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METHODS: We included a stratified random sample of 20 physicians practicing in both urban and rural settings drawn from 400 family physicians in London, Ontario, Canada, and the surrounding area. These physicians administered the WAST to 10 to 15 eligible and consenting patients during the course of regular care. Following the physician-patient encounter, patients were asked to complete both a measure about their comfort in being asked each of the WAST questions and the Abuse Risk Inventory (ARI).
RESULTS: Scores on the WAST correlated well with those on the ARI. The reliability of the WAST among this sample was demonstrated by a coefficient a of 0.75. With the WAST-Short (the first 2 questions of the WAST), 26 of the 307 patients screened (8.5%) were identified as experiencing abuse. The physicians were comfortable administering the WAST to their women patients, and 91% of the patients reported being comfortable or very comfortable when asked the WAST questions by their family physician.
CONCLUSIONS: The WAST was found to be a reliable and valid measure of abuse in the family practice setting, with both patients and family physicians reporting comfort with it being part of the clinical encounter.
Family physicians are in an optimal position to identify women who are victims of abuse, because they are often the first point of contact in the medical arena. However, recent studies indicate that family physicians continue to be reticent in accepting this responsibility, thus contributing to the underdetection of woman abuse.1,2 For almost 2 decades family medicine educators and researchers have made a concerted effort to understand and increase identification and treatment of woman abuse by family physicians.1-17 As part of this initiative, our focus has been on the development of a screening tool for family physicians to use in the context of a routine office visit or a well-woman examination to identify and assess women who are experiencing emotional, physical, or sexual abuse by their partners.8,18
The Woman Abuse Screening Tool (WAST), which consists of 7 questions, was developed and pilot tested using purposive samples of abused and nonabused women.18 It was found to have high internal consistency among this sample ({a} =0.95). It also demonstrated construct validity, with total scores correlating highly (r=0.96) with scores on the Abuse Risk Inventory (ARI).18 The validation study also provided evidence of discriminant validity, finding significant differences in the scores of abused and nonabused women both on individual items and on the overall scores.18
The first 2 questions of the WAST (“In general, how would you describe your relationship: a lot of tension, some tension, no tension?” and “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?” constitute the WAST-Short, which has been an effective tool for initially screening for the presence of abuse.18 The screening tool correctly classified 91.7% of the abused women and 100% of the nonabused women in the validation study.18 These 2 questions were also identified by the abused women in the validation study as those with which they would be most comfortable if asked by their family physicians. The remaining questions on the WAST were used to gain a more complete assessment of the abuse. In the validation study there were significant differences found between the abused and nonabused women on the mean overall WAST scores (18 vs 8.8, respectively; P <.001).
To establish the generalizability of the WAST, we field-tested it by having family physicians ask the questions of adult women in the general population who were presenting for routine visits (complete physical examination or prenatal care) as well as acute complaints.19 Although reported interest of family physicians in having a brief screening tool had been the genesis of this program of study, their comfort in using the WAST during a clinical encounter had not been assessed.8 Also, determining the level of comfort of women patients being asked the WAST questions by a family physician during an actual office visit versus a hypothetical encounter (as was the case in the validation study) was viewed as important.18
Inquiring about abuse has been found to cause discomfort for both physicians and women patients. It has been noted previously that family physicians remain reluctant to delve into the issue of woman abuse in spite of the fact that educating physicians about this abuse (including the use of a screening protocol) has been shown to significantly increase the detection rates of abused women in emergency departments.20,21 Also, both patients and physicians have indicated that the discomfort of physicians with issues of abuse may deter them from inquiring about this topic.7,8,22,23 Data from previous studies showing a decline in detection once a formal assessment protocol is discontinued emphasize the importance of maintaining a continuous screening approach if woman abuse is to be detected.21 Thus knowledge of the level of comfort physicians have in using the WAST and whether it aided in their identification of woman abuse and determining their ongoing commitment to use it required investigation.
Women are often reluctant to disclose abuse to their family physicians for numerous reasons, including shame, denial, fear of reprisal by their partner, a tendency to minimize or normalize the abuse, fear of a negative or punitive response by their physician, or assignment of power and control to the physician.6,24-26 However, studies have shown that when women feel understood, listened to, and validated by their physicians they are more inclined to discuss the abuse.27-29 Also, previous studies with abused women22,23,27-29 have found that they want their physicians to take responsibility for asking questions about abuse and to do so in a manner that is caring, respectful, and supportive. Thus, determining the comfort of women being asked the WAST questions by their family physicians was viewed as essential to our study.
Therefore, the objectives of field testing the WAST were to assess its validity and reliability in the general population within the context of the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in their practices; and to determine the self-reported comfort of patients with being asked the WAST questions by their family physicians.
Our study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.
Methods
Setting
Our study was conducted in the offices of family physicians located in London, Ontario, Canada, and the surrounding area. The recruitment and data collection took place from March 1997 to August 1998.
Instruments
The WAST. Although the original version of the WAST consisted of 7 questions, an eighth question (“Has your partner ever abused you sexually?”) was added for our study (Figure). This question was thought to be clinically important when assessing women who screen positive on the WAST-Short. The 2 questions that make up the WAST-Short assess the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments on a scale of 1 to 3.
Scores on the WAST-Short are computed on the basis of a criterion cutoff score of 1, which involves assigning a score of 1 to the most extreme positive responses for each of the 2 items (ie, “a lot of tension” and “great difficulty”) and a score of 0 to the other response options.18 The remaining 6 questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score.
The Abuse Risk Inventory. The Abuse Risk Inventory (ARI) is a 25-item self-report measure used in the identification of woman abuse and is also described as being useful in the assessment process.30 Respondents rate 25 items on the basis of frequency of occurrence using a 4-point scale ranging from “rarely or never” to “always.” A score of 50 or higher suggests that the respondent may be in an abusive situation or at risk for abuse.30 The ARI has demonstrated reliability (a=.91).30
Physician and Patient Comfort with the WAST Questionnaires. These self-report questionnaires were used to determine the level of comfort of physicians and patients with asking or being asked each of the WAST questions. Responses were given using a 4-point scale ranging from 1 (not at all comfortable) to 4 (very comfortable).
Prior Knowledge Questionnaire. This questionnaire assessed a physician’s previous or concurrent relationships with the patient and her partner by identifying various contexts (eg, workplace, leisure) through which the physician is connected with the patient and her partner in the role other than as the family physician. This questionnaire was included because of the potential influence of the physician’s personal relationship with the patient and her partner on both the patient’s willingness to disclose abuse and the physician’s comfort in inquiring about it.
The Perceived Usefulness Questionnaire. This questionnaire asked physicians to respond to the following statements using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree): “The wording of the WAST was clear”; “The WAST helped me to identify women who are abused”; “I feel better able to identify women who are abused using the WAST”; and “I felt comfortable asking questions on the WAST.” Physicians were also asked to indicate whether they would continue to use the WAST in their practice using the same 5-point scale.
Physician Participants
Our goal was to achieve a stratified random sample of 20 physicians practicing in urban and rural settings from a sampling frame of 400 family physicians in London, Ontario, Canada, and the surrounding area. The family physician investigators telephoned a total of 44 physicians who were selected from the sampling frame using a random numbers table. This followed the recruitment process reported by Borgeil and colleagues.31 Physicians who agreed to participate in our study were mailed a letter of information, a consent form, and directions for the study protocol, including how to administer the WAST and a list of community resources for women who were abused.
Patient Participants
For patients, we followed the recommendations of DeVellis, who has outlined a sample size range with a minimum of 200 and a maximum of 1000 respondents to explore the factorial validity of a new measure.32 To ensure that sufficient variability would exist across responses, we aimed for a moderate sample size of approximately 300 subjects.
To be included in our study the women patients were required to be older than 18 years; attending for a periodic health examination, for prenatal care, or with acute symptoms of illness; English speaking; unaccompanied by another person; currently involved in an intimate relationship (married or common law); and they had to consider the attending physician their primary care physician.
Instrument Administration
The 20 participating physicians were asked to administer the WAST to 15 to 20 consecutive women patients who met the inclusion criteria and consented to participate in the study. At the conclusion of each patient visit the physicians were requested to complete the WAST comfort questionnaire and the prior knowledge questionnaire. When the data collection was completed they were asked to report their perceptions of the WAST.
Each woman was approached by the research assistant in one of the physician’s examining rooms before her visit with the family physician. The research assistant explained the study, provided the patient with a letter of information, and if she agreed to participate supplied a consent form for signature. During the patient recruitment process, the research assistant maintained a written log describing eligible and ineligible patients, reasons for refusal, and other pertinent data, such as the physician’s knowledge of whether a patient was in an abusive relationship. At the conclusion of the physician-patient encounter, the research assistant met with the patient in a private area and asked her to complete the ARI and the measure assessing her comfort with the WAST questions asked.
