Title: The association between violence against women and chronic pain: A systematic review
and meta-analysis
Version: 1 Date: 20 Dec 2023
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
No - there are minor issues
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 technical rigor to allow
confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
Yes - the author's interpretation is reasonable
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: This paper looks to undertake a systematic review of the association
between pain and violence experience. Overall this has the potential to suitable for publication,
however it is let down by some poorly constructed sentences and paragraphs, which makes the
argument hard to follow. The main analysis appears to be done quite well. As such, most of the
comments relate to how the paper is written, and clarifying some of the key arguments/analysis
steps.
REQUESTED REVISIONS:
Introduction – the introduction needs to be restructured/rewritten into a more coherent structure.
While the majority of information is within the introduction there is no clear argument or
structure. Please focus on doing this systematically.
Research gap – towards the end of the introduction the research gap is outlined: “Studies on
gender violence began many years ago, and are still present in recent years creating a large
database in which experts and researchers can find any information to orient their study or
clinical practices. With so much data available it’s necessary to group and systematize them into
various evidence collections. In particular, data regarding abused women’s health can direct the
health policies and guidelines, but also can help the healthcare professionals in their clinical
work and can better direct women towards proper treatment. Unfortunately, there aren’t reviews
in this regard that consider chronic pain as a general concept.”
This does not make sense – a better argument can be made about what studies have occurred
before, e.g. those which have looked at chronic pain and violence – these are mentioned but their
limitations/weaknesses are not adequately discussed and they do not then shape the research
gap. In the introduction of the paper, please ensure the review of previous research on violence
and pain is then clearly linked to the research gap.
Revision of the objective: Currently it reads as: “This systematic review and meta-analysis aim
to contribute to the systematization of the literature on the association between violence against
women and chronic pain, considering all types of abuse verified only in adulthood, and the
major chronic pain diagnoses found in the literature.” There are some repeated components
– (systematisation of the literature), some words which aren’t clear: “abuse verified only in
adulthood”. Please rework the objective to be clearer.
Methods
Please clearly explain the exclusion of low quality studies. What counted as low quality? Was
it just those which were not high quality? How did you decide on the level for exclusion? Why
not include them and adjust for them in the meta analysis?
Results
The quality analysis – did it happen? What was the quality rating of studies, maybe include in
the table? Please report this and if there were exclusions, how many?
Discussion
In the discussion there are very long paragraphs which make the argument clear to follow.
A central argument is that healthcare workers should screen for violence women who report
chronic pain, which is fine, but please rewrite: “Even the health policies, guidelines, and
prevention practices should take this into account to direct victims to a bio-psycho-social
individualized path. The exit from violence must pass not only through the elimination of
the problem but also through the resolution of short and long-term health consequences.
Unfortunately, the etiology of these conditions isn’t clear. According to the bio-psycho-social
model [86], we may suppose many different factors that contribute to the onset of pain symptoms
in violence victims,” This does not make sense. Please use paragraphs to split up the argument
more clearly.
The point about the potential bi-directional relationship between violence and chronic pain is
fine, but please have this as a separate paragraph. Also please support with references to studies
that show that chronic pain leads to violence – else it seems a slightly odd argument.
The discussion about the association between the other forms of pain and violence is only briefly
discussed. Given that the relationship between pelvic pain and violence showed no relationship
and indeed the odds were not even positive, saying that the lack of association is because of a
small sample size does not make sense. Please reflect on why this may be the case.
Also, fibromyalgia saw a positive and significant relationship with violence experience, thus
supporting the main thesis of the paper. Please rework this into the discussion to make it clear.
What does this mean: “In addition, the number of eligible studies was greater than the final
number of included ones.” Why were they excluded?
ADDITIONAL REQUESTS/SUGGESTIONS:
Abstract
Wording – the opening sentence requires rewriting to make greater sense: “Violence against
women is still a recurring phenomenon that involves at least 35% of women worldwide”
Writing style: The introduction includes single sentences as paragraphs. It needs rewriting into
full paragraphs/properly structured paragraphs.
Wording, rewrite: “Despite the contrast and prevention policies…”
Wording, rewrite: “is the most prevalent, most commonly, most difficult to detect, and most
difficult to study…” hard to read, lots of different ideas going on. Not sure why it is the most
difficult to study? Compared to what?
Wording, rewrite: “There are also longitudinal studies in which abused women are monitored
over time concerning their health [32-34].” This needs writing into a full sentence, which makes
a statistical point as well
Methods
Wording, rewrite: “For the definition of abuse, it was adopted an inclusive approach with a
composite of sexual, physical, and psychological violence” – any or all needed to be measured?
Exclusion: childhood abuse was excluded, how was this defined?
Please break the paragraph on “Assessment of study quality” into two paragraphs to make it
more readable.
Spell out: “CMA v4” what is CMA?
Statistical analysis: why only three outcomes included in the meta analysis? Maybe in the
statistical analysis explain the rules/decisions that enable a meta-analysis to be done, rather than
saying which outcomes were done.
Statistical analysis: what if studies did not report odds ratios? How were these dealt with?
Results
In the results, some p-values are presented as: p=0.00 or p<0.000 please rewrite so that these
are p<0.001 or similar, as per statistical conventions.
Also, please report all odds ratios to two decimal places.
Reword: “pelvic pain showed a not significant effect size of the overall” please rewrite this to
be clearer.