Razyeh Bajoulvand¹, Mohammad R. Ramezanlou², Naser Derakhshani¹, Salime Goharinezhad^1,3, Mohammad R. Gholami², Fatemeh Toranjizadeh², Nadia Saniee³

¹Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence: S. Goharinezhad, عنوان البريد الإلكتروني هذا محمي من روبوتات السبام. يجب عليك تفعيل الجافاسكربت لرؤيته.). ²School of Medicine, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. ³Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences (IUMS), Tehran, Islamic Republic of Iran. 4Social

Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Islamic Republic of Iran.

Abstract

Background: The affordability, accessibility, and quality of a primary health care system can make a crucial contribution to mitigation and management of a pandemic. Strong primary health care puts less strain on health systems during times of crisis.

Aims: A systematic mapping review was conducted to identify specific capabilities required to establish resilient primary health care in response to a crisis, and to highlight any research gaps that may need to be addressed.

Methods: A bibliographic search was conducted on PubMed, Scopus, Web of Science, and ProQuest from 2000 to 2021. The data were extracted to map the included studies and categorize published research into a framework of 6 building blocks. A graphical and tabular representation of the data was provided.

Results: A total of 4276 studies were retrieved, and 28 met the final inclusion criteria for the systematic map. Data extraction was done based on study design, year of publication, countries, type of communicable disease, and main interventions to build resilient primary health care. Most studies were conducted in 2020 and 2021 during the COVID-19 pandemic. A large number of studies emphasized telehealth during the pandemic.

Conclusion: This review summarizes > 20 years of research on how primary health care responded to public health emergencies. The review will enable policy-makers to take a broad view of the subject and determine which fields of research are well developed.

Keywords: primary health crisis, disaster, resilience, pandemic, mapping review

Citation: Bajoulvand R, Ramezanlou MR, Derakhshani N, Goharinezhad S, Gholami MR, Toranjizadeh F, et al. Systematic mapping review of measures to strengthen primary health care against pandemics. East Mediterr Health J. 2023;29(6):xxx-xxx http://doi.org/10.26719/emhj.20.xxx Received: 12/06/22, Accepted: 08/12/22

Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

 Introduction

Over the next 50 years, the number of disasters is expected to multiply 5-fold (1). WHO defines a disaster as serious disruption of the function of a community or society, which causes widespread human, social, economic, or ecological losses that cannot be resolved (2, 3). Disasters are divided into 3 broad groups: natural, human-made, and pandemic (4).

The global population is currently in the midst of the COVID-19 pandemic, which has spread rapidly across the world (5). On 22 February 2021, according to Johns Hopkins University, the global death toll from COVID-19 was ~2 500 000, making it the second most devastating event in a century and one of the 15 deadliest pandemics in history (6). Infectious disease epidemics are so widespread and complicated that health systems must have effective programmes to deal with these problems, otherwise, it will place a lot of pressure on the health systems (7–10). Most of the efforts to control COVID-19 have focused on laboratories and hospitals, and the role of primary health care in mitigation, preparedness, response, and recovery has been ignored. The concept of primary health care means making essential health care available to the community at large in a way that is acceptable to them, with their full participation, and at an affordable cost.

Globally, primary health care is recognized as a foundation for health systems due to its unique ability to deliver accessible, cost-effective, and equitable care. In the COVID-19 pandemic, health systems have faced extreme levels of morbidity and mortality, and primary health care has been pivotal in reducing hospital burden, screening, and monitoring. There is no single way to create a resilient primary health care system and it depends on the background and context of each country. Some systems have been able to deal with crises more effectively, and along with controlling the pandemic, they have relieved the pressure on hospitals. A pandemic is a major health crisis that occurs over a large geographical area, crosses international borders, and affects large numbers of people. There is no doubt that the COVID-19 pandemic is a public health crisis and a social, economic, and political crisis affecting all areas of health and life.

This review aimed to identify strategies to strengthen the primary health care system during disasters by reviewing previous literature and empirical evidence, and to provide guidance to policy-makers in designing a more resilient system. By taking into account the literature and new research related to the ongoing COVID-19 pandemic, strategies for strengthening resilience in primary health care were identified and mapped according to 6 building blocks of leadership and governance; health workforce; medical products, vaccines, and technologies; service delivery; health information systems; and health financing.

Methods

Study design

We conducted a systematic mapping review of studies that reported interventions to improve primary health care during health crises, especially pandemics. The review visually summarized evidence production and publication patterns, trends, and themes by categorizing, classifying, and describing the data. Mapping reviews can be helpful especially when there is an abundance of literature. Standard methodology was followed for screening, data extraction, data analysis, and visualizing the findings in systematic mapping. Two main themes were explored in this mapping review: interventions proposed for strengthening primary health care, and research gaps that need to be addressed.

Search strategy

We searched PubMed, Web of Science, Scopus and ProQuest for English-language articles published between 1 January 2000 and 11 July 2021. The search strategy was developed in consultation with a medical librarian (Table 1). The keywords were: primary health care, communicable diseases, epidemic, pandemic, SARS-CoV, MERS-CoV, SARS-CoV-2, disaster, resilience, risk reduction, response, model, best practice, and policy. Additional searches were performed on the WHO website and in Google Scholar. A review of the final list of articles for inclusion in the study was done manually.

