1. health and fitness

If, when and how to ask the
questions: Assessing approaches
to identifying woman abuse in
health care settings
A program of research funded by the
Ontario Women’s Health Council
Harriet MacMillan, MD, MSc
Nadine Wathen, PhD
McMaster University
Overall Objective
To answer the question:
Does universal screening for VAW in
health settings do more good than harm?
By testing the effectiveness of universal
screening vs. no screening in:
– reducing violence and improving life quality
– balanced against potential harms
VAW Team
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Harriet MacMillan
Tom Abernathy
Kathryn Bennett
Charlene Beynon
Michael Boyle
Cristina Catallo
Marilyn Ford-Gilboe
Clare Freeman
Amiram Gafni
Iris Gutmanis
Susan Jack
Barb Lent
Joyce Lock
Daina Mueller
•
•
•
•
•
•
•
•
•
•
•
Rosana Pellizzari
Anna Marie Pietrantonio
Rachelle Sender
Helen Thomas
Jackie Thomas
Diana Tikasz
Leslie Tutty
Nadine Wathen
Margo Wilson
Andrew Worster
Bonnie Lynn Wright
CONSULTANTS
• Jacquelyn Campbell
• Jeff Coben
• Louise-Anne McNutt
VAW team of McMaster-based staff
• Sandy Brooks, site
research coordinator
• Susanne King, research
associate
• Cristina Catallo,
research coordinator
• Janet McLeod, admin
assistant
• Pearl Dodd, program
manager
• Sarah Phillips, research
assistant
• Jill Hancock, clinical
research coordinator
• Ellen Jamieson,
research associate
Acknowledgments
• Ontario Women’s Health Council,
Ministry of Health & Long-term Care
• Canadian Institutes of Health Research
New Emerging Team Program (Institutes
for Gender & Health, Aging, Human
Development, Child & Youth Health,
Neurosciences, Mental Health, & Addiction
and Population & Public Health)
Research program
Phase 1
studies
RCT of Screening
Methods
Screening
Effectiveness RCT
• Focus groups with abused
and non-abused women
• Health care provider
survey
• Population attitudes
towards screening
• Meta-analysis of risk
indicators
Women’s Experiences &
Views Re: Screening
S. Jack, M. Webb, N. Wathen, H. MacMillan
lead investigators
Objectives
• Explore knowledge, attitudes and
beliefs about identification of woman
abuse, including acceptability of
universal screening
• Information on barriers to screening
and how to overcome them
• Targets abused and non-abused women
between the ages of 18 – 64 years
Method
• Focus groups with identified abused
women
– Saakaate House (Lake-of-the-Woods)
– Women In Crisis (Sault Ste. Marie)
– Interval House (Hamilton)
– Inasmuch House (Hamilton)
– Native Women’s Centre (Hamilton)
– Martha House Shelter (Hamilton)
– Martha House Outreach Program
(Hamilton)
Method - 2
•
•
•
•
•
•
•
•
•
•
•
•
•
Shelter Workers (Lake-of-the-Woods)
SOS – Francophone Community Centre
Aboriginal Friendship Centre (moms & tots)
Recent immigrants (Iran, Afghanistan)
Canadian Blood Services (staff)
YWCA (residents)
Zonta Club
Calvin Christian Reform (Faith group)
Dragon Boat Team
Hamilton Aquatic Club Mothers
Rhyme time group - North Hamilton Community Centre
Sault Ste. Marie University Students
Flamborough Chamber of Commerce
Total to date: 172 women in 20 groups
Selected Results & Observations
Focus groups with women:
¾Education for health providers and the
public is needed to overcome potential
barriers to screening
¾Groups of abused women generally
supported universal screening
¾Groups of non-abused women willing to
be screened if everyone asked
Who should screen for IPV?
• For non-abused women:
– The ‘type’ of health care provider is not as
important as the quality of client-provider
relationship
– Changes to family practices (locums, family
health networks, increased reliance on
locums) creates barriers to screening by
and disclosures to physicians
Who should screen for IPV?
• For abused women:
– Prefer the anonymity that comes with a
walk-in clinic or emergency room
– Shame associated with disclosure to hcp
with whom they have a relationship
– Articulate that providers who screen must
be prepared to respond to disclosures
Where should screening occur?
• Regardless of type of health care
setting, guarantee of privacy is essential
• Non-abused women support integration
of screening into regular, nonemergency physician appointments and
not in the ER.
