Psychology
2012. Vol.3, No.2, 183-191
Published Online February 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.32027
Assessing the Structural and Concurrent Validity of a Shortened
Version of the Domestic Violence Healthcare Providers’ Survey
Questionnaire for Use in Sweden
Stephen Lawo ko 1*, Sören Sanz2, Lotti Helström3, Maaret Castren3
1Department of Public Health Sciences, Karolinska Institute, Stoc kholm, Sweden
2Department of Emergency Medicine, Södersjukhuset, Stockholm , Sweden
3Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
Received November 21st, 2011; revised December 29th, 2011; accepted January 28th, 2012
Background: It has recently become incumbent on researchers to develop tools for the assessment of
healthcare practitioners’ readiness to screen for Intimate Partner Violence (IPV). One such comprehensive
tool is the Healthcare Provider Survey Scales (DVHPSS). Its usefulness in new settings however warrants
a validity test. Aim: We assessed some aspects of the structural validity of a shortened version of the
DVHPSS. Method: Health care workers at a health facility in Sweden (n = 193) responded to a shortened
version of the DVHPSS. Exploratory factor analysis, Cronbach’s Alpha, correlation, T-test, and ANOVA
were used to analyse the data. Criteria for inclusion were set a priori. Results: All items of the shortened
DVHPSS were retained following analysis. A six factor model emerged, with slight modifications of the
original scales. Concurrent validity of the emerging scales was confirmed. Conclusions: The DVHPSS is
a valid tool to assess readiness to screen for IPV in Swedish healthcare.
Keywords: Domestic Violence Survey; Structural Validity; Healthcare Providers; Sweden
Introduction
Intimate Partner Violence (IPV) against women has long
been recognised as a public health problem considering its so-
cial and health implications. When contrasted with women
living in non-violent intimate relationships, abused women to a
higher degree report injuries that range in severity from bruises
to fractured bones following physical assaults (Aimakhu,
Olayemi, Iwe, Oluyemi, Ojoko, Shoretire, Adeniji, & Aimakhu,
2004; Koenig, Ahmed, Hossain, & Khorshed, 2003; Fawole,
Aderonmu, & Fawole, 2005), evidence reproductive health
problems including terminated pregnancies, undesired pregnan-
cies and child loss during infancy (Garcia-Morena, Jansen,
Ellsberg, Heise, & Watts, 2005; Kishor & Johnson, 2004), ex-
hibit psychosocial manifestations of depression, anxiety and
post-traumatic stress disorder and adopt health risk behaviours
such as unhealthy feeding habits, substance abuse, alcoholism
and suicidal behaviours (Koss, 1990; Heise & Garcia-Moreno,
2002; Tjaden & Thoennes, 2000; Tolman & Rosen, 2001; Pe-
tersen, Gazmararian, & Clark, 2001).
Despite the higher likelihood for morbidity, women experi-
encing IPV when contrasted with non-abused peers, tend to use
community and healthcare services more sparingly and exhibit
restraint towards bonding with healthcare providers and em-
ployers (Heise & Garcia-Moreno, 2002; Petersen, Gazmararian,
& Clark, 2001). A recent WHO multi-country study of 10
countries including low, middle and high income countries,
(WHO, 2005) found fear of retaliation from the abuser, stigma-
tizing attitudes from service providers and community at large
to hinder abused women from seeking sanctuary from formal
networks (e.g. healthcare). They were however more prone to
report abuse to the informal networks (e .g. family and relatives).
A recent Swedish study indicated that trust in the judiciary
among abused women was low and that few abused women
(25%) are offered assistance from relevant formal institutions
(BRÅ rapport 2009). Overall, these findings suggest that vic-
tims of IPV may be prone to social and institutional marginali-
sation or that formal institutions are inadequately equipped to
assist IPV victims. The healthcare system thus could play an
important role to reverse this notion through the institutional
detection and management of IPV enhanced by screening for
the phenomena among women visiting healthcare settings.
Over the past decade, a number of instruments to assist
healthcare providers in screening for IPV have been developed,
particularly in Europe and America (Feldhaus, Kozio-Mclain,
Amsbury, Norton, Lowenstein, & Abbott, 1997; McFarlane,
Parker, Soeken, & Bullock, 1992; Sohal, Eldridge, & Feder,
2007). Despite these developments, barely one in ten healthcare
providers screen for IPV evidencing barriers to such screening
(Roelens, Verstraelen, Van Egmond, & Temmerman, 2006;
Erikson, Hill, & Siegal, 2001). These barriers may evolve from
structural factors inherent in care provision, healthcare provider
characteristics as well as characteristics incumbent in the re-
cipient of care (i.e. patients/clients). Together, such factors
could influence providers’ readiness to screen for IPV as well
as consumers’ acceptance for being probed on IPV. In this pa-
per, emphasis is laid on the former.