Inclusion and exclusion criteria

We included studies that investigated primary health care, disasters (particularly communicable disease epidemics), risk management, and best practices. The following types of study design were included: reviews, reports, perspectives, qualitative, descriptive, mixed-method studies, case studies, and commentaries. Studies that examined similar cases in health sectors other than primary health care, studies published in languages other than English, and conference abstracts were excluded. We only included papers published after 2000 because of the greater diversity of epidemics and pandemics of communicable diseases in the current century.

Study selection process

Two authors screened all the retrieved articles. After elimination of duplicate studies, the titles and abstracts were reviewed and articles that were not consistent with the objectives of the study were excluded. Full texts of the articles were reviewed, and those that did not meet the inclusion criteria or were not related to the study objectives were excluded. A third author appraised the final summary. Endnote X9 reference management software was used to organize the documents.

Data extraction

To identify any flaws in the data extraction form and reach a finalized version, a pilot study was conducted on 5 studies . The final data extraction form included: title, author, country, year, study type, aim of study, type of disaster, disaster management cycle, intervention/experience, barriers/challenges, facilitators, and results. Two reviewers entered the data in Microsoft Excel. The reviewers resolved any disagreement by discussion, with the help of a third author if needed.

Data analysis

The extracted information was analysed using framework analysis, which is a hierarchical approach used to categorize data based on key themes and concepts (11, 12). We used the six building blocks of a health system framework for strengthening health systems (13). The components of this framework were: (1) service delivery: access and barriers to health services; (2) health human resources: availability, gender, and attitude of health workers; (3) medical supplies: availability and stock of selected medical supplies; (4) governance: accountability and community participation; (5) health information: information flow from health facility to the community; and (6) finance: user fees and indirect payments. The data coding process followed predetermined themes according to the 6 building blocks. These formed the basis for broader themes that were subcategorized to increase the explanatory ability of the data (14, 15) using the following steps: (1) familiarization with the data; (2) coding the data to systematically identify and document similarities, differences, and patterns; (3) collecting the coded data and organizing them into a thematic framework by developing a matrix, chart, or table; (4) analysing the data by comparing and contrasting, summarizing, and synthesizing the key issues and themes, and exploring the relationships between them; and (5) drawing conclusions and validating the findings.

Results

Search results

We extracted 4276 articles from the database searches, and included 28 that were relevant to primary health care resilience against communicable disease pandemics (16–43) (Figure 1). During the screening process, 1280 articles were removed because of duplication. In the next phase of screening, the articles were reviewed by title and abstract and 2940 were removed. Finally, during full-text review, 28 articles were excluded because of insufficient information and lack of relevance. Twenty-two studies were conducted in 2020 or 2021 during the COVID-19 pandemic and the remainder in 2010–2019. Most of the studies (75%) of communicable diseases were related to COVID-19, and other diseases were measles, Ebola, cholera, and H1N1 influenza.

Disaster risk management cycle

Only 7 studies were related to the prevention/mitigation phase of disaster management, and 13 to the preparation phase (Figure 2). All 28 studies addressed the response phase but only 2 mentioned the recovery phase.

Country of study

Oman, Liberia, America, South Korea, Qatar, Germany, Sweden, Greece, Papua New Guinea, Singapore, and Islamic Republic of Iran had 1 study each. India, England, Australia, New Zealand, and Brazil had 2 studies each. There were 3 studies in China. There was 1 study from the WHO South-East Asia Region; 1 collaborative study in Australia and Canada; 1 joint study in Australia, Canada, England, and United States of America (USA); and 1 joint study in Guinea, Sierra Leone, and Liberia.

Interventions, challenges, and facilitators identified

In studies of interventions for strengthening primary health care against epidemics and pandemics, 10 themes were identified: telehealth, clinical interventions, vaccination, strengthening health workers (e.g. skills, knowledge, motivation, and capacity to deliver quality health services), continuity of care, policy-making, guidelines, equipment availability, appropriate infrastructure, and education. We classified these into 6 main categories based on the WHO building blocks framework. For each intervention, some challenges and facilitators were identified (Table 2). A list of essential considerations for health policy-makers is shown in Table 3.

Discussion

The present study was conducted to identify the best practices and interventions made by countries to establish strong and resilient primary health care to tackle communicable disease pandemics and health emergencies. In this systematic mapping review, 28 articles from 20 countries were identified and reviewed. The WHO 6 building blocks framework was used to classify the identified categories. Ten subcategories were identified to strengthen primary health care against epidemics and pandemics: telehealth, clinical interventions, vaccination, strengthening health workers, continuity of care, policy-making, guidelines, equipment availability, appropriate infrastructure, and education.