• Abused women support integration of
screening for IPV in the ER
How should screening be done?
• Abused women:
– Hesitant to disclose in a face-to-face
screen.
– Prefer written questionnaire
– Onus on professionals to ensure that part
of examination conducted in private
– If S&S present that are indicative of IPV;
physicians must take a thorough diagnostic
history
Barriers to Disclosure of IPV
•
•
•
•
•
•
•
Stigma associated with abuse
Becomes the ‘norm’ to deny the abuse
Fear abuse will escalate
Less harmful to not disclose
Fear nothing can be done
Feelings of shame, embarrasment
Fear of consequences related to child welfare
– Fear of CAS involvement
– Fear of breaking up the family
Barriers to Disclosure
• “If I were to say something was going on
and I had my little ones at home, would I
want to risk that? Would I want to roll
the dice and take my chances? It’s a big
risk. So you know, a lot to lose.”
• “It’s such a risky thing to come out. Your
whole life could change.”
Meta
-Analysis of Risk
Meta-Analysis
Indicators for WA
N. Wathen, S. Jack, C. Catallo, J. Fear, S. Strohm,
H. MacMillan, M. Wilson
lead investigators
Objective
• To review the evidence for associations
between intimate partner violence
against women and characteristics of
– men* (abusive vs. not abusive)
– relationships (abusive vs. not abusive)
– women (abused vs. not abused)
*there is very little data on risk indicators for violence in same
sex couples therefore this was not included in the current
review
Methods
1. Systematic evidence review
– double independent review of included
studies using standard forms & criteria
– quality ratings: “good”, “fair”, “poor”
2. Quantitative meta-analysis
– 2 x 2 tables converted to z-scores
– z-statistic: k
z ( pi )
∑
k
i =1
Inclusion / Exclusion Criteria
Inclusion
• Pre-existing indicator
of risk, NOT
consequence of
abuse
• English language
• Peer reviewed
publication
• Non-abused
comparison group
Exclusion
• Case studies
• Dissertations
• Studies that address
risk in developing
countries
• Studies of dating,
sexual or physical
violence by a nonintimate
Literature Searches
• Databases searched
– MEDLINE, EMBASE, CINAHL, PsycINFO, Soc.
Abstracts, ERIC
• Search terms (database specific),
including:
– “spouse/woman abuse” and/or “family
violence” or “battered women”, “risk”
and/or “risk factors”, “epidemiological
studies”
Results (to date)
• 645 studies identified for abstract
review
• 134 selected for full text review
• 97 met inclusion criteria for critical
appraisal
• additional studies added via handsearching (in progress)
Results (to date)
•
•
•
•
11 studies rated ‘Good’ quality
51 studies rated ‘Fair’ quality
27 studies rated ‘Poor’ quality
3 studies to review
• Data extraction under way for metaanalysis
Results (to date)
5 characteristics significantly related to VAW:
¾
¾
¾
¾
¾
Substance abuse (11*)
Men
Unemployment (8)
Depression (1)
Women (predictors or
Somatization (2) consequences?)
