Journal of Interpersonal

Violence
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Testing the Woman Abuse Screening Tool to Identify Intimate

Partner Violence in Indonesia
Livia Iskandar, Kathryn L. Braun and Alan R. Katz
J Interpers Violence published online 10 July 2014
DOI: 10.1177/0886260514539844

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research-article2014
JIVXXX10.1177/0886260514539844Journal of Interpersonal ViolenceIskandar et al.

Article
Journal of Interpersonal Violence
1­–18
Testing the Woman © The Author(s) 2014
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DOI: 10.1177/0886260514539844
Identify Intimate Partner jiv.sagepub.com

Violence in Indonesia

Livia Iskandar, MSc, DrPH,1 Kathryn L. Braun, DrPH,1

and Alan R. Katz, MD, MPH1

Abstract
Intimate Partner Violence (IPV) is a global public health problem. IPV
prevalence in Indonesia has been estimated to be less than 1%, based on
reported cases. It is likely that IPV prevalence is underreported in Indonesia,
as it is in many other countries. Screening for IPV has been found to increase
IPV identification, but no screening tools are in use in Indonesia. The aim of
this study was to test the translated Woman Abuse Screening Tool (WAST)
for detecting IPV in Indonesia. The WAST was tested against a diagnostic
interview by a trained psychologist on 240 women attending two Primary
Health Centers in Jakarta. IPV prevalence and the reliability, sensitivity, and
specificity of the WAST were estimated. Prevalence of IPV by diagnostic
interview was 36.3%, much higher than published estimates. The most
common forms of IPV identified were psychological (85%) and physical
abuse (24%). Internal reliability of the WAST was high (α = .801). A WAST
score of 13 (out of 24) is the recommended cutoff for identifying IPV, but
only 17% of the Indonesian sample scored 13 or higher. Test sensitivity of
the WAST with a cutoff score of 13 was only 41.9%, with a specificity of
96.8%. With a cutoff score of 10, the sensitivity improved to 84.9%, while
the specificity decreased to 61.0%. Use of the WAST with a cutoff score of
10 provides good sensitivity and reasonable specificity and would provide a

1University of Hawaii, Honolulu, USA

Corresponding Author:
Kathryn L. Braun, Office of Public Health Studies, John A. Burns School of Medicine,
University of Hawaii, 1960 East-West Road, Biomed D-204, Honolulu, HI 96822, USA.
Email: [email protected]

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2 Journal of Interpersonal Violence 

much-needed screening tool for use in Indonesia. Although a lower cutoff

would yield a greater proportion of false positives, most of the true cases
would be identified, increasing the possibility that women experiencing
abuse would receive needed assistance.

Keywords
Asia, battered women, domestic violence, reliability, sensitivity and specificity

Introduction
Intimate Partner Violence (IPV) has been declared a global public health
problem and a violation of human rights (Harvey, Garcia-Moreno, & Butchart,
2007), which is associated with significant, negative physical health and psy-
chological consequences for women (Campbell, 2002). IPV prevalence in
Indonesia has been estimated to be less than 1%, based on cases reported by
service providers to the Indonesian National Commission on Violence
Against Women (2011, 2012). About 91% of reported cases were considered
psychological in nature (feeling put down, humiliated, or controlled). It is
likely that overall IPV prevalence in Indonesia is underreported. Results from
a multicountry household survey by the World Health Organization (WHO)
suggest a lifetime IPV prevalence of 13% in Japan, 23% in urban Thailand,
and 40% in urban Bangladesh (Garcia-Moreno, Jansen, Ellsberg, Heise, &
Watts, 2005), and a survey of 765 women in rural Java found a lifetime prev-
alence of 22% for sexual violence and 11% for physical violence (Hayati,
Högberg, Hakimi, Ellsberg, & Emmelin, 2011). Possible reasons for not
reporting IPV in Indonesia and other countries include shame, gender inequal-
ity in married couples, fear of reprisal, economic circumstances, and percep-
tions that help may not be available (Hayati et al., 2011; Hyman, Forte, Du
Mont, Romans, & Cohen, 2009).
Screening for IPV has been found to increase IPV identification (Nelson,
Bougatsos, & Blazina, 2012; Taft et al., 2013). However, the use of routine
IPV screening is not widespread and may be controversial. In the United
States, the Institute of Medicine (2011) recommended routine screening of
women and adolescents, the U.S. Preventive Services Task Force (USPSTF;
2013) recommended routine screening of women of childbearing age, and
the American Medical Association (AMA) believes that IPV is sufficiently
prevalent and serious “to justify routine screening of all women patients in
emergency, surgical, primary care, pediatric, prenatal, and mental health
settings” (R. Brown, 2002, p. 11). However, routine screening is not
endorsed by the WHO (2013), and a 2013 Cochrane review found