The use of teleconsultation reduces crowding and infection risk in primary health care facilities, especially for high-risk populations (16, 17, 19, 25, 28). Epidemics and pandemics provide many challenges to provision of primary health care. One of the innovative solutions for population health coverage is using technological advances and telehealth (44, 45). Telehealth is one of the most effective and important interventions during epidemics to reduce transmission, especially in quarantine conditions (46, 47). Many high-income countries, such as Australia and the USA have implemented telehealth systems (48).

Continuity of health care, equipment availability, and education were identified as important strategies in strong primary health care systems. These can reduce treatment costs, improve community health, increase patient satisfaction, and reduce unnecessary hospitalization, especially in pandemic and epidemic situations (49–51). Screening and follow-up are widely used for diseases in primary health care and can meet the needs of patients with multiple morbidities (52).

Another strategy identified in our study was strengthening health workers (e.g. skills, knowledge, motivation, and capacity to deliver quality health services). Proactive training of community health workers is necessary to maximize the effectiveness of interventions during a crisis, as well as strengthening the supply chain management of drugs and finding suitable methods of providing supportive supervision when movements are restricted (23, 53, 54). The most important factors in emergency and disaster planning are encouraging healthcare personnel to provide effective services, and enhancing motivation of the workforce (10).

In epidemic and pandemic situations, primary health care centres and hospitals have to provide services for a large number of patients. The continuity of these services requires meticulous planning by officials, formulation of guidelines, and policy-making (10, 55). Decision-making during epidemics and pandemics is not easy. When an infectious disease appears, policy-makers take early actions to try and control onward transmission of the disease. However, decision-making in these situations brings many problems that must be investigated and resolved (56). Countries need to develop rapid and comprehensive research and strengthen strategies for evidence-based policy-making that can handle uncertainty (54, 57, 58).

Medical emergencies pose significant challenges to health systems because of heavy workloads, labour shortages, and reduced willingness of health workers to participate (10, 59). Volunteers can assist health workers in a variety of roles, including patient triage, treatment, and rehabilitation, and primary health care activities can be carried out if they receive proper training (59). Other necessities in epidemics and pandemics are comprehensive individual and family support programmes, attention to the needs of health workers, involvement of community members in addressing challenges, and the design and implementation of preventive planning, according to the number of employees in the primary health care system (10).

The COVID-19 pandemic disrupted routine primary care for various reasons, including fear of infection, travel restrictions, lack of monitoring systems, repurposing of facilities, personal decisions, and restriction of movement (60). This disruption will have negative consequences for the health system in the future. Recurrence of some diseases has resulted from delays in routine vaccination of children under the age of 5 years. It is essential to distribute vaccines and drugs according to the needs of each region and to establish acute care centres rapidly in areas where hospitals are unable to provide adequate care for patients with infection (60).

Effective leadership and good governance are key factors in strengthening the health system in epidemics and pandemics, so that it can assist in various ways, including intersectoral cooperation and construction of appropriate infrastructure. To achieve inter- and intrasectoral cooperation, we have to go beyond isolated thinking. Adoption of a social participation approach to improving health is one aspect of strengthening governance and leadership (61).

The health system needs to establish clear mechanisms to promote better coordination and cooperation among its different components. This can be achieved by fostering a trusting environment and strengthening information management. Another recommendation to improve collaboration across sectors is to adopt the health in all policies approach, which involves assessing the potential impact on the health of every policy before it is implemented, and making it a standard institutional practice (62).

Globally, pandemics and health emergencies have become a major burden on health systems, affecting other health services as well. Countries have adjusted their primary health care systems in response to crises in proportion to their needs and capabilities. Several of these measures indicate the effectiveness of policies and in some cases the need to implement compensatory policies.

This review had some limitations. First, only English-language studies were included; therefore, other important studies in different languages were not retrieved. Second, potentially important studies published before 2000 were not included. Third, there was limited access to Embase and the full text of some studies in our region.

Conclusion

There has been little research showing how to build resilient primary health care systems. Telehealth infrastructure needs to be strengthened because the COVID-19 pandemic is ongoing, and there may be other pandemics in the future that require people to stay at home or avoid visiting health care facilities. To improve primary health care, the workforce plays a vital role; therefore, it is important to address the challenges they face such as heavy workload, lack of protective equipment, and mental and emotional issues. Continuity of routine care during disasters promotes a more resilient public health system; however, this goal is challenged by an inefficient surveillance system, which can be mitigated with electronic health records. Primary health care becomes more resilient when there is community involvement and intersectoral collaboration. Finally, this review highlights that more research into primary health care resilience is needed to inform future plans and policy recommendations for the response to a global pandemic.

Acknowledgements

We would like to thank the Student Centre at Iran University of Medical Sciences for its support. In addition, we acknowledge the assistance of the anonymous reviewers that led to an improved version of the paper.

Conflict of interest: The authors report no potential conflict of interest.

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Table 1. Complete search strategy for PubMed database

Figure 2. Numbers of studies that addressed the different stages of the risk management cycle.