Presence of step-children in the home (1)
Relationships
* Indicates # of studies entered into the meta-analysis
Next steps
• Finish data abstraction
• Conduct full meta-analysis
• Report outcomes
Development of the Risk
Indicator Tool (RIT) for
Woman Abuse
N. Wathen, E. Jamieson, M. Wilson, H. MacMillan
lead investigators
Objectives
• To design a tool to ask women about risk
indicators for woman abuse, including:
– *Employment status of male partners
– *Substance abuse in male partners
– Relationship status
– Age of participants and partners
– *Presence of step-children in the home
– *Depression and somatization in women
* From the risk review meta-analysis
RIT Development Process
Phase 1 meta-analysis
to determine indicators
Selection of indicators
to measure
Selection of questions/
instruments to address
each indicator
Input from team and
consultants
Pilot testing w/ women
Revision
Revision
19 drafts later
Method
• 769 English-speaking women aged 1864 in 2 emergency sites completed:
– the RIT
– two screening instruments
• 8-item Woman Abuse Screening Tool (WAST)
• 3-item Partner Violence Screen (PVS)
– the 30-item Composite Abuse Scale (CAS)
as the “gold standard” for abuse status
• They also answered questions about
the acceptability of the RIT questions
Status
• Currently finalizing the analysis
• Validate results
– Comparison to data emerging from RCT of
screening effectiveness (underway)
– Comparison with data from complete metaanalysis of risk indicators for woman abuse
(underway)
• Disseminate findings
Testing Approaches to
Screening for Violence
Against Women
Final results
Objectives of “Testing Trial”
To determine
1. The best of three methods
•
•
•
Paper-pencil
Face-to-face with health care provider
Computerized (tablet PC)
2. The better of two screening tools
•
•
Partner Violence Screen (PVS)
Woman Abuse Screening Tool (WAST)
Settings
Acute care:
• Norfolk General Hospital Emergency
Department (Simcoe)
• Cambridge Memorial Hospital
Primary care:
• Carlisle Medical Centre
• Victoria Family Medical Centre (London)
Settings
Specialty care:
• London HSC, 5A Clinic (Obstetrics)
• Hamilton HSC Obstetrics & Gynecology
Colposcopy Clinic
Community:
• Public Health Hamilton, Parent and
Child Branch, Nurse home visits
Measures
• Partner Violence Screen (PVS) 3 items
• Woman Abuse Screening Tool (WAST)
8 items (first 2 for pos/neg status)
• Composite Abuse Scale (CAS) “gold
standard” 30 items
• Evaluation of method by participant (3
items)
Measures – staff evaluation
• Adapted from McNutt provider survey
• Questions for each method
– Effect on workload
– Effect on patient flow
– Overall satisfaction
• Want to continue screening
• Any method sustainable over long
term
Methods
• Women aged 18 – 64
• PVS & WAST administered in PP & C; one
or the other in FTF
• All self-completed CAS
• Administration method randomized by
day (and shift, in ED)
• Randomly ordered: PVS or WAST first
• Target sample size: 246 per group per
care type* (2214 total)
*Not including Public Health
Criteria for choosing method
• Disclosure rates
• Rates of missing data
• Women’s responses to the 3 evaluation
items
• Site staff’s responses to the feedback
questionnaire
Results
Sample recruitment
Appeared at site
N= 13767
Eligible
N = 2602
Ineligible = 11165
Not patient
Age
Missed
Prev app
Other
3646
3317
1216
982
2004
Refused= 141 (5%)
Completed screen
N= 2461
Computerized
N= 769
Face-to-face
N= 853
Paper-pencil
N= 839
Description of the sample
• Mean age 37 (sd 11.9, range 18 – 64)
• 56% married, 18% common-law
• 43% have no children living at home,
24% have 1 and 22% have 2
• 87% born in Canada; 9% minority
• Mean years of education 14.0 (sd 3.1)
• 47% working outside home, 21%
working + caring for family
• About 20% in each of income quintiles
Disclosure
Disclosure (prevalence) by tool
11
10.7
10.3
Percent
8.9
0
PVS
WAST
Tool
CAS >=7
Prevalence by care type
17
16.3
13.9
Percent
13.7
9.5
9.2
7.1
7.0
8.0
6.3
0
PVS
WAST
Acute
Primary
CAS >=7
Specialty
Prevalence by method
12
11.2
