Author Verified RCT ACE Report #5049 Read Full Publication The prevalence of intimate partner violence in women presenting to orthopaedic clinics Study Type: N/A OE Level Evidence: N/A Journal Level of Evidence: N/A Prevalence of abuse and intimate partner violence surgical evaluation (PRAISE) in orthopaedic fracture clinics: a multinational prevalence study Lancet. 2013 Sep 7;382(9895):866-76 Contributing Authors: PRAISE Investigators

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OE EXCLUSIVE Sheila Sprague discuss the prevalence of intimate partner violence in orthopaedic clinics. Your browser does not support audio

Synopsis 2945 women presenting to orthopaedic injury clinics were included in this multinational survey study to investigate the prevalence of intimate partner violence (IPV). Female patients who met eligibility criteria at one of the 12 orthopaedic fracture clinics in Canada, USA, Denmark, the Netherlands, or India anonymously answered direct questions about physical, emotional and sexual IPV. Additionally, these patients completed the Women Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS) questionnaires to determine the prevalence of women suffering from IPV within the past year and over their lifetime. Results indicated that approximately 1 in 6 women presenting to an orthopaedic injury clinics have experienced IPV in the past year, and 1 in 3 women experience IPV in their life time. In addition, 1 in 50 women were presenting to the clinic as a direct result of IPV. Few of the women had ever been asked about IPV by any physician. Most patients thought orthopaedic surgeons should ask women about IPV.

Publication Funding Details + Funding: Non-Industry funded Sponsor: McMaster University Surgical Associates, Orthopaedic Trauma Association & Canadian Orthopaedic Foundation Conflicts: None disclosed

Risk of Bias 10/10 Reporting Criteria 21/21 Fragility Index N/A Was the allocation sequence adequately generated? Was allocation adequately concealed? Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented? Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented? Blinding Patients: Was knowledge of the allocated interventions adequately prevented? Was loss to follow-up (missing outcome data) infrequent? Are reports of the study free of suggestion of selective outcome reporting? Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)? Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events? Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)? Yes = 1 Uncertain = 0.5 Not Relevant = 0 No = 0 The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below. 4/4 Randomization 4/4 Outcome Measurements 4/4 Inclusion / Exclusion 4/4 Therapy Description 5/5 Statistics Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65 The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now? Intimate partner violence (IPV) is characterized by physical, emotional, sexual, psychological or financial abuse between intimate partners and is often referred to as domestic violence, battering or spouse abuse. IPV is a prevalent issue in society and recent international studies have documented the lifetime prevalence of IPV in women ranging from 15% to 71%. IPV in orthopaedic fracture clinical settings is a topic that has been underdeveloped, with a paucity of literature investigating the topic. This multinational study was needed to estimate prevalence rates of IPV in orthopaedic fracture and trauma centres across the globe.

What was the principal research question? What is the prevalence of women reporting to orthopaedic fracture clinics, who have been subjected to intimate partner violence in the past 12 months or over their life time?

Study Characteristics - Population: 2945 women (of at least 16 or 18 years of age, depending on location) who had presented to the orthopaedic injury clinic with a musculoskeletal injury. Intervention: N/A Comparison: N/A Outcomes: Patients under went direct questioning using three direct questions that were rephrased to assess 12 month prevalence and life time prevalence of IPV. The questions were: Have you been physically abused? Have you been emotionally abused? Have you been sexually abused? Two questionnaires were also completed to establish prevalence of IPV, the Women Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS). A female study coordinator provided every participant with the questionnaire to complete independently in a private location. Responses were then returned to the coordinator in a sealed envelope. Methods: Cross-sectional: Multinational: Prevalence study: Survey Time: N/A

What were the important findings? A total of 2945 women from 12 centers were included in this study. The response rate was 85% for the 10 centers that maintained screening records. Due to missing data the primary outcome is based on 2839 participants.

Based on direct questioning, the overall prevalence of IPV was 16% in the past 12 months. Emotional abuse was experienced by 16% of women, physical abuse was experienced by 3% of women and sexual abuse was experienced by 1% of women.

The prevalence of IPV in the past 12 months in the Canadian and US centres (18%) was significantly higher compared to the Dutch and Danish centres (12%) (p<0.001), but was no different than that observed in the Indian centres (18%) (p=0.35).

The PVS and WAST identified almost 50% fewer women who had suffered IPV with in the past 12months compared to the direct questions (7.1%, 95% CI 6.2-8.1 and 7.4% 6.5-8.4, respectively)

The overall lifetime prevalence of IPV was 35%. Approximately 33% of women experienced emotional abuse, 18% experienced physical abuse and just fewer than 10% experienced sexual abuse.

The lifetime prevalence of IPV in North American centres (40%) was significantly higher compared to European centres (24%) (p=0.001) and the Indian centre (p=18%) (p=0.016).

North American women reported significantly higher rates of physical abuse in their lifetime (20%) compared to those in the Netherlands and Denmark (13%) and India (2%) (p<0.004).

Just fewer than 2% of women presented to fracture clinics as a direct result of IPV. Of these women, only 14% had ever been asked by a health care provider whether they had experienced IPV.

Those at a lower risk of IPV throughout their lifetime included married women, women with children, women with injuries of the limbs and women living in the Netherlands or Denmark. Those at a lower risk of IPV in the previous 12 months included women who were older, in a short-term relationship (less than 10 years), who live in the Netherlands or Denmark and those who had no children.

More than 60% of women believed that orthopaedic surgeons should directly ask women about IPV.

What should I remember most? The results from this study indicate that approximately 1 in 6 women presenting to orthopaedic clinics have experienced intimate partner violence (IPV) in the past year, and 1 in 50 women were visiting the clinic as a direct result of IPV. Over a life time IPV appears to affect close to 1 in every 3 women with musculoskeletal injuries. The prevalence of IPV by region differed significantly, with North America having a higher prevalence based on the current assessment. Orthopaedic surgeons are in a good position to identify and support women who have experienced IPV.

How will this affect the care of my patients? Based on the relatively high prevalence of women who have suffered from intimate partner violence in orthopaedic clinic settings, establishing an identification and support program for these patients is necessary. With the top cause of death following domestic violence being trauma (42%), surgeon awareness, as well as support programs, at the orthopaedic injury clinic level are crucial. It should also be noted that this study may have been limited by a number of factors including; the broad definition of IPV, the fact that questionnaires were only validated for an English speaking population, and the cultural acceptability of asking questions pertaining to IPV.