Özgür Önal,¹ Fatma Y. Evcil,¹Kıymet Batmaz,¹ Betül Çoban¹ and Edanur Doğan¹

¹Suleyman Demirel Universitesi, Tip Fakultesi [Faculty of Medicine, Suleyman Demirel University], Isparta, Türkiye (Correspondence to Fatma Y. Evcil: عنوان البريد الإلكتروني هذا محمي من روبوتات السبام. يجب عليك تفعيل الجافاسكربت لرؤيته.).

Abstract

Background: Workplace violence is a serious public health problem threatening health care workers worldwide.

Aim: We aimed to determine the prevalence of physical and verbal violence over the previous year and during the career of health workers in countries of the WHO Eastern Mediterranean Region and Türkiye.

Methods: The databases MEDLINE (via PubMed), Cochrane Library, Scopus, Science Direct, Web of Science and ProQuest were explored along with reference lists from selected articles. Inclusion criteria were: studies carried out in the WHO Eastern Mediterranean Region or Türkiye, staff working in hospitals and primary health care services, studies on health workers exposed to verbal and/or physical violence by patients/relatives. We initially identified 3513 articles. After further review, 75 studies conducted during 1999–2021 were eligible. These were analysed using MetaXL, version 5.3, and STATA, version 16.

Results: The study covered 69 024 health care professionals from 22 countries. Meta-analysis showed that 63.0% (95% CI: 46.7–79.2) of health care professionals had experienced verbal violence and 17.0% (95.0% CI: 14.0–21.0) physical violence. There was no difference for sample size, professional group, quality score or response rate. The frequency of physical and verbal violence in the subgroup analysis was statistically significantly different for country and year.

Conclusion: A variety of questionnaires and time intervals had been used, making it difficult to calculate a standard severity prevalence and compare subgroups. Examining the temporal trend of workplace violence by country and determining how country-specific social factors and policies affect it would be valuable in future studies.

Keywords: verbal violence, physical violence, health care workers, Eastern Mediterranean Region, systematic review, meta-analysis

Citation: Önal Ö, Evcil FY, Batmaz K, Çoban B, Doğan E. Verbal and physical violence against health care workers in the Eastern Mediterranean Region: a systematic review. East Mediterr Health J. 2023;29():xxx–xxx. https://doi.org/10.26719/emhj.XXXX Received: 23/12/22, accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Workplace violence is a serious public health problem that threatens health care workers worldwide. Health care workers are an occupational group at high risk of workplace violence (1). The World Health Organization (WHO) has reported that at least 3 out of every 5 health care workers had been exposed to violence over the previous year (2,3). Violence negatively affects the health of all employees working in health institutions, from cleaning staff to doctors. Workplace violence is defined as threats, abuse and attacks that occur in work-related conditions and may affect the health of employees (4). All kinds of behaviours, from threats and insults to murder, are considered within the scope of workplace violence (5).

Violence in the workplace is examined under 2 main headings: physical and psychological. Physical violence is defined as the use of physical force that causes physical, psychological or sexual problems in the exposed person. Many situations, such as pushing, kicking, hitting, slapping and injuring with an object, can be given as examples (4). According to WHO, health workers are exposed to physical violence at rates ranging from 8% to 38% throughout their careers (1). It has been reported that 24.4% of health care workers have been exposed to physical violence in the previous year (3).

Psychological violence is any behaviour that causes the individual to be negatively affected psychologically (4). Verbal violence, such as insulting, shouting, threatening, swearing, etc., is the most common subdimension of psychological violence (6–9). According to WHO, health care workers are exposed to verbal violence at a much higher rate than physical violence (2). A recent meta-analysis in China found that 61.2% of health care workers were exposed to verbal violence in the last year (10).

Violence has a negative mental, physical and social impact. Violence against health care workers is known to cause a number of health issues, including psychological harm, injuries and death. Decreased job satisfaction and staff quitting their positions are also among the consequences (11). Therefore, violence in the health sector is a significant issue that has a direct impact on the health of employees and an indirect impact on the health of patients.

Determining the frequency of the violence that health care workers are exposed to is important for protecting the health of both employees and society. Studies have been conducted on the prevalence of violence among health care workers in different regions, however, we did not find any systematic review or meta-analysis that reported the frequency of violence (physical or verbal) among health care workers in the Eastern Mediterranean Region which compared different subgroups (country, occupation, time interval, sample size, study year, quality score, response rate). One meta-analysis conducted worldwide on this subject examined a specific subgroup and the prevalence of physical violence experienced in the previous year only (12). Detailed examination of health violence in the Eastern Mediterranean Region, as in our study, will reveal the regional dimensions of the problem.

In this study, we aimed to determine the prevalence of physical and verbal violence experienced by health care workers during one year and throughout their careers in countries with sociocultural similarities in the Eastern Mediterranean Region.

Methods

Study design

This study was conducted in accordance with the Preferred Reporting Elements for Systematic Reviews and Meta-analyses (PRISMA) (13) and was registered in the International Prospective Systematic Review Registry (PROSPERO) under the code CRD42022314256.

This meta-analysis was conducted following the checklist of the Meta-Analysis of Observational Studies in Epidemiology guidelines for the design. The specified guideline includes recommendations on reporting background, search strategy, methods, results, discussion and conclusions (14).