11.2
10.710.5
10.5
10.1
9.9
Percent
8.7
7.0
0
PVS
WAST
Computer
FTF
CAS >=7
PP
PVS+ by method & care type
18
Percent
17.7
17.4
11.6
10.9
8.4
8.6
8.2
7.6
4.1
42
13 44
20 16 23
19
6 24
0
Acute
Primary
Computer
FTF
Specialty
PP
WAST+ by method & care type
18
16.9
Percent
12.6
11.3
7.8
10.0
9.0
5.9
5.4
4.8
41 16 29
19 12 15
15 15 14
Acute
Primary
Specialty
0
Computer
FTF
PP
Missing data
Missing data* by tool
5
Percent
3.7
2.2
0
PVS
WAST
Tool
*to the extent that positive/negative status cannot be determined
Missing data by method
8
Percent
5.7
2.7
3.5
3.0
1.8
0
PVS
WAST
Computer
FTF
PP
1.5
PVS missing by method & care type
7
6.4
5.6
Percent
5.2
3.1
3.6
2.9 2.7
2.7
2.1
0
Acute
Primary
Computer
FTF
Specialty
PP
WAST missing by method & care type
7
Percent
4.9
2.8
2.8
1.6 1.5
2.7
2.1
1.6
0.4
0
Acute
Primary
Computer
FTF
Specialty
PP
Evaluation by participants
Distribution of eval items
Did you like answering on [the method] 1-5
Was [the method] easy to use 1-5
1600
3000
1400
1200
2000
1000
800
600
Frequency
Std. Dev = .84
Mean = 4.7
N = 2333.00
0
1.0
2.0
3.0
4.0
400
Std. Dev = .95
200
Mean = 4.4
N = 2326.00
0
1.0
5.0
2.0
3.0
4.0
5.0
Did you like answering on [the method] 1-5
Was [the method] easy to use 1-5
Did [the method] feel private enough 1-5
2000
1000
Frequency
Frequency
1000
Std. Dev = .88
Mean = 4.5
N = 2323.00
0
1.0
2.0
3.0
4.0
5.0
Did [the method] feel private enough 1-5
Evaluation of method
100
94.8
87.5
77.0
70.6
76.9
78.4
68.2
58.0
39.9
0
Easy
% rating 5
Like it
Computer
FTF
Private
PP
“Easy” by method & care type
100
93.3
85.8
94.9
95.9
89.2
87.6
76.6
76.3
78.0
Acute
Primary
Specialty
0
% rating 5
Computer
FTF
PP
“Like” by method & care type
100
69.9
63.8
69.2
74.5
72.8
65.7
43.9
43.6
32.1
0
Acute
% rating 5
Primary
Computer
FTF
Specialty
PP
“Private” by method & care type
100
75.2
68.4
79.7
76.2
57.4
60.2
Acute
Primary
83.2
82.5
56.5
0
% rating 5
Computer
FTF
Specialty
PP
Evaluation by site staff
Staff response, by role
All staff
Nurses
Physicians
Other
Respondents
Nurses
Physicians
Other
203
81
58
64
Nurses
Physicians
Other
22
21
19
141 (70%)
81
37
45
Analysis sample 72
Nurses
Physicians
Other
Non-responders 62
40
14
18
(73%)
(64%)
(70%)
(35%)
(49%)
(24%)
(28%)
Not involved
Nurses
Physicians
Other
19
23
27
69
Staff response, by care type
All staff
Acute
Primary
Specialty
Respondents
Acute
Primary
Specialty
Nurses 40
Phys 14
Other 18
203
88
62
53
Acute
Primary
Specialty
34
17
11
141 (70%)
54
45
42
Analysis sample 72
Acute
Primary
Specialty
Non-responders 62
23
29
20
(61%)
(73%)
(79%)
(35%)
(26%)
(47%)
(38%)
Not involved 69
Acute
Primary
Specialty
31
16
22
Work, flow, satisfaction by method
100
89.5 88.2
95.1
91.0 91.7
91.5 90.9
81.8
80.0
0
Workload
Pt flow
Computer
FTF
Satisfaction
PP
% endorsing no to minimal effect / very to satisfied
Workload by method & care type
100
88.9 91.3
94.7
100.0
96.2
88.2
85.7
93.8
73.3
0
Acute
Primary
Computer
% endorsing no to minimal effect
FTF
Specialty
PP
Patient flow by method & care type
100
95.7
95
91.3
83.3
94.1
92
85.2
86.7
64.3
0
Acute
Primary
Computer
% endorsing no to minimal effect
FTF
Specialty
PP
Satisfaction by method & care type
100
95.0
80.0
100.0
95.8
93.3
100.0
78.6
76.5
62.5
0
Acute
Primary
Computer
% endorsing very to satisfied
FTF
Specialty
PP
Continue screening by care type
100
75.0
55.6
36.8
21.1
25.9
12.5
0
Yes
Don't care
Acute
Primary
Specialty
Method sustainable
45
44.4
31.9
19.4
11.1
0
Computer
FTF
PP
% answering “yes” - check as many as apply
None
Method sustainable by care type
60
60.0
40.0
37.9
31.0
41.4
34.8
26.1
15.0
17.4
8.7
3.4 5.0
0
Computer
FTF
Acute
PP
Primary
Specialty
% answering “yes” - check as many as apply
None
Summary
• Disclosure rates not significantly higher
for computerized screen
• Computerized screen had highest rates
of missing data
• Women least prefer FTF screening
• Computer affected patient flow, least
satisfaction, least sustainable
New Studies
New studies
• Qualitative exploration of VAW screening in
the context of PHN home visitation
– S. Jack et al.