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Iskandar et al. 3

insufficient evidence to justify universal screening in health care settings,

although the authors also concluded that routine screening does no harm
(Taft et al., 2013).
In 2004, Indonesia passed a law criminalizing IPV (Indonesia Department
of Justice, 2004) and is making efforts to identify and assist patients attend-
ing Primary Health Centers (PHCs) who experience IPV (Indonesia
Ministry of Health, 2009). For example, district PHCs are required to
accept and manage referrals for IPV supportive services from subdistrict
PHCs and to have a private exam room for IPV counseling. However, no
IPV screening tools or protocols have been put in place. PHCs, found in
districts and subdistricts in all 33 provinces of Indonesia, are analogous to
Community Health Centers in the United States, serving the lower socio-
economic strata of the population. (Wealthier Indonesians prefer to receive
health care from private physicians and clinics.) PHCs serve many clients
each year; for example, the two PHCs participating in this study together
documented 87,382 patient visits in 2009.
Based on a review of IPV screening tools (Basile, Hertz, & Back, 2007),
the Woman Abuse Screening Tool (WAST) was felt to be the best IPV
screening tool to use in Indonesian PHCs because (a) it asks about psycho-
logical as well as physical and sexual abuse, (b) several studies have
reported that the WAST has high reliability, (c) the English-language ver-
sion has good specificity and fairly good sensitivity, and (d) in addition to
its full eight-item format, the WAST can be applied in a short form, or the
WAST-Short, which may be useful in a busy PHC setting. The WAST was
also used successfully by Wong and Othman to screen women in Malaysia
(Wong & Othman, 2008). These authors found an IPV prevalence of 5.6%
in their sample of 710 female patients, and the WAST was found acceptable
among the women screened.
Although the WAST has demonstrated good sensitivity and specificity in
U.S. study populations, the sensitivity and specificity of an Indonesian lan-
guage version of the WAST has not been established. The best way to estab-
lish validity of IPV screening tools is to compare a self-administered tool
against a clinician-administered face-to-face interview, which is considered
superior to written screening questions (Anderst, Hill, & Siegel, 2004). Thus,
the purpose of this study was to test the sensitivity, specificity, and reliability
of the WAST translated into Indonesian and to estimate the prevalence of IPV
among women in an Indonesian population. The study was approved by the
Institutional Review Board of the University of Hawaii and by the Indonesian
Ministry of Health, with the provision that services be offered to any woman
identified with IPV.

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4 Journal of Interpersonal Violence 

Method
Sample
Power calculation estimated a sample size of 240 women would be needed to
estimate the prevalence of IPV with alpha = .05 and beta = .20. An eligible
woman was (a) a client of one of two participating PHCs in Jakarta, (b) age
18 years or older, (c) married or involved with a male partner, (d) unaccom-
panied by husband/partner at the time of the study, (e) in good physical con-
dition (self-reported), (f) able to read and write Indonesian, and (g) willing to
spend 20 to 30 min for the study. Women were recruited in waiting rooms of
the PHC in February to March 2012. Of 250 women who were approached
and found eligible, 240 (96%) agreed to participate and completed a consent
form. The 10 who did not consent said they were too busy (3), could not par-
ticipate because they had children they needed to attend to (5), and/or had
their husbands waiting for them in the PHC’s parking lot (2).
Participants were assigned randomly to one of two study arms. In one arm,
women first completed the WAST, and then were interviewed by a psycholo-
gist (Method 1). In the other arm, participants were first interviewed by the
psychologist, and then completed the WAST (Method 2). This was done to
test whether taking the WAST before the interview might increase the likeli-
hood of identifying IPV. The psychologist interview was done in a private
room. Psychologists were blinded to assignment, as well as to WAST results
for women who completed the WAST before the interview. Study partici-
pants received a package of basic food necessities (rice, sugar, flour, salt, soy
sauce) for their participation.
The study was conducted in collaboration with PULIH Center for Trauma
Recovery and Psychosocial Empowerment, a nongovernmental organization
in Jakarta with a mission to assist victims of violence and disaster. PULIH
psychologists were contracted to conduct interviews with the 240 women in
the study. Each of six licensed psychologists from PULIH had at least 3 years
of experience working with women experiencing IPV in Indonesia. The two
participating PHCs were within the service district of PULIH, so women
identified with IPV could easily be referred to PULIH for further assistance.