A few instruments are available to researchers for the as-
sessment of providers’ readiness to screen for IPV (Short, Al-
pert, Harris, & Surprenant, 2006; Rodríguez, Bauer, McLough-
lin, & Grumbach, 1999). Among the most comprehensive of
*Corresponding author.

S. LAWOKO ET AL.
them is the Domestic Violence Healthcare Provider Survey
Scales (DVHPSS) (Maiuro, Vitaliano, Sugg, Thompson, Rivara,
& Thompson, 2000). The scale measures healthcare profes-
sionals’ readiness to screen in terms of their perceived knowl-
edge, efficacy in screening, conflicting professional roles, avai-
lability of social support networks to which IPV victims can be
referred, client safety challenges that IPV inquiries could im-
pose, and providers’ general attitudes towards screening for
IPV. Though the DVHPSS has been validated in some coun-
tries (e.g. USA and Nigeria) its usefulness in other societal
contexts is yet to be verified. This study sets the foundation to
fill this knowledge gap by validating the DVHPSS before it can
be used in the future assessment of planned programs to screen
for IPV in healthcare Sweden.
Validity is an important issue when using abstract meas-
ures/questions to represent theoretical concepts. In very general
terms, an instrument is said to be valid when it measures what it
is supposed to measure (Nunnaly, 1978). Structural validity is
an important aspect of validity. It comprises primarily the fac-
torial structure of an instrument and its reliability. Factorial
structure attempts to identify which underlying concepts a set
of questions/items/variables may be capturing, without impos-
ing a preconceived structure on what these questions are meas-
uring. When measuring readiness to screen for IPV therefore,
one may be interested in understanding the detailed struc-
tures/concepts that may emerge given a set of variables/items
purported to measure readiness as a whole.
Reliability refers to the accuracy and precision of a meas-
urement procedure or instrument (Thorndike, Cunningham,
Thorndike, & Hagen, 1991). It answers the question of how
well an instrument measures what it is purported to measure.
Internal consistency is one form of reliability measure which
assesses individuals performance from item to item when data
is collected using a single form (Cronbach & Meehl, 1995). The
rationale behind internal consistency is that items assumed to
represent a specific sub-scale (concept) will exhibit high corre-
lations with each other on average. A low/non-significant cor-
relation evidences low reliability. It is based on this rationale
that sub-scales are tested for reliability. In this study, the concepts
that emerge from the factor analysis are tested for reliability.
Concurrent validity refers to an instruments ability to distin-
guish between groups hypothesised to differ in the measure-
ment in question (Nunnaly, 1978). For instance, it may be hy-
pothesised that female care providers are more prone than male
peers to inquire about IPV as they are more likely to identify
with the problem, being potential victims; nurses/midwives
may be more prone to inquire about IPV as they are more often
at the forefront of care provision for women; experienced per-
sonal may be more likely to probe for IPV etc. Indeed, prior
studies have suggested differences in readiness to screen de-
pending on gender, staff cadre, training and experience (Maiuro,
Vitaliano, Sugg, Thompson, Rivara, & Thompson, 2000).
The rationale of testing the validity of readiness to screen in-
struments before use in new contexts/populations cannot be
overemphasised as an important area of Public health research.
Healthcare systems vary in their structure and so do providers
in their training and attitudes from one context to another. The
structure of readiness to screen for IPV indicators could there-
fore vary between dissimilar populations. Indeed, it has long
been emphasised that the psychometric properties of any in-
strument need an assessment in new populations before their
use in explanatory modelling (e.g. to examine theoretical rela-
tionships with other constructs, study predictors of outcome
variables and in assessment of interventions impact on particu-
lar outcome measures) (Cronbach & Meehl, 1995). It is on this
basis that the structural validity of the Domestic Violence
Healthcare Provider Survey Scales (DVHPSS) is tested in
Sweden for the first time in this study, for later use in evalua-
tion of training programmes aimed at promoting IPV screening
in Swedish healthcare facilities. Moreover, an extension of the
application of the DVHSS to new settings will enhance the
development of internationally comparable database to assess
and compare efforts towards IPV screening on a global front.
The objective of this study thus is to assess the structural va-
lidity of the DVHPSS in terms of its factorial structure, sub-
scale reliability and concurrent validity. More concretely, the
following research questions are addressed:
1) Do the questions of the DVHPSS capture adequately the
underlying constructs they are purported to measure when ap-
plied in the Swedish healthcare context (i.e. the question of
factorial stability)?
2) Do Swedish care providers identify with/respond consis-
tently to the questions of the DVHPSS (i.e. the question of
internal consiste n t/ re liability)?
3) Does the DVHPSS distinguish between different catego-
ries (e.g. cadres) of healthcare workers hypothesised to differ in
readiness to screen (i.e. concurrent validity)?