Data Analysis
To determine the reliability and validity of the WAST, we calculated Cronbach a and Pearson correlation coefficients for the WAST and the ARI. Differences in both the nominal-level demographic information of patients and the responses of physicians and patients to the study measures on the basis of selected variables (family practice certification status for physicians, positive versus negative screen for patients) were analyzed using cross-tabulations and chi-square calculations. Differences in interval and ratio level measures (including demographic information and scale totals) were analyzed with independent samples Student t tests. Analyses involving the length of time physicians had been in practice were conducted using a computed variable (1997 minus year of graduation), which was then recoded into the decade of graduation. Scoring of the WAST involved recoding the responses to reflect a higher score for higher reported frequency of experiences and then summing the WAST scores for individuals who answered all 8 items. ARI scores were calculated for respondents who had answered all 25 items using the procedure outlined by Yegidis.30
Results
Validity and Reliability of the WAST in the Family Practice Context Overall WAST and ARI scores were correlated (r=0.69, P=.01). The WAST was found to be a reliable measure in the family practice context, achieving a coefficient a of 0.75, indicating good internal consistency.
Physician Characteristics
To secure the 20 family physicians required for the study, we had to contact 44 physicians randomly selected from the sampling frame, yielding an acceptance rate of 45.5%. The final sample of physicians consisted of 7 women and 13 men. The average number of years since graduation was 22.9 (range=6-46 years). There were 8 physicians in rural practice and 12 from the city of London, Ontario. Fourteen were in a group practice arrangement, and 14 were certificants of the College of Family Physicians of Canada (CFPC). There were no significant differences between the physicians who agreed to participate and those who declined, on the basis of sex, certification status, years since graduation, practice type (solo vs group), and practice location (urban vs rural).
Patient Characteristics
A total of 456 patients were asked to participate in our study. Fifty-seven women were deemed ineligible on the basis of the inclusion criteria, resulting in 399 eligible patients. Ninety-two (23.1%) of these refused, giving lack of time, degree of sickness, and discomfort in discussing personal issues as their reasons. Thus the final sample included 307 women.
The average age of these patients was 46.2 years (range=18-86 years). The majority (87.6%) were married or in a common-law relationship. The patients were primarily white (97.6%), and 44.7% reported having postsecondary education. More than half of the subjects (58.9%) were employed, and 58.7% reported an annual household income of more than $30,000 (Table 1).
Of the 307 patients screened, 26 (8.5%) were identified by the WAST-Short as experiencing abuse. The demographics of the sample for those who screened positive and negative for abuse are provided in Table 1. No significant differences were found. However, the 26 women who screened positive for abuse reported a wide range of income levels, with 9 women (34.6%) indicating an annual income of more than $50,000.
Table 2 shows the individual WAST item responses and overall scores for the total sample divided into 2 groups: those who screened positive for experiencing abuse and those who screened negative. Significant differences were found between the 2 groups for each item and for the overall WAST scores.
Physician Perceptions of and Comfort with the WAST
The majority of the physicians (85%) thought the wording of the WAST was clear. Sixty-five percent indicated that it assisted them in identifying women who were abused, and 70% felt more confident in identifying abused women when using the WAST. Also, 75% of physicians reported that they would continue to use the WAST in their practice. We did not systematically inquire about a physician’s previous knowledge of a patient’s experience with abuse. However, this information was often reported to the research assistant anecdotally, who then recorded these conversations in her logbook. According to the logbook entries, 6 of the physicians had been aware of previous abuse experienced by some of the women participating in the study.
All the physicians were comfortable with the items on the WAST, as indicated by a mean score of 3.6 on the question “How comfortable were you in asking your patients the WAST questions?” (1=not at all comfortable; 4=very comfortable).
There was a significant association between the number of years since graduation and the reported comfort level of physicians with asking each of the WAST questions; those who had been in practice for a greater length of time were more comfortable than more recent graduates. For example, 85.7% and 100% of physicians who graduated in the 1950s and 1960s, respectively, reported feeling very comfortable asking question 8, compared with 62.1% and 0% of graduates from the 1980s and 1990s, respectively (P <.001). This trend was consistent for each of the WAST items. No significant differences were found in the level of comfort of the physicians on 6 of the WAST questions on the basis of certification status. However, this was not the case when asking the 2 items related to physical abuse, which had smaller proportions of physicians with CFPC certification feeling very comfortable compared with the noncertificants (57.4% vs 76.7% and 60.6% vs 78.1% on questions 4 and 6, respectively; P <.05). Higher proportions of women physicians than men reported being very comfortable when asking the WAST questions addressing physical, emotional, and sexual abuse (77.9% vs 54.9%; 74.8% vs 52.0%; and 77.9% vs 53.8%, respectively; P <.001). There was no association found between the comfort level of physicians and their previous knowledge of their patients.
Patient Comfort with the WAST
For all the WAST items, a minimum of 91% of the women reported being comfortable or very comfortable when asked the questions by their family physician. The average comfort level score across all items was 3.6 (Table 3). However, the abused women were significantly less comfortable than the nonabused women with the questions that addressed physical and sexual abuse (including the question asking whether arguments resulted in a violent outcome) with all 3 questions achieving a significance level of P <.05.
Discussion
The 8-item WAST was found to be a reliable and valid measure in the family practice context among the general population. The WAST-Short identified 26 women (8.5% of the sample) as experiencing abuse, and there was a significant difference between the abused and nonabused women on their total WAST scores. Although not directly transferable, these findings are noteworthy when compared with a 1993 survey of 12,300 Canadian women older than 18 years reporting that 10% of women had experienced violence in the 12 months before the survey.33
There were no differences in the demographic characteristics between the women who screened positive for abuse and those who screened negative. However, there was a wider range of income reported by the 26 women who screened positive. This finding supports the literature, which indicates that woman abuse is present at all economic levels and in all social classes.34,35
Both the patients and their family physicians reported they were comfortable with the WAST, and the comfort level scores of the physicians remained high despite the increasingly sensitive nature of the questions. This strong endorsement suggests that the WAST should be applied in the family practice setting. The majority of physicians perceived the WAST to be helpful for identifying women experiencing abuse and indicated their intentions to continue using it.
Physicians who had been practicing longer expressed more comfort with asking the WAST questions than did their colleagues with less experience. This may reflect their greater awareness of the important role played by psychosocial factors in the lives and health of their patients.
Tudiver and Permaul-Woods36 found no difference in the perceived diagnostic skills for identifying woman abuse between certificants and noncertificants of the CFPC. Our study findings indicate that certificants were less comfortable in asking the 2 questions about physical abuse. Despite their reluctance to ask these questions, the majority of physicians with CFPC certification indicated their commitment to continue using the WAST. The ultimate test will be to see if family physicians persist in the application of the WAST despite fears of opening a “Pandora’s box”7 or “a can of worms”.8
Some authors have considered the influence of physician sex on the level of comfort of physicians inquiring about abuse.37,38 In our study the women physicians reported more comfort than the men in asking about emotional, physical, and sexual abuse.
The vast majority of women patients were comfortable in being asked the WAST questions. However, those who screened positive for abuse did express less comfort with questions related to physical and sexual abuse. These findings suggest that for some patients discussing abuse with their family physician may be problematic. They may view physical violence as socially unacceptable behavior and thus a taboo subject for discussion. It may also reflect the patient’s feelings of shame, fear, guilt, and self blame.11,22,24,25 An environment promoting safety, confidentiality, respect, trust, caring, validation, and a nonjudgemental atmosphere is necessary when screening for abuse.22,23,27,29,39
Compared with a decade ago, several reliable and valid screening tools for detecting woman abuse are now available for use by primary care physicians.18,40-42 The WAST joins the menu of screening tools from which physicians can choose. Its future use is supported by the reported physician and patient comfort levels with its questions being asked during the clinical encounter.
Limitations
Our study was based on a sample of family physicians drawn from a single geographic area, which limits the generalizability of the findings to physicians in other regions. Also, because of the recruitment method physicians may have agreed to participate because of their previous knowledge of the recruiter’s expertise in the field of abuse, resulting in a biased sample. Although the majority of physicians indicated that they would continue to use the WAST in the future we did not ask them how this would occur. Our recommendation would be that at minimum the WAST-Short be administered to women presenting for routine visits, including complete physical examinations and prenatal care as well as acute complaints.
As reported, we did not systematically inquire about the physician’s previous knowledge of the past abuse of a participant. Furthermore, we did not document if a specific intervention transpired with the women identified as abused. These issues are paramount if screening tools for woman abuse are to be viewed as useful and effective in addressing this serious problem. Future studies should include ways to assess and evaluate both interventions and patient outcomes.
