Katherine M. Iverson, Ph.D.

Women’s Health Sciences Division of the National Center for PTSD and the 

Center for Organization, Leadership and Management Research,

VA Boston Healthcare System

Clinical Utility of an Intimate Partner Violence 

Screening Tool for Female VA Patients

VA HSR&D Cyberseminar 

Spotlight on Women’s Health, February 13, 2013
Acknowledgements

• Co-authors:

– Matthew King, Patricia Resick, Megan R. Gerber, Rachel 

Kimerling, and Dawne Vogt

• Funding:

– HSR&D CDA-2 (10-029)

– National Center for PTSD, Executive Division

• Thank you to:

– Drs. Errol Baker and Mark Meterko from COLMR

– The women Veterans who participated in this research 

project
Poll Question #1

Which category describes your current role in 

working with women Veterans (select all that 

apply)? 

– Primary care provider

– Mental health provider, substance use or other 

counselor

– Social worker, case manager (e.g., HUD-VASH)

– Administrator

– Researcher
Poll Question #2

How often do you screen female patients for 

intimate partner violence? 

– Most or all of the time

– Some of the time

– Rarely

– Never

– Not applicable
Poll Question #3

For those who do screen for intimate partner 

violence, how often do you use a validated 

screening tool to facilitate this process? 

– Most or all of the time

– Some of the time

– Rarely

– Never

– Not sure if it is validated
VHA Domestic Violence Taskforce 

Recommendations 

• VA is well-positioned to be a leader in provision of 

health care for those who use and/or experience 

IPV

– Strong evidence-base for implementation of IPV 

screening to identify women who have experienced 

IPV (“victims”) and provide relevant follow-up care
IPV Among Female Veterans

• Service Members and Veterans:

– 19-30% of female service members 

and Veterans report IPV prior to enlisting in 

the military

– At least 22% of women report physical or 

sexual IPV during military service

– 33% of the general population of female Veterans 

report lifetime IPV (compared to 23.8% of non-Veteran 

women)

Campbell et al., 2003; Dichter et al., 2011; Merrill et al. 

2006; Sadler et al., 2004
IPV Among Female VA Patients 

• VA Patients:

– 24% past-year IPV among female VA patients under age 50

– 50% - 74% lifetime IPV among women in VA primary care 

settings 

– 75% of WSDTT patients report lifetime IPV

– Data on IPV among LGBT VA patients is lacking...this work is 

needed 

• For recent data from CDC, see: 

http://www.cdc.gov/ViolencePrevention/pdf/NISVS_SOfindings.p

df 

Campbell et al., 2008; Iverson, unpublished; Latta, 

Elwy, Ngo, & Kelly, in submission; 

Murdoch & Nichol, 1995; Sadler et al., 2004
Health Burden of IPV 

• IPV is strongly associated with negative health 

outcomes that impact quality of life and carry a heavy 

economic and health care burden

– Physical health (physical injuries, chronic physical health 

conditions, stress-related illnesses)

– Mental health (PTSD, depression, anxiety, substance use, 

suicidality) 

– Revictimization (re-abuse from index or new partner)

– Service utilization (2 to 4-fold increase)

Campbell, 2002; CDC, 2007; Iverson et al., 2012; Iverson et al., in press; 

Kelly, Skelton, Patel, & Bradley, 2011; Liebschutz & Rothman, 2012; Rivara

et al., 2007
IPV Screening Has Benefits

• Screening allows for accurate identification of women 

experiencing IPV

• IPV screening can have important benefits for women’s 

health, safety, and satisfaction with care

• Minimal adverse effects

• USPTF recommends screening of women ages 14-46

• IOM recommends routine screening of all women for IPV

• Guidance from VHA is forthcoming

Campbell et al., 2001; Institute of Medicine, 2011; 

Nelson, Bougatsos, & Blazina, 2012
Screening Female VA Patients for IPV

• Feasible and accurate detection of IPV among female VA 

patients is a necessary first step 

• Some VA clinics have 

implemented screening but 

most have not

• Accuracy of tools must be evaluated 

with VA patients

• Female VA patients (gray bar) 

are different from their civilian 

counterparts (black bar)

Frayne et al., 2006; Iverson, Wells, Wiltsey-Stirman, Vaughn, & Gerber, in 

submission; 

Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012; Schnurr, 2010

0

20

40

60

80

100

PF RP BP GH RE MH VT SF

Mean Score

SF-36 Subscales

Physical Health 

Subscales

Mental Health 

Subscales
VHA

• VA is committed to improving the health and health 

care of female Veterans

– Comprehensive 

– Gender-sensitive 

• The number of women using VA services has nearly 

doubled in the past decade

• VA providers have the opportunity to detect IPV, 

provide appropriate support, and ensure a high 

standard of care to meet the multi-faced needs of 

women impacted by IPV

Frayne et al., 2010
VA Provider Perspectives

• Qualitative study of VA primary care providers in VISN 1

• Themes

– IPV Screening of Female VA Patients Should Be Routine

– Insufficient Awareness, Lack of Knowledge and Comfort Are Barriers to 

Screening

– We Need Educational Trainings Specific To Identifying and Addressing 

IPV

– Provide Us With Clinical Tools To Make IPV Screening Easy And 

Systematic

Edwardsen, Dichter, Walsh & Cerulli, 2011; 

