Intimate partner violence (IPV) is a major public health problem with harmful consequences on the health of women, (1) and their unborn babies and children. (2, 3) Globally, it is estimated that about 1 in 3 women have experienced physical and/or sexual violence by an intimate partner. (4) IPV is common during pregnancy, with estimates varying from 3–29% depending on the measure used, and for many women, violence begins or escalates during pregnancy and the postpartum period. (5–7) Women experiencing IPV have higher risk for adverse maternal and perinatal health outcomes including postnatal depression, perceived stress; (8) unintended pregnancies, abortions; (9) low birth weight and preterm births. (10)
Given the increased contact with healthcare providers during pregnancy, antenatal care presents a unique opportunity to enquire routinely about IPV.
(
11) A Cochrane systematic review (
12) suggests that IPV screening and initial response by a health professional increases identification with no increase in referrals or changes in women’s experience of violence or wellbeing. However, in antenatal care there may be sufficient evidence to recommend screening all women attending, with two antenatal studies (
13,
14) showing improvement in some outcomes for women. (
12) Despite increased efforts to reduce IPV and its negative health consequences, it is not consistently screened for in antenatal care across the world. (
15,
16) Although there are many barriers to effective identification and response for women experiencing IPV, (
16) one factor increasing a health professional’s likelihood of screening for IPV is having a set of scripted questions. (
17–
20) The use of a validated tool suitable to antenatal settings may facilitate consistent screening but also allow comparisons across health facilities and changes over time for quality improvement purposes. (
17)
Testing the validity of a brief screening tool against a gold standard helps to ascertain whether the tool can correctly identify those experiencing IPV (sensitivity), while eliminating those not experiencing it (specificity). (21) However, there are several analysis issues including that there is no agreed upon gold standard for IPV measurement and pre-test prevalence will alter the positive predictive value of the screening tool. There are also interpretation issues, such as the reductionist approach of IPV screening tools in which women are dichotomised into abused or non-abused categories. Among any group of women who do not report IPV on a particular tool, will be some who have experienced abusive behaviours but do not wish to label themselves as abused. This should be respected and understood. In evaluating IPV screening tools, the balancing act between the true positive rate (sensitivity) and true negative rate (specificity) is difficult when dealing with a social problem rather than a biomedical disease with a straight-forward diagnostic gold standard. With IPV it is important to maximise reach to those who have been abused by a partner so that support can be offered, that is, there is a need to maximise the true positive rate. An ‘over-inclusive’ IPV screen, however, will mean that some women will be identified as experiencing abuse when the behaviours they experience are not consistent with the current understanding of the coercive controlling dynamics of IPV. For these women (returning a false positive IPV screen), there is a risk of being labelled as someone who is experiencing IPV with unnecessary use of intervention resources. Thus, there are implications of false-negatives (missing cases of IPV) and false positives (overidentifying cases of IPV). Where the prevalence of the condition of interest is very low, as it often is with screening for IPV, a test has to be highly specific to reduce the number of false-positive results to an acceptable level. (22)
Although there is an extensive body of knowledge on the prevalence and health impacts of IPV, gaps remain on the most effective ways of screening those affected. (23) A 2009 systematic review showed that the psychometric properties varied across IPV screening tools and settings. (24) This review reported that the most studied screening tools were the Hurt, Insult, Threaten, and Scream (HITS, sensitivity 30–100%, specificity 86–99%); the Woman Abuse Screening Tool (WAST, sensitivity 47%, specificity 96%); the Partner Violence Screen (PVS, sensitivity 35–71%, specificity 80–94%); and the Abuse Assessment Screen (AAS, sensitivity 93–94%, specificity 55–99%). Internal reliability (HITS, WAST); test–retest reliability (AAS); concurrent validity (HITS, WAST); discriminant validity (WAST); and predictive validity (PVS) were also assessed, however the authors concluded that no single IPV screening tool had well-established psychometric properties. A 2016 systematic review (23) found ten IPV screening tools and recommended three as having stronger psychometric values, assessing all areas of IPV and having been validated against a reference standard: Women Abuse Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation, Afraid, Rape and Kick (HARK).
However, the eight item tool WAST, (25) though comprehensive, is longer than most tools. This is a consideration in light of findings about the importance of tool brevity e.g., HARK four-item tool. (20, 26) A strength of the WAST and HARK tools is inclusion of questions about fear, which has the potential to identify the majority of women experiencing IPV. (27) Both tools also include items about sexual violence, which is common in abusive relationships, yet in the context of an initial screen, may be difficult for health providers to ask about and a particularly challenging form of abuse for women to name. (28, 29) The AAS has a simple scoring system and has been validated in perinatal settings. (30–36) It is a five item questionnaire that has demonstrated a large range of prevalence from 2.8% (34) to 35.5% (35) for IPV during the antenatal period and up to 41% (31) for any history of IPV among a sample of pregnant women. Further, all three of these scales (i.e., WAST, AAS, HARK) do not capture coercive control which is seen as an important part of the pattern of IPV. (37)
Systematic reviews have shown that women find screening tools acceptable; (38, 39) however, an additional characteristic of IPV screening tools that is understudied is the format of item responses. Women are generally asked to report the occurrence of abusive behaviours in the past 12 months in either a binary response format (yes or no) or an ordinal frequency format. While HARK, (26) AAS, (40) and PVS (41) response choices are yes or no, the WAST has three options (‘often’, ‘sometimes’ and ‘never’) (42) and HITS has five options (‘never’, ‘rarely’, ‘sometimes’, ‘fairly often’, ‘frequently). (43) It is not known whether response format effects IPV screening tool validity. It is also not known whether women prefer to respond to screening questions with a binary yes/no or have a range of frequency options. IPV screen length, response options and scoring may all impact on both validity and ease of use for health practitioners and women clients.
Recognising the shortcomings of current IPV screening tools for use in antenatal care, we developed the brief ACTS tool through reviewing items on existing tools and a consensus discussion amongst the authors. (17) In this paper, we introduce the ACTS tool and present our findings of initial tool testing.
Our aim was to test in antenatal care i) the accuracy of the new IPV screening tool and ii) how women prefer to be asked about IPV.
We present test statistics (sensitivity, specificity, negative and positive predictive values and area under the receiver operating curve [AUC]) against the reference standard Composite Abuse Scale (CAS) (
44) and the utility of the ACTS tool with two alternative response formats. We also assess women’s preference for IPV screen response format and frequency of asking, along with their comfort level in being screened.