Methods
Study Setti ng s, Design a nd Particip an t s
This study was carried out among healthcare providers at the
emergency clinic, women’s clinic and ambulatory services at
the Södersjukhuset, Sweden, which is one of the largest multi-
departmental hospitals in the country. The healthcare providers
at the hospital have not previously undergone any formal train-
ing in screening for IPV among their female clients. This study
undertakes to assess the validity of an instrument that could be
used to assess readiness to screen at the hospital, and to inform
training needs for eventual screening.
A total of 193 providers participated. Table 1 provides in-
formation regarding demographic and occupa tional distr ibution
of the participants. Convenient sampling was used to arrive at
this figure. The questionnaire was availa ble to all staff memb ers
online and was left there until an optimal sample size to run a
structural validity test was reached (for about 30 items you need
at least 3 times as many participants to run a factor analysis).
Also, to run a concurrent validity a common approach (Altman,
1991; Altman, 1982) that takes into account the level of preci-
sion (set by the authors at plus/minus 4%), the level of statisti-
cal significance to be assumed (by convention usually 95%
confidence interval), the total number of number in the popula-
tion (in this case the total number of care providers working at
the study departments during that period i.e. approximately n =
800) and the expected prevalence of screening (estimated at
10% from previous studies (Erikson et al., 2001; Roelens, Ver-
straelen, Van Egmond, & Temmerman, 2006)). These condi-
tions would give an optimal sample size of approximately n =
170. We opted for 217 but 193 of these responded to the ques-
tions relevant for this study.
All employees at the above mentioned departments were of-
fered the opportunity to participate in this study through a web
survey accessible to all employees who visit the internal hospi-
184

S. LAWOKO ET AL.
Table 1.
Demographic and occupational characteristics of participants respond-
ing to all DVHSS scales.
n %
Gender
Male 39 21
Female 154 79
Staff Cadr e
Doctor 29 16
Nurse 71 40
Nursing Assistant 44 24
Midwife 27 15
Other 8 5
Department
Emergency 125 67
Women’s Clinic 49 26
Ambulatory 12 7
Age
(mean (st.dev in brackets)) 41 years (10. 0 years)
Years in Service
(mean (st.dev in brackets)) 17 years (11.2 years)
n = number within category; % = proportion within category.
tal employee website. The survey was available on the website
during the period June-August of 2009. Information of the
study was given by the respective department heads and further
emphasised on the website. Voluntary participation was em-
phasised and informed consent given. The study design was
cross-sectional.
Ethical Consideration
This study received ethical approval from the regional ethical
review board. The aims and relevance of the study were ex-
plained to the participants and information on the same offered
on the web. Voluntary participation was emphasised, privacy
guaranteed and informed consent given. Participants’ responses
were anonymous.
Instrument Measures in Original Format
The Domestic Violence Health Care Provider Survey Scale
measures healthcare providers’ readiness to screen for IPV as
well as actual screening activity (Maiuro, Vitaliano, Sugg,
Thompson, Rivara, & Thompson, 2000). The instrument has
been previously validated with promising results in some coun-
tries including USA and Nigeria. The questionnaire, in its
original format, is composed of the following 5 subscales:
The perceived self efficacy subscale scale (4 items) assesses
providers own perceived efficacy in inquiring about IPV (de-
tails in Table 2).
The system support sub-scale (4 items) assesses healthcare
providers’ access to support networks for referral/management
of IPV victims (details in Table 2).
The professional roles resistant/fear of offending clients
sub-scale (6 items) assesses whether providers perceive inquir-
ies about IPV may conflict with ethical issues governing their
communication with clients (details in Table 2).
The blame victim sub-scale (7 items), assesses providers at-
titudes towards victims (details in Table 2).
The victim/provider safety sub-scale (10 items), assesses
whether providers perceive inquiries about IPV from batterers
to further jeopardize safety of victims and/or care provider
(these items are not used in this study as they are not applicable
to providers at the current setting).
All items require of the respondent to take a position on spe-
cific statements. The response alternatives to each statement
range from 1 (strongly disagree) to 5 (strongly agree).
Instrument Re-Adaptation to Swedish Setting
The entire questionnaire was first translated to the Swedish
language (the official language in the country) by a professional
translator. Another independent translator with good knowledge
of both languages then translated the Swedish translation back
to English. The authors (who understand both languages) then
studied and scrutinised the translation and agreed to adopt it
with minor modifications. The team however also scrutinised
the content of all 35 questions and their applicability in the
studied setting. All questions relating to probing about IPV
from the potential perpetrators were excluded from this study,
as the hospital leadership indicated that their organisation in-
tends to introduce a screening protocol that exclusively probes
of IPV possibility only among potential victims. A crucial and
first step in validity assessment is that the questions should
appear relevant to the participants in question. The research
team acknowledged thus that including questions that the par-
ticipants would not identify with was likely to affect negatively
the overall validity of the questionnaire. A total of 13 questions
were therefore excluded from the web-survey. Thus, this work
scrutinizes the validity of a shortened version of the DVHSS.