The occurrence of abuse in this group of patients may have been underestimated. The information spontaneously offered by some patients at the time of their refusal to participate in our study suggests that they were in an abusive relationship. This reflects the reality of conducting research on a sensitive issue. Also, the preponderance of white English-speaking middle-class women in our study may limit the generalizability to more diverse populations.
However, these limitations do not detract from the important findings of our study, which demonstrates that the WAST-Short questionnaire identifies women experiencing abuse, and the full 8-item WAST helps family physicians explore the extent of that abuse. Finally, and perhaps of most clinical significance, both patients and family physicians were comfortable with the incorporation of WAST into the clinical encounter.
Acknowledgments
Our study was supported by a grant from Searle Canada. The conclusions are those of the authors, and no endorsement by Searle Canada is intended or should be inferred.
1. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.
2. 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.
3. Ontario Medical Association Committee on Wife Assault. Reports on wife assault. Toronto: Ontario Medical Association. CMAJ 1991; January supplement.
4. Candib LM. Violence against women: no more excuses. Fam Med 1989;21:339, 341-42.
5. Herbert C. Family violence and family physicians. Can Fam Physician 1991;37:385-90.
6. Mehta P, Dandrea LA. The battered woman. Am Fam Physician 1988;37:193-99.
7. Sugg NC, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60.
8. Brown JB, Sas G, Lent B. Identifying and treating wife abuse. J Fam Pract 1993;36:185-91.
9. Ferris L, Tudiver F. Family physicians’ approach to wife assault: a study of Ontario, Canada, practices. Fam Med 1992;24:276-82.
10. Sas G, Brown JB, Lent B. Detecting woman abuse in family practice. Can Fam Physician 1994;40:861-64.
11. Archer LA. Empowering women in a violent society: role of the family physician. Can Fam Physician 1994;40:974-85.
12. Knowlden SM, Frith JF. Domestic violence and the general practitioner. Med J Aust 1993;158:402-06.
13. Ferris LE. Canadian family physicians’ and general practitioners’ perceptions of their effectiveness in identifying and treating wife abuse. Med Care 1995;32:1163-72.
14. Radomsky N. Domestic violence. Life’s stories: her eyes and my glasses. Special series. Fam Med 1992;24:273-74.
15. Brown JB, Lent B, Sas G. Woman abuse: educating family physicians. Can J Ob Gyn Women’s Health Care 1994;6:759-62.
16. Lent B. Diagnosing wife assault. Can Fam Physician 1986;32:547-49.
17. Kirkland K. Assessment and treatment of family violence. J Fam Pract 1982;14:713-18.
18. Brown JB, Lent B, Brett P, Sas G, Pederson L. Development of the woman abuse screening tool for use in family practice. Fam Med 1996;28:422-28.
19. Elliot BA, Johnson MMP. Domestic violence in a primary care setting: patterns and prevalence. Arch Fam Med 1995;4:113-19.
20. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-78.
21. McLeer SV, Anwar RAH, Herman S, Maquiling K. Education is not enough: a system’s failure in protecting battered women. Ann Emerg Med 1989;18:651-53.
22. Gerbert B, Johnston K, Caspers N, Bleecker T, Woods A, Rosenbaum A. Experiences of battered women in health care settings: a qualitative study. Women Health 1996;24:1-17.
23. McCauley J, Yurk RA, Jenckes MW, Ford DE. Inside “Pandora’s box”: abused women’s experiences with clinicians and health services. J Gen Intern Med 1998;13:549-55.
24. Hopayian K, Horrocks G, Garner P, Levitt A. Battered women presenting in general practice. J R Coll Gen Pract 1983;33:506-07.
25. Buel SM, Candib LM, Dauphine J, Sassetti MR, Sugg NK. Domestic violence: it can happen to anyone. Patient Care 1993;27:63-95.
26. Burge SK. Violence against women as a health care issue. Fam Med 1989;21:368-73.
27. Rodriguez MA, Quiroga SS, Bauer HM. Breaking the silence: battered women’s perspectives on medical care. Arch Fam Med 1996;5:153-58.
28. Hamberger LK, Ambuel B, Marbella A, Donze J. Physician interaction with battered women: the women’s perspective. Arch Fam Med 1998;7:575-82.
29. Hamberg K, Johansson EV, Lindgren G. ‘I was always on guard’: an exploration of woman abuse in a group of women with musculoskeletal pain. Fam Pract 1999;16:238-44.
30. Yegidis BL. Abuse risk inventory manual. Palo Alto, Calif: Consulting Psychologist Press; 1989.
31. Borgiel AEM, Dunn EV, Lamont CT, et al. Recruiting family physicians as participants in research. Fam Pract 1989;6:168-71.
32. DeVellis RF. Scale development: theory and applications. Newbury Park, Calif: Sage Publications; 1991.
33. Statistics Canada. The violence against women survey. The Daily November 18, 1993.
34. Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. Garden City, NY: Anchor Press/Doubleday; 1980.
35. Russell DEH. Sexual explication: rape, child sexual abuse, and workplace harassment. Beverly Hills, Calif: Sage Publications; 1984.
36. Tudiver F, Permaul-Woods JA. Physicians’ perceptions of and approaches to woman abuse: does certification in family medicine make a difference? Can Fam Physician 1996;42:1475-80.
37. Saunders D, Kindy P. Predictors of physicians’ responses to woman abuse. J Gen Intern Med 1993;8:606-09.
38. Ferris L, Norton P, Dunn E, Gort E. Clinical factors affecting physicians’ management decisions in cases of female partner abuse. Fam Med 1999;31:415-25.
39. Candib LM. Moving on to strengths. Arch Fam Med 1995;4:397-400.
40. Sherin KM, Sinacore JM, Li X-Q, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med 1998;30:508-12.
41. Pan HS, Ehrensaft MK, Heyman RE, O’Leary KD, Schwartz R. Evaluating domestic partner abuse in a family practice clinic. Fam Med 1997;29:492-5.
42. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.
METHODS: We included a stratified random sample of 20 physicians practicing in both urban and rural settings drawn from 400 family physicians in London, Ontario, Canada, and the surrounding area. These physicians administered the WAST to 10 to 15 eligible and consenting patients during the course of regular care. Following the physician-patient encounter, patients were asked to complete both a measure about their comfort in being asked each of the WAST questions and the Abuse Risk Inventory (ARI).
RESULTS: Scores on the WAST correlated well with those on the ARI. The reliability of the WAST among this sample was demonstrated by a coefficient a of 0.75. With the WAST-Short (the first 2 questions of the WAST), 26 of the 307 patients screened (8.5%) were identified as experiencing abuse. The physicians were comfortable administering the WAST to their women patients, and 91% of the patients reported being comfortable or very comfortable when asked the WAST questions by their family physician.
CONCLUSIONS: The WAST was found to be a reliable and valid measure of abuse in the family practice setting, with both patients and family physicians reporting comfort with it being part of the clinical encounter.
Family physicians are in an optimal position to identify women who are victims of abuse, because they are often the first point of contact in the medical arena. However, recent studies indicate that family physicians continue to be reticent in accepting this responsibility, thus contributing to the underdetection of woman abuse.1,2 For almost 2 decades family medicine educators and researchers have made a concerted effort to understand and increase identification and treatment of woman abuse by family physicians.1-17 As part of this initiative, our focus has been on the development of a screening tool for family physicians to use in the context of a routine office visit or a well-woman examination to identify and assess women who are experiencing emotional, physical, or sexual abuse by their partners.8,18
The Woman Abuse Screening Tool (WAST), which consists of 7 questions, was developed and pilot tested using purposive samples of abused and nonabused women.18 It was found to have high internal consistency among this sample ({a} =0.95). It also demonstrated construct validity, with total scores correlating highly (r=0.96) with scores on the Abuse Risk Inventory (ARI).18 The validation study also provided evidence of discriminant validity, finding significant differences in the scores of abused and nonabused women both on individual items and on the overall scores.18
The first 2 questions of the WAST (“In general, how would you describe your relationship: a lot of tension, some tension, no tension?” and “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?” constitute the WAST-Short, which has been an effective tool for initially screening for the presence of abuse.18 The screening tool correctly classified 91.7% of the abused women and 100% of the nonabused women in the validation study.18 These 2 questions were also identified by the abused women in the validation study as those with which they would be most comfortable if asked by their family physicians. The remaining questions on the WAST were used to gain a more complete assessment of the abuse. In the validation study there were significant differences found between the abused and nonabused women on the mean overall WAST scores (18 vs 8.8, respectively; P <.001).