Search strategy

We searched 6 academic databases, MEDLINE (via PubMed), Cochrane Library, Scopus, Science Direct, Web of Science and ProQuest, with words arranged in accordance with MeSH terms. Search strategies for each database are shown in Table 1. The following search terms were used “physical violence”, “verbal violence”, “workplace violence”, “nurse”, ”doctor”, “health care professional”, “prevalence” and “incidence”.

Study selection and selection criteria

We carried out the research and selection of the studies in line with previously defined inclusion criteria. Studies were included if they met the following criteria: conducted in the countries of the WHO Eastern Mediterranean Region and Türkiye due to their sociocultural proximity; participants working in hospitals and primary health care services; and studies conducted on health workers exposed to verbal and/or physical violence by patients and their relatives. Only observational studies reporting prevalence of violence were included in the systematic review and meta-analysis. Only studies whose language of publication was English were selected.

Studies were excluded if they met the following criteria: randomized controlled trials and systematic reviews; studies whose main research topic was mobbing and burnout; studies in which the cause of violence was conflict and chaos in the country; and studies dealing with only sexual violence in health care professionals.

All the data detected in the literature search were transferred to Excel, and duplicates were removed. Scanning of titles and abstracts for these studies was done by referees (ÖÖ, FYE). Unclear titles/summaries were scanned by another reviewer (KB, BÇ, ED) and discussed by the reviewers until approval for inclusion or exclusion was obtained. All reviewers independently scanned full-text articles using a standardized search tool according to eligibility criteria such as country of study, study design, type of publication and sample studied. Studies meeting all criteria were included in the review. When contradictory conclusions were reached about inclusion or exclusion, these were resolved by discussion.

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for the systematic review and selection of studies to be included in the meta-analysis.

Quality assessment

Loney criteria (8 items) were used for the quality scoring of the studies evaluated in this review (15). The criteria were: sampling method (random sample or whole population), sampling frame (defining the study population), sample size (< 355 or ≥ 355), questioning the violent event (using standard measurement form/other), unbiased measurement, response rate (< 70% or ≥ 70%), confidence intervals (CIs) and subgroup details and study subject. The total score was calculated by giving a score to the studies for each item; the overall scores ranged from zero (0) to 8 points, with higher scores indicating higher quality.

Statistical analysis

Data were analysed using MetaXL, version 5.3, and STATA, version 16. Small-study effects and publication bias were examined using the Luis Furuya-Kanamori (LFK) index, the Doi plot and the funnel plot (16). The Doi plot has been reported to be more intuitive and the LFK index more robust than the traditionally used Egger’s regression-intercept test (17). An LFK index value > 1 or 2 or < 2 indicate major asymmetry. For optimal interpretation, at least 5 studies are required, therefore only the LFK index and Doi plots relating to the prevalence of physical and verbal violence in the last year and during the career period were prepared for the subgroups. The LFK index was calculated by applying double arcsin, logit, and no transformation to the prevalence data, and the value with the least asymmetry was used in the analysis. Graphics and tables related to this subject are available from the authors on request.

Both the Cochran Q test and the I2 statistics were used to test the heterogeneity of the data (18). Significant heterogeneity between studies was assumed to be P 50% (19). If significant heterogeneity was observed between studies, a random effects model was adopted to calculate the prevalence of physical and verbal violence; otherwise, a fixed effects model was adopted. The same procedure was followed to generate meta-analytically derived national estimates of the prevalence of workplace violence (physical and verbal) based only on studies available from each country. Meta-analytical estimates could not be calculated for countries with < 2 studies (20). Prevalence estimates for the countries where the studies were conducted (Bahrain, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Saudi Arabia, Syrian Arab Republic, Türkiye), the year of study (2010 and before vs 2011 and later) and sample size (< 355 and ≥ 355) were analysed by subdividing the professional group (physicians only, nurses only, all health care workers), quality score (< 6 vs ≥ 6) and response rate (< 70% and ≥ 70%). Statistical significance was set at P < 0.05.

Results

Study selection and study characteristics

For the systematic review and meta-analysis, a keywords search was carried out on the 6 academic databases, and 3513 articles were identified (Figure 1). After removing duplicates, 2675 articles were scanned for titles and abstracts. The remaining 274 full texts were reviewed, and we included 75 studies that met the eligibility criteria.

The selected studies were examined under 2 separate headings according to the type of violence, physical and verbal. Prevalence of violence was evaluated in 2 groups according to the time interval as “last year of the study (last year, last 6 months, last 2 months)” and “during career”. From the meta-analysis, 69 (92.0%) studies covered the prevalence of physical violence, 18 (24.0%) covered the frequency of physical violence encountered throughout the career, and 51 (68.0%) covered the frequency of physical violence encountered in the last year. Also from the meta-analysis, 71 (94.7%) studies included the prevalence of verbal violence, 17 (22.7%) the frequency of verbal violence encountered throughout the career, and 54 (72.0%) the frequency of verbal violence in the last year.

