extracted data from records that contained a completed Maternity Social Support Scale and a completed Domestic Violence Initiative screening form. A standard proforma was used to record data; it included all of the items from the Maternity Social Support Scale and all of the responses to the Domestic Violence Initiative questions. Medical records containing forms with missing data were not included. The only demographic data collected were parity and number of pregnancies. Approval to access medical records was sought and obtained from the Medical Director; this is the standard procedure at this institution for audits by staff.

Responses to Maternity Social Support Scale items "I feel controlled by my husband/partner" and "there is conflict with my husband/partner" were dichotomized for the analysis. Scores of 1–3 for either question were considered a "case" of abuse. A "yes" response to any of the Domestic Violence Initiative questions also indicated a "case." Because we did not have a "gold standard" measure, cases identified by the Maternity Social Support Scale were compared with cases identified by the Domestic Violence Initiative instrument using the Kappa statistic. Landis and Koch15 suggest that {kappa} < .00 should be interpreted as "poor" agreement, 0.00–0.20 as "slight" agreement, 0.21–0.40 as "fair" agreement, 0.61–0.81 as "substantial" agreement, and 0.81–0.99 as "almost perfect" agreement. The effect of parity on domestic violence was assessed by the {chi}2 test. The power calculation was based on the rate of domestic violence found in this clinic in a previous study. We estimated that at the 5% level we would require approximately 1,100 patients to give an 80% power of detecting an absolute increase of 4% in the detection rate from 7% to 11%. The actual difference between the 2 instruments was 8.7%; therefore, the sample size of 937 was adequate. Data analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows 11.0 Inc, Troy, NY).


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
There were 1,596 medical records for women who were pregnant and attending the prenatal clinic during the data collection period; 937 (58.7%) of these contained a completed Maternity Social Support Scale form and a completed Domestic Violence Initiative form. Consistent with the hospital population generally, approximately one third (33.9%) of these women were primi-gravida, and 44.2% were nulliparous. Parity was not associated with abuse when measured by either the Maternity Social Support Scale questions on conflict or control ({chi}2 = 0.69, P = .141) or by any of the Domestic Violence Initiative questions ({chi}2 = 0.09, P = .557). Responses to each of the screening questions are shown in Table 1Go.


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  		Table 1. Responses to the Maternity Social Support Scale and the Domestic Violence Initiative Questions
 
Women reported more abuse when they completed the Maternity Social Support Scale than when they answered the Domestic Violence Initiative questions. On 107 occasions, abuse was reported on the Maternity Social Support Scale and not on the Domestic Violence Initiative form. Seventy-seven (72%) of these discrepancies occurred when a woman stated that she was experiencing conflict with her partner "some of the time." There were 7 women who reported being in conflict "all of the time" who would have been missed if only the Domestic Violence Initiative screen had been used. Twenty-one of the women who felt controlled in their relationship did not disclose abuse through direct questioning. Five of these women were being controlled "all of the time."

Conversely, the Domestic Violence Initiative questions identified 22 cases that were not picked up by the Maternity Social Support Scale. Fourteen (63.6%) of these were emotional abuse alone, without any other forms of abuse documented. There were 7 cases of physical abuse identified by the Domestic Violence Initiative screen that would have been missed if the Maternity Social Support Scale had been used alone. Fear was reported by 17 (1.8%) women, and these women were all also identified as "cases" using the Maternity Social Support Scale. The Kappa statistic for the level of agreement between the two screens, when "any abuse" identified by the maternity Social Support Scale was compared with "any abuse" identified by the Domestic Violence Initiative questions, was .34, indicating "fair" agreement.


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We conducted the current audit to estimate whether direct questioning, using the Domestic Violence Initiative screening questions, was more effective than the self-report Maternity Social Support Scale in detecting women who were experiencing existing partner abuse. Each instrument was developed for a different and distinct purpose, the former to screen for social risk factors for postnatal depression (including aspects of partner violence) and the latter to screen only for partner violence. The rate of 7%, elicited by direct questioning, was closer to rates reported elsewhere16,17 and almost identical to the proportion of women experiencing partner violence that we found in the same clinic, at the equivalent visit, almost a decade ago.18 However, the higher rate of 16% obtained by the self-report method was similar to that in a recent study, which also used a self-administered questionnaire.20 The discrepancy may be the result of the more oblique way in which questions are phrased in the Maternity Social Support Scale. Acknowledging conflict or control is probably less confronting than admitting to being hit, punched, or threatened with such forms of abuse.

Although the Maternity Social Support Scale identified a greater number of cases, these were mostly women who reported having conflict "some of the time" in their relationship. For many people, this would not be unusual, and it seems that many of the women responding to the question perceived it in this way. However, when we repeated the analysis using 2 as the cut off (including only women who experienced conflict or control all or most of the time), the Kappa correlation did not improve. This is probably because 28 of the women who stated that they were experiencing conflict "some of the time" also admitted to significant abuse when questioned directly.

Of concern was the low rate of direct questioning for abuse, despite this being hospital policy. The rate of screening using this method has fallen from 89.2% at the height of the rollout of the Domestic Violence Initiative to approximately 50% of the women attending our clinic during the study period. Although we have not conducted any formal evaluation, anecdotal evidence indicates that the reasons for a drop in the rate of screening are 2-fold. First, most of the women attending the clinic are accompanied by their partner, and questions are not asked if the partner is present. Second, there has been a significant turnover of staff since the introduction of the Domestic Violence Initiative, and formal education, which was a component of the initial rollout of the initiative, has not been offered to new staff. The program included useful strategies that build the confidence necessary to ask domestic violence questions, such as role-play, and approaches for separating the couple so that the questions about domestic violence may be asked. Although the rollout was associated with a high level of enthusiasm among participating staff, as other projects have demonstrated, program maintenance is difficult in the absence of ongoing education.20 The audit has identified that the opportunity to disclose partner violence would be severely restricted if the direct questioning method alone was retained in the current environment.

