Health Evidence hosted a 90 minute webinar examining different types of screening tool administration methods used for the detection of intimate partner violence. Nasir Hussain, MD Candidate, Central Michigan University College of Medicine will present findings from his latest Trauma, Violence & Abuse review: Hussain N., Sprague S., Madden K., Hussain F., Pindiprolu B., & Bhandari M. (2015). A comparison of the types of screening tool administration methods used for the detection of intimate partner violence: A systematic review and meta-analysis. Trauma, Violence & Abuse, 16(1), 60-69. Intimate partner violence (IPV) is associated with significant health consequences for victims, including acute/chronic pain, depression, trauma, suicide, death, as well as physical, emotional, and mental harms for families and children. This review discusses the rate of IPV disclosure in adult women (over 18 years of age) with the use of three different screening tool administration methods: computer-assisted self-administered screen, self-administered written screen, and face-to-face interview screen. This webinar highlighted factors that contribute to the effectiveness of screening tool administration methods used for the detection of intimate partner violence.

1. Welcome!
Comparing screening tools for
intimate partner violence
detection: What's the
evidence?
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2

3. What’s the evidence?
Hussain N., Sprague S., Madden K., Hussain F.,
Pindiprolu B., & Bhandari M. (2015). A comparison
of the types of screening tool administration
methods used for the detection of intimate partner
violence: A systematic review and meta-analysis.
Trauma, Violence & Abuse, 16(1), 60-69.
http://www.healthevidence.org/view-article.aspx?a=

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National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

11. Stages in the process of Evidence-
Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informed
Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

12. Poll Question #1
Have you heard of PICO(S) before?
1.Yes
2.No

13. Searchable Questions Think “PICOS”
1. Population (situation)
2. Intervention (exposure)
3. Comparison (other group)
4. Outcomes
5. Setting

14. How often do you use Systematic Reviews
to inform a program/services?
A.Always
B.Often
C.Sometimes
D.Never
E.I don’t know what a systematic review is
Poll Question #2

15. Nasir Hussain, MD Candidate,
Central Michigan University,
College of Medicine
Nasir Hussain, MSc

16. Computer-assisted self-administered screens
leads to higher rates of IPV disclosure,
compared to both face-to-face interview and
self-administered written screens.
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree
Poll Question #3

17. Hussain N., Sprague S., Madden K., Hussain F.,
Pindiprolu B., & Bhandari M. (2015). A
comparison of the types of screening tool
administration methods used for the detection
of intimate partner violence: A systematic
review and meta-analysis. Trauma, Violence &
Abuse, 16(1), 60-69.
Nasir Hussain BSc MSc(Cand)1
Sheila Sprague BSc MSc PhD(Cand)1
Kim Madden BSc MSc(Cand)1
Farrah Hussain BSc MD(Cand)2
Bharadwaj Pindiprolu BSc(Cand)1
Mohit Bhandari MD PhD FRCSC3
1
McMaster University, Hamilton, ON, Canada
2
Wayne State University, Detroit, MI, USA
3
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada

18. Intimate Partner Violence
• Defined by the Center for Disease Control
and Prevention as the “physical, sexual, or
psychological harm by a current or former
partner or spouse”
• Associated with significant health
consequences that can have adverse
effects on the victim and surrounding
individuals

19. Intimate Partner Violence
• 2-5 million women
affected every year
• Approximately 85% of
victims are women
• 1/3 to 1/4 women will be
affected at least once in
lifetime
• More often seen in
divorced and separated
women and those with
recent struggles in life

20. Concerns?

21. Intimate Partner Violence
• Most women do not disclose abuse to their
physician
– Several reasons for this including potential fear of
stigma, further harm, and fear of the unknown
• What are we left to do as healthcare
professionals?
– Do we screen all women who enter the clinic?
– Do we screen only those that are at high risk?
– How do we screen these women?
– What do we use to screen these women?

22. Screening for IPV
• Currently, approximately 33 screening
tools and scales exist to positively identify
victims of IPV, each of which has its own
advantages and drawbacks
– Sensitivities and specificities differ between
tools as well!
– With so many screening tools, what are we
left to do? Which do we choose?