The studies included in the systematic review and meta-analysis were conducted between 1999 and 2021. Although violence was examined through the questionnaires in these studies, there was no standard measurement tool used in all of the studies. While the scale developed by WHO/ILO was used in 22 (29.4%) studies, other scales were used in 6 (8.0%) studies. In 47 (62.7%) studies, the questions were created by the researchers, i.e. they did not use any standard scales. The total number of health care workers examined in all studies was 69 024. Among the studies examining physical violence, 50 (66.7%) were from 2011 and later. Data from a total of 61 241 health care workers were assessed in studies on the frequency of physical violence. Fifty (66.7%) studies evaluating the prevalence of verbal violence were conducted in 2011 and later. The total number of health care workers covered in the studies examining verbal violence was 62 261. The countries that had the greatest number of studies on both physical and verbal violence were Türkiye and Saudi Arabia.

The mean quality score (Loney score) for the 75 studies reviewed was 5.2, with 34 (45.4%) scoring ≥ 6 (Table 2). Of the studies reporting the frequency of physical violence, 12 (16.0%) were conducted on physicians only and 23 (30.7%) on nurses only. Ammong those studies reporting the prevalence of verbal violence, 10 (13.4%) included only physicians and 27 (36.0%) included only nurses. An equal number of studies evaluated more than one occupational group for both physical and verbal violence. Since the frequency of verbal violence was examined in many categories in the one (1.4%) study included, and the participants could choose more than one proposition, the net frequency of this type of violence could not be calculated, and only the frequency of physical violence was included in the meta-analysis for that study (21).

For the calculation of the frequency of verbal violence in another study, the category sexual violence, which had been included with non-physical violence, was not included in the frequency of verbal violence (22), which we calculated as 57.9% for that study.

Publication bias was checked using a funnel plot. In the funnel plot analysis, although the prevalence of physical and verbal violence was symmetrical in the studies included in the meta-analysis, mean differences were widely spread. This may have occurred due to variations in sociodemographic characteristics. It was observed that the studies concentrated on a low level of standard errors, an indication that the sample size in most studies was satisfactory.

All studies included in the systematic review, along with their characteristics and the number of violent incidents, are presented in Table 3. The prevalence values obtained from the studies were transformed in accordance with the LFK index scores: transformation with the lowest LFK index was applied. The transformations applied in this framework are detailed in Table 4.

Prevalence of physical violence against health care workers

We analysed 18 studies to determine the prevalence of physical violence encountered by health care workers in the Eastern Mediterranean Region throughout their careers, in the last year, in the previous 6 months, and in the last 2 months (Figure 2). The estimated frequency was 23.4% (95% CI: 16.1–32.0) (Table 5). There was significant heterogeneity among the studies reviewed (Q = 1224.4, P < 0.001, I2 = 99%). The prevalence of physical violence in the last year was calculated at 19.0% (95% CI: 15.4–22.6) by pooling the data reported from 51 studies showing high heterogeneity (Q = 4024.39, P < 0.001, I2 = 99%).

Studies reporting the frequency of physical violence encountered throughout the career were conducted in the Islamic Republic of Iran, Iraq, Jordan, Morocco, Saudi Arabia and Türkiye. Prevalence varied between 8.0% (95% CI: 0.5–15.5) and 39.5% (95% CI: 0.1–97.3) by country, with a statistically significant difference between countries for the prevalence of physical violence (P < 0.027) (Table 5). The prevalence of physical violence in the last year was reported in more studies, and the estimates ranged from 10.6% (95% CI: 2.2–19.1) to 42.2% (95% CI: 33.3–51.1). The frequency of being exposed to physical violence in the last year also differed significantly between countries (P < 0.001).

When the studies were analysed according to the occupation of the health care professionals, the highest frequency of physical violence throughout the career was reported in studies involving only physicians (31.0%; 95% CI: 9.5–52.5). For studies reporting physical violence during the previous year, the highest prevalence (23.4%, 95% CI: 17.0–29.9) was reported in those that included only nurses. There was no statistically significant difference between the frequency of physical violence according to the occupational group for both time intervals investigated (during career, P = 0.412; for the last year, P = 0.147).

For studies examining the frequency of physical violence throughout the career, the prevalence calculated for those conducted in 2011 and later (29.7%; 95% CI: 17.9–41.4) was statistically significantly higher than that for studies conducted over the previous years (15.6%; 95% CI: 10.3–21.0) (P = 0.033). In studies examining the frequency of physical violence during the previous year, there was no significant difference in prevalence between studies conducted in in these 2 periods (P = 0.564).

Studies included in the meta-analysis were further divided into subgroups based on sample size (< 355 and ≥ 355), response rate (< 70% and ≥ 70%) and quality score ( 0.05).

Prevalence of verbal violence against health care workers

We analysed 71 studies to determine the prevalence of verbal violence. Data from 17 studies reporting the frequency of exposure to verbal violence during the professional career were pooled and the frequency of verbal violence was estimated at 73.7% (95% CI: 67.8–80.4) (Table 5). The frequency of exposure to verbal violence in the last year was calculated at 59.9% (95% CI: 54.7–65.1) (data from 54 studies). Heterogeneity was found between studies examined for both time intervals (during career Q = 784.76, P < 0.001, I2 = 98%; Q = 10 150.03, P < 0.001, I2 = 99%). The prevalence of verbal violence encountered during the career, in the last year, last 6 months, and last 2 months, and heterogeneity between studies are shown in Figure 3.