Statistical Analysis
Data cleansing: Prior to analyses, certain procedures were
carried out to clean data. First, only participants who had re-
sponded to all items of the DVHSS were included in the analy-
ses above to reduce the likelihood of erroneous estimates as a
result of missing data. Second, items were checked for normal-
ity using the skewness statistic and its confidence interval.
Skewness statistic of magnitude zero is an indication of perfect
symmetry. Relevant transformations (e.g. square roots, loga-
rithm, inverse or reflection) were applied to transform skewed
data.
Factor analysis and reliability test: An exploratory factor
analysis (instead of a confirmatory one) was preferred. The
advantage of such an analysis is that it does not take a precon-
ceived position on which questions should be included under
each sub-scale. It is plausible that certain questions could in
another context merge or split to form new sub-scales. Thus,
exploratory factor analysis using principal component method
was performed to test underlying factors and their stability as
expressed in the factor loadings. Varimax rotation was applied
to limit the number of high loadings under the same factor. This
would enhance clearer identification of items emerging under

S. LAWOKO ET AL.
186
Table 2.
Rotated factor loadin gs of the items of the shortened domestic violence healt h c a re providers survey scales restricted to 6 factors.
Components 1 2 3 4 5 6
Factor 1: Perceived self -efficacy
I have no time to ask about IPV in my practice. 0.398 0.271 –0.020 0.270 0.288 0.036
There are strategies I can use to help victims of IPV change their situation. –0.724 –0.147 –0.080 0.010 0.347 –0.079
I feel confident that I can make the appropriate referrals for abused patients. 0.767 0.276 –0.104 –0.029 –0.080 –0.037
I have ready a ccess to information detailing management of IPV. –0.848 0.003 0.008 –0.071 0.083 –0.074
I have ready access to medical social workers or community
advocate s to assist in the mana g ement of IPV. 0.778 –0.025 –0.065 0.060 0.227 0.137
I feel that me dical social work pe rsonnel ca n help manage IPV pa tients. 0.661 –0.046 0.036 0.092 0.237 0.203
Factor 2: Fear of offe nding patie n ts
I am afrai d of of fending the patient if I ask about IP V. 0.251 0.658 0.128 0.077 0.093 0.072
Asking patients about IPV is an inva sion of their privacy. 0.119 0.850 0.170 0.055 –0.158 0.012
It is deme aning to patie nt s to question them about a bu se. 0.044 0.808 0.022 0.132 0.118 –0.002
If I ask non–abus ed patients about IPV, they will get very angry. –0.117 0 .532 –0.077 0.270 0.240 0.018
Factor 3: Vi ctim personality/tr ait
A victim must be getti ng somethin g out of the abusive relationship,
or else he/she would leave. 0.125 –0.013
–0.655 –0.115 –0.263 –0.229
People are onl y victims if they cho ose to be. 0.005 0.019 0.704 0.078 0.069 0.048
When it come s t o do mestic viole nce victim iz ation, it usually
takes two to tango. 0.060 0.034 0.639 0.151 –0.083 –0.191
I have patients whose personalities cause them to be abused. –0.069 0.100 0.523 –0.116 0.322 –0.175
The victim’s pa ssive-dependent persona lity often leads to a buse. –0.118 0.283 0.502 –0.147 0.366 –0.176
Factor 4: Pr ofessional role resistance
It is not my pla ce to interfere with how a couple chooses to resolve conflicts. 0.083 0.283 0.429 0.545 –0.162 –0.204
Investigating the cause of IPV is not part of medical pra ctice. 0.086 0.094 –0.045 0.797 0.161 –0.122
If patients do not reveal abuse to me, then they feel it is none of my business. 0.046 0.280 0.294 0.673 –0.041 0.181
Factor 5: Victim disobedience
Women who choose to step out of traditional roles are a major cause of IPV. 0.069 0.154 0.266 0.025 0.672 –0.011
The victim has often don e something to bring a bout violence in the relationship. 0.063 –0.021 0.395 0.243 0.452 –0.179
Factor 6: P s ychiatric support
I have ready access to mental health services should our patients need referrals. 0.428 0.041 –0.063 –0.119 –0.047 0.619
I feel that the mental health services at my clinic or agency can
meet the needs to IPV victims in cases where they are needed. 0.129 0.056 –0.096 0.001 –0.075
0.850
Eigenvalues 4.27 3.52 1.78 1.28 1.12 1.06
% of Variance 19.39 16.02 8.20 5.82 5.10 4.83
Note: Factors lo ading over 0.30 appear in bold. The ext raction method used was principal component Analysis and ro tation method: Varimax rotation with Kaiser Nor-
malization (eigenvalues  1).
each subscale. Criteria for the number of resulting significant
factors was based on Kaiser Criterion and confirmed with scree
plots (Carrol, 1957; Field, Aneja, & Rosner, 2007). Items with
factor loading of at least 0.30 were considered significant; this
is based on criteria for significant correlation (Cohen, 1988).