Measures
WAST. The English-language version of the WAST has good reliability and
validity (J. B. Brown, Lent, Brett, Sas, & Pederson, 1996; J. B. Brown, Lent,
Schmidt, & Sas, 2000; Ernst, Weiss, Cham, & Marquez, 2002; Wathen,
Jamieson, & MacMillan, 2008). In U.S. studies, Brown and colleagues (the

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Iskandar et al. 5

tool developers) reported good internal consistency (Cronbach’s α = .75), and

that the WAST correctly classified 100% of nonabused women and 91.7% of
abused women (J. B. Brown et al., 1996; J. B. Brown et al., 2000). Moreover,
more than 90% of woman reported being comfortable or very comfortable
when the WAST was administered to them (J. B. Brown et al., 2000). The
full WAST includes eight items, scored 1 (never or none) to 3 (a lot or often).
Total scores range from 8 to 24, and the tool developer recommended a cutoff
of 13 to indicate presence of abuse. This cutoff score also was used in Wong
and Othman’s (2008) IPV study in Malaysia.
However, the WAST was designed as a two-part screening tool. The
screener starts by asking the first two questions, which inquire about the level
of tension a woman feels in her intimate partner relationship and the amount
of difficulty she experiences working out conflicts with her partner. Only if
the woman answers these two questions with “a lot of tension” and “great
difficulty,” respectively, will the screener ask her to complete the other six
WAST items. The latter six items ask specifically about a woman’s experi-
ence with feeling put down or frightened or being physically, emotionally, or
sexually abused. As PHC workers may feel overburdened and may be reluc-
tant to spend extra time with patients, the WAST-Short can be the critical
point of buy-in for PHC workers. In this study, we used the eight-item version
of the WAST so that we could correlate the score of the first two items with
the score on the last six items, as well as with the psychologist’s determina-
tion of IPV. The principal investigator (L.I.), an Indonesian native speaker,
translated the WAST into Indonesian; it was then back-translated into English
by an Indonesian bilingual certified translator.

Psychologist Interview, guided by the Domestic Violence Initiative Screening

(DVIS). The judgment of a licensed psychologist conducting a diagnostic
interview was considered the gold standard against which to validate the
translated WAST. To standardize the diagnostic interview, six female PULIH
psychologists experienced in identifying and assisting IPV clients were
trained in the DVIS interview guide (Basile et al., 2007) by the principal
investigator. As with the WAST, forward and backward translation was used
to translate the guide into Indonesian. Following the DVIS, psychologists
opened the interview with this introduction,

At this health service, we are concerned about your health and safety, so we ask
all women the same questions about violence at home. The reason is because
violence is very common, and we want to improve our response to families
experiencing violence.

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6 Journal of Interpersonal Violence 

Then the psychologist asked the women to answer yes or no to four ques-
tions: (a) Are you ever afraid of your partner? (b) In the last year, has your
partner hit, kicked, punched, or otherwise hurt you? (c) In the last year, has
your partner put you down, humiliated you, or tried to control your actions in
any way? and (d) In the last year, has your partner threatened to hurt you
physically or sexually? If the respondent did not understand or was reluctant
to answer, the PULIH psychologists were instructed to rephrase the question.
For example, if the woman didn’t grasp the word merendahkan (Indonesian
for “put you down”), the psychologist might substitute the phrase membuat
Ibu merasa kecil (made you feel smaller). Based on the diagnostic interview
conducted by the psychologist, women who reported being physically, emo-
tionally, or sexually abused by their partners were categorized as experienc-
ing IPV. In a 1-day training in the DVIS, the psychologists demonstrated high
agreement in their diagnoses during role-play.
Women experiencing IPV were offered brief intervention by a psycholo-
gist, which included counseling, providing information on IPV services,
helping the women develop a safety plan and other necessary safety promot-
ing behaviors, and referring the women to appropriate service providers as
requested. Psychologists also provided women identified as experiencing
IPV with wallet-sized hotline cards with a Trauma Recovery Center’s contact
details and flyers explaining the different types of IPV. If further assistance
was requested, women were linked to the PULIH office.

