Title: The association between violence against women and chronic pain: A systematic review
and meta-analysis
Version: 3 Date: 15 Mar 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
Yes - experiments and analyses were performed appropriately
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Thank you for the opportunity to review the revised manuscript
titled, “The association between violence against women and chronic pain: A systematic review
and meta-analysis”. This is the first meta-analysis examining the association between violence
against women and chronic pain. This is an important area of research and this paper has
the potential to make a significant contribution to the field. The authors addressed many of
the concerns raised by previous reviewers; however, there are some points that still need
clarification, particularly in the inclusion/exclusion criteria, data extraction methods, and overall
contribution to the field.
REQUESTED REVISIONS:
Introduction
- The introduction is difficult to follow. I would recommend a thorough copy edit of the entire
paper to improve clarity.
- The authors describe the consequences of violence against women, including chronic pain;
however, there is no information about why this may occur. This is touched on in the
discussion where the authors describe the biopsychosocial model. This should be presented in
the introduction and expanded to include specifics about the biopsychosocial changes that occur
which contribute to increased risk for chronic pain. There are numerous theoretical perspectives
describing these processes, such as stress response theory, psychoneuroimmunology framework,
and allostatic load.
- It would be helpful to include additional information about chronic pain. What is the definition
of chronic pain? What is the prevalence in the general population and among those who have
experienced violence?
- A stronger case could be made for the importance of this work. For example, are there mixed
findings in the literature about the relationship between violence against women and chronic
pain? Are more precise estimates needed?
- On page 3, the authors state, “Unfortunately, there aren’t reviews in this regard that consider
chronic pain as a general concept.” Why is it important to consider chronic pain as a general
concept?
- On page 3, the authors state, “this is the first meta-analysis that investigates the association
between all types of women abuse and the onset of chronic pain”. I suggest revising to say “this
is the first meta-analysis that investigates the association between violence against women in
adulthood and chronic pain.” This meta-analysis is only looking at abuse during adulthood and
it does not examine the onset of chronic pain symptoms.
Methods
- Pg. 4, change “experimental high-quality studies” to “high-quality empirical studies”. The
studies included in this review are observational not experimental.
- Pg. 4, it is not clear what is meant by “is not included due to its generalizable meaning.” In
reading the authors’ response to previous reviewers I see that the term “violence against women”
was not included because it resulted in too many irrelevant articles. I would say this explicitly
in the paper. That being said, I do think excluding this and other related terms (e.g., sexual
assault, trauma) is a limitation that may have resulted in missing relevant studies and should be
acknowledged in the limitations section.
- I found the criteria for selection of studies difficult to understand. More precision is needed
when describing the inclusion and exclusion criteria.
o For example, it is unclear what type of pain data/analyses needed to be presented. I am
assuming that articles needed to examine associations between violence and chronic pain
(e.g., an article that examined history of violence among women with chronic pain would be
excluded)?
o It states that articles were excluded if they included male subjects, minor subjects, and
childhood abuse. So, if an article included both males and females, but reported data and results
separately, was it still excluded or was it only excluded if the study included only males or the
data/results could not be separated for females? Same clarification needed for minor subjects
and childhood abuse.
o Define “control group”. Is this women without a history of violence, without chronic pain,
either, etc.?
o The revision made to clarify the types of abuse included does not match the authors’ response
to previous reviewer feedback. I recommend changing the sentence, “For the definition of abuse,
it was adopted an inclusive approach with a composite of sexual, physical, and psychological
violence, both when present individually or together” to say “We did not limit inclusion criteria
based on specific types of violence.” Then, in the results section, state that only physical, sexual,
and psychological violence were examined in the included studies. You could then make a point
in the discussion that future research is needed to examine associations between chronic pain and
other forms of violence against women (e.g., financial abuse, stalking, cyber abuse, coercion).
- In the Study Selection and Data Extraction section, please list the data that was extracted from
each article.
- Pg. 6, it states “Low-quality studies were excluded,” but in the response to prior reviewers,
the authors state that “no articles were excluded for the quality standard”. I would revise this
sentence in the paper to say, “All articles were found to meet the high-quality criteria, therefore,
no articles were excluded based on the quality standard.”
Results
- I found the presentation of the three groups (i.e., general chronic pain, pelvic pain, and
fibromyalgia) a bit confusing. It took me time to realize that pelvic pain and fibromyalgia are
a subset of articles from the general chronic pain group. I think this is because general chronic
pain is often used for unspecified or generalized pain which is separate from a specific chronic
pain diagnosis. In addition, table 1 lists these as “fibromyalgia and general chronic pain” or
“fibromyalgia, pelvic pain, and general chronic pain” which gives the impression that general
chronic pain is separate from fibromyalgia and pelvic pain, which it is not. It would be helpful
to add a specific statement in the analysis section noting that fibromyalgia and pelvic pain are
a subset. I would also recommend using “any chronic pain” instead of “general chronic pain”
throughout. Finally, I would recommend listing the specific types of chronic pain (e.g., orofacial,
sickle cell, TMJ, rhematic, GI tract) included in each article in Table 1. It would be interesting
to see the different types of chronic pain conditions examined in the evidence base. If this is not
possible, I would suggest changing the heading of this column from “type of pain” to “meta-
analysis inclusion group” or something like that.
- Pg. 7, The sentence that states, “After the quality assessment was carried out 37 studies” is
incomplete. Add “were included” or “remained” to the end of the sentence.
Discussion
- I feel the discussion could make more specific statements to the results of the meta-analysis.
For example, that results show that women who have experienced violence during adulthood
have a 2 times greater odds of developing chronic pain. This is a statistics that I think will be
highly cited.
- I think more information can be provided about areas for future research, such as understanding
the relationship of specific types of violence (e.g., physical, psychological, sexual violence
separately rather than in combination) or violence not included in this study (e.g., financial
abuse, stalking) on chronic pain as well as specific chronic pain diagnoses for which there was
not enough literature to conduct sub-group analyses.
- More justification is needed for the statement, “Furthermore, the cause-effect relationship
between violence and pain hasn’t yet been fully clarified; in some cases, violence is a risk factor,
and in others is a consequence.” No citations are provided for this statement. There is clear
evidence from numerous longitudinal studies that violence precedes the development of chronic
pain. I am not aware of many studies that show chronic pain preceding violence."