The contribution of each factor in explaining the total variation
in the item pool was reported. Significant factors (i.e. those
having a highest loading of over 0.30) were tested for internal
consistency using Cronbach’s Alpha. Each item was then scru-
tinised further to assess whether the removal of that item would
improve the alpha coefficient. If removal of an item implied
improved alpha, that item would be removed and the reliability
test re-run without that item. The process would continue until
a point of saturation was reached (i.e. removal of additional
items would not improve alpha). Alpha coefficients of at least
0.70 were considered significant, a threshold adequate for re-
search purposes (Streiner & Norman, 1989; Nunnaly, 1978).
However, for scales with only two items, a lower threshold (i.e.
0.30) was considered modest, as this is the boundary set for
significant bivariate correlation (Cohen, 1988). The resulting
items/scales following the reliability test were then re-examined
in a new factor analysis. If any of the highest item loadings was
less than 0.30, the process de scribed above (i.e. series of factor
analyses and reliability test) would continue until all remaining
items loaded at least 0.30, the a priori set threshold. Where
double loadings were evident, the item was assigned to the

S. LAWOKO ET AL.
factor under which it loaded highest.
Scale distinctiveness: Bivariate correlations were run to in-
vestigate factor distinctiveness of the final factor solution
(Streiner & Norman, 1989; Nunnaly, 1978).
Testing for concurrent validity/sensitivity: The individual
means on the emerging sub-scales (obtained via factor analysis
and reliability tests described above) were calculated so as to
assess for differences between groups hypothesised to differ in
such scores (concurrent validity). The distribution of the indi-
vidual means on sub-scales followed a normal distribution.
Thus, T-test, Analysis of Variance (ANOVA) (with benferroni
adjustment for multiple pairwise comparison) and bivariate
correlations were run to test for hypothesised differences in
scores (means, range 1 - 5) by gender, age, staff cadre, depart-
ment and experience.
Results
Data Cleansing
Of the 217 respondents, a total of 193 participants (i.e. 89%)
had completed all questions of the DVHSS. Responses to most
of the questions followed a skewed distribution. Relevant
transformations e.g. logarithm, square roots and inverses were
therefore made to transform non-normal data.
Initial Factorial Structure with All Items
When all items of the original scales (in their transformed or
original format) were included in the factor analysis, 6 factors
emerged based on the Kaiser Criterion (Eigen values > 1) (Ta-
ble 2). All items of the shortened DVHPSS exhibited signifi-
cant factor loading according to the apriori decided threshold of
at least 0.30 (Table 2).
Factor 1 emerged as the perceived self-efficacy subscale with
all items of the original scale loading significantly under this
factor. This six-itemed subscale explained 19.3% of the varia-
tion in the total item pool.
Factor 2 emerged as fear of offending patient subscale, a split
of the original merger between professional role resistance/fear
of offending clients subscale. This 4-itemed subscale explained
16% of the variation in the total item pool. The remaining items
of the original scale loaded under factor 4, a professional role
resistant subscale. This 3-itemed subscale explained 5.8% of
the variation in the total item pool.
Factor 3 reflected a victim personality/trait component, with
5 items resulting from a split of the original blame the victim
scale which comprised 7 items. The other two items emerged as
factor 5 reflecting a victim disobedience aspect. Factor 3 ex-
plained 8% while factor 5 explained 5% variation in the total
item pool.
Factor 6 reflected a psychiatric support component with two
out of four of the original items loading heavily under this fac-
tor. The factor explained 4.8% of the variation in the total item
pool.
Internal Reliability
As all items loaded significantly (with highest loadings of
0.30 and above) under specific factors, the items included under
each factor were subjected to reliability test. As indicated in
Table 3, the internal reliability of the 6-itemed perceived
self-efficacy subscale was 0.71. Though removal of the item “I
do not have time to ask about DV in my practice” could en-
hance reliability to 0.83, we choose not to remove this item as
the reliability coefficient with it present met the apriori decided
threshold (i.e. 0.70 or higher). In addition, the internal reliabil-
ity of the 4-itemed fear of offending patient subscale was 0.76.
Removal of additional items was therefore not necessary and
would not improve the internal consistency. The internal reli-
ability of the 5 itemed victim personality/trait subscale was
0.63. Removal of additional items would not improve the in-
ternal consistency. The internal reliability of the 3-itemed pro-
fessional role resistant subscale was 0.57. Removal of addi-
tional items from this scale would only reduce the internal reli-
ability. The internal reliability of the 2-itemed victim disobedi-
ence subscale was 0.38. Finally, the internal reliability of the 2
itemed of the psychiatric support subscale was 0.60.
In total therefore, the reliability test did not drop any items
based on aprior i decided crit e ria.
Inter-Fac t o r Co rr elation
As indicated by the bivariate correlations in Table 4, signifi-
cant correlations ranging in magnitude between 0.17 and 0.52
were found between many of the factors.