To establish the generalizability of the WAST, we field-tested it by having family physicians ask the questions of adult women in the general population who were presenting for routine visits (complete physical examination or prenatal care) as well as acute complaints.19 Although reported interest of family physicians in having a brief screening tool had been the genesis of this program of study, their comfort in using the WAST during a clinical encounter had not been assessed.8 Also, determining the level of comfort of women patients being asked the WAST questions by a family physician during an actual office visit versus a hypothetical encounter (as was the case in the validation study) was viewed as important.18
Inquiring about abuse has been found to cause discomfort for both physicians and women patients. It has been noted previously that family physicians remain reluctant to delve into the issue of woman abuse in spite of the fact that educating physicians about this abuse (including the use of a screening protocol) has been shown to significantly increase the detection rates of abused women in emergency departments.20,21 Also, both patients and physicians have indicated that the discomfort of physicians with issues of abuse may deter them from inquiring about this topic.7,8,22,23 Data from previous studies showing a decline in detection once a formal assessment protocol is discontinued emphasize the importance of maintaining a continuous screening approach if woman abuse is to be detected.21 Thus knowledge of the level of comfort physicians have in using the WAST and whether it aided in their identification of woman abuse and determining their ongoing commitment to use it required investigation.
Women are often reluctant to disclose abuse to their family physicians for numerous reasons, including shame, denial, fear of reprisal by their partner, a tendency to minimize or normalize the abuse, fear of a negative or punitive response by their physician, or assignment of power and control to the physician.6,24-26 However, studies have shown that when women feel understood, listened to, and validated by their physicians they are more inclined to discuss the abuse.27-29 Also, previous studies with abused women22,23,27-29 have found that they want their physicians to take responsibility for asking questions about abuse and to do so in a manner that is caring, respectful, and supportive. Thus, determining the comfort of women being asked the WAST questions by their family physicians was viewed as essential to our study.
Therefore, the objectives of field testing the WAST were to assess its validity and reliability in the general population within the context of the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in their practices; and to determine the self-reported comfort of patients with being asked the WAST questions by their family physicians.
Our study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.
Methods
Setting
Our study was conducted in the offices of family physicians located in London, Ontario, Canada, and the surrounding area. The recruitment and data collection took place from March 1997 to August 1998.
Instruments
The WAST. Although the original version of the WAST consisted of 7 questions, an eighth question (“Has your partner ever abused you sexually?”) was added for our study (Figure). This question was thought to be clinically important when assessing women who screen positive on the WAST-Short. The 2 questions that make up the WAST-Short assess the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments on a scale of 1 to 3.
Scores on the WAST-Short are computed on the basis of a criterion cutoff score of 1, which involves assigning a score of 1 to the most extreme positive responses for each of the 2 items (ie, “a lot of tension” and “great difficulty”) and a score of 0 to the other response options.18 The remaining 6 questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score.
The Abuse Risk Inventory. The Abuse Risk Inventory (ARI) is a 25-item self-report measure used in the identification of woman abuse and is also described as being useful in the assessment process.30 Respondents rate 25 items on the basis of frequency of occurrence using a 4-point scale ranging from “rarely or never” to “always.” A score of 50 or higher suggests that the respondent may be in an abusive situation or at risk for abuse.30 The ARI has demonstrated reliability (a=.91).30
Physician and Patient Comfort with the WAST Questionnaires. These self-report questionnaires were used to determine the level of comfort of physicians and patients with asking or being asked each of the WAST questions. Responses were given using a 4-point scale ranging from 1 (not at all comfortable) to 4 (very comfortable).
Prior Knowledge Questionnaire. This questionnaire assessed a physician’s previous or concurrent relationships with the patient and her partner by identifying various contexts (eg, workplace, leisure) through which the physician is connected with the patient and her partner in the role other than as the family physician. This questionnaire was included because of the potential influence of the physician’s personal relationship with the patient and her partner on both the patient’s willingness to disclose abuse and the physician’s comfort in inquiring about it.
The Perceived Usefulness Questionnaire. This questionnaire asked physicians to respond to the following statements using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree): “The wording of the WAST was clear”; “The WAST helped me to identify women who are abused”; “I feel better able to identify women who are abused using the WAST”; and “I felt comfortable asking questions on the WAST.” Physicians were also asked to indicate whether they would continue to use the WAST in their practice using the same 5-point scale.
Physician Participants
Our goal was to achieve a stratified random sample of 20 physicians practicing in urban and rural settings from a sampling frame of 400 family physicians in London, Ontario, Canada, and the surrounding area. The family physician investigators telephoned a total of 44 physicians who were selected from the sampling frame using a random numbers table. This followed the recruitment process reported by Borgeil and colleagues.31 Physicians who agreed to participate in our study were mailed a letter of information, a consent form, and directions for the study protocol, including how to administer the WAST and a list of community resources for women who were abused.
Patient Participants
For patients, we followed the recommendations of DeVellis, who has outlined a sample size range with a minimum of 200 and a maximum of 1000 respondents to explore the factorial validity of a new measure.32 To ensure that sufficient variability would exist across responses, we aimed for a moderate sample size of approximately 300 subjects.
To be included in our study the women patients were required to be older than 18 years; attending for a periodic health examination, for prenatal care, or with acute symptoms of illness; English speaking; unaccompanied by another person; currently involved in an intimate relationship (married or common law); and they had to consider the attending physician their primary care physician.
Instrument Administration
The 20 participating physicians were asked to administer the WAST to 15 to 20 consecutive women patients who met the inclusion criteria and consented to participate in the study. At the conclusion of each patient visit the physicians were requested to complete the WAST comfort questionnaire and the prior knowledge questionnaire. When the data collection was completed they were asked to report their perceptions of the WAST.
Each woman was approached by the research assistant in one of the physician’s examining rooms before her visit with the family physician. The research assistant explained the study, provided the patient with a letter of information, and if she agreed to participate supplied a consent form for signature. During the patient recruitment process, the research assistant maintained a written log describing eligible and ineligible patients, reasons for refusal, and other pertinent data, such as the physician’s knowledge of whether a patient was in an abusive relationship. At the conclusion of the physician-patient encounter, the research assistant met with the patient in a private area and asked her to complete the ARI and the measure assessing her comfort with the WAST questions asked.
Data Analysis
To determine the reliability and validity of the WAST, we calculated Cronbach a and Pearson correlation coefficients for the WAST and the ARI. Differences in both the nominal-level demographic information of patients and the responses of physicians and patients to the study measures on the basis of selected variables (family practice certification status for physicians, positive versus negative screen for patients) were analyzed using cross-tabulations and chi-square calculations. Differences in interval and ratio level measures (including demographic information and scale totals) were analyzed with independent samples Student t tests. Analyses involving the length of time physicians had been in practice were conducted using a computed variable (1997 minus year of graduation), which was then recoded into the decade of graduation. Scoring of the WAST involved recoding the responses to reflect a higher score for higher reported frequency of experiences and then summing the WAST scores for individuals who answered all 8 items. ARI scores were calculated for respondents who had answered all 25 items using the procedure outlined by Yegidis.30
Results
Validity and Reliability of the WAST in the Family Practice Context Overall WAST and ARI scores were correlated (r=0.69, P=.01). The WAST was found to be a reliable measure in the family practice context, achieving a coefficient a of 0.75, indicating good internal consistency.
Physician Characteristics
To secure the 20 family physicians required for the study, we had to contact 44 physicians randomly selected from the sampling frame, yielding an acceptance rate of 45.5%. The final sample of physicians consisted of 7 women and 13 men. The average number of years since graduation was 22.9 (range=6-46 years). There were 8 physicians in rural practice and 12 from the city of London, Ontario. Fourteen were in a group practice arrangement, and 14 were certificants of the College of Family Physicians of Canada (CFPC). There were no significant differences between the physicians who agreed to participate and those who declined, on the basis of sex, certification status, years since graduation, practice type (solo vs group), and practice location (urban vs rural).
Patient Characteristics
A total of 456 patients were asked to participate in our study. Fifty-seven women were deemed ineligible on the basis of the inclusion criteria, resulting in 399 eligible patients. Ninety-two (23.1%) of these refused, giving lack of time, degree of sickness, and discomfort in discussing personal issues as their reasons. Thus the final sample included 307 women.
The average age of these patients was 46.2 years (range=18-86 years). The majority (87.6%) were married or in a common-law relationship. The patients were primarily white (97.6%), and 44.7% reported having postsecondary education. More than half of the subjects (58.9%) were employed, and 58.7% reported an annual household income of more than $30,000 (Table 1).
Of the 307 patients screened, 26 (8.5%) were identified by the WAST-Short as experiencing abuse. The demographics of the sample for those who screened positive and negative for abuse are provided in Table 1. No significant differences were found. However, the 26 women who screened positive for abuse reported a wide range of income levels, with 9 women (34.6%) indicating an annual income of more than $50,000.
Table 2 shows the individual WAST item responses and overall scores for the total sample divided into 2 groups: those who screened positive for experiencing abuse and those who screened negative. Significant differences were found between the 2 groups for each item and for the overall WAST scores.