Demographic and Help-Seeking Questionnaire. On another form, respondents

were asked to indicate their age group (18-24, 25-34, 35-44, 45-54, 55-64,
and 65+ years), educational attainment (elementary, middle school, high
school, and > high school), employment status (yes/no), ethnicity (Jakartan/
Javanese, Sumatran, and other), years of marriage, and number of children.
Because we were interested in IPV help-seeking patterns, a final question
asked, “If you ever experienced Intimate Partner Violence, what would you
do?” Women were asked to select one response. Options included the follow-
ing: visit a PHC, visit an Emergency Response Unit, visit a service provider,
call a hotline service, report to a policewoman’s desk, and other (specify).

Data Analysis
Data were analyzed using SPSS version 19. IPV prevalence was estimated
based on the psychologist diagnostic interview. We examined whether preva-
lence varied by whether the participant was interviewed before (Method 1) or
after (Method 2) completing the WAST. To determine the sensitivity and
specificity of the WAST, two-by-two tables were constructed, noting

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Iskandar et al. 7

proportions of true and false positives and negatives when comparing the
psychologist’s determination against the WAST determination (Weiss, 2008).
Although the recommended WAST cutoff for IPV is 13, we calculated sensi-
tivity and specificity at cutoffs from 9 to 13. Reliability of the WAST was
measured using Cronbach’s coefficient alpha. Pearson correlation was used
to correlate the score from the WAST-Short (the first two items) with the
score from the other six WAST items. We compared women who experience
IPV against those that did not by sociodemographic variables and clinic using
χ2 and unpaired t tests. Responses to the help-seeking question were tallied,
and the “other” responses were post-coded. All responses then were orga-
nized into “would report” and “would not report.” Subcategories for the for-
mer included report to PHC, visit emergency service, talk to service provider,
go to a policewoman’s desk, and call a hotline service; subcategories for the
latter included talk to family and friends, remain quiet, leave my husband,
and practice self defense.

Results
Demographic Characteristics of the Research Participants
Approximately 6% of participants were aged 18 to 24, 46% were 25 to 34,
33% were 35 to 44, and 15% were older. Almost half (48%) had graduated
from high school, 14% had some college education, and 80% were unem-
ployed. The majority (87%) said they were Jakartans or Javanese, and 11%
said they were Sumatran (Table 1). On average, women had been married 13
years and had 2 to 3 children (not shown in table).

Help-Seeking for IPV. Of the 240 participants, 83 (34.6%) said they would
report IPV if it happened to them, 148 (61.7%) said they would not report it,
and 9 (3.7%) did not answer this question. Looking at subcategories, about
11% would visit a PHC, about 10% would report to a policewoman’s desk,
and about 8% would visit a service provider, while about 44% would talk to
family and friends, and about 13% would remain quiet (Table 2).

Prevalence of IPV
The prevalence of IPV as determined by psychologist diagnostic interview
was 36.3% (87 of 240), with no significant difference in prevalence by clinic
or between those women who completed the WAST before the interview and
those women who completed it after the interview (p = .50). Based on the
DVIS, 24% of IPV cases reported physical abuse, 30% reported that their

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8 Journal of Interpersonal Violence 

Table 1. Demographic Characteristics and IPV Help-Seeking Preferences of the

Sample (N = 240).

Age
18-24 15 (6.2%)
25-34 110 (45.8%)
35-44 80 (33.3%)
45-54 29 (12.1%)
55-64 6 (2.5%)
Education
≤ elementary school 30 (12.5%)
Middle school 62 (25.8%)
High school 114 (47.5%)
> high school 34 (14.2%)
Working status
Working 48 (20%)
Unemployed 192 (80%)
Ethnicity
Jakartan, Javanese 208 (86.7%)
Sumatran 26 (10.8%)
Other 6 (2.5%)

Note. IPV = Intimate Partner Violence.