When analysed by country of study, the frequency of verbal violence throughout the career ranged from 63.0% (95% CI 46.7–79.2) to 87.0% (95% CI 82.0–92.0) (Table 5). Data obtained from studies conducted in the Islamic Republic of Iran, Iraq, Jordan, Saudi Arabia and Türkiye showed a statistically significant difference (P < 0.001). The frequency reported from studies examining verbal violence over the last year ranged from 45.0% (95% CI 30.7–59.4) to 85.0% (95% CI 83.0–87.0) by country (Table 5). The highest prevalence, 85.0%, was reported from the Syrian Arab Republic, followed by the Islamic Republic of Iran, 80.7%, and Bahrain, 78.0%. There was also a significant difference between the countries included in the meta-analysis for prevalence of verbal violence in the last year (P < 0.001).

Studies that included only physicians reported the highest frequency of verbal violence throughout the career, with a prevalence of 77.0% (95% CI: 67.1–86.8) (Table 5). The frequency of verbal violence reported in the last year was highest in studies that included only nurses (65.5%; 95% CI: 56.9–74.1). However, there was no significant difference between the frequency of verbal violence according to occupational group for both time intervals (during career, P = 0.799; for the last year (P = 0.099).

The frequency of encountering verbal violence throughout the career was higher in studies conducted diring or after 2011. However, the difference was not statistically significant (P = 0.201) (Table 5). For studies conducted in 2010 and before reporting on encountering verbal violence during the last year, the frequency (67.9%; 95% CI: 58.3–77.4) was statistically significantly higher than in studies conducted in 2011 and after (55.9%; 95% CI: 50.1–61.7) (P = 0.035) (Table 5).

Studies included in the meta-analysis were divided into subgroups based on sample size (< 355 and ≥ 355), response rate (< 70% and ≥ 70%) and quality score ( 0.05).

Supplementary materials, including Doi plots and funnel plots, are available from the authors on request.

Discussion

In this study, we pooled the prevalence estimates of physical and verbal violence in the workplace against health professionals reported in 75 studies published from 1999 to 2021. A total of 69 024 health care professionals from 22 countries in the WHO Eastern Mediterranean Region and Türkiye having similar sociocultural characteristics were included in the study. Our meta-analysis revealed that 63.0% (95.0% CI: 58.0–68.0) of health care workers in the Eastern Mediterranean Region experienced verbal violence and 17.0% (95.0% CI: 14.0–21.0) were exposed to physical violence. During their career, 3 out of every 5 health professionals had been exposed to verbal violence and 1 out of 5 had been subjected to physical violence.

This study provides the first quantitative estimate of the prevalence of physical and verbal violence perpetrated against health professionals in the countries of the WHO Eastern Mediterranean Region. The prevalence estimates presented are based on a pool of 75 studies on health care professionals at all levels of care and various types of profession conducted in many countries in the Region.

Although studies from all countries in the Region were eligible for inclusion, there were none on the prevalence of physical and verbal violence from 10 countries, Afghanistan, Djibouti, Libya, Oman, Qatar, Somalia, Sudan, Tunisia, United Arab Emirates and Yemen. In addition, more than half of the eligible studies were reported from Türkiye (20 studies), Saudi Arabia (12 studies) and the Islamic Republic of Iran (11 studies). It is clear that more studies are needed from the low- and middle-income countries of the Region.

We determined the frequency of physical violence to be 23.4% throughout the career and 19.0% during the last year. Some reviews we examined focused on the prevalence of physical violence in the workplace for health professionals; a wide range of frequencies (2% to 32%) was reported (3,23,24). Li et al., who presented the prevalence estimates of physical violence in all WHO regions and the world in 2018, determined the prevalence of physical violence in the last year in the Eastern Mediterranean Region at 17.1% (12). Corresponding results for other WHO regions were: Africa 20.7%; America 23.6%; Europe 26.4%; Western Pacific 14.5%; Southeast Asia 5.6%; and worldwide 19.3%. Our estimation for the Eastern Mediterranean Region was similar to the world value and higher than some regions (Western Pacific and Southeast Asia) reported by Li et al.

We found the frequency of verbal violence against health care providers was 73.7% during the career and 59.9% for the last year. Previous meta-analyses have reported the frequency of verbal violence from different regions or the frequency of verbal violence experienced by a specific health care profession group in the Eastern Mediterranean Region (25,26). In a 2019 meta-analysis, which included studies from 5 regions of the world, the frequency of exposure to non-physical violence in the last year was 42.5%. The highest frequency was reported from North America (58.7%), followed by Asia (45.5%) and Australia (38.7%). In the same study, the most common subtypes of non-physical violence were 57.6% for verbal abuse and 33.2% for threats (3). In an umbrella review and meta-analysis examining violence against health care professionals, the prevalence of verbal violence was 66.8% (27). In a meta-analysis encompassing studies in China, the frequency of verbal abuse was 61.2% and the frequency of threat 39.4% (10). In all the meta-analyses cited above, the frequency of verbal violence was freater than that of physical violence (3,10,27), similar to our own findings.