Physician Perceptions of and Comfort with the WAST
The majority of the physicians (85%) thought the wording of the WAST was clear. Sixty-five percent indicated that it assisted them in identifying women who were abused, and 70% felt more confident in identifying abused women when using the WAST. Also, 75% of physicians reported that they would continue to use the WAST in their practice. We did not systematically inquire about a physician’s previous knowledge of a patient’s experience with abuse. However, this information was often reported to the research assistant anecdotally, who then recorded these conversations in her logbook. According to the logbook entries, 6 of the physicians had been aware of previous abuse experienced by some of the women participating in the study.
All the physicians were comfortable with the items on the WAST, as indicated by a mean score of 3.6 on the question “How comfortable were you in asking your patients the WAST questions?” (1=not at all comfortable; 4=very comfortable).
There was a significant association between the number of years since graduation and the reported comfort level of physicians with asking each of the WAST questions; those who had been in practice for a greater length of time were more comfortable than more recent graduates. For example, 85.7% and 100% of physicians who graduated in the 1950s and 1960s, respectively, reported feeling very comfortable asking question 8, compared with 62.1% and 0% of graduates from the 1980s and 1990s, respectively (P <.001). This trend was consistent for each of the WAST items. No significant differences were found in the level of comfort of the physicians on 6 of the WAST questions on the basis of certification status. However, this was not the case when asking the 2 items related to physical abuse, which had smaller proportions of physicians with CFPC certification feeling very comfortable compared with the noncertificants (57.4% vs 76.7% and 60.6% vs 78.1% on questions 4 and 6, respectively; P <.05). Higher proportions of women physicians than men reported being very comfortable when asking the WAST questions addressing physical, emotional, and sexual abuse (77.9% vs 54.9%; 74.8% vs 52.0%; and 77.9% vs 53.8%, respectively; P <.001). There was no association found between the comfort level of physicians and their previous knowledge of their patients.
Patient Comfort with the WAST
For all the WAST items, a minimum of 91% of the women reported being comfortable or very comfortable when asked the questions by their family physician. The average comfort level score across all items was 3.6 (Table 3). However, the abused women were significantly less comfortable than the nonabused women with the questions that addressed physical and sexual abuse (including the question asking whether arguments resulted in a violent outcome) with all 3 questions achieving a significance level of P <.05.
Discussion
The 8-item WAST was found to be a reliable and valid measure in the family practice context among the general population. The WAST-Short identified 26 women (8.5% of the sample) as experiencing abuse, and there was a significant difference between the abused and nonabused women on their total WAST scores. Although not directly transferable, these findings are noteworthy when compared with a 1993 survey of 12,300 Canadian women older than 18 years reporting that 10% of women had experienced violence in the 12 months before the survey.33
There were no differences in the demographic characteristics between the women who screened positive for abuse and those who screened negative. However, there was a wider range of income reported by the 26 women who screened positive. This finding supports the literature, which indicates that woman abuse is present at all economic levels and in all social classes.34,35
Both the patients and their family physicians reported they were comfortable with the WAST, and the comfort level scores of the physicians remained high despite the increasingly sensitive nature of the questions. This strong endorsement suggests that the WAST should be applied in the family practice setting. The majority of physicians perceived the WAST to be helpful for identifying women experiencing abuse and indicated their intentions to continue using it.
Physicians who had been practicing longer expressed more comfort with asking the WAST questions than did their colleagues with less experience. This may reflect their greater awareness of the important role played by psychosocial factors in the lives and health of their patients.
Tudiver and Permaul-Woods36 found no difference in the perceived diagnostic skills for identifying woman abuse between certificants and noncertificants of the CFPC. Our study findings indicate that certificants were less comfortable in asking the 2 questions about physical abuse. Despite their reluctance to ask these questions, the majority of physicians with CFPC certification indicated their commitment to continue using the WAST. The ultimate test will be to see if family physicians persist in the application of the WAST despite fears of opening a “Pandora’s box”7 or “a can of worms”.8
Some authors have considered the influence of physician sex on the level of comfort of physicians inquiring about abuse.37,38 In our study the women physicians reported more comfort than the men in asking about emotional, physical, and sexual abuse.
The vast majority of women patients were comfortable in being asked the WAST questions. However, those who screened positive for abuse did express less comfort with questions related to physical and sexual abuse. These findings suggest that for some patients discussing abuse with their family physician may be problematic. They may view physical violence as socially unacceptable behavior and thus a taboo subject for discussion. It may also reflect the patient’s feelings of shame, fear, guilt, and self blame.11,22,24,25 An environment promoting safety, confidentiality, respect, trust, caring, validation, and a nonjudgemental atmosphere is necessary when screening for abuse.22,23,27,29,39
Compared with a decade ago, several reliable and valid screening tools for detecting woman abuse are now available for use by primary care physicians.18,40-42 The WAST joins the menu of screening tools from which physicians can choose. Its future use is supported by the reported physician and patient comfort levels with its questions being asked during the clinical encounter.
Limitations
Our study was based on a sample of family physicians drawn from a single geographic area, which limits the generalizability of the findings to physicians in other regions. Also, because of the recruitment method physicians may have agreed to participate because of their previous knowledge of the recruiter’s expertise in the field of abuse, resulting in a biased sample. Although the majority of physicians indicated that they would continue to use the WAST in the future we did not ask them how this would occur. Our recommendation would be that at minimum the WAST-Short be administered to women presenting for routine visits, including complete physical examinations and prenatal care as well as acute complaints.
As reported, we did not systematically inquire about the physician’s previous knowledge of the past abuse of a participant. Furthermore, we did not document if a specific intervention transpired with the women identified as abused. These issues are paramount if screening tools for woman abuse are to be viewed as useful and effective in addressing this serious problem. Future studies should include ways to assess and evaluate both interventions and patient outcomes.
The occurrence of abuse in this group of patients may have been underestimated. The information spontaneously offered by some patients at the time of their refusal to participate in our study suggests that they were in an abusive relationship. This reflects the reality of conducting research on a sensitive issue. Also, the preponderance of white English-speaking middle-class women in our study may limit the generalizability to more diverse populations.
However, these limitations do not detract from the important findings of our study, which demonstrates that the WAST-Short questionnaire identifies women experiencing abuse, and the full 8-item WAST helps family physicians explore the extent of that abuse. Finally, and perhaps of most clinical significance, both patients and family physicians were comfortable with the incorporation of WAST into the clinical encounter.
Acknowledgments
Our study was supported by a grant from Searle Canada. The conclusions are those of the authors, and no endorsement by Searle Canada is intended or should be inferred.
METHODS: We included a stratified random sample of 20 physicians practicing in both urban and rural settings drawn from 400 family physicians in London, Ontario, Canada, and the surrounding area. These physicians administered the WAST to 10 to 15 eligible and consenting patients during the course of regular care. Following the physician-patient encounter, patients were asked to complete both a measure about their comfort in being asked each of the WAST questions and the Abuse Risk Inventory (ARI).
RESULTS: Scores on the WAST correlated well with those on the ARI. The reliability of the WAST among this sample was demonstrated by a coefficient a of 0.75. With the WAST-Short (the first 2 questions of the WAST), 26 of the 307 patients screened (8.5%) were identified as experiencing abuse. The physicians were comfortable administering the WAST to their women patients, and 91% of the patients reported being comfortable or very comfortable when asked the WAST questions by their family physician.
CONCLUSIONS: The WAST was found to be a reliable and valid measure of abuse in the family practice setting, with both patients and family physicians reporting comfort with it being part of the clinical encounter.
Family physicians are in an optimal position to identify women who are victims of abuse, because they are often the first point of contact in the medical arena. However, recent studies indicate that family physicians continue to be reticent in accepting this responsibility, thus contributing to the underdetection of woman abuse.1,2 For almost 2 decades family medicine educators and researchers have made a concerted effort to understand and increase identification and treatment of woman abuse by family physicians.1-17 As part of this initiative, our focus has been on the development of a screening tool for family physicians to use in the context of a routine office visit or a well-woman examination to identify and assess women who are experiencing emotional, physical, or sexual abuse by their partners.8,18
The Woman Abuse Screening Tool (WAST), which consists of 7 questions, was developed and pilot tested using purposive samples of abused and nonabused women.18 It was found to have high internal consistency among this sample ({a} =0.95). It also demonstrated construct validity, with total scores correlating highly (r=0.96) with scores on the Abuse Risk Inventory (ARI).18 The validation study also provided evidence of discriminant validity, finding significant differences in the scores of abused and nonabused women both on individual items and on the overall scores.18
The first 2 questions of the WAST (“In general, how would you describe your relationship: a lot of tension, some tension, no tension?” and “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?” constitute the WAST-Short, which has been an effective tool for initially screening for the presence of abuse.18 The screening tool correctly classified 91.7% of the abused women and 100% of the nonabused women in the validation study.18 These 2 questions were also identified by the abused women in the validation study as those with which they would be most comfortable if asked by their family physicians. The remaining questions on the WAST were used to gain a more complete assessment of the abuse. In the validation study there were significant differences found between the abused and nonabused women on the mean overall WAST scores (18 vs 8.8, respectively; P <.001).