Testing for Concurrent Validity/Sensitivity
As indicated in Table 5, male care providers were more
likely than female peers to perceive that victim personality (p <
0.05) and victim disobedience (p < 0.001) triggered abuse of
women. In addition, male providers perceived that screening for
IPV conflicted with professional roles to a higher degree than
female peers (p < 0.01).
Staff cadres differed significantly in readiness to screen with
regard to self-efficacy (p < 0.001), perceptions of victims per-
sonality as a cause of abuse (p < 0.01) and availability of psy-
chiatric support (p < 0.01) (Table 5). Midwives on average
graded a lower self-efficacy in probing for IPV than all staff
cadre categories studied (p < 0.05 for all pairwise comparisons),
but were less likely to endorse that victim personality was the
cause of abuse when contrasted with nursing assistants (p <
0.05). On the other hand, nursing assi stants perceived on average
higher access to psychiatric support than midwives (p < 0.05).
Departments differed significantly on readiness to screen for
IPV with regard to self-efficacy (p < 0.001), fear of offending
clients (p < 0.05) and perceptions that victim disobedience was
the cause of IPV (p < 0.01). The emergency department per-
ceived a higher efficacy when contrasted with women’s clinic
(p < 0.05) and ambulatory department (p < 0.05). On the other
hand, the ambulatory department were more fearful of offend-
ing clients with regard to IPV inquiry than peers in emergency
(p < 0.05) and women’s clinics (p < 0.05). They were also more
likely to perceive that victim disobedience was the cause of IPV
than peers in emergency (p < 0.05) and women’s clinics (p <
0.05).
Significant correlation was observed between age/experience
and some indicators of readiness to screen. With increasing age,
care providers perceived increasing efficacy in handling IPV
against women (p < 0.05) and decreasing fear of offending
clients (p < 0.05). Similarly, with increasing working experi-
ence care providers perceived increasing efficacy in handling
IPV against women (p < 0.05) and decreasing fear of offending
clients (p < 0.05).

S. LAWOKO ET AL.
188
Table 3.
Internal consistency of items of the shortened domestic violence healthcare p rovider survey.
Components Cronbach alpha Cronbachs alpha if item removed
Factor 1: Perceived self -efficacy 0.71
I have no time to ask about IPV in my practice. 0.83
There are strategies I can use to help victims of IPV change their situation. 0.62
I feel confident that I can make the appropriate referrals for abused patients. 0.61
I have ready a ccess to information detailing management of IPV. 0.58
I have rea dy access to medical social workers or community advocates
to assist in the manage ment of IPV. 0.60
I feel that me dical social work pe rsonnel ca n help manage IPV pa tients. 0.66
Factor 2: Fear of offending patients 0.76
I am afra id of o f fending the patient if I ask about I PV. 0.73
Asking patients about IPV is an i nvasion of their privacy. 0.65
It is deme aning to patients to questi o n them about abuse. 0.66
If I ask non-abused patients about IPV, they will get very angry. 0.75
Factor 3: Vic t im personali t y/trait 0.63
A victim must be getti ng somethin g out of the abusive relationship,
or else he/she would leave. 0.52
People are only victims if they choose to be. 0.55
When it comes to d omestic violence victim iz ation, it usual l y takes two to tango. 0.62
I have patients whose personalit ies cause them to be abused. 0.56
The victim’s passive-dependent personality often lea ds t o abuse. 0.54
Factor 4: Professio n a l role resis tance 0.57
It is not my place to interfere with how a coupl e chooses to resolve conflicts. 0.42
Investigating the cause of I PV is not part of medical practice. 0.56
If patients do not reveal a bu se to me, then they feel it is none of my business. 0.41
Factor 5: Victim disobedience 0.38
Women who c hoose to step out of traditional roles are a ma jor cause of IPV. na
The victim has often done somet h in g to bring about violence in the relationship. na
Factor 6: P sy chiatr i c support 0.60
I have ready access to mental health services should our patients need referrals. na
I feel that the mental health services at my clinic or agency can meet the
needs to IPV victims in cases where they are needed. na
Table 4.
Bivariate pearson corr elations between scales of the s h o rtened domest i c v iolence healthcare provider survey tool.
Self-efficacy Fear of offending clients Victim per sonality Professional roles Victim disobedience
Self-efficacy
Fear of offending clients –0.17*
Victim personality 0.12 0.22**
Professional roles –0.08 0.44** 0.28**
Victim disobe dience –0.02 0.23** 0.52** 0.31**
Psychiatric support 0.43** –0.07 0.23** 0.07 0.14
Discussion
The factorial structure, internal reliability and sensitivity of a
shortened version of the Domestic Violence Healthcare Pro-
vider Survey Scales (DVHPSS) in a sample of Swedish health-
care providers were tested based on apriori defined criteria.