Iverson, Wells, Wiltsey-Stirman, Vaughn, & Gerber, in 

submission
IPV Screening Tools

• Several IPV screening tools have demonstrated validity in 

detecting IPV in female patients across different medical 

settings 

• Literature review  HITS*

– Preliminary data with female VA patients

– One of the most commonly studied tools, including 

evaluations in diverse populations

– Decent psychometric properties

– Easy to score

– Includes psychological IPV assessment

Chan, Chan & Cheung, 2010; Chen, et al., 2007; Chen, Rovi et al., 2007; Coker 

et al., 2002; Latta et al., in submission; Pico-Alfonso et al., 2006; *Sherin, 

Sinacore, Li, Ritter, & Shakil, 1998
HITS Screening Tool

• In the past 12 months, how often has your partner:

1) Physically hurt you?

2) Insult or talk down to you?

3) Threaten you with harm?

4) Scream or curse at you?

• Response options:

 Never Rarely Sometimes Fairly Often Frequently 

 (1) (2) (3) (4) (5)

• Scores range from 4-20 

Sherin et al., 1998
Specific Aims

• To investigate the accuracy of the HITS in identifying 

past-year IPV in direct comparison with a reference 

standard among a sample of VA patients 

– Sensitivity: % of women with IPV who are correctly 

identified as IPV+

– Specificity: % of non-IPV exposed women who are correctly 

identified as IPV- 

• To investigate the concurrent validity of the HITS in 

terms of its association with current psychological 

distress
Method

• Paper-and-pencil mail survey of female VA 

patients from VISN 1 focused on Women’s 

Interpersonal Relationships and Health

– Random selection of 700 female Veterans who used 

VISN 1 services in the year prior to survey 

administration

– Multiple mailing survey methodology was employed

1) IC fact sheet, survey packet and $10 incentive

2) 2 weeks later: Thank you/Reminder postcard

3) 2 weeks later: Second survey and $10 incentive
Method

Potential 

Participants

n = 700

Remaining 

Potential 

Participants

n = 585

Never 

Responded

n = 191

Respondents

n = 369 

In An 

Intimate 

Relationship

n = 179

Completed 

Both IPV 

Measures

n = 160

Declined 

Participation

n = 21

Deceased

n = 4

Not Found

n = 115

63.5% 

response rate
Method: IPV Measurement

• Test Measure: HITS

• Criterion standard: *Revised Conflict Tactics Scales (CTS-2)

– Most commonly used “gold-standard” in IPV screening literature (Nelson et 

al., 2012; Rabin et al., 2009)

• Physical assault (e.g., throwing something at, shoving, punching, choking, and beating up) 

(α = .87)

• Sexual coercion (e.g., being forced to do various sexual acts) (α = .79)

• Severe psychological aggression (e.g., threatening to hit or throw something and 

destroying things) (α = .80)

– Response options range from 0 (“never”) to 6 (“>20 times”) 

• IPV+ if participant reported any physical, sexual and/or severe

psychological IPV

Straus, 2007; *Straus, Hamby, Boney-McCoy, & Sugarman, 1996
Method: Measurement (cont.)

• Psychological distress:

– PTSD Checklist (PCL; Weathers et al., 1991) (α = .97) to 

assess probable PTSD 

– Center for Epidemiologic Studies Depression Scale (CES-D; 

Radloff, 1977) (α = .82) to assess probable depression
Results: Sample Characteristics By IPV 

Status on CTS-2 (N = 160)

Respondent Characteristics IPV + Women (n=46) IPV – Women (n=114)

Age (years, mean SD)* 43.78 12.71 49.14 14.59

Race, n (%)* 

 White 32 (69.6) 96 (84.2)

 Non-White 14 (30.4) 18 (15.8)

Education, n (%)

 High school, GED, Vocational or Technical 

 training

7 (15.2) 20 (17.5)

 Some college 27 (58.7) 42 (36.8)

 4-year college graduate or beyond 12 (26.1) 51 (44.7)

Household income, n (%)

 $15,000 or less 4 (8.7) 9 (7.9)

 $15,001 - $25,000 8 (17.4) 14 (12.3)

 $25,001 - $35,000 9 (19.6) 15 (13.2)

 $35,001 - $50,000 9 (19.6) 21 (18.4)

 $50,001 - $75,000 6 (13.0) 22 (19.3)

 $75,001 - $100,000 3 (6.5) 14 (12.3)

 $100,000 or more 5 (10.9) 8 (7.0)

Marital status, n (%)

 Married 27 (59.0) 65 (57.0)

 Unmarried 19 (41.0) 49 (43.0)

*p < .05 
Results: IPV Experiences

• Of the 160 women, 46 (28.8%) reported past-year 

IPV on the CTS-2 

• Among women who experienced IPV:

– 12 (41.1%) reported physical aggression

– 12 (41.1%) reported sexual aggression

– 29 (63.0%) reported severe psychological aggression

• 50% reported more than one form of aggression in the past year
Results

Figure 1. Receiver operating characteristics (ROC) curve; entire sample (N = 160). 