• Development of the Consequences of
Screening Tool (COST)
– J. Lock et al.
• Information use by women exposed to
violence
– N. Wathen
• Characteristics of women with false-negative
screening results
– C. Catallo
Knowledge Translation
Dissemination
• > 20 presentations at:
– research conferences
– clinical rounds
– policy meetings & workshops
– public forums
• Several abstracts and posters submitted
or accepted for forthcoming meetings
• Several manuscripts in preparation
Knowledge Translation Project
• Partnering with OWHC
• Will develop strategies to identify and
translate messages from all VAW
projects for key stakeholders
• Will ask project teams for input
• Applying to October CIHR KT RFA
Screening Effectiveness RCT
H. MacMillan & VAW research team
RCT design
Follow up
Baseline* 3m** 6m
9m
12m
15m
100%
Positive
Universal
screening
Negative
Positive
<5%
Negative
R
Positive
No
Screening
100%
Positive
Negative
*Baseline within 7 days of screen
**”mini” phone interview at 3, 9, 15 m
18m
Outcomes
• Primary
– Reduction in repeat violence
– Improvement in quality of life
– Potential harms of screening*
• Secondary
– Health measures (physical and mental)
– Health service utilization
– Social support, use of information, specific
strategies and safety behaviours
– Women’s perceptions re: screening & follow-up
* Since no standardized approaches to measuring harms of screening and
intervention exist, we are developing and testing an instrument to measure this
What happens at the index visit
Intervention
Group
WAST
HCP Visit
CAS
(exit)
HCP Visit
WAST
CAS
(exit)
R
Control
Group
R = Randomization
WAST = Woman Abuse Screening Tool
HCP = Health care provider
CAS = Composite Abuse Scale
Instrument Administration Schedule
• Index – Intake
– Consent
– Demographics, contact information
– WAST (screen gp)
• Index – Exit
– WAST (control gp)
– Relevant sections of COST
– CAS
– VAW Care Received Checklist
Instrument Admin. Schedule - 2
• Baseline
–
–
–
–
–
–
–
–
–
–
WHO-Bref (quality of life)
Partner Demographics
Relevant sections of COST
Domestic Violence Survivor Assessment (DVSA)
(positives only)
IPV Strategies Index (positives only)
Information & resource use
Health (SF-12, PHQ15, CESD, PHQ-Brief Anxiety,
SPAN-PTSD)
Substance use (TWEAK, DAST)
Health and social service use
Child QoL (KIDScreen)
Instrument Admin. Schedule - 3
• Follow-up (6, 12, 18 months)
– CAS
– All q’aires asked at Baseline
– Exposure to maltreatment as a child
(CEVQ-Brief) (at 12 months only)
Progress to date
• Ethical permission for RCT obtained
from McMaster University and University
of Western Ontario
• Sites (ER, FP, Obs/Gyne, Public health)
stagger-started beginning April 2005
• To date: MUMC ER, Joseph Brant
Memorial ER, West Lincoln Memorial*
• FPs in Sudbury, Hamilton, Brantford,
London*
(about to start)*
Progress to date
• Public health in Sudbury
• Obs/gyne in Hamilton
• Obs/gyne (Mount Sinai) in Toronto to start
this fall
• Recruitment of London ER, St. Catharine’s ER
• Public health in Chatham to start in a few
weeks
Participant Enrollment
• Recruitment from 8 sites
Type
of Site
Primary
Acute
Public Health
Obs/Gyn
Overall totals
Total #
Seen
at Site
Total #
Ineligible
2745
5532
1230
771
10,278
Eligible
n
(%)
2454
5208
1016
668
291
324
214
103
(10.6)
(5.9)
(17.4)
(13.4)
9,346
932
(9.1)
Participant Enrollment , cont’d
• Consent Status
Type
of Site
Total # of
Eligible
Consented
n
(%)
Primary
Acute
Public Health
Obs/Gyn
291
324
214
103
273
283
202
78
(93.8)
(87.3)
(94.4)
(75.7)
Overall totals
932
836
(89.7)
Participant Enrollment , cont’d
Completion of Index Visit Q’naires
Type
of Site
Consented
n
n
(%)
Primary
273