These criteria are in line with recommendations for assessment
of structural validity (Streiner & Norman, 1989; Nunnaly, 1978;
Carrol, 1957; Field, Aneja, & Rosner, 2007; Cohen, 1988). The
analysis was thus designed so as to maintain only items and
factors that met these criteria. None of the items where dropped
following the criteria set, suggesting that the current Swedish
sample identified with the questions. However, though many of
the emerging concepts from this analysis were congruent with
those of the original instrument, there were some notable dis-
tinctions discussed in the following text.
All items reflecting self efficacy in the original scale loaded
nder factor 1 in our study, but an additional two items from u

S. LAWOKO ET AL.
Table 5.
Differences in DVHSS sub-scales by gender, staff cadre, department, age and exper i e nce : a s s e s s i n g concurrent validity.
Self-efficacy* Fear of offending
clients* B l a me victim personality* Victim disobedience* Psychiatric support* Prof essional role conflict*
Mean (S.E) Mean (S.E) Mean (S.E) Mean (S.E) Mean (S.E) Mean (S.E)
Gender
Male 3.52 (0.16) 1.88 (0.11) 2.05 (0.14) 1.47 (0.09) 2.76 (0.15) 1.73 (0.12)
Female 3.65 (0.07) 1. 66 (0.05) 1.73 (0.05) 1.15 (0. 03) 2.70 (0.08) 1.41 (0.04)
Staff cadre
Doctor 3.84 (0.16) 1.49 (0. 09) 1.95 (0.12) 1.19 (0.09) 2.77 (0.22) 1.58 (0.12)
Nurse 3.82 (0.07) 1.83 (0.08) 1.71 (0.08) 1.14 (0.04) 2.62 (0.13) 1.50 (0.07)
Nursing assistant 3.91 (0.13) 1.63 (0.09) 2.07 (0.12) 1.33 (0.08) 3.10 (0.17) 1.40 (0.07)
Midwife 2.83 (0.14) 1.62 (0.15) 1.44 (0.10) 1.11 ( 0.08) 2.24 (0.14) 1.28 (0.10)
Other 4.39 (0.20) 1.25 (0. 08) 1.80 (0.12) 1.25 (0.09) 3.56 (0. 15) 1.29 (0.16)
Department
Women’s clinic 3.16 (0.13) 1. 65 (0.10) 1.64 (0.09) 1.13 (0. 06) 2.55 (0.16) 1.37 (0.08)
Emergency 3.88 (0.06) 1.70 (0.06) 1.85 (0.06) 1.20 (0.03) 2.78 (0.09) 1.49 (0.05)
Ambulatory 2.15 (0.14) 2. 22 (0.13) 1.73 (0.15) 1.62 (0. 22) 2.08 (0.12) 1.80 (0.20)
Age
Correlation c oefficient (r) r = 0.28 r = –0.21 r = –0.04 r = 0.02 r = 0.06 r = –0.06
Years in service
Correlation c oefficient (r) r = 0.25 r = –0.20 r = –0.04 r = –0.01 r = 0.08 r = –0.08
*Scores for means ranges between 1 - 5 with high scores denoting: Higher efficacy, more fear of offending clients, higher likelihood of blaming victim (for personality or
disobedience), higher access to psychiatric suppo rt and a higher feeling of confli cting pro fes s i onal roles respectively.
the original system support scale also loaded under the same
factor (i.e. having access to social workers). The remaining two
items initially belonging to the system support scale (i.e. having
access to mental health workers) now formed a new distinct
subscale reflecting support from mental health services (i.e.
psychiatric support). The splitting of the support network scale
into two distinct scales is at odds with results from Nigeria
(John & Lawoko, 2011) and USA (Maiuro, Vitaliano, Sugg,
Thompson, Rivara, & Thompson, 2000). That the Swedish
sample identified mental support as a distinct aspect of IPV
management and support from social worker as a component of
self-efficacy, unlike their peers in the USA and Nigeria could
be reflecting contextual issues related to service provision in
the different context. Psychiatric care in Nigeria for example is
an integrated part of the healthcare service and is usually one of
the departments of care at most hospitals. Thus, the Nigerian
sample may have viewed a support network to which to refer
clients as one component, irrespective of whether such support
was from mental healthcare providers or social workers. At
Södersjukhuset, the current study setting, on the other hand, a
psychiatric care unit is lacking. Therefore any mental health
referrals have to be external. It is on these grounds perhaps, that
the Swedish respondents may have identified mental services
and social services as two distinct aspects related with readiness
to screen.
The original scale reflecting a victim blame component was
in this study split into two components; “Victim personal-
ity/traits” which assigns the occurrence of IPV to individual
factors related to the victims personality and voluntary submis-
sion to abuse and the other, “Victim disobedience”, which as-
signs the occurrence of abuse to women’s divergence from
normative societal expectations related to gender. It seems
therefore that the Swedish sample were able to acknowledge
individual related and societal related aspects of victim blame
as distinct aspects affecting readiness to screen, unlike their
peers elsewhere (John & Lawoko, 2011; Maiuro, Vitaliano,
Sugg, Thompson, Rivara, & Thompson, 2000). Likewise, items
that in other context (John & Lawoko, 2011; Maiuro, Vitaliano,
Sugg, Thompson, Rivara, & Thompson, 2000) formed a pro-
fessional role resistance/fear of offending clients scale, were in
this work split into two distinct factors reflecting a professional
role resistance and a fear of offending clients scale. Overall
therefore, the discrepancy observed between the Swedish and
other samples in this regard (i.e. splitting of the original scales)
in may be a result of structural differences in availability of
services (e.g. social and mental support) at the different set-
tings.