Table 2. IPV Help-Seeking Behavior (N = 240).

Would report IPV

Would visit a PHC 26 (10.8%)
Would visit an Emergency Response Unit 3 (1.3%)
Would visit to service provider 20 (8.3%)
Would report to a policewoman’s desk 24 (10.0%)
Would call a hotline service 3 (1.3%)
Would report, but did not specify to whom 7 (2.9%)
Total 83 (34.6%)
Would not report
Would talk to family and friends 106 (44.2%)
Would remain quiet 32 (13.3%)
Would leave husband 4 (1.7%)
Would practice self defense 6 (2.5%)
Total 148 (61.7%)
Did not respond to question 9 (3.7%)

Note. IPV = Intimate Partner Violence; PHC = Primary Health Centers.

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Iskandar et al. 9

Table 3. Domestic Violence Initiative Screening Items by IPV Status, as

Determined by Psychologists.

Women
Total Women With Without IPV
(N = 240) IPV (n = 87) (n = 153) p Value
Q1. Are you ever afraid of 70 (29.2%) 57 (65.5%) 13 (8.5%) <.001
your partner? YES
Q2. In the last year, has your 21 (8.8%) 21 (24.1%) 0 <.001
partner hit, kicked, punched
or otherwise hurt you? YES
Q3. In the last year, has your 74 (30.8%) 74 (85.1%) 0 <.001
partner put you down,
humiliated you, or tried to
control in any way? YES
Q4. In the last year, has your 26 (10.8%) 26 (29.9%) 0 <.001
partner threatened to hurt
you physically or sexually?
YES

Note. IPV = Intimate Partner Violence.

partner threatened to hurt them physically or sexually, 66% at times felt afraid
of their partners, and 85% reported being put down, humiliated, or controlled
(Table 3).
In comparison, only 17% of women had a WAST score of 13 or higher, the
recommended cutoff for IPV determination. In examining demographic char-
acteristics that might distinguish women experiencing IPV from those who
were not, only one variable was significant. Specifically, of the 87 women
who were determined to be experiencing IPV, 31.4% were working outside
the home, whereas 13.6% of women who were not determined to be experi-
encing IPV were working outside the home (p < .001, not shown in table).

Sensitivity and Specificity

Sensitivity and specificity for the WAST and the associated positive predic-
tive values (the proportion of positive test results that are true positives) at
different cutoff values are shown in Table 4. At a cutoff point of 9, the sensi-
tivity of the WAST was 91.9% and the specificity was 35.7%. At increasingly
higher cutoff points, the specificity increased, but the sensitivity decreased.
For example, at a cutoff of 13 (recommended by WAST developers) the sen-
sitivity was 41.9%, and the specificity was 96.8%.

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10 Journal of Interpersonal Violence 

Table 4. Sensitivity and Specificity at Different Woman Abuse Screening Tool

Cutoff Points.

Number of Women Positive

With a WAST Score at Predictive
the Cutoff or Higher Sensitivity Specificity Value
Cutoff point of 9 178 (74.2%) 91.9% 35.7% 44.3%
Cutoff point of 10 133 (55.4%) 84.9% 61.0% 54.9%
Cutoff point of 11 98 (40.8%) 75.6% 78.6% 66.4%
Cutoff point of 12 63 (26.3%) 58.1% 91.6% 79.4%
Cutoff point of 13 41 (17.1%) 41.9% 96.8% 88.3%

Note. WAST = Woman Abuse Screening.

Reliability of the WAST and Interscale Correlations

Cronbach’s coefficient alpha to test the reliability of the WAST yielded the
following results: .801 for the eight items, .713 for Items 3-8, and .667 for
Items 1 to 2. As shown in Table 5, correlation between the WAST-Short
(Items 1-2) and the WAST-Long (Items 1-8) was moderate (r = .799, p <
.001). Correlations between the WAST and DVIS (Items 1-4) scores and the
psychologist’s determination were also examined. All correlations were sig-
nificant at p < .001. However, the correlation between the psychologist’s
determination and the WAST-Short was only .410, compared with .564 for
the WAST total, and .0811 with the DVIS total score.