To establish the generalizability of the WAST, we field-tested it by having family physicians ask the questions of adult women in the general population who were presenting for routine visits (complete physical examination or prenatal care) as well as acute complaints.19 Although reported interest of family physicians in having a brief screening tool had been the genesis of this program of study, their comfort in using the WAST during a clinical encounter had not been assessed.8 Also, determining the level of comfort of women patients being asked the WAST questions by a family physician during an actual office visit versus a hypothetical encounter (as was the case in the validation study) was viewed as important.18
Inquiring about abuse has been found to cause discomfort for both physicians and women patients. It has been noted previously that family physicians remain reluctant to delve into the issue of woman abuse in spite of the fact that educating physicians about this abuse (including the use of a screening protocol) has been shown to significantly increase the detection rates of abused women in emergency departments.20,21 Also, both patients and physicians have indicated that the discomfort of physicians with issues of abuse may deter them from inquiring about this topic.7,8,22,23 Data from previous studies showing a decline in detection once a formal assessment protocol is discontinued emphasize the importance of maintaining a continuous screening approach if woman abuse is to be detected.21 Thus knowledge of the level of comfort physicians have in using the WAST and whether it aided in their identification of woman abuse and determining their ongoing commitment to use it required investigation.
Women are often reluctant to disclose abuse to their family physicians for numerous reasons, including shame, denial, fear of reprisal by their partner, a tendency to minimize or normalize the abuse, fear of a negative or punitive response by their physician, or assignment of power and control to the physician.6,24-26 However, studies have shown that when women feel understood, listened to, and validated by their physicians they are more inclined to discuss the abuse.27-29 Also, previous studies with abused women22,23,27-29 have found that they want their physicians to take responsibility for asking questions about abuse and to do so in a manner that is caring, respectful, and supportive. Thus, determining the comfort of women being asked the WAST questions by their family physicians was viewed as essential to our study.
Therefore, the objectives of field testing the WAST were to assess its validity and reliability in the general population within the context of the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in their practices; and to determine the self-reported comfort of patients with being asked the WAST questions by their family physicians.
Our study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.
Methods
Setting
Our study was conducted in the offices of family physicians located in London, Ontario, Canada, and the surrounding area. The recruitment and data collection took place from March 1997 to August 1998.
Instruments
The WAST. Although the original version of the WAST consisted of 7 questions, an eighth question (“Has your partner ever abused you sexually?”) was added for our study (Figure). This question was thought to be clinically important when assessing women who screen positive on the WAST-Short. The 2 questions that make up the WAST-Short assess the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments on a scale of 1 to 3.
Scores on the WAST-Short are computed on the basis of a criterion cutoff score of 1, which involves assigning a score of 1 to the most extreme positive responses for each of the 2 items (ie, “a lot of tension” and “great difficulty”) and a score of 0 to the other response options.18 The remaining 6 questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score.
The Abuse Risk Inventory. The Abuse Risk Inventory (ARI) is a 25-item self-report measure used in the identification of woman abuse and is also described as being useful in the assessment process.30 Respondents rate 25 items on the basis of frequency of occurrence using a 4-point scale ranging from “rarely or never” to “always.” A score of 50 or higher suggests that the respondent may be in an abusive situation or at risk for abuse.30 The ARI has demonstrated reliability (a=.91).30
Physician and Patient Comfort with the WAST Questionnaires. These self-report questionnaires were used to determine the level of comfort of physicians and patients with asking or being asked each of the WAST questions. Responses were given using a 4-point scale ranging from 1 (not at all comfortable) to 4 (very comfortable).
Prior Knowledge Questionnaire. This questionnaire assessed a physician’s previous or concurrent relationships with the patient and her partner by identifying various contexts (eg, workplace, leisure) through which the physician is connected with the patient and her partner in the role other than as the family physician. This questionnaire was included because of the potential influence of the physician’s personal relationship with the patient and her partner on both the patient’s willingness to disclose abuse and the physician’s comfort in inquiring about it.
The Perceived Usefulness Questionnaire. This questionnaire asked physicians to respond to the following statements using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree): “The wording of the WAST was clear”; “The WAST helped me to identify women who are abused”; “I feel better able to identify women who are abused using the WAST”; and “I felt comfortable asking questions on the WAST.” Physicians were also asked to indicate whether they would continue to use the WAST in their practice using the same 5-point scale.
Physician Participants
Our goal was to achieve a stratified random sample of 20 physicians practicing in urban and rural settings from a sampling frame of 400 family physicians in London, Ontario, Canada, and the surrounding area. The family physician investigators telephoned a total of 44 physicians who were selected from the sampling frame using a random numbers table. This followed the recruitment process reported by Borgeil and colleagues.31 Physicians who agreed to participate in our study were mailed a letter of information, a consent form, and directions for the study protocol, including how to administer the WAST and a list of community resources for women who were abused.
Patient Participants
For patients, we followed the recommendations of DeVellis, who has outlined a sample size range with a minimum of 200 and a maximum of 1000 respondents to explore the factorial validity of a new measure.32 To ensure that sufficient variability would exist across responses, we aimed for a moderate sample size of approximately 300 subjects.
To be included in our study the women patients were required to be older than 18 years; attending for a periodic health examination, for prenatal care, or with acute symptoms of illness; English speaking; unaccompanied by another person; currently involved in an intimate relationship (married or common law); and they had to consider the attending physician their primary care physician.
Instrument Administration
The 20 participating physicians were asked to administer the WAST to 15 to 20 consecutive women patients who met the inclusion criteria and consented to participate in the study. At the conclusion of each patient visit the physicians were requested to complete the WAST comfort questionnaire and the prior knowledge questionnaire. When the data collection was completed they were asked to report their perceptions of the WAST.
Each woman was approached by the research assistant in one of the physician’s examining rooms before her visit with the family physician. The research assistant explained the study, provided the patient with a letter of information, and if she agreed to participate supplied a consent form for signature. During the patient recruitment process, the research assistant maintained a written log describing eligible and ineligible patients, reasons for refusal, and other pertinent data, such as the physician’s knowledge of whether a patient was in an abusive relationship. At the conclusion of the physician-patient encounter, the research assistant met with the patient in a private area and asked her to complete the ARI and the measure assessing her comfort with the WAST questions asked.
Data Analysis
To determine the reliability and validity of the WAST, we calculated Cronbach a and Pearson correlation coefficients for the WAST and the ARI. Differences in both the nominal-level demographic information of patients and the responses of physicians and patients to the study measures on the basis of selected variables (family practice certification status for physicians, positive versus negative screen for patients) were analyzed using cross-tabulations and chi-square calculations. Differences in interval and ratio level measures (including demographic information and scale totals) were analyzed with independent samples Student t tests. Analyses involving the length of time physicians had been in practice were conducted using a computed variable (1997 minus year of graduation), which was then recoded into the decade of graduation. Scoring of the WAST involved recoding the responses to reflect a higher score for higher reported frequency of experiences and then summing the WAST scores for individuals who answered all 8 items. ARI scores were calculated for respondents who had answered all 25 items using the procedure outlined by Yegidis.30
Results
Validity and Reliability of the WAST in the Family Practice Context Overall WAST and ARI scores were correlated (r=0.69, P=.01). The WAST was found to be a reliable measure in the family practice context, achieving a coefficient a of 0.75, indicating good internal consistency.
Physician Characteristics
To secure the 20 family physicians required for the study, we had to contact 44 physicians randomly selected from the sampling frame, yielding an acceptance rate of 45.5%. The final sample of physicians consisted of 7 women and 13 men. The average number of years since graduation was 22.9 (range=6-46 years). There were 8 physicians in rural practice and 12 from the city of London, Ontario. Fourteen were in a group practice arrangement, and 14 were certificants of the College of Family Physicians of Canada (CFPC). There were no significant differences between the physicians who agreed to participate and those who declined, on the basis of sex, certification status, years since graduation, practice type (solo vs group), and practice location (urban vs rural).
Patient Characteristics
A total of 456 patients were asked to participate in our study. Fifty-seven women were deemed ineligible on the basis of the inclusion criteria, resulting in 399 eligible patients. Ninety-two (23.1%) of these refused, giving lack of time, degree of sickness, and discomfort in discussing personal issues as their reasons. Thus the final sample included 307 women.
The average age of these patients was 46.2 years (range=18-86 years). The majority (87.6%) were married or in a common-law relationship. The patients were primarily white (97.6%), and 44.7% reported having postsecondary education. More than half of the subjects (58.9%) were employed, and 58.7% reported an annual household income of more than $30,000 (Table 1).