2
(0.7) 14
(5.1) 257
(94.1)
Acute
283
17
(6.0) 65
(23.0) 201
(71.0)
PH
202
2
(1.0)
(4.5) 191
(95.0)
78
2
(2.6) 12
(15.4)
23
(2.8) 100
(12.0) 713
Obs/Gyn
Overall
totals
836
Withdrawn
MEQ Not
Completed
n
(%)
9
Completed
Index Visit
n
(%)
64
(82.1)
(85.3)
Participant Enrollment ,cont’d
Status of Screening
Type
of Site
Completed
Index Visit
n
n
Primary
257
38
(14.8) 15/116 (12.9) 23/141 (16.3)
Acute
201
37
(18.4) 18/103 (17.5) 19/98
(19.4)
PH
191
50
(26.2) 19/104 (18.3) 31/87
(35.6)
8
(12.5) 6/25
(5.1)
133
(18.7) 58/348 (12.0)
Obs/Gyn
Overall
totals
64
713
Pos/Pos
(%)
Pos/Pos
Screen Day
n
(%)
(24.0)
Pos/Pos
No Screen
n
(%)
2/39
75/365 (20.5)
Follow-Up Interviews To Date
• Baseline = 107 (61 screening/46
control)
• 3 month (contact only) = 16 (10 /6)
• Majority of losses due to inability to
contact (30/49), or because refused
further involvement (12/49)
Missed Exit Q’naires (MEQs)
• Leave index visit before completing post
q’naires
• Once off-site, some MEQs are not able
to be completed in a timely fashion
Background to MEQs
• Pre-July 29 – 3 sites in operation
– Follow-up within 48 hrs
– ED started in mid-July
– Increase in MEQs: 13 at ED over 2 wks
– Only 2 completed; not within 48 hrs
• New Strategy on July 29
– Extend timeframe: 72 hrs (3 days)
– If unable to complete, take up to 6 days
MEQs, cont’d
How are we doing to complete MEQs
– Data from 6 sites only
Type
of Site
#
Consented
# MEQs
n
(%)
MEQs
Completed
n
(%)
Primary
162
11
(6.8)
4
(36.4)
Acute
211
61
(28.9)
18
(29.5)
Public
Health
27
0
(0.0)
--
---
Obs/Gyn
78
22
(28.2)
12
(54.5)
Overall
totals
478
94
(19.7)
34
(36.2)
MEQs, cont’d
• Completed MEQs - - n=34
– Within 3 days: 15 or 44%
– Within 6 days: 15 or 44%
– Beyond 6 days: 4 or 12%
• MEQs Not Completed - - n=60
– Contacted & declined: 18 or 30%
– Not able to contact/locate: 42 or 70%
www.fhs.mcmaster.ca/vaw
Extra Slides
RIT Questions
1. Have you been in an adult intimate
relationship in the past 12 months?
2. Are you currently in a relationship?
3. Is your partner male or female?
4. How old is your partner?
5. Please describe your partner’s
employment status.
6. Does your partner have an alcohol
problem?
RIT Questions, cont.
7.
Does your partner have a drug
problem?
8. Does your partner live with you at least
half the time?
9. Are there any children living with you at
least half the time who are not your
partner’s biological children?
10. Are you currently pregnant?
RIT Questions, cont.
11. Brief standard depression instrument
(CESD)
12. Brief standard somatization
instrument (PHQ15)
Measures - WAST
1. In general how would you describe your
relationship...
a lot of tension
some tension
no tension
2. Do you and your partner work out arguments
with...
great difficulty
some difficulty
no difficulty
Brown et al. Fam Med 1996; 28(6):422-428.
Measures – WAST cont’d
3. Do arguments ever result in you feeling
put down or bad about yourself?
4. Do arguments ever result in hitting,
kicking or pushing?
5. Do you ever feel frightened by what your
partner says or does?
6. Has your partner ever abused you
physically?
7. … emotionally?
8. … sexually?
Measures – CAS
•
•
•
•
•
Severe combined abuse
(8 items)
Emotional abuse
(11 items)
Physical abuse
(7 items)
Harassment
(4 items)
Responses: 0 Never, 1 Only once, 2
Several times, 3 Once a month, 4 Once
a week, 5 Daily
• Overall score >=7 gives 95.8% true +,
0.0 false +
CAS sample items
•
•
•
•
Told me that I wasn’t good enough.
Kept me from medical care.
Followed me.
Tried to turn my family, friends and
children against me.
• Locked me in the bedroom.
• Slapped me.
• Forced me to have sex.
Hegarty et al. J Fam Viol 1999; 14(4):399-415.