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.