Of the 307 patients screened, 26 (8.5%) were identified by the WAST-Short as experiencing abuse. The demographics of the sample for those who screened positive and negative for abuse are provided in Table 1. No significant differences were found. However, the 26 women who screened positive for abuse reported a wide range of income levels, with 9 women (34.6%) indicating an annual income of more than $50,000.
Table 2 shows the individual WAST item responses and overall scores for the total sample divided into 2 groups: those who screened positive for experiencing abuse and those who screened negative. Significant differences were found between the 2 groups for each item and for the overall WAST scores.
Physician Perceptions of and Comfort with the WAST
The majority of the physicians (85%) thought the wording of the WAST was clear. Sixty-five percent indicated that it assisted them in identifying women who were abused, and 70% felt more confident in identifying abused women when using the WAST. Also, 75% of physicians reported that they would continue to use the WAST in their practice. We did not systematically inquire about a physician’s previous knowledge of a patient’s experience with abuse. However, this information was often reported to the research assistant anecdotally, who then recorded these conversations in her logbook. According to the logbook entries, 6 of the physicians had been aware of previous abuse experienced by some of the women participating in the study.
All the physicians were comfortable with the items on the WAST, as indicated by a mean score of 3.6 on the question “How comfortable were you in asking your patients the WAST questions?” (1=not at all comfortable; 4=very comfortable).
There was a significant association between the number of years since graduation and the reported comfort level of physicians with asking each of the WAST questions; those who had been in practice for a greater length of time were more comfortable than more recent graduates. For example, 85.7% and 100% of physicians who graduated in the 1950s and 1960s, respectively, reported feeling very comfortable asking question 8, compared with 62.1% and 0% of graduates from the 1980s and 1990s, respectively (P <.001). This trend was consistent for each of the WAST items. No significant differences were found in the level of comfort of the physicians on 6 of the WAST questions on the basis of certification status. However, this was not the case when asking the 2 items related to physical abuse, which had smaller proportions of physicians with CFPC certification feeling very comfortable compared with the noncertificants (57.4% vs 76.7% and 60.6% vs 78.1% on questions 4 and 6, respectively; P <.05). Higher proportions of women physicians than men reported being very comfortable when asking the WAST questions addressing physical, emotional, and sexual abuse (77.9% vs 54.9%; 74.8% vs 52.0%; and 77.9% vs 53.8%, respectively; P <.001). There was no association found between the comfort level of physicians and their previous knowledge of their patients.
Patient Comfort with the WAST
For all the WAST items, a minimum of 91% of the women reported being comfortable or very comfortable when asked the questions by their family physician. The average comfort level score across all items was 3.6 (Table 3). However, the abused women were significantly less comfortable than the nonabused women with the questions that addressed physical and sexual abuse (including the question asking whether arguments resulted in a violent outcome) with all 3 questions achieving a significance level of P <.05.
Discussion
The 8-item WAST was found to be a reliable and valid measure in the family practice context among the general population. The WAST-Short identified 26 women (8.5% of the sample) as experiencing abuse, and there was a significant difference between the abused and nonabused women on their total WAST scores. Although not directly transferable, these findings are noteworthy when compared with a 1993 survey of 12,300 Canadian women older than 18 years reporting that 10% of women had experienced violence in the 12 months before the survey.33
There were no differences in the demographic characteristics between the women who screened positive for abuse and those who screened negative. However, there was a wider range of income reported by the 26 women who screened positive. This finding supports the literature, which indicates that woman abuse is present at all economic levels and in all social classes.34,35
Both the patients and their family physicians reported they were comfortable with the WAST, and the comfort level scores of the physicians remained high despite the increasingly sensitive nature of the questions. This strong endorsement suggests that the WAST should be applied in the family practice setting. The majority of physicians perceived the WAST to be helpful for identifying women experiencing abuse and indicated their intentions to continue using it.
Physicians who had been practicing longer expressed more comfort with asking the WAST questions than did their colleagues with less experience. This may reflect their greater awareness of the important role played by psychosocial factors in the lives and health of their patients.
Tudiver and Permaul-Woods36 found no difference in the perceived diagnostic skills for identifying woman abuse between certificants and noncertificants of the CFPC. Our study findings indicate that certificants were less comfortable in asking the 2 questions about physical abuse. Despite their reluctance to ask these questions, the majority of physicians with CFPC certification indicated their commitment to continue using the WAST. The ultimate test will be to see if family physicians persist in the application of the WAST despite fears of opening a “Pandora’s box”7 or “a can of worms”.8
Some authors have considered the influence of physician sex on the level of comfort of physicians inquiring about abuse.37,38 In our study the women physicians reported more comfort than the men in asking about emotional, physical, and sexual abuse.
The vast majority of women patients were comfortable in being asked the WAST questions. However, those who screened positive for abuse did express less comfort with questions related to physical and sexual abuse. These findings suggest that for some patients discussing abuse with their family physician may be problematic. They may view physical violence as socially unacceptable behavior and thus a taboo subject for discussion. It may also reflect the patient’s feelings of shame, fear, guilt, and self blame.11,22,24,25 An environment promoting safety, confidentiality, respect, trust, caring, validation, and a nonjudgemental atmosphere is necessary when screening for abuse.22,23,27,29,39
Compared with a decade ago, several reliable and valid screening tools for detecting woman abuse are now available for use by primary care physicians.18,40-42 The WAST joins the menu of screening tools from which physicians can choose. Its future use is supported by the reported physician and patient comfort levels with its questions being asked during the clinical encounter.
Limitations
Our study was based on a sample of family physicians drawn from a single geographic area, which limits the generalizability of the findings to physicians in other regions. Also, because of the recruitment method physicians may have agreed to participate because of their previous knowledge of the recruiter’s expertise in the field of abuse, resulting in a biased sample. Although the majority of physicians indicated that they would continue to use the WAST in the future we did not ask them how this would occur. Our recommendation would be that at minimum the WAST-Short be administered to women presenting for routine visits, including complete physical examinations and prenatal care as well as acute complaints.
As reported, we did not systematically inquire about the physician’s previous knowledge of the past abuse of a participant. Furthermore, we did not document if a specific intervention transpired with the women identified as abused. These issues are paramount if screening tools for woman abuse are to be viewed as useful and effective in addressing this serious problem. Future studies should include ways to assess and evaluate both interventions and patient outcomes.
The occurrence of abuse in this group of patients may have been underestimated. The information spontaneously offered by some patients at the time of their refusal to participate in our study suggests that they were in an abusive relationship. This reflects the reality of conducting research on a sensitive issue. Also, the preponderance of white English-speaking middle-class women in our study may limit the generalizability to more diverse populations.
However, these limitations do not detract from the important findings of our study, which demonstrates that the WAST-Short questionnaire identifies women experiencing abuse, and the full 8-item WAST helps family physicians explore the extent of that abuse. Finally, and perhaps of most clinical significance, both patients and family physicians were comfortable with the incorporation of WAST into the clinical encounter.
Acknowledgments
Our study was supported by a grant from Searle Canada. The conclusions are those of the authors, and no endorsement by Searle Canada is intended or should be inferred.
1. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.
2. 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.
3. Ontario Medical Association Committee on Wife Assault. Reports on wife assault. Toronto: Ontario Medical Association. CMAJ 1991; January supplement.
4. Candib LM. Violence against women: no more excuses. Fam Med 1989;21:339, 341-42.
5. Herbert C. Family violence and family physicians. Can Fam Physician 1991;37:385-90.
6. Mehta P, Dandrea LA. The battered woman. Am Fam Physician 1988;37:193-99.
7. Sugg NC, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60.
8. Brown JB, Sas G, Lent B. Identifying and treating wife abuse. J Fam Pract 1993;36:185-91.
9. Ferris L, Tudiver F. Family physicians’ approach to wife assault: a study of Ontario, Canada, practices. Fam Med 1992;24:276-82.
10. Sas G, Brown JB, Lent B. Detecting woman abuse in family practice. Can Fam Physician 1994;40:861-64.
11. Archer LA. Empowering women in a violent society: role of the family physician. Can Fam Physician 1994;40:974-85.
12. Knowlden SM, Frith JF. Domestic violence and the general practitioner. Med J Aust 1993;158:402-06.
13. Ferris LE. Canadian family physicians’ and general practitioners’ perceptions of their effectiveness in identifying and treating wife abuse. Med Care 1995;32:1163-72.