Discussion
The 36.3% IPV prevalence found through the psychologist diagnostic inter-
view indicates that IPV is much more common among PHC patients than
expected based on reports provided to the Indonesian National Commission
on Violence Against Women (2011, 2012) and earlier studies of women in
Malaysia (Wong & Othman, 2008) and rural Java (Hayati et al., 2011).
Because we confined our study to two PHCs in South Jakarta, these find-
ings may not be generalizable to other parts of Jakarta or to rural areas of
the Indonesia. A probability household sample would be able to provide a
more accurate estimate of IPV prevalence in the country. Geographically,
Indonesia is an archipelago consisting of 17,506 islands with more than 300
ethnic groups and 365 active languages spoken. Thus, the prevalence of
IPV is likely to vary by region. However, the type of IPV most commonly
found in our study—psychological abuse—concurs with the type of IPV

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Iskandar et al. 11

Table 5. Correlations Among WAST and DVIS Scores and the Psychologist’s
Determination.

IPV as
Determined by WAST- WAST- WAST DVIS
Psychologist Short Long Total Total
IPV as determined by 1.0000
psychologist
WAST-Short score .410* 1.0000
(two items)
WAST-Long score .556* .561* 1.0000
(six items)
WAST Total score .564* .799* .946* 1.0000
(eight items)
DVIS Total score .811* .460* .639* .645* 1.0000
(four items)

Note. WAST = Woman Abuse Screening Tool; DVIS = Domestic Violence Initiative Screening;
IPV = Intimate Partner Violence.
*p < .001.

most commonly reported to the Indonesian National Commission on

Violence Against Women (2011, 2012). Of the 212,455 reported cases of
domestic violence in 2010 and 2011 (combined), 91% were psychological
in nature.
In our study, the overall prevalence of IPV identified by the psycholo-
gist diagnostic interview (gold standard) was 2 times higher (36.3%) than
prevalence estimated by the WAST when using the recommended cutoff
score of 13 (17.1%). This is higher than estimates of lifetime prevalence in
the United States (31%) and of prevalence estimated in a sample of women
seeking care at a trauma center in Ontario (30.5%; Moyer, 2013; Sprague,
Madden, Dosanjh, Petrisor, Schemitsch, & Bhandari, 2012). We consid-
ered the possibility that the psychologists, based on their background with
PULIH, may have overdiagnosed IPV. However, in all cases, women’s
experience of IPV was confirmed during the provision of brief interven-
tion. This was offered to all women identified as experiencing IPV based
on the DVIS. In this brief intervention session, psychologists provided
counseling, gave information on IPV services, helped the women develop
a safety plan, and referred the women to appropriate service providers as
requested.
We experienced a high rate of participation in the research (96%), and
found women very willing to talk with our research psychologists about IPV.

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12 Journal of Interpersonal Violence 

It could be that women were attracted to the study because of the opportunity
to consult with a female psychologist at the PHC, to consult at no cost, and to
receive the free bag of basic food commodities. Moreover, psychologists
prefaced their interviews with an acknowledgment that family violence is
common and that the PHC wanted to learn how to assist women experiencing
violence, which may have encouraged women to talk openly about IPV. In
the Malaysia study, Wong and Othman (2008) found that 67% women in their
study would be willing to voluntarily disclose experience of IPV if asked by
their doctor. J. B. Brown et al. (2000) also found that women would be will-
ing to discuss IPV with their physicians if they were asked in a respectful and
caring manner.
If the WAST is to be used as an IPV screening tool in Indonesia, applying
a cutoff score of 13 would miss many cases of IPV. With 10 as the cutoff
score, the WAST had a sensitivity of 84.9% and specificity of 61.0% in this
Indonesian population. At this score, 55.4% of women screened would be
identified as abused, yielding more false positives than desired, but assuring
that most of the true cases would be correctly identified. Because the PHC
setting is very busy, it was gratifying that a self-administered screening tool,
such as the WAST, can be used to identify IPV (rather than a psychologist
interview, which is more time-consuming and expensive). However, because
the WAST-Short score did not correlate as well with the gold standard deter-
mination (r = .410), it is recommended that the full eight-item WAST be used
as a screening tool, and a cutoff of 10 be used to identify women who may be
experiencing IPV.
The research literature suggests that there is no perfect IPV screening tool
(Rabin, Jennings, Campbell, & Bair-Merritt, 2009), and choosing one
depends on the context of use. In a systematic review of IPV tools, the
USPSTF found that the Hurt, Insult, Threaten, Scream (HITS) scale, the
Ongoing Violence Assessment Tool (OVAT), the Slapped, Threatened, and
Throw tool, the Humiliation, Afraid, Rape, Kick (HARK) tool, the Modified
Childhood Trauma Questionnaire–Short Form, and the WAST had the high-
est levels of sensitivity and specificity for identifying IPV. A review in the
United Kingdom found that the HITS had the best predictive power, followed
by the Women’s Experience With Battering Scale (WEB), the OVAT, and
Partner Violence Screen (PVS). In reviewing tools (HITS, WAST, WEB,
OVAT, HARK, and the Index of Spouse Abuse–Physical Scale) for potential
use in Pakistan and Afghanistan, Vogel (2013) determined that the WAST-
Short and the OVAT might be the most useful because of their brevity and
their ease of administration for busy health care providers. Findings from a
review by Hussain and colleagues (2013) suggested that higher rates of dis-
closure may be obtained using computer assisted self-administered screens

