FACTORS INFLUENCING VIOLENCE EXPERIENCED BY MEDICAL STAFF IN PRIMARY HEALTH CARE CENTERS, TAIF CITY

Turki Adnan Kamal 1 , Abdulmajeed Ahmad Alsofiany 2 , Nemer Khidhran Husain Alghamdi 1 and Ali Eissa Hassan Al-Rajhi 3 . 1. Family and community medicine department, Military hospitals, Taif. 2. Family medicine-Public health, Ministry of Health, Taif. 3. Hospital administration, Psychiatric care center, Taif military hospitals; Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Health care workers are ranked as one of the most vulnerable groups experiencing violence and aggressive behavior compared to other occupational groups (Jansen et al., 2005, andMagin et al., 2005).The ILO (2002) stated that "while workplace violence affects practically all sectors and all categories of workers, the health sector is at major risk"(International Labor Office, 2002).
Violence is defined as"the intentional use of force that makes threats to individuals or groups, which may result in injury, death, or psychological harm" (World Health Organization, 2002). One of the most difficult situations that health care providers face is being threatened or physically harmed by their patients, or by patients" relatives, or even by their colleagues (Ayranci et al., 2006). The problem of "violence" against health workers has been investigated in a number of countries and it seems that its prevalence depends on the criteria used to define the term and the populations studied. However, studies indicate that as much as 90% of health workers have experienced violent incidents at work, with percentages ranging from 70-80% for nurses and doctors (Merecz et al., 2006). However, the actual prevalence of violence against health workers is unknown because there is no "standard definition" on what constitutes a violent incident in health care (Adib et al., 2002).
Violence has several bad outcomes as it may lead to lost workdays, loss of consciousness, termination of employment, shortage of health care workers, and undermines the quality of health services delivered to patients (Needham et al., 2005).
Workplace violence can be physical, sexual or psychological in nature and can be actual or threatened (Mohamad and Motasem, 2012).
Bullying, harassment, and violence are more prevalent in the health sector than any other sector, with 54.4% taking place in the hospital due to some situations such as long bureaucracy in service delivery and lack of needed materials in the facility (Ogbonnaya et al., 2012 andAytac et al., 2009). Patients and clients themselves may have personality and behavioral issues such as alcoholism and drug abuse while some hospital members of staff have poor attitude and approach in relating with patients (Samir and Moustafa, 2012). Furthermore, patients are usually under stress and in pain or are financially handicapped and so they transfer their aggression to health workers (Aytac et al., 2009). Aggression may be more serious at the accident and emergency unit (Magnavita and Heponiemi, 2012). Policy and procedure addressing workplace violence in the healthcare setting has been documented in many developed countries (Magnavita,and Heponiemi, 2012),but is almost non-existence in developing countries. Many violence and harassment against the health professionals go often unreported officially (Ferns, 2006 andPawlin, 2008).
Despite the high frequency of violence towards medical staff working at primary health care centers, there remains a lack of adequate research evidence about the issue.
The aim of this study to investigate the problem of work-related violence against medical staff (physicians and nurses) working in Primary health care centers in Taif city.

Subjects and Methods:-
A cross-sectional study design was applied in primary health care centers, affiliated to the Ministry of Health (MOH) in Taif city. It is a city in the Mecca Province of Saudi Arabia at an elevation of 1,879 m (6,165 ft.) on the slopes of the Sarawat Mountains. It has a population of ≈1200000 (General Census of Population and Housing in 1436 AH) (Central Department of Statistics and Information, 2015). The total numbers of primary health care centers (PHCCs) are 113 centers which are divided into urban and rural centers. Nineteen of these centers are located inside the Taif city and distributed on four administrative sectors.
All medical staff (physicians and nurses) working in PHC centers inside Taif city (MOH) at the time of study conduction were eligible for inclusion in the study. Using recent data is from the database system of primary health care directory, MOH in Taif city: For physicians: the total number of 89 physicians working in 19 primary care centers while for nurses: the total number of 305 working in 19 primary health care centers. Regarding physicians: all of them were invited to participate in the study while for nurses, using Roasoft Online sample size calculator, (Online Raosoft sample size calculator) putting into consideration that the expected proportion of outcome is 54.3% as reported by Mohammed in a study conducted among nurses in Riyadh (Mohamed, 2002; 1642 51-56) and the worst accepted proportion was ± 5% and the level of confidence is 95%, sample size was estimated to be 170. This sample size constituted almost 55.7% of the nurses working in PHC centers, MOH in Taif city. For nurses, 10 PHC centers were selected through a simple random technique and all nurses working in these centers were recruited in the study till we reached the required sample size.
A predesigned self-administered questionnaire distributed to all working physicians and nurses in the selected PHC centers. The questionnaire includes demographic data of the respondents, workplace characteristics, prevalence of violence events during the previous 12 months, risk factors contributing to workplace violence, personal opinions, perceptions, attitudes, experiences and recommendations concerning the subjects" workplace violence (International Labor Office, 2003).It is in Arabic and previously validated and tested for reliability (Abbas, et al, 2010). The used questionnaire was valid and reliable since it was mainly developed from the WHO survey questionnaire about violence in health care settings, and it used in many international, regional and local studies in many languages.
Permissions from the Research and Ethical Committee at King Abdul-Aziz University, Faculty of Economics and Administration, department of Health Services and Hospital Administration were obtained for conducting the study were obtained prior to study conduction. Acceptance to participate in the study was considered as consent.
Data were collected, reviewed, coded and entered into the computer. Data were presented in the form of frequencies and percentages for qualitative variables and mean±standard deviation for continuous variables. Chisquared test was used for comparing qualitative data. Statistical analysis was done using SPSS program version 20 where p-value at or below 0.05 was utilized a s a cut-off for statistical significance.