By comparison, approximately 98% of women completed the self-report Maternity Social Support Scale, so we were pleased to see that it functioned well, alone, as a screening instrument for major abuse, only 7 women who had a positive result using direct questioning were missed. Importantly, the conflict or control question on the Maternity Social Support Scale also detected every occasion in which "fear" was divulged using the Domestic Violence Initiative questions. This is quite critical given the strong association between being afraid of one’s partner and severe physical abuse. For example, Bradley and colleagues21 found that women who were afraid of their partner were 32 times more likely to experience violent incidents than those who were not fearful.

Although a number of instruments have been devised to assess for partner violence, we are unaware of one that embeds 2 abuse questions in a more general measure of social support. The Maternity Social Support Scale takes less than 1 minute to complete and therefore is an efficient and acceptable method for use in busy clinics. Subsequently, a positive response provides an appropriate starting point for initiating a discussion about domestic violence.

The Maternity Social Support Scale has not been tested in the community and so cannot be recommended for wider application until its usefulness has been tested in a general practice setting. Moreover, screening should only be considered where physicians and midwives have received education about abuse and have enough knowledge about local resources to be able to respond appropriately. The danger of not providing this training before screening is that women will be reluctant to discuss the issue again if a disclosure is mismanaged.12 Given our experience with the 2 data collection methods, we recommend the use of the Maternity Social Support Scale to screen for domestic violence among women attending hospital-based maternity clinics.


   Footnotes
 
doi: 10.1097/01.AOG.0000110245.83404.3d

Received July 29, 2003. Received in revised form October 8, 2003. Accepted October 24, 2003.


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Heise L, Ellsberg M, Gottmoeller M. A global overview of gender-based violence [review]. Int J Gynaecol Obstet 2002;78(suppl 1):S5–14.

2. Webster J, Chandler J, Battistutta D. Pregnancy outcomes and health care use: effects of abuse. Am J Obstet Gynecol 1996;174:760–7.[Medline]

3. Granja AC, Zacarias E, Bergstrom S. Violent deaths: the hidden face of maternal mortality. BJOG 2002;109:5–8.[Medline]

4. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: Effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84: 323–8.[Abstract/Free Full Text]

5. Wiist WH, McFarlane J. The effectiveness of an abuse assessment protocol in public health prenatal clinics. Am J Public Health 1999;89:1217–21.[Abstract/Free Full Text]

6. Lazzaro MV, McFarlane J. Establishing a screening program for abused women. J Nurs Admin 1991;21:24–9.

7. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176–8.[Abstract]

8. Straus M. Measuring intrafamily conflict and violence: the Conflict Tactics (CT) scales. J Marriage Fam 1979;41: 75–88.

9. Hegarty K, Sheehan M, Schonfeld C. A multidimensional definition of partner abuse: development and preliminary validation of the Composite Abuse Scale. J Fam Viol 1999;14:399–415.

10. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282:468–74.[Abstract/Free Full Text]

11. Webster J, Stratigos SM, Grimes KM. Women’s responses to screening for domestic violence in a health-care setting. Midwifery 2001;17:289–94.[Medline]

12. Bacchu L, Mezey G, Bewley S. Women’s perceptions and experiences of routine enquiry for domestic violence in a maternity service. BJOG 2002;109:9–16.[Medline]

13. Sugg NK, Inui T. Primary care physicians’ response to domestic violence. Opening Pandora’s box. JAMA 1992; 267:3157–60.[Abstract]

14. Webster J, Linnane J, Dibley L, Hinson J, Starrenburg S, Roberts J. Measuring social support in pregnancy: can it be simple and meaningful? Birth 2000;27:97–101.

15. Landis J, Koch G. Measurement of observer agreement for categorical data. Biometrics 1977;33:159–74.[Medline]

16. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996;275:1915–20.[Abstract]

17. Martin SL, Mackie L, Kupper LL, Buescher P, Moracco KE. Physical abuse of women before, during, and after pregnancy. JAMA 2001;285:1581–4.[Abstract/Free Full Text]

18. Webster J, Sweett S, Stolz TA. Domestic violence in pregnancy. A prevalence study. Med J Aust 1994;161: 466–470.[Medline]

19. Richardson J, Coid J, Petruckevitch A, Chung WS, Moorey S, Feder G. Identifying domestic violence: cross sectional study in primary care. BMJ 2002;324:274.[Abstract/Free Full Text]

20. Fanslow JL, Norton RN, Robinson EM. One year follow-up of an emergency department protocol for abused women. Aust N Z J Public Health 1999;23:418–20.[Medline]

21. Bradley F, Smith M, Long J, O’Dowd T. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002;324:271.[Abstract/Free Full Text]




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H. L. MacMillan, C. N. Wathen, E. Jamieson, M. Boyle, L.-A. McNutt, A. Worster, B. Lent, M. Webb, and for the McMaster Violence Against Women Research G
Approaches to screening for intimate partner violence in health care settings: a randomized trial.
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