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Iskandar et al. 13

than from face-to-face interview and self-administered written screens, but

patient access to this technology may be limited.
Other IPV screening questionnaires may work equally well or better in the
Indonesian context. For example, the four-item DVIS might be a good screen-
ing tool for use in PHCs, as it is shorter than the eight-item WAST. Sprague
and colleagues (2012) found that asking the three “direct” questions about
abuse from the WAST (Has your partner ever abused you physically? Has
your partner ever abused you emotionally? and Has your partner ever abused
you sexually?) led to a higher estimate of IPV prevalence (30.5%) than using
the eight-item WAST with the 13-point cutoff (12.4%) or using the PVS
(9.2%). In both cases, a short inventory of “direct” questions could be admin-
istered by a clerk, and a “yes” to any of the items could trigger a referral to a
health professional. Future research in Indonesia should test translated ver-
sions of these shorter tools in PHC settings.
Institutionalizing universal IPV screening in PHCs would require more
than the identification of a valid screening tool. A systematic review of stud-
ies testing the sustainability of universal IPV screening in health care settings
suggests that successful programs also must garner institutional support, put
screening protocols in place, train providers in tools and protocols, and facili-
tate immediate access or referrals to services for clients experiencing IPV
(O’Campo, Kirst, Tsamis, Chambers, & Ahmad, 2011).
Although some professional bodies, including the AMA and the USPSTF,
recommend universal screening of women for IPV, the 2013 WHO guide-
lines do not. WHO recommendations, based on the review of available evi-
dence, raise several important issues. For example, implementing universal
screening can place a high burden on health center staff. In understaffed set-
tings, universal screening may meet with resistance from clinicians, who may
ignore or perfunctorily complete screening forms. Women who do not experi-
ence IPV may find repeated screening a waste of time. Women who do may
become discouraged or resentful if repeated screening does not lead to
improved conditions. Finally, questions are raised as to the ethics of identify-
ing women in need of assistance in communities that have no IPV support
services. Proponents of universal screening counter that screening programs
are not harmful to patients, and that providers who are not knowledgeable
about IPV may miss its signs and symptoms in the absence of screening
(WHO, 2013).
WHO (2103) does recommend that providers respond to women who dis-
close IPV and be alert to symptoms of IPV in vulnerable populations, includ-
ing pregnant women and those that have physical or mental disabilities.
Epidemiological studies may identify other “flags.” For example, although
80% of women in our study were not employed, being employed outside the

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14 Journal of Interpersonal Violence 