In the subgroup analysis, we found no statistically significant relationship between the prevalence estimates for physical and verbal violence that health professionals were exposed to during the career and in the last year or less and sample size, response rate, quality score or professional group. The meta-analysis by Li et al. reported that the prevalence estimates were significantly higher in studies with a sample size ≤ 500, a quality score < 5 or a low response rate (12). However, it has also been found that studies with fewer participants may be associated with higher prevalence estimates that could be attributed to selection bias and publication bias (28). In a 2019 systematic review that evaluated workplace violence as physical and non-physical, nurses had the highest exposure to any type of violence, followed by doctors and other health professionals (3). In another systematic review, nurses were exposed to physical violence more frequently than doctors (12). It is clear that further studies are needed to provide more evidence about violence against health professionals in the workplace.

Our findings indicated that there was a significant difference between countries in terms of the frequency of verbal and physical violence, both throughout the career and during the last year. Data on the frequency of verbal and physical violence throughout the career were available from only 6 countries. Only one study covering 2 countries (Iraq and Jordan) was included in the meta-analysis. These findings suggest that more studies are needed to examine the frequency of physical and verbal violence throughout the career in countries in the Region. The frequency of verbal violence in the last year has been reported in more countries and more studies, however, analysis of publication bias revealed major asymmetry between studies. The results reporting the prevalence of violence in the last year should be carefully evaluated due to the small number of countries involved, the results relating to the frequency of violence throughout the career, and the major asymmetry from publication bias. It should, however, be taken into account that each country has its own particular working environment and conditions and geographical and cultural differences in the perception of violence, and that any standard definition and measurement of violence are not included in the studies.

We found that the year of publication was correlated with the prevalence estimates. In studies conducted in 2011 and later, physical violence throughout the career was significantly more prevalent than in those conducted in 2010 and before. For verbal violence, frequency in the last year was 67.9% in studies published in 2010 and before. This was significantly higher than the results for later years. In contrast, in our study we did not find any significant relationship reported in other systematic reviews on violence in health settings (3,12). The fact that more recent studies reported a higher prevalence of violence in our meta-analysis may be due to the increase in violence in the last decade, or it may be a result of an increase in awareness about workplace violence. Also, the number of studies conducted on violence in health has seen an increase over the past decade, with only 23 of the 75 studies dating from 2010 or earlier.

Our study had certain strengths and weaknesses. There was no standard measurement method in studies conducted to evaluate workplace violence among health professionals. There were definitional differences in terms of severity and typs. The time intervals in which violence was investigated differed in the studies we included. For this reason, we need to consider bias in recall studies that assess long-term violence (for example, throughout the career). The studies examined were analysed according to characteristics such as sample size, quality score and year of study; even so, it should be considered that many other factors may affect the frequency of violence when examining the results. For example, the frequency of violence encountered throughout the career may be greater in older participants, and some participants may not report the violence they have been exposed to for fear of losing their job. A particular behaviour perceived as violence in one society may be perceived as normal in another; a circumstance that may be misleading when comparing results.

Along with these limitations, our research also had some strengths. As far as we know, this is the first study in which physical and verbal violence related to the Eastern Mediterranean Region, which covers a vast geographical area and many countries, are examined together.In addition, within the scope of the study, the frequencies of both physical and verbal violence were discussed separately during the whole career and in the last year. This has allowed the frequency of violence to be discussed for specific time intervals.

Conclusion

Different questionnaires and different time intervals were used in the studies examined. This makes it difficult to calculate a standard severity prevalence and compare subgroups. Using a standard questionnaire in future studies would provide clearer results. In addition, practical interventions in the health sector are still urgently needed. In future research, it would be helpful to examine the temporal trend of workplace violence by country to determine how country-specific social factors and policies affect it and to investigate the causes of violence and methods for prevention.

Funding: None.

Competing interests: None declared.

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Table 2. Loney criteria quality scores for 75 studies from the WHO Eastern Mediterranean Region and Türkiye conducted during 1999–2021

^a1: Random sample or whole population; 2: Unbiased sampling frame; 3: Adequated sample size (≥ 355); 4: Measures were standard; 5: Outcomes measured by unbiased assessors; 6: Adequated response rate (≥ 70); 7: Confidence intervals, subgroup analysis; 8: Study subject defined.

Table 3. Characteristics of the 75 studies reviewed conducted in the WHO Eastern Mediterranean Region and Türkiye during 1999–2021, noting numbers of violent incidents

Table 4. Luis Furuya-Kanamori (LFK) index for the studies reviewed

Table 5. Subgroup analysis of physical and verbal violence reported in 75 studies from the WHO Eastern Mediterranean Region and Türkiye conducted during 1999–2021