BACKGROUND: Our study objectives were to assess the validity and reliability of the Woman Abuse Screening Tool (WAST) in the general population within 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 practice; and to determine the self-reported comfort of patients being asked the WAST questions by their family physicians.
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.