home helped distinguish women with IPV from those without. This concurs
with the findings of Hayati et al. (2011) who found that women in rural Java
who experienced sexual violence were more likely to have some amount of
financial independence from their husbands. The Hayati findings also sug-
gest a high degree of gender inequality in Indonesian couples. They found
that a woman’s exposure to physical violence was associated with the hus-
band’s childhood witnessing of abuse of his mother and the husband being
unfaithful, using alcohol, or fighting with other men. These findings also
confirm that gender-based violence is a complex issue. Some investigators
are seeing success in changing gender-based expectations during adolescence
by incorporating information on healthy relationships, power dynamics,
refusal skills, and sexual health into high school health classes (O’Leary &
Slep, 2012). Researchers also agree that IPV is a serious public health prob-
lem. It is estimated that 40% to 60% of murders of women in North America
are committed by intimate partners (Campbell, 2002). Health problems asso-
ciated with IPV include digestive problems, eating disorders, abdominal
pain, bladder and kidney infections, vaginal infections and bleeding, pelvic
pain, headaches, fainting, seizures, chronic neck and back pain, and hyper-
tension (Campbell, 2002; Ellsberg et al., 2008). Lifetime experiences of part-
ner violence is significantly associated with self-reported poor health, specific
health problems in the previous four weeks, difficulty walking, difficulty
with daily activities, memory loss, emotional distress, suicidal thoughts, and
suicidal attempts (Ellsberg et al., 2008). Children are hurt when they witness
abuse, and may experience it themselves from the same perpetrator, and chil-
dren in abusive households may became abusers themselves (Langhinrichsen-
Rohling, 2005). Psychological abuse is a “critical variable in the domestic
violence field” because it is may precede or be concurrent with physical vio-
lence and undermines self-esteem, self-acceptance, and/or emotional regula-
tion (Langhinrichsen-Rohling, 2005, p. 113).
In the absence of routine inquiry from health providers, responses to our
question on help-seeking suggest that women would be more likely to talk
with their friends and family about their IPV experience than to introduce it
with health care providers. This resonates with the Hayati et al.’s (2011) find-
ing that 94% of the rural Javanese women in their study agreed that “family
problems should only be discussed with people in the family” (p. 5).
Because many women are not likely to report IPV, and because IPV has
many detrimental effects on women, children, and families, we believe that
identifying IPV through universal screening is warranted. Doing so will help
raise awareness about IPV in the PHC and general population and signal that
the government is concerned about it. Universal screening will increase iden-
tification of IPV cases, which can help raise demand for services. Increased

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Iskandar et al. 15

awareness of IPV as a negative behavior and increased demand for attention

to this issue may help change social norms about gender-based violence in
Indonesia and elsewhere.

Authors’ Note
The research was approved by the Institutional Review Board of the University of
Hawaii, by the Indonesian Ministry of Health, and the Jakarta Governor’s Office. The
first author was a doctoral student at the University of Hawaii, and these data were
collected as part of her dissertation research. The coauthors were chair and member of
her dissertation committee. All three were involved in conceptualization of the
research, data interpretation, and writing of this manuscript. Livia Iskandar and
Kathryn Braun have had full access to all of the data in the study and take responsibil-
ity for the integrity of the data and the accuracy of the data analysis.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This research was supported by the East
West Center, the Ann Dunham-Soetoro award, the Joseph Alicata award, and the
USINDO (US-Indo Society) travel grant.

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Author Biographies
Livia Iskandar, MSc, DrPH, graduated in December 2012 with her doctoral degree
from Office of Public Health Studies, John A. Burns School of Medicine, University
of Hawaii. She is from Indonesia and has returned home after living in Washington,
D.C. She is the former director of PULIH Foundation, Center for Trauma Recovery
and Psychosocial Empowerment in Jakarta and Banda Aceh, and currently serves as
chairperson of PULIH Foundation’s Board of Trustees.
Kathryn L. Braun, DrPH, is a professor and chair of the DrPH program at the Office
of Public Health Studies, John A. Burns School of Medicine, University of Hawaii.
She also serves as co–principal investigator of ‘Imi Hale—Native Hawaiian Cancer
Network and co-investigator of Hā Kūpuna National Resource Center for Native
Hawaiian Elders. She is known for her work in community-based participatory
research in cancer and gerontology, and has published more than 150 peer-reviewed
journal articles on these topics. She is a past winner of a Board of Regent’s Medal for
Excellence in Teaching from the University of Hawaii. She is a fellow in the
Gerontological Society of America and president of the Active Aging Consortium
Asia-Pacific.
Alan R. Katz, MD, MPH, is a professor and chair of the MPH program at the Office
of Public Health Studies, John A. Burns School of Medicine, University of Hawaii.
His research interests include infectious diseases, including sexually transmitted dis-
eases. He currently serves as a member of the Hawaii State Board of Health and is a
staff physician and medical consultant at the Hawaii State Department of Health’s
Diamond Head STD Clinic. He is a fellow of the American College of Epidemiology
and the American College of Preventive Medicine.

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