Area under the curve = 0.85, SE = 0.03, CI: .78, .91.

Area Under the 

Curve = .85

Area Under the 

Curve = .85
Results

HITS Cutoff 

Scores

Sensitivity (95% CI) Specificity (95% CI)

4 1.00 (.90, 1.00) 0.00 (0, .04)

5 0.94 (.81, .98) 0.61 (.52, .70)

6 0.78 (.63, .89) 0.80 (.71, .87)

7 0.52 (.37, .67) 0.89 (.82, .94)

8 0.37 (.24, .52) 0.94 (.87, .97)

9 0.26 (.15, .14) 0.97 (.92, .99)

10 0.20 (.10, .34) 0.98 (.93, .99)

11 0.09 (.03, .22) 0.98 (.93, .99)
Results for Sexual IPV

Figure 2. Receiver operating characteristics (ROC) curve of the HITS (N = 160) for detecting 

sexual IPV (dotted line). The area under the curve = 0.79, SE = 0.05, CI: .69, .89.

At a cut-point of 6:

Sensitivity = .87

Specificity = .72

Area Under the 

Curve = .79
Screening Status on the HITS is 

Associated with Current Distress

Probable 

PTSD

Probable 

Depression

Odds Ratio

(95% CI)

Odds Ratio 

(95% CI)

IPV + on HITS 2.7 (1.30, 5.50) 3.5 (1.51, 8.01)
Summary of Findings

• HITS accurately identifies female VA patients who 

have experienced past-year IPV

• Nearly 29% of women reported past-year IPV

• Identifying effective screening tools for a unique 

population is the first step in implementing 

systematic IPV screening and response programming 

within VA

• Use of HITS must be combined with an 

interdisciplinary approach to screening, assessment, 

and intervention
IPV Screening Starts A Process!

• Comprehensive response includes:

– Starting a more open-ended discussion

– Acknowledge the patient’s disclosure

• Express concern for their safety and health

– Ask the patient if they would like a referral to a social worker or 

other provider with specialized training in IPV or an IPV agency in 

the community

• Risk and safety assessment

– Provide education, hotline number (1-800-799-HELP; 1-800-799- 7233), and empowerment

– Let patients know their options, but do not tell him/her what to 

do

– MH treatment is often an important resource
IPV Response (cont.)

• Comprehensive response includes:

– Know your states mandated reporting requirements

• Most states do not mandate reporting for IPV, but some do 

(many have mandated reporting for child witness to severe 

IPV)

• Tell the patient ahead of time if/what you are required to 

report

– Talk to the patient about what you’d like to document 

in their medical records

– Consult with your colleagues

• VA guidance is forthcoming
Potential Benefits of IPV Screening and 

Response Programming

• Targeted care for a major underlying cause of health 

problems

• Improvements in patients’ safety, physical and 

mental health

• Increased patient satisfaction with care

• Increased provider satisfaction

• Possible reductions in health care costs in the longrun

Burke, Kelley, Rudman, & McLeod, 2002; Campbell et al., 2001; Frayne, 

Saxe, & Robinson, 2000; McCauley et al., 1998; O’Campo et al., 2011; 
Helpful Resources

• See also Dr. Megan Gerber’s Cyberseminar “IPV: 

An Overview for the VA Clinician”

– http://www.hsrd.research.va.gov/for_researchers/cyber_seminar

s/archives/video_archive.cfm?SessionID=612

• Futures Without Violence

– http://www.futureswithoutviolence.org/

• National Center for PTSD webpage on IPV

– http://www.ptsd.va.gov/public/pages/domestic-violence.asp

• National HSR&D Work Group on IPV 

– Co-Chairs: Kate Iverson and Melissa Dichter
Thank you!

My Contact Information:

Katherine.Iverson@va.gov
Women’s Health Workgroups

To join a workgroup please contact Ruth Klap at Ruth.Klap@va.gov

Workgroup Name Workgroup Chair

 Post Traumatic Stress Disorder Keren Lehavot

 Chronic Pain Erin Krebs 

 Substance Use Disorders Michael Cucciare

 Intimate Partner Violence Kate Iverson & Melissa Dichter

 Qualitative Research Alison Hamilton

 Access/Disparities Sonya Borrero

 Military Sexual Trauma Rachel Kimerling

 Reproductive Health Kristin Mattocks

 Lesbian, Gay, Bisexual, Transgender Kristin Mattocks