23. Screening for IPV
• Different screening tool administration
methods
– Computerized questionnaire
– Nurse/Physician administered face-to-face
questionnaire
– Self-administered questionnaire
• Potential advantages and disadvantages of
each on an empirical level?
• Which type leads to higher rates of
disclosure?

24. Levels of Evidence

25. What is a meta-analysis?
• A meta-analysis effectively pools the data
from all relevant studies found for a
specific research question
• Pooling allows the results to be more
generalized then they normally would from
the results of a single trial
• Increase in precision and size of estimate
of effect

26. The Question
• To assess the rate of IPV disclosure in
adult women (≥18 years of age) with the
use of three different screening methods:
1. computer assisted self-administered screen
2. self-administered written screen
3. face-to-face interview screen

27. PICO(T)
• P = adult women (≥18 years of age)
• I = Computer Assisted Screening
• C = Self-administered screening OR face-
to-face screening
• O = rate of IPV disclosure
– Secondary outcome = patient satisfaction and
ease of use

28. Inclusion Criteria
• Any clinical trial that randomly allocated adult women
aged 18 and above to undergo IPV screening using at
least two of the following methods was considered for
inclusion and eligibility: 1) computer-assisted self-
administered screen 2) self-administered written screen
or 3) face-to-face interview screen
• Studies with exclusive data only on males were excluded
• Health care setting was defined to be a general/family
practice, emergency medicine clinic, women’s health
clinic, public hospital, specialist clinics, or
prenatal/postnatal services
• Studies not excluded if they also assessed the
effectiveness of the screening questionnaire

29. Search Methods
• Search strategy developed by an evidence-
based medicine librarian for MEDLINE,
EMBASE, PsycINFO, CINAHL, DARE and
Cochrane Library
– Use the help of one!
• Two reviewers screened the articles found by
the search strategy for eligibility
– First screen title and abstracts  identify those
that may be relevant  screen full text

30. Search Strategy

31. Study Selection
• Two independent reviewers assessed
each potential article for inclusion and
eligibility
– Agreement between the two reviewers was
assessed through the calculation of an un-
weighted kappa
• Kappa = measurement of interobserver variation
– Can range from 0 to 1
– A number closer to 1 means that there was little variation
between the two reviewers

32. Full Text Inclusion Form

33. Study Flow
Diagram

34. Data Extraction
• A data extraction form was created and piloted by an
independent reviewer
– Following the initial pilot and feedback, the form was used
to collect all relevant data from included studies
• Contained relevant information pertaining to:
– total number of participants in trial
– clinical setting
– screening methods compared
– rates of disclosure for each compared method
– types of questionnaires (e.g. WAST or PVS) used in each
method
– information relating to patient satisfaction of the specific
intervention when relevant

35. Methodological Quality
• All included trials were assessed for
methodological quality using the
Cochrane Risk of Bias Assessment tool
– Questions in this tool were related to:
randomization sequence used, sequence
concealment, blinding of participants and
study personnel, blinding of outcome
assessors, level of incomplete outcome data,
and selective outcome reporting
• Kappa calculated between reviewers

37. Measurement of Treatment
Effect
• Dichotomous or Continuous Outcome?
– If Dichotomous = use odds ratio, risk ratio or
risk difference
– If Continuous = use mean difference or
standardized mean difference
• Our primary outcome = dichotomous
– Therefore we reported an odds ratio

38. Assessment of Heterogeneity
• Heterogeneity evaluates the differences
between studies
– Evaluated through analysis of the I2
statistic

39. Subgroup Analysis
• Generally, the subgroups are determined
a priori
– Otherwise, you will be fishing to find
something!
• Our review: Subgroup based on the type
of questionnaire used (WAST, PVS, HITS,
VAWS) and the clinical setting

40. Data Synthesis
• Meta-analysis was performed using the Mantel-
Haenszel random-effects model as there was
expected heterogeneity between the included
studies
• Three individual one-on-one comparisons were
made for which data was pooled
– Face-to-face interview versus computer based self-
administered screen
– Face-to-face interview versus self-administered
written screen
– Computer based self-administered screen versus
self-administered written screen
• Network Meta-analysis?