The correlations between the emerging scales were consis-
tent with theory (i.e. significant for scales where significance
was expected and non-significant for scales where non-sig-
nificance was expected). For instance, there is no theoretical or
logical support for an association between staffs’ blaming atti-
tude towards victim and staffs’ self-efficacy. Likewise, there is
no logic to explain an association between staffs’ access to
psychiatric support and their fear of offending clients. Accord-
ingly, no significant correlations were observed between these
readiness indicators. On the other hand, significant correlation
would be expected (and were observed) between the attitude
scales that assign blame to the victim for either personality
reason and/or breaking of social norms (i.e. victim personality
vs victim disobedience). The significant correlations were
however not too high to suspect that the concepts measured a
uni-demensional construct. As such, the significant bivariate
correlations were an indication that the emerging factors though

S. LAWOKO ET AL.
related, represented distinct aspects of readiness to screen for
IPV.
Concurrent validity of the shortened DVHSS survey was
largely confirmed. Corroborating our hypothesis (i.e. women
may be more sympathetic towards abuse of fellow women),
together with previous findings from other societal contexts
(John, Lawoko, Svanström, & Mohammed, 2010), female
health workers were less likely to perceive conflicting profes-
sional roles in relation to IPV inquiries, and to endorse that
victims of IPV are to blame for abuse owing to their personality
or breaking of gender norms. Similarly, the hypothesis linking
readiness to screen to experience was confirmed in our data.
Older and more experienced care providers perceived a higher
efficacy in handling IPV against women and were less fearful
of offending clients through IPV inquiry. That midwives per-
ceived a lower self-efficacy in probing for IPV than other staff
cadres is difficult to reconcile based only on this data, but could
be a reflection of differences in factors embedded in the train-
ing of respective cadre. Further research is warranted to assess
training content. Similarly, ambulatory personal appeared less
prepared to screen for IPV, were more fearful of offending
clients and more likely to perceive that victim disobedience was
the cause of IPV than peers in other departments. Overall, the
variation in readiness to screen by demographic and occupa-
tional characteristics of participants observed in this study is
evidence of the concurrent validity of the DVHSS.
The current study assessed the usefulness of an already ex-
isting instrument (developed in the USA) in the Swedish con-
text and found the instrument applicable based on its structural
validity. However, the item pool used in this study may not be
exhaustive of challenges to screening for IPV in the Swedish
context. Qualitative studies could reveal additional challenges
to screening specific to this context.
A potential weakness of this study concerns the exclusion of
certain items in the study. The items in the original scale that
concerned IPV inquiry from the perpetrator were dropped from
this study. This was because organisation studied intends to
introduce screening for IPV predominantly among female cli-
ents. An inclusion of these items may have grossly weakened
the validity indicators used in this study as participants in the
organisation may have failed to identify with these items.
Nonetheless, the potential usefulness of involving the perpetra-
tor in IPV prevention need not be overlooked. While it could be
assumed that inquiring of IPV perpetration of the perpetrator
himself could jeopardize the safety of the healthcare provider
and increase victimization of the client, the importance of staff
training in improving readiness to inquire of IPV from both
victims and perpetrators has been evidenced. Internet-based
education, teaching problem-solving skills, was shown to im-
prove physician confidence in domestic violence inquiry among
their patients, even in areas that involved probing of domestic
violence from the perpetrator (Harris, Kutob, Surprenant, Mai-
uro, & Delate, 2002). Similar results have been reported among
care professionals who attended extensive on location training
on domestic violence screening (Thompson, Rivara, Thompson
et al., 2000). Thus comprehensively screening for IPV (i.e. of
both victim and perpetrator) in Swedish healthcare should be
considered following specific staff training in the matter.
In conclusion, the shortened version of the Domestic Vio-
lence Healthcare Provider Survey Scales (DVHPSS) exhibited
good factorial stability, internal consistency and concurrent
validity. Though none of the items were eliminated through our
stringent screening process, the Swedish sample identified a
more detailed breakdown of the initial underlying concepts,
suggesting that some of the original scales may not in the
Swedish healthcare context be measuring a uni-dimensional
construct. Thus, to improve the structural validity of the
DVHSS in assessment of Swedish careproviders we recom-
mend that items be scored in accordance with the scales identi-
fied in this study.
Acknowledgements
We are most grateful to Centrum För Vårdvetenskap, Karo-
linska Institutet for funding this study.
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