14. Radomsky N. Domestic violence. Life’s stories: her eyes and my glasses. Special series. Fam Med 1992;24:273-74.
15. Brown JB, Lent B, Sas G. Woman abuse: educating family physicians. Can J Ob Gyn Women’s Health Care 1994;6:759-62.
16. Lent B. Diagnosing wife assault. Can Fam Physician 1986;32:547-49.
17. Kirkland K. Assessment and treatment of family violence. J Fam Pract 1982;14:713-18.
18. Brown JB, Lent B, Brett P, Sas G, Pederson L. Development of the woman abuse screening tool for use in family practice. Fam Med 1996;28:422-28.
19. Elliot BA, Johnson MMP. Domestic violence in a primary care setting: patterns and prevalence. Arch Fam Med 1995;4:113-19.
20. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-78.
21. McLeer SV, Anwar RAH, Herman S, Maquiling K. Education is not enough: a system’s failure in protecting battered women. Ann Emerg Med 1989;18:651-53.
22. Gerbert B, Johnston K, Caspers N, Bleecker T, Woods A, Rosenbaum A. Experiences of battered women in health care settings: a qualitative study. Women Health 1996;24:1-17.
23. McCauley J, Yurk RA, Jenckes MW, Ford DE. Inside “Pandora’s box”: abused women’s experiences with clinicians and health services. J Gen Intern Med 1998;13:549-55.
24. Hopayian K, Horrocks G, Garner P, Levitt A. Battered women presenting in general practice. J R Coll Gen Pract 1983;33:506-07.
25. Buel SM, Candib LM, Dauphine J, Sassetti MR, Sugg NK. Domestic violence: it can happen to anyone. Patient Care 1993;27:63-95.
26. Burge SK. Violence against women as a health care issue. Fam Med 1989;21:368-73.
27. Rodriguez MA, Quiroga SS, Bauer HM. Breaking the silence: battered women’s perspectives on medical care. Arch Fam Med 1996;5:153-58.
28. Hamberger LK, Ambuel B, Marbella A, Donze J. Physician interaction with battered women: the women’s perspective. Arch Fam Med 1998;7:575-82.
29. Hamberg K, Johansson EV, Lindgren G. ‘I was always on guard’: an exploration of woman abuse in a group of women with musculoskeletal pain. Fam Pract 1999;16:238-44.
30. Yegidis BL. Abuse risk inventory manual. Palo Alto, Calif: Consulting Psychologist Press; 1989.
31. Borgiel AEM, Dunn EV, Lamont CT, et al. Recruiting family physicians as participants in research. Fam Pract 1989;6:168-71.
32. DeVellis RF. Scale development: theory and applications. Newbury Park, Calif: Sage Publications; 1991.
33. Statistics Canada. The violence against women survey. The Daily November 18, 1993.
34. Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. Garden City, NY: Anchor Press/Doubleday; 1980.
35. Russell DEH. Sexual explication: rape, child sexual abuse, and workplace harassment. Beverly Hills, Calif: Sage Publications; 1984.
36. Tudiver F, Permaul-Woods JA. Physicians’ perceptions of and approaches to woman abuse: does certification in family medicine make a difference? Can Fam Physician 1996;42:1475-80.
37. Saunders D, Kindy P. Predictors of physicians’ responses to woman abuse. J Gen Intern Med 1993;8:606-09.
38. Ferris L, Norton P, Dunn E, Gort E. Clinical factors affecting physicians’ management decisions in cases of female partner abuse. Fam Med 1999;31:415-25.
39. Candib LM. Moving on to strengths. Arch Fam Med 1995;4:397-400.
40. Sherin KM, Sinacore JM, Li X-Q, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med 1998;30:508-12.
41. Pan HS, Ehrensaft MK, Heyman RE, O’Leary KD, Schwartz R. Evaluating domestic partner abuse in a family practice clinic. Fam Med 1997;29:492-5.
42. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.
1. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-87.
2. 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.
3. Ontario Medical Association Committee on Wife Assault. Reports on wife assault. Toronto: Ontario Medical Association. CMAJ 1991; January supplement.
4. Candib LM. Violence against women: no more excuses. Fam Med 1989;21:339, 341-42.
5. Herbert C. Family violence and family physicians. Can Fam Physician 1991;37:385-90.
6. Mehta P, Dandrea LA. The battered woman. Am Fam Physician 1988;37:193-99.
7. Sugg NC, Inui T. Primary care physicians’ response to domestic violence. JAMA 1992;267:3157-60.
8. Brown JB, Sas G, Lent B. Identifying and treating wife abuse. J Fam Pract 1993;36:185-91.
9. Ferris L, Tudiver F. Family physicians’ approach to wife assault: a study of Ontario, Canada, practices. Fam Med 1992;24:276-82.
10. Sas G, Brown JB, Lent B. Detecting woman abuse in family practice. Can Fam Physician 1994;40:861-64.
11. Archer LA. Empowering women in a violent society: role of the family physician. Can Fam Physician 1994;40:974-85.
12. Knowlden SM, Frith JF. Domestic violence and the general practitioner. Med J Aust 1993;158:402-06.
13. Ferris LE. Canadian family physicians’ and general practitioners’ perceptions of their effectiveness in identifying and treating wife abuse. Med Care 1995;32:1163-72.
14. Radomsky N. Domestic violence. Life’s stories: her eyes and my glasses. Special series. Fam Med 1992;24:273-74.
15. Brown JB, Lent B, Sas G. Woman abuse: educating family physicians. Can J Ob Gyn Women’s Health Care 1994;6:759-62.
16. Lent B. Diagnosing wife assault. Can Fam Physician 1986;32:547-49.
17. Kirkland K. Assessment and treatment of family violence. J Fam Pract 1982;14:713-18.
18. Brown JB, Lent B, Brett P, Sas G, Pederson L. Development of the woman abuse screening tool for use in family practice. Fam Med 1996;28:422-28.
19. Elliot BA, Johnson MMP. Domestic violence in a primary care setting: patterns and prevalence. Arch Fam Med 1995;4:113-19.
20. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-78.
21. McLeer SV, Anwar RAH, Herman S, Maquiling K. Education is not enough: a system’s failure in protecting battered women. Ann Emerg Med 1989;18:651-53.
22. Gerbert B, Johnston K, Caspers N, Bleecker T, Woods A, Rosenbaum A. Experiences of battered women in health care settings: a qualitative study. Women Health 1996;24:1-17.
23. McCauley J, Yurk RA, Jenckes MW, Ford DE. Inside “Pandora’s box”: abused women’s experiences with clinicians and health services. J Gen Intern Med 1998;13:549-55.
24. Hopayian K, Horrocks G, Garner P, Levitt A. Battered women presenting in general practice. J R Coll Gen Pract 1983;33:506-07.
25. Buel SM, Candib LM, Dauphine J, Sassetti MR, Sugg NK. Domestic violence: it can happen to anyone. Patient Care 1993;27:63-95.
26. Burge SK. Violence against women as a health care issue. Fam Med 1989;21:368-73.
27. Rodriguez MA, Quiroga SS, Bauer HM. Breaking the silence: battered women’s perspectives on medical care. Arch Fam Med 1996;5:153-58.
28. Hamberger LK, Ambuel B, Marbella A, Donze J. Physician interaction with battered women: the women’s perspective. Arch Fam Med 1998;7:575-82.
29. Hamberg K, Johansson EV, Lindgren G. ‘I was always on guard’: an exploration of woman abuse in a group of women with musculoskeletal pain. Fam Pract 1999;16:238-44.
30. Yegidis BL. Abuse risk inventory manual. Palo Alto, Calif: Consulting Psychologist Press; 1989.
31. Borgiel AEM, Dunn EV, Lamont CT, et al. Recruiting family physicians as participants in research. Fam Pract 1989;6:168-71.
32. DeVellis RF. Scale development: theory and applications. Newbury Park, Calif: Sage Publications; 1991.
33. Statistics Canada. The violence against women survey. The Daily November 18, 1993.
34. Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. Garden City, NY: Anchor Press/Doubleday; 1980.
35. Russell DEH. Sexual explication: rape, child sexual abuse, and workplace harassment. Beverly Hills, Calif: Sage Publications; 1984.
36. Tudiver F, Permaul-Woods JA. Physicians’ perceptions of and approaches to woman abuse: does certification in family medicine make a difference? Can Fam Physician 1996;42:1475-80.
37. Saunders D, Kindy P. Predictors of physicians’ responses to woman abuse. J Gen Intern Med 1993;8:606-09.
38. Ferris L, Norton P, Dunn E, Gort E. Clinical factors affecting physicians’ management decisions in cases of female partner abuse. Fam Med 1999;31:415-25.
39. Candib LM. Moving on to strengths. Arch Fam Med 1995;4:397-400.
40. Sherin KM, Sinacore JM, Li X-Q, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med 1998;30:508-12.
41. Pan HS, Ehrensaft MK, Heyman RE, O’Leary KD, Schwartz R. Evaluating domestic partner abuse in a family practice clinic. Fam Med 1997;29:492-5.
42. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.