Results:-
Out of 259 targeted HCWs (89 physicians and 170 nurses) to be included in the study, 201 (56 physicians and 145 nurses) responded giving a response rate of 77.6%. Table 1 presents socio-demographic characteristics of the participants. Their age ranged between 25 and 60 years (36.2±8.2), 59.7% of them aged between 25 and 35 years. Males represent 55.7% of them. More than half of them (52.2%) were Saudis. Most of them (76.1%) were married. The experience of work after graduation exceeded 10 years in more than half of them (53.7%). a scale ranged between 0 (not worried) to 5 (extremely worried). The mean±SD of the scale was 1.5±1.3. More than one-fourth of them (29.4%) were not worried whereas only one (0.5%) was extremely worried.   Table 3 describes the violent event. Majority of them were attached by patients (86.8%), claimed that the incident took place in the workplace (91.8%), in the morning period (78.7%) and during the working days of the week (Sunday-Thursday) (77%). As regard the response to the incident, more than one-third of the victims (37.7%) told a special consultant, 21.3% told their mates and 18% told family members or friends whereas 16.4% of them did nothing. Only 6 victims (9.8%) filled a form of assault notification. More than two-thirds of them (68.9%) claimed that the incident could have been prevented. All of them were not injured as a result of the incident and 14.8% of them took time-off from work after being attached (few hours in all). Action taken to investigate the cause was reported by 34.4% of them. In majority of them (85.7%) investigation was done by the management. For those who did the assault, nothing done in 70.5% of them while oral warning was done for 21.3% of them and notifying the police was done for 5 of them (8.2%). More than half of the victims (57.4%) were severely dissatisfied toward the process after the assault. Regarding reason for not reporting the incident, almost two-thirds of them (67.2%) reported that there is no benefit to notify.  Almost one-quarter of the health care workers has witnessed incident/s of violence at their workplace during the last year. In most of occasions (74.5%), this happened monthly.. Only five health care workers (4.6%) claimed that they were punished or blamed because of notifying an incident of workplace violence.
Among studied HCWs` socio-demographic and work-related characteristics, HCWs who deal with male patients were exposed to workplace violence more significantly compared to those deal with females or both genders (42.4% versus 32.3% and 19.5%, respectively, p=0.015. Other factors (gender, age, nationality, marital status, experience, job, history of dealing with patients, patient`s age, and number of colleagues in workplace) were not significantly associated with workplace violence. Table 4  Table 4:-Association between health care workers` characteristics and workplace violence.
Workplace violence X 2 p-value Exposed N=61 N (%)   Presence of any written or hanged procedures in work place related to violence against health care workers was demonstrated in figure 3. . Work health and safety was present as cited by 23.4% of HCWs whereas assault on workers, the verbal assault and threats were present according to 5%, 7% and 5% of HCWs, respectively. From table 5, security was present as mentioned by 10% of HCWs whereas presence of place organized and suitable for work was reported by 64.6% of them. Public not allowed to enter the work place, registered patients, families and friends enter to the place of work and special uniform for staff at work place were reported by 28.9%, 39.3% and 63.2% of the participants, respectively. Reduced periods of working alone, training on the procedures that must be followed and training on how to deal with others in work zone were mentioned by 21.9%, 35.3% and 41.3% of them, respectively. were not significantly associated with workplace violence.  Rehmani, 2004) countries vary in their estimation of the volume of health workers who exposed to violent acts.
Comparing the results reported here with those from other countries is difficult because of differences in the definition of violence, variation in setting and population and the methodologies used.
The fact that almost one-third of HCWs were exposed to violence may question the availability of violence prevention programs and security measures in the Saudi primary health care centers and may have an implication on occupational health. O'Brien-Pallas et al., (2009) showed that workplace violence significantly increased the likelihood of HCWs' absenteeism, job dissatisfaction and poor physical and mental health and can negatively impact quality of care.
Contrary to several studies, (Merecz et al., 2006, Needham et al., 2005and Erkol et al., 2007 the physicians were overwhelmingly more likely to be exposed to violent events than nurses despite the fact that nurses comprise one of the largest groups in the health care professions, they provide 24-hours care and they have direct contacts with patients. The conduction of this study in primary health care centers may explain this as physicians are in direct contact with patients as equal as nurses. Anyhow, the difference was not significant in the present study. In this study, male respondents were more likely to experience violent acts than females, although not significant. HCWs who deal with male patients only were more significantly exposed to workplace violence in the present survey. The evidence on whether a worker"s gender has a risk for being assaulted is contradictory. While some researchers (Gillespie et al., 2010) reported that men experience violent events more significantly than women, others ascertained the opposite and reported that women, particularly nurses, are more likely toencounter violence and aggressive behavior than men (Miedema et al., 2009 andThomas et al., 2006). In fact, other authors in line with us reported that there was in difference in the overall frequency violent events between health staff according to their gender (Tolhurst et al., 2003).
Training on the procedures that must be followed to avoid violence at workplace and presence of security at workplace were significantly associated with avoidance of violence at workplace in the present study. Martino