41. Study Flow
Diagram

42. Characteristics of Included
Studies
• Total of six studies:
– Various settings, including family medicine
clinic, emergency department, women’s
health clinic, and pediatric care
– Conducted in Japan, US or Canada
– Five studies reported patient satisfaction
outcomes
– Rate of disclosure was assessed by all
studies

43. Agreement Between
Reviewers
• Kappa
– Study inclusion stage – 0.80
– Risk of bias assessment – 0.83

44. Results

45. Results

46. Results

47. Results

48. Results

49. Overall Message
• Self-administered screening tools,
especially those delivered by computers,
trend to higher rates of disclosure and
better overall satisfaction among women

50. Explanation of Heterogeneity
• Heterogeneity, or apparent difference in
the results across studies, found in both 1)
Face-to-face interview screen versus Self-
administered written screen and 2) Face-
to-face interview screen versus Computer
assisted self-administered screen
supported our pre-defined subgroup
analysis

51. Explanation of Heterogeneity
• Face-to-face interview screen versus self-
administered written screen
– Resolved based on type of questionnaire
used
– Systematic review Kataoka and colleagues
(2004) found that the VAWS was most
appropriate for clinical settings in Japan
• Also found that the VAWS was significantly more
sensitive when a self-administered written version
was used in comparison to a face-to-face interview
version

52. Explanation of Heterogeneity
• Face-to-face interview screen versus
computer assisted self-administered screen
– Resolved on the basis of clinical setting
• Has also been reported by several studies
– McCloskey et al. (2005) = highest rates of IPV
were found in hospital-based addiction units
(36%) and emergency departments (17%)
– Kovac et al. (2003) = IPV prevalence was
relatively small in obstetrics and gynecology
departments at approximately 8%

53. Discussion
• For victims of IPV, physicians are often
the first and only chance that they may get
to seek help for their problems
– Review suggests potential benefit of allowing
victims the opportunity to complete
questionnaires in privacy
• Use of self-administered methods such as
computer screening, may allow for
identification of the greatest number of
victims

54. Strengths and Limitations
• Language bias?
• Publication bias?
• Strength of pooled estimates?
• Extent of abuse or violence a factor?

55. One study leads all
• Results are heavily dominated by one
study that randomized over 2000 patients
– MacMillan et al., 2006
• What are the implications of this?
– External validity of our results?

56. GRADE
• Helps assess the overall quality of
evidence for pooled outcome (i.e.
confidence in the evidence)
– Assessments are made based upon the overall risk of
bias, inconsistency between studies, indirectness of
evidence, imprecision, and publication bias

57. GRADE Tables
Face-to-face screen vs. Computer
assisted self-administered screen

58. GRADE Tables
Face-to-face screen vs. Self-
administered written screen

59. GRADE Tables
Computer assisted self-administered
screen vs. Self-administered written
screen

60. GRADE Tables
Computer assisted or
Self/administered written screen vs.
Face-to-Face screen

61. Implications of results
• Healthcare professionals should consider
utilizing self-administered questionnaires
to help identify victims of IPV
– Computer assisted self-administered screens
APPEAR to provide the the best results in
terms of disclosure and patient satisfaction
– Costs? Availability? Rural settings?

62. Future Research
• More studies needed that evaluate
satisfaction on standardized tools which
allow for pooling and generalizability
• Standardized questionnaires should be
used – currently 33 exist!
• Are the efficacy of these tools clinical
setting dependent?
• Benefits in males?

63. Computer-assisted self-administered screens
leads to higher rates of IPV disclosure,
compared to both face-to-face interview and
self-administered written screens.
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree
Poll Question #4

64. Poll Question #5
Do you agree with the findings of this
review?
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree

65. Questions?